Complementary Therapies in Clinical Practice 40 (2020) 101176

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

Acupuncture therapy for poststroke spastic hemiplegia: A systematic review

and meta-analysis of randomized controlled trials
Wenjuan Fan a, 1, Xu Kuang a, 1, Jiawei Hu a, Xiaowei Chen a, Wei Yi b, Liming Lu b, **,
Nenggui Xu b, ***, Lin Wang b, *
a
Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, 510006, China
b
Clinical Research Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of
Chinese Medicine, Guangzhou, 510006, China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Hemiplegia after stroke is one of the main dysfunctions in stroke patients. Acupuncture had been
Acupuncture widely used for poststroke spastic hemiplegia (PSSH), but the efficiency was unclear. This study aimed to
Poststroke spastic hemiplegia examine the efficiency and safety of acupuncture for individuals with PSSH.
Systematic review
Methods: We searched nine databases from their inception to 27th July 2019. Randomized controlled trials (RCTs)
Meta-analysis
of acupuncture for the treatment of PSSH met the screening criteria. The quality of methodology was evaluated
by Cochrane’s risk of bias tool. RevMan 5.3 was used to perform the meta-analysis. The primary outcome was the
Fugl-Myer Assessment (FMA) score, and the secondary outcomes were the Ashworth Scale for Spasticity (ASS)
and Barthel Index (BI) scores. To evaluated the safety of acupuncture therapy, researchers scanned the full text to
collect adverse events.
Results: Researchers retrieved 2452 articles in total, after screening, thirty-eight studies with 2628 participants of
were included. In this meta-analysis, twenty-seven trials revealed that acupuncture therapy was associated with
an increase in FMA scores compared with rehabilitation training (RT) (MD: 8.43, 95% CI, 6.57 to 10.28, p <
0.00001, I2 ¼ 75%). According to the analysis of subgroup of interventions, ten trials showed that manual
acupuncture (MA) plus RT was associated with an increase in FMA compared with RT (MD: 10.84, 95% CI, 9.29
to 13.29, p < 0.00001, I2 ¼ 24%), three trials showed that electroacupuncture (EA) plus RT was associated with
an improvement in FMA compared with RT (MD: 9.44, 95% CI, 1.00 to 17.88, p ¼ 0.03, I2 ¼ 81%), twelve trials
showed that MA was associated with an increase in FMA compared with RT (MD: 5.48, 95% CI, 2.07 to 8.89, p ¼
0.002, I2 ¼ 74%), and one trials showed that EA was associated with an improvement in FMA compared with RT
(MD: 11.35, 95% CI, 5.03 to 17.67, p ¼ 0.0004). According to the analysis of subgroup of treatment duration,
four trials used acupuncture therapy for more than 1 month, revealed that acupuncture therapy was associated
with an increase in FMA scores compared with RT (MD: 9.24, 95% CI, 0.42 to 18.06, p ¼ 0.04, I2 ¼ 93%). Thirty-
two trials used acupuncture therapy for less than or equal to 1 month, revealed that acupuncture therapy was
associated with an increase in FMA scores compared with RT (MD: 8.32, 95% CI, 6.56 to 10.09, p < 0.00001, I2
¼ 61%). Six trials indicated that acupuncture therapy was better than RT in terms of the ASS (MD: 0.46, 95% CI,
0.65 to 0.27, p < 0.00001, I2 ¼ 67%), twenty-four trials indicated that acupuncture therapy was better than
RT in terms of the BI scores (MD: 8.32, 95% CI, 5.30 to 11.35, p < 0.00001, I2 ¼ 88%). In general, the meth­
odologies of the RCTs were of poor quality. Two RCTs reported no adverse events, one trial reported five adverse
events without severe influence, others did not mention.
Conclusions: This review discovered that acupuncture might be a safe and effective adjuvant therapy for in­
dividuals with PSSH. Nevertheless, there were methodological limitations in the included RCTs, and well-
designed and large-scale studies should be carried out to confirm our results.

* Corresponding author.
** Corresponding author.
*** Corresponding author.
E-mail addresses: fanwjlw@163.com (W. Fan), kuangxukx@163.com (X. Kuang), 1297805975@qq.com (J. Hu), dashingxiaowei@163.com (X. Chen),
1050021893@qq.com (W. Yi), lulimingleon@126.com (L. Lu), ngxu@tom.com (N. Xu), wanglin16@gzucm.edu.cn (L. Wang).
1
Wenjuan Fan and Xu Kuang contributed equally to this work.

https://doi.org/10.1016/j.ctcp.2020.101176
Received 11 March 2020; Received in revised form 5 April 2020; Accepted 14 April 2020
Available online 21 April 2020
1744-3881/© 2020 Elsevier Ltd. All rights reserved.
W. Fan et al.
1. Background
Stroke has been regarded as the third major cause of disability
around the world [1]. Hemiplegia after stroke is one of the main dys­
functions in stroke patients [2]. In the early stage after stroke, most of
the limbs demonstrate flaccid paralysis. As individuals recover from the
disease and active movement increases, the muscle tension in the
paralyzed limbs gradually increases, and spasms occur. The morbidity of
spasticity in both arms or legs ranges from 25% to 43% in the first year
after stroke [3–6]. Spasticity is related to pain and restrictions in ac­
tivities related to hygiene and dressing. According to the EuroQol-5 test,
these activity restrictions increase the burden on caregivers and reduce
the quality of life of the individual [7]. When spasms occur, the
expenditure of care is four times more than that when there are no
spasms [8]. Accordingly, controlling spasms is the main goal of post­
stroke rehabilitation.
At present, the main treatments for poststroke spastic hemiplegia
(PSSH) include drug therapy (e.g., botulinum toxin and antispasticity
agents), exercise rehabilitation training (e.g., resting hand splints and
spastic muscle slow stretching), and physical therapy (e.g., neuromus­
cular electrical stimulation (NMES)). However, these therapies have
some drawbacks. Botulinum toxins are suggested for the control of
spasticity in clinics, but it is unclear whether they are a cost-effective
therapy for spastic hypertonia compared with physical or occupational
therapies alone [9]. Resting hand splints are insufficient for relieving
wrist and finger spasticity; furthermore, the application of such splints is
disputable due to the occurrence of contractures in a state of spasticity
[10]. NMES in addition to another treatment is likely to relieve spas­
ticity; however, there is not a sufficient amount of evidence suggesting
that the use of NMES with other treatments ameliorates functional
limitations [11]. Oral antispasticity agents, such as baclofen, dantrolene
sodium, and tizanidine, have an insignificant impact on improving
general spasticity, and there are dose-limiting side effects, such as
tiredness and lethargy [12–14].
Acupuncture is an effective [15–17], inexpensive [18], and safe
treatment, with no side effects or infections have been reported [19]; it
has been widely used in China for thousands of years and has been
accepted worldwide. In recent years, the number of published ran­
domized controlled trials (RCTs) has increased, allowing us to explore
the effect of acupuncture on the symptoms of individuals with PSSH.
However, previous studies have reached inconsistent conclusions
regarding the use of acupuncture for the treatment of PSSH. Many
studies have stated that acupuncture improves PSSH [15–17], while
some studies have reported the opposite results [20,21], and the reviews
in 2014 [22] and 2015 [23] gave the different conclusion about whether
acupuncture therapy make sense in the treatment of PSSH. Therefore,
this study additionally incorporates the RCTs published in recent years
in a more comprehensive meta-analysis that explores the effectiveness
and safety of acupuncture for the treatment of PSSH.
2. Methods
The protocol of this systematic review was developed and submitted
to PROSPERO, the registration number is: CRD42020151865.
2.1. Data sources and search strategy
We searched nine databases from their inception to 27th July 2019:
The Cochrane Library, Embase, Medline, Web of Science, Scopus, China
National Knowledge Infrastructure (CNKI) database, Chinese Science
and Technology periodical Database (VIP), Wanfang Database and
Chinese Biological Medicine Database (CBM).
The search strategies for Embase were as follows: ((stroke or post­
stroke or post-stroke or cerebrovasc$ or brain vasc$ or cerebral vasc$ or
cva$ or apoplex$ or SAH).tw.) OR (((brain$ or cerebr$ or cerebell$ or
intracran$ or intracerebral) adj5 (isch?emi$ or infarct$ or thrombo$ or
2
Complementary Therapies in Clinical Practice 40 (2020) 101176
emboli$ or occlus$)).tw.) OR (((brain$ or cerebr$ or cerebell$ or
intracerebral or intracranial or subarachnoid) adj5) AND (((hemorrhage
$ or hemorrhage$ or haematoma$ or haematoma$ or bleed$)).tw.) OR
(hemiparesis/or hemiplegia/or paresis/)) AND (random$ or factorial$
or crossover$ or cross over$ or cross-over$ or placebo$ or assign$ or
allocat$ or volunteer$).ti,ab. And the detailed search strategies are
shown in Appendix S1.
2.2. Inclusion criteria
RCTs assessing acupuncture for the treatment of PSSH were
included. Two reviewers worked independently when using the
following items as inclusion criteria: (a) types of participants: patients
were included if (1) they were diagnosed with stroke (cerebral infarc­
tion, intracerebral hemorrhage, cerebral embolism, or unclassified
stroke); (2) their condition was diagnosed in a clinic and/or using
computed tomography or magnetic resonance imaging; (3) they
demonstrated spasticity by the ASS (Ashworth Scale for Spasticity) or
Brunnstrom scale; (b) types of interventions: the experimental group
was treated with manual acupuncture (MA) or electroacupuncture (EA),
combined with rehabilitation therapy (RT) or not, and the control group
must be treated with rehabilitation therapy, other kinds of interventions
should not be included; (c) types of outcome measures: the primary
outcome measure was the FMA (Fugl-Myer Assessment) index, which is
usually used to evaluate motor function. The secondary outcomes
included the ASS score, BI (Barthel Index), and adverse events. There
were no restrictions on the age, sex, or race of the patient or duration of
the disease. The language of the paper must be written in Chinese or
English.
2.3. Exclusion criteria
The studies were excluded if they were opinions, case reports, case
series, conference papers, editorials, abstracts and crossover studies.
2.4. Data extraction and collection of adverse events
We input the studies retrieved from databases into EndNote and
eliminated duplicate literatures. The two authors independently
screened studies by evaluating the titles, abstracts, and full-texts of the
articles. Any disagreements were resolved by another author, Hu JW.
The following data from the articles were extracted: author, year of
publication, characteristics of the subjects, experimental intervention,
control intervention, course of treatment, measurement of results, dif­
ferences between groups, and adverse events. For studies with more
than 1 control group, such as electroacupuncture vs manual acupunc­
ture vs rehabilitation training, the results were split into pairwise
comparisons by the different interventions. After the data of articles had
been extracted, two researchers evaluate the safety of acupuncture
therapy by scanning all of the paper to collect adverse events if there
were ever reported in the texts.
2.5. Quality assessment
To evaluate included studies’ quality of methodology, two authors
rated the risk of bias independently by Cochrane’s risk of bias tool [24].
There was a total of seven domains, each of which is judged as one of the
following levels: “low risk of bias”, “unclear risk of bias”, or “high risk of
bias”. Any disagreements were resolved by Hu JW. If all seven items
were assessed as “low risk of bias”, the study was assessed as having high
quality. If one or more items were assessed as “high risk of bias” or
“unclear risk of bias”, the study was rated as having low quality.
2.6. Data analysis
Continuous outcomes were evaluated by the mean difference (MD)
W. Fan et al.
Fig. 1. Flow chart of trial selection process. PSSH: Post-stroke spastic hemiplegia.
with the 95% confidence interval (CI). Statistical heterogeneity was
evaluated by I2 statistics. According to the Cochrane handbook, het­
erogeneity more than 50% may represent substantial heterogeneity, and
a p value of 0.10 determined statistical significance [25]. Therefore, if
the p value from the Chi-squared test was greater than 0.10 or the I2
statistic was less than 50%, we adopted a fixed effects model to calculate
the effect size. Otherwise, a random effects model was adopted to pro­
vide more conservative evaluations of the intervention effects. To
explore the possible factors for the statistical heterogeneity, one of the
subgroup analyses was performed on the basis of the interventions: (1)
manual acupuncture plus rehabilitation training versus rehabilitation
training (MA þ RT vs RT); (2) electroacupuncture plus rehabilitation
training versus rehabilitation training (EA þ RT vs RT); (3) manual
acupuncture versus rehabilitation training (MA vs RT); the other of the
subgroup analyses was performed on the basis of treatment duration: (1)
treatment duration more than 1 month ; (2) treatment duaration less
than or equal to 1 month.
All statistical analyses were performed by RevMan 5.3 and Stata
12.1. A two-sided 5% level revealed a statistically significant difference.
3. Results
3.1. Description of the articles
A total of 2452 eligible articles were identified from the 9 different
databases. No additional articles were retrieved from other sources.
According to the title, the author’s names and the time of publication,
665 articles were replicates and were excluded, and 1785 articles were
screened. A total of 1728 studies were excluded based on the titles,
3
Complementary Therapies in Clinical Practice 40 (2020) 101176
abstracts and key words because they did not meet the inclusion criteria.
Fifty-seven records were read carefully in full to ensure qualification.
Nineteen studies were excluded after the full-text evaluation of the ar­
ticles. Finally, 36 studies were included in the qualitative analysis
(Fig. 1).
3.2. Feature list of included literature
The features of the included literature are summarized and listed in
Table 1.
3.2.1. Description of participants
The characteristics of the thirty-six studies, which included 2628
participants (1315 in the experimental group and 1313 in the control
group), are summarized in Table 1. All studies were published between
2010 and 2019 in China. The sample size of both the experimental group
and the control group ranged from 22 to 71.
3.2.2. Description of interventions
Acupuncture and electroacupuncture treatments were adopted in the
included studies. For interventions, six studies [29,30,35,39,57,60]
adopted electroacupuncture combined with rehabilitation training, two
studies [53,58] adopted pure electroacupuncture, fifteen RCTs [
26-28,31,33,34,38,43,45,47,50,52,54,56,59] adopted manual
acupuncture combined with rehabilitation, and 13 trials [32,36,37,
40–42,44,46,48,49,51,55,61] adopted manual acupuncture. All of the
trials adopted rehabilitation training as comparator. The detailed in­
terventions’ features of the included literature are summarized and lis­
ted in Table 2.
W. Fan et al. Complementary Therapies in Clinical Practice 40 (2020) 101176

Table 1
Characteristics of included trials.
Study Sample size (EG/CG) Sex (male/female) Mean age Methods of intervention Comparison Main outcomes Adverse Effect p value
(EG/CG)

01-Li 2019 [26] 33/33 40/26 59.6 � 13.2 MA þ RT RT ①③ / <0.05

59.8 � 12.9
02-Wang 2018 [27] 30/30 35/25 60 � 8 MA þ RT RT ①③ / <0.05
61 � 8
03-Tan 2018 [28] 44/44 46/42 54.78 � 7.69 MA þ RT RT ③ / <0.05
54.93 � 7.82
04-Hu 2017 [29] 30/30 33/27 64.2 � 9.1 EA þ RT RT ①③ / <0.05
65.8 � 8.3
05-Lei 2017 [30] 39/40 50/29 55.1 � 8.7 EA þ RT RT ①②③ / <0.05
54.6 � 8.3
06-Xu 2017 [31] 30/30 31/29 58 � 10 MA þ RT RT ①②③ / <0.05
61 � 10
07-Xu 2017 [32] 30/30 33/29 55 � 5 MA RT ①②③ / >0.05
61 � 10
08-Xu 2016 [33] 36/35 52/19 60 � 10 MA þ RT RT ③ N <0.05
65 � 6
09-Cheng 2016 [34] 60/32 93/87 65.76 � 11.87 MA þ RT RT ③ / <0.05
65.31 � 12.35
10-Huang 2016 [35] 35/71 36/32 60.15 � 11.52 EA þ RT RT ②③ / <0.05
57.40 � 11.09
11-Wang 2016 [36] 33/32 40/25 56.24 � 7.89 MA RT ①③ / <0.05
55.11 � 8.57
12-Chai 2015 [37] 71/71 87/55 63.4 � 6.5 MA RT ①②③ / <0.05
62.7 � 6.4
13-Hao 2015 [38] 30/29 41/19 / MA þ RT RT ①③ N <0.05

14-Xing 2015 [39] 30/30 37/23 60.0 � 8.7 EA þ RT RT ② / <0.05

62.6 � 7.1
15-Li 2015 [40] 30/30 32/28 61.47 � 8.98 MA RT ① / <0.05
65.73 � 7.96
16-Si 2014 [41] 30/30 / / MA RT ① / <0.05

17-Yang 2013 [42] 40/38 38/40 61.42 � 9.35 MA RT ① / <0.05

62.36 � 9.67
18-Yang 2013 [43] 38/38 39/37 64.69 � 8.90 MA þ RT RT ① / <0.05
62.36 � 9.67
19-Yang 2013 [44] 35/33 33/35 62 � 9 MA RT ① / <0.05
63 � 9
20-Yang 2013 [45] 32/33 34/31 64 � 9 MA þ RT RT ① / <0.05
63 � 9
21-Yang 2013 [46] 35/33 33/35 62.30 � 8.59 MA RT ① / <0.05
63.1 � 9.28
22-Yang 2013 [47] 32/33 34/31 64.0 � 8.67 MA þ RT RT ① / <0.05
63.1 � 9.28
23-Yu 2013 [48] 32/32 39/25 64.80 � 7.42 MA RT ①③ / >0.05
62.5 � 8.72
24-Lang 2013 [49] 47/47 56/38 67 � 8 MA RT ③ / >0.05
64 � 9
25-Lang 2013 [50] 47/47 55/39 65 � 9 MA þ RT RT ③ / <0.05
64 � 9
26-Lu 2013 [51] 40/40 37/43 61.30 � 7.59 MA RT ① / <0.05
62.10 � 8.14
27-Lu 2013 [52] 40/40 35/55 61.50 � 7.32 MA þ RT RT ① / <0.05
62.10 � 8.14
28-Gu 2013 [53] 40/40 / / EA RT ①②③ / <0.05

29-Tong 2013 [54] 44/42 47/39 69 � 6 MA þ RT RT ① / <0.05

69 � 6
30-Lang 2011 [55] 36/42 46/32 66.20 � 7.41 MA RT ①③ / >0.05
63.60 � 8.73
31-Lang 2011 [56] 37/42 48/31 66.20 � 7.41 MA RT ①③ / <0.05
63.60 � 8.73
32-Jin 2010 [57] 24/22 43/27 / EA þ RT RT ②③ / <0.05

33-Jin 2010 [58] 24/22 43/27 / EA RT ②③ / <0.05

34-Chen 2010 [59] 40/40 43/37 66.7 � 10.3 MA þ RT RT ①③ / <0.05

67.9 � 9.4
35-Lu 2011 [60] 30/30 43/17 56.70 � 9.14 EA þ RT RT ①③ / <0.05
56.83 � 9.60
36-Sun 2017 [61] 31/30 37/24 63.10 � 8.00 MA RT ①③ 5 <0.05
63.10 � 8.45

MA, Manual Acupuncture; EA, Electroacupuncture; RT, rehabilitation training; EG, Experimental Group; CG, Control Group; ①Fugl-Myer Assessment (FMA)
②Ashworth Scale for Spasticity(ASS) ③Barthel (BI) scale; N, no adverse effect;/, not mentioned.

4
W. Fan et al. Complementary Therapies in Clinical Practice 40 (2020) 101176

Table 2
Details of interventions in included trials.
Study Methods of Acupuncture techniques Acupoint formula Acupuncture skills Dosage Treatment
intervention duration

01-Li MA þ RT Eye acupuncture The area of upper-jiao, lower-jiao, liver, Opposing needling, reinforcing and reducing once a 4 weeks
2019 kidney in eyes’ area, LI 15, LI 4, TE 5, LI by lifting and thrusting, manipulating the day
[26] 11, GB 34, ST 36, GB 39 in uninjured side needle for 3 min, retaining the needle for 30
min.
02-Wang MA þ RT Needling seam of skull Sagittal suture, lambdoidal suture, Mild reinforcing and attenuating, once a 20 days
2018 coronal suture in lesion side manipulating the needle for every 10 min, day
[27] retaining the needle for 30 min.
03-Tan MA þ RT Penetration acupuncture LI 15 through LI 14, LI 11 through HT3, To get a strong sense of needle, electric shock once a 12 weeks
2018 TE 5 through PC 6, LI 4 through SI 3, GB is preferred, reinforcing and reducing by day
[28] 34 through SP 9, GB 39 through SP 6,BL lifting and thrusting, entwisting, quick-slow
60 through KI 3,LR 3 through KI 1 in supplementation and draining method.
hemiplegia side Retaining the needle for 20 min.
04-Hu EA þ RT Electroacupuncture LI 15, SJ 14, inside-SJ 10, jiuneixuan, TE Continuous electricity for 40 min. Once a 8 weeks
2017 antagonistic needling 5, inside-eight-xie, inside-ST 31, lower- day
[29] SP 10, GB 34, jiuneifan
05-Lei EA þ RT Electroacupuncture SI 10, SI11, SJ 10, LI 11, jiuneixuan, LI Mild reinforcing and attenuating, retaining once a 2 weeks
2017 antagonistic needling 10, iliopsoas, ST 31, BL36, BL 37, ST 36, the needle for 30 min. day
[30] ST37, jiuneifan, GB 34
06-Xu MA þ RT Simple acupuncture Acupoints of Du meridian, Huatuo Jiaji Twist and turn, mild reinforcing and / 40 days
2017 points, LI 15, LI 11, TE 5, LI 4, GB 30, ST attenuating, retaining the needle for 30 min.
[31] 32, ST 36, GB 39, GB 40,BL 60
07-Xu MA Simple acupuncture Acupoints of Du meridian, Huatuo Jiaji Twist and turn, mild reinforcing and / 40 days
2017 points, LI 15, LI 11, TE 5, LI 4, GB 30, ST attenuating, retaining the needle for 30 min
[32] 32, ST 36, GB 39, GB 40,BL 60
08-Xu MA þ RT Jin’s three needle Three needle of spasm, three needle of Twist the needle after deqi at the frequency / 4 weeks
2016 tongue, three needle of mouth, three of 180–200 times/min for 2 min, retaining
[33] needle of wrist, three needle of ankle, the needle for 30 min.
three needle of open method, EX-UE9,
EX-LE 10, LR 3, ST 40, ST 36, KI 3
09- MA þ RT Pin therapy Acupoints on the meridian of the large Twist and turn, twist the needle after / 30 days
Cheng intestine meridian of Hand-Yangming, retaining the needle for every 10 min,
2016 bladder meridian of Foot-TaiYang and retaining the needle for 30 min.
[34] the stomach meridian of Foot-Yangming,
Huatuo Jiaji acupoints
10- EA þ RT Scalp acupuncture and Anterior oblique line of vertex-temporal, Reducing method Once a 4 weeks
Huang body acupuncture posterior oblique line of vertex- day
2016 temporal, middle line of vertex, LI 15, SJ
[35] 14, SJ 10, LI 10, TE 5, LI 4, ST 31, SP 10,
GB 34, jiuneifan
11-Wang MA Abdominal needle ST 25, RN 6, RN 12, RN 4, RN 10, ST 26, Twist and turn, retaining the needle for 30 once a 4 weeks
2016 SP 15, ST 24 min. day
[36]
12-Chai MA Qiao channel acupoint and DU 26,piantan acupoint, tuntong Twist and turn, mild reinforcing and 4 weeks
2015 balance acupuncture acupoint, xitong acupoint, huaitong attenuating,twist the needle for every 15
[37] acupoint, jiantong acupoint, KI 6, BL 62, min, retaining the needle for 30 min.
LI 16, LI 15
13-Hao MA þ RT Abdominal needle RN 12,RN 10,RN 6,RN 4,ST 24, ST 26, SP Wait for qi in 3–5mins, induce qi in 3–5mins, 2 weeks
2015 15, up and down rheumatism acupoint twist the needle in every 5 min, retaining the
[38] needle for 30 min.
14-Xing EA þ RT Simple acupuncture LI 15, LI 14, LI 11, LI 10, TE 5, LI 4, SP Mild reinforcing and attenuating, retaining once a 30 days
2015 10, GB 34, ST 40, SP 6, ST 41 the needle for 30 min, day
[39]
15-Li MA Penetration acupuncture LI 15 through HT 1,LI 11 through PC 3, reinforcing and reducing by lifting and Once a 3 weeks
2015 TE 5 through PC 6,SP 9 through GB 34, thrusting,mild reinforcing and attenuating day
[40] SP 6 through GB 39
16-Si MA Balance acupuncture DU 26, piantan acupoint, tuntong Cross acupoint selection, retaining the once a 28 days
2014 acupoint, xitong acupoint, huaitong needle for 30 min, day
[41] acupoint, jiantong acupoint
17-Yang MA Jin’s three needle Three needle of temple, three needle of After deqi, twist the needle at a frequency of once a 14 days
2013 spasm, three needle of open methods, 180–200 times/min, twist the needle in day
[42] three needle of wrist, three needle of every 10 min, retaining the needle for 30
ankle min.
18-Yang MA þ RT Jin’s three needle Three needle of temple, three needle of After deqi, twist the needle at a frequency of once a 14 days
2013 spasm, three needle of open methods, 180–200 times/min, twist the needle in day
[43] three needle of wrist, three needle of every 10 min, retaining the needle for 30
ankle min.
19-Yang MA Jin’s three needle Three needle of temple, three needle of After deqi, twist the needle at a frequency of once a 14 days
2013 spasm, three needle of open methods, 180–200 times/min, twist the needle in day
[44] three needle of wrist, three needle of every 10 min, retaining the needle for 30
ankle min.
20-Yang MA þ RT Jin’s three needle Three needle of temple, three needle of After deqi, twist the needle at a frequency of once a 14 days
2013 spasm, three needle of open methods, 180–200 times/min, twist the needle in day
[45]
(continued on next page)

5
W. Fan et al. Complementary Therapies in Clinical Practice 40 (2020) 101176

Table 2 (continued )
Study Methods of Acupuncture techniques Acupoint formula Acupuncture skills Dosage Treatment
intervention duration

three needle of wrist, three needle of every 10 min, retaining the needle for 30
ankle min.
21-Yang MA Jin’s three needle Three needle of temple, three needle of After deqi, twist the needle at a frequency of once a 14 days
2013 spasm, three needle of open methods, 180–200 times/min, twist the needle in day
[46] three needle of wrist, three needle of every 10 min, retaining the needle for 30
ankle min.
22-Yang MA þ RT Jin’s three needle Three needle of temple, three needle of After deqi, twist the needle at a frequency of once a 14 days
2013 spasm, three needle of open methods, 180–200 times/min, twist the needle in day
[47] three needle of wrist, three needle of every 10 min, retaining the needle for 30
ankle min.
23-Yu MA Acupuncture therapy of RN 4, RN 6, RN 12, RN 24, DU 20, DU 26 mild reinforcing and attenuating, retaining 28 days
2013 adjustment in Chong and the needle for 30 min, manipulating the
[48] Ren meridian needle twice during the treatment
24-Lang MA Jin’s three needle Three needle of spasm, three needle of Twist the needle in every 10 min, retaining once a 4 weeks
2013 tongue, three needle of wrist, three the needle for 30 min. day
[49] needle of open method, three needle of
ankle, EX-UE9, EX-LE 10
25-Lang MA þ RT Jin’s three needle Three needle of spasm, three needle of Twist the needle in every 10 min, retaining once a 4 weeks
2013 tongue, three needle of wrist, three the needle for 30 min. day
[50] needle of open method, three needle of
ankle, EX-UE9, EX-LE 10
26-Lu MA Jin’s three needle Three needle of temple, three needle of Twist the needle to supplement, reinforcing once a 14 days
2013 spasm, three needle of open methods, and attenuating, twist the needle in every 10 day
[51] three needle of wrist, three needle of min, retaining the needle for 30 min.
ankle
27-Lu MA þ RT Jin’s three needle Three needle of temple, three needle of Twist the needle to supplement, reinforcing once a 14 days
2013 spasm, three needle of open methods, and attenuating,twist the needle in every 10 day
[52] three needle of wrist, three needle of min, retaining the needle for 30 min.
ankle
28-Gu EA Simple acupuncture DU 26, Huatuo Jiaji acupoints Twist the needle to reduce, retaining the once a 28 days
2013 needle for 30 min. day
[53]
29-Tong MA þ RT Simple acupuncture LI 15, LI 11, BL 2, SJ 23, LI 20, RN 23, ST Twist the needle to supplement, retaining the once a 4 weeks
2013 4, RN 17, RN 12, SI 10, SI 6, SJ 3, BL 62, needle for 30 min. day
[54] BL 61, BL 59, ST 45, BL 67, GB 44
30-Lang MA Jin’s three needle Three needle of temple, three needle of Mild reinforcing and attenuating, retaining / 28 days
2011 spasm, three needle of open methods, the needle for 30 min.
[55] three needle of wrist, three needle of
ankle, EX-UE9, EX-LE 10
31-Lang MA Jin’s three needle Three needle of temple, three needle of Mild reinforcing and attenuating, retaining / 28 days
2011 spasm, three needle of open methods, the needle for 30 min.
[56] three needle of wrist, three needle of
ankle, EX-UE9, EX-LE 10
32-Jin EA þ RT Electroacupuncture LI 15, LI 11, TE 5, LI 4, SP 9, SP 6, BL 40, To make antagonistic muscles contract, / 4 weeks
2010 antagonistic needling BL 57, ST 41, GB 40 retaining the needle for 30 min
[57]
33-Jin EA Electroacupuncture LI 15, LI 11, TE 5, LI 4, SP 9, SP 6, BL 40, To make antagonistic muscles contract, / 4 weeks
2010 antagonistic needling BL 57, ST 41, GB 40 retaining the needle for 30 min
[58]
34-Chen MA þ RT Acupuncture therapy of the Jianqian acupoint,EX-23,LI 4, SP 10,SP Method of reduce, Retaining the needle for once a 2 months
2010 staged and whole body 9,SP 6,BL 57,PC 2, LU 5, PC 7, ST 32, ST 30 min, day
[59] 34, SP 1
35-Lu EA þ RT Acupuncture on tendon Anterior oblique line of vertex-temporal, After deqi, twist the needle at a frequency of twice a 4 weeks
2011 junction of meridian tendon junction 200 times/min, twist the needle in every 10 day
[60] min, retaining the needle for 30 min.
36-Sun MA “Jin gou diao yu” LU 3, LU 5, PC 6, PC 7, ST 34, SP 9, SP 6, After deqi, keep twisting the needle to make once a 28 days
2017 acupuncture KI 6 muscle become tight, then retaining the day
[61] needle for 30 min.

MA, Manual Acupuncture; EA, Electroacupuncture; RT, rehabilitation training; EG, Experimental Group; CG, Control Group.

3.2.3. Description of outcomes
In all of the studies included, twenty-seven trials used the FMA [26,
27,29–32,36–38,40–48,51–56,59–61] to assess limb function, and six
trials used the ASS [30–32,35,39,53] to assess spasticity. To evaluate the
improvement in quality of daily life, twenty-four studies adopted the BI
[26–38,48–50,53,55–61].
3.3. Risk of bias
The risk of bias in the literature was evaluated and is illustrated in
Figs. 2 and 3. All of the trials were RCT, and 23 [26,27,29,30,35–39,42,
43,49–52,55,56,60,61] trials described appropriates sequence
generation, one [54] trials adopted the order of admission as the method
of random, and the remaining studies did not clarify the specific random
methods. Ten [35,46,47,49–52,55,56,61] studies conducted allocation
concealment. Only one [36] study conducted the blinding of partici­
pants and personnel, and three [57,58,61] studies conducted the
blinding of outcome assessment. Only one [38] study did not illustrate
the incomplete outcome data. In our study, all of the study protocols
couldn’t be found. Finally, among the 36 studies, all studies were
considered to have high risk after the evaluation.

6
W. Fan et al. Complementary Therapies in Clinical Practice 40 (2020) 101176

Fig. 3. Graph of the risk of bias: percentages across all included studies.

3.4. Outcome measures

3.4.1. FMA
Twenty-seven studies [26,27,29–32,36–38,40–48,51–56,59–61]
used the FMA scores to assess the effectiveness of acupuncture. A
meta-analysis of the FMA scores illustrated that acupuncture therapy
improved the FMA scores more than rehabilitation training did. (MD:
8.43, 95% CI, 6.57 to 10.28, p < 0.00001). There was heterogeneity
among the included studies (I2 ¼ 75%, p < 0.00001) (Fig. 4).

3.4.1.1. Subgroup analysis of interventions

3.4.1.1.1. MA þ RT vs RT. Ten trials [26,27,31,38,43,45,47,52,54,
56,59] compared MA þ RT with RT and assessed the effectiveness of
acupuncture by FMA scores. A meta-analysis demonstrated that MA þ
RT improved more than RT did on the FMA scores (MD: 10.84, 95% CI,
9.29 to 13.29, p < 0.00001). There was heterogeneity among the trials
(I2 ¼ 24%, p ¼ 0.22) (Fig. 5), lower than before, and the heterogeneity
was not statistically significant.
3.4.1.1.2. EA þ RT vs RT. Three trials [29,30,60] compared EA þ
RT with RT and assessed the effectiveness of acupuncture by FMA
scores. A meta-analysis demonstrated that EA þ RT did not have a larger
effect than RT did on the FMA scores (MD: 9.44, 95% CI, 1.00 to 17.88, p
¼ 0.03). There was heterogeneity among the trials (I2 ¼ 81%, p ¼ 0.006)
(Fig. 5).
3.4.1.1.3. MA vs RT. Twelve trials [32,36,37,40–42,44,46,48,51,
55,61] compared MA with RT and assessed the effectiveness of
acupuncture by FMA scores. A meta-analysis demonstrated that MA had
a larger effect than RT did on the FMA scores (MD: 5.48, 95% CI, 2.07 to
8.89, p ¼ 0.002). There was heterogeneity among the trials (I2 ¼ 74%, p
< 0.0001) (Fig. 5), lower than before.
3.4.1.1.4. EA vs RT. Only one trials [53] compared EA with RT and
assessed the effectiveness of acupuncture by FMA scores. The data
demonstrated that EA had a larger effect than RT did on the FMA scores
(MD: 11.35, 95% CI, 5.03 to 17.67, p ¼ 0.0004) (Fig. 5).

3.4.1.2. Subgroup analysis of treatment duration

Fig. 2. Risk of bias in the included studies, as assessed using the Cochrane
Collaboration’s risk of bias tool. þ, high risk of bias; ?, unclear risk of bias; -,
low risk of bias.
3.4.1.2.1. Treatment duration more than 1 month. Four trials [29–32,
59] used acupuncture therapy for more than 1 month, compared
acupuncture therapy with RT and assessed the effectiveness of
acupuncture by FMA scores. A meta-analysis demonstrated that
acupuncture improved more than RT did on the FMA scores (MD: 9.24,
95% CI, 0.42 to 18.06, p ¼ 0.04). There was heterogeneity among the
trials (I2 ¼ 93%, p < 0.00001) (Fig. 6), higher than before.
3.4.1.2.2. Treatment duration less than or equal to 1 month. Thirty-
two trials [26,27,30,36–38,40–48,51–56,60,61] used acupuncture
therapy for less than or equal to 1 month, compared acupuncture ther­
apy with RT and assessed the effectiveness of acupuncture by FMA
scores. A meta-analysis demonstrated that acupuncture improved more
than RT did on the FMA scores (MD: 8.32, 95% CI, 6.56 to 10.09, p <
0.00001). There was heterogeneity among the trials (I2 ¼ 61%, p <
0.0001) (Fig. 6),lower than before.

7
W. Fan et al.
Fig. 4. Forest plot of acupuncture therapy versus rehabilitation training on FMA.
3.4.2. ASS
Six trials [30–32,35,39,53] used the ASS scores to assess the effec­
tiveness of acupuncture. A meta-analysis demonstrated that acupunc­
ture therapy had an obviously improvement than rehabilitation training
on the ASS scores (MD: 0.46, 95% CI, 0.65 to 0.27, p < 0.00001).
There was heterogeneity among the included studies (I2 ¼ 67%, p ¼
0.009) (Fig. 7).
3.4.3. BI
Twenty-four trials [26–38,48–50,53,55–61] used the BI scores to
assess the effectiveness of acupuncture. A meta-analysis demonstrated
that acupuncture had an obviously improvement than non-acupuncture
on the BI scores. (MD: 8.32, 95% CI, 5.30 to 11.35, p < 0.00001). There
was heterogeneity among the included studies (I2 ¼ 88%, p < 0.00001)
(Fig. 8).
3.5. Publication bias
The publication bias of all trials was calculated by Stata12.1 and
displayed as a funnel plot and Egger’s test for the FMA scores. The funnel
plot indicates asymmetry, but the Egger’s test result showed p ¼ 0.138
> 0.05, which suggests that the publication bias was not statistically
significant in our study (Figs. 9–10).
3.6. Adverse events
After scanning, among the 36 studies, two [33,38] of the studies
reported no adverse events, one [61] reported that there were two pa­
tients fainted during the acupuncture treatment and three patients stuck
needle but could be released after rest. Others did not mention adverse
events. Therefore, the acupuncture therapy seems to be safe.
8
Complementary Therapies in Clinical Practice 40 (2020) 101176
4. Discussion
4.1. Summary of the results
This study was conducted using the AHA/ASA guidelines [62] to
evaluate the effectiveness and safety of acupuncture in the treatment of
PSSH. From the inception of the nine Chinese and English databases to
July 2019, 36 RCTs were reviewed and included in a meta-analysis. The
results of the comparison of the FMA and ASS scores showed that
manual acupuncture and electroacupuncture had benefits in improving
myodynamia and spasms in the treatment of PSSH. The meta-analysis
revealed that the acupuncture group had a better quality of life. All
trials were ranked as low quality after the evaluation. Two of the 36
trials reported no adverse effect, one trial reported five slightly adverse
effects, while others trials did not report about adverse effects.
4.2. Comparison with and description of similar studies
According to the AHA/ASA guidelines published in 2016 [62], which
aimed to provide the best clinical practice guidelines for patients who
are recovering from stroke, doctors are increasingly concerned about the
recovery from myodynamia, the degree of the spasms and the quality of
life of the patients.
After search, researchers found that there were two similar study
about acupuncture therapy for PSSH which had been published in 2014
and 2015. In contrast to the meta-analysis in 2014 [22], which searched
literature before 2009, compared acupuncture therapy with
non-acupuncture therapy, used ASS scale and the H-reflex/M-response
ratio as outcomes, expressed that the effectiveness of acupuncture did
not have a beneficial effect on PSSH, our study expanded the scope of
search, choose rehabilitation training as comparator, used FMA scale,
ASS scale and BI scale as outcomes, and demonstrated a supportive
result and paid more attention to patients’ recovery from myodynamia
and quality of life. Comparing with the meta-analysis in 2015 [23],
which searched the literatures before 2013 including Medline, Embase,
W. Fan et al.
Fig. 5. Forest plot of subgroup of interventions of acupuncture therapy versus rehabilitation training on FMA.
Cochrane library, CNKI and Korean databases, selected placebo or
conventional treatments as comparator, used ASS scale as primary
outcome, we expanded the scope of search including Medline, Embase,
Cochrane library, Web of Science, Scopus, CNKI, VIP, Wanfang, CBM
databases, renewed the literatures till 2019, used FMA scale as primary
outcome and the ASS scale and BI scale as secondary outcomes. In the
past, researchers have always used the effective rate [63,64] and other
scales to assess the efficacy of acupuncture, while we now use the FMA
scale to evaluate the myodynamia, ASS scale to evaluate the degree of
spasm, and BI scale to evaluate the quality of living.
4.3. Limitations of the results
Participants with PSSH cured by manual acupuncture or electro­
acupuncture showed distinct improvements in the FMA, ASS and BI
scores compared with those only treated with rehabilitation training. As
the literature included still had some limitations, we could not allege
that this study provided ample evidence of this observation.
9
Complementary Therapies in Clinical Practice 40 (2020) 101176
First, a large number of trials had shortcomings in the methodolo­
gies. All 36 studies included were evaluated as having low quality.
However, this situation should be further detailed analysis. In most of
the articles, the authors did not illustrate the blind method, allocation
and other bias in the procession of study very clearly. Therefore, the
researchers could not judge whether the authors of the paper were not
implemented these steps or implemented but not written in the papers.
The non-standard written led the researchers couldn’t give specific
judgement of information.
Second, there was obvious heterogeneity in the FMA scores, which
was the primary outcome measure. The heterogeneity became lower in
the subgroup analysis by interventions, but became higher in one of the
subgroups by treatment duration, which indicated that this obvious
heterogeneity may be triggered by different interventions more, and we
could not clarify that whether the heterogeneity was triggered by
treatment duration. Also, it is not clear that whether the severity of the
disease, the use of personalized medicine, and the variability in pop­
ulations influenced final outcomes. In the meantime, though researchers
W. Fan et al. Complementary Therapies in Clinical Practice 40 (2020) 101176

Fig. 6. Forest plot of subgroup of treatment duration of acupuncture therapy versus rehabilitation training on FMA.

Fig. 7. Forest plot of acupuncture therapy versus rehabilitation training on ASS.

searched some English databases, the trials we finally included were all
in Chinese language, and the research scope of these paper were only in
China. Therefore, the outcome of this study could only interpret that
acupuncture therapy make better effect in PSSH when comparing with
rehabilitation therapy in China. These may all led to heterogeneity.
Third, the funnel graph of publication bias seemed asymmetry, the
egger’s test result showed p ¼ 0.138, which demonstrated that there was
no obviously publication bias. Because of the limited amount of trials,
the result of our study should be treated carefully.
In consideration of these limitations, the results in our study should
be interpreted prudently. Among the 36 studies included, two studies
reported no adverse events during acupuncture therapy, one study re­
ported five patients suffered slightly adverse events. It seemed that
acupuncture therapy did not cause any severe adverse events, but we
could not find sufficient evidence to support this claim.
4.4. Suggestions for future studies
In the future, studies must provide accurate details of the acupunc­
ture techniques, then standardized acupuncture could be applied in
clinical practice. In this study, researchers adopted RT as the only
comparator instead of placebo or sham acupuncture, which may influ­
ence the credible in our study and reduce the quality of this research. In
the further study, researchers could adopt placebo or sham acupuncture
as comparison to elevate the quality of meta-analysis and systematic
review. In addition, researchers should identify different symptoms,

10
W. Fan et al. Complementary Therapies in Clinical Practice 40 (2020) 101176

Fig. 8. Forest plot of acupuncture versus rehabilitation training on BI.

Fig. 10. Egger’s test plot of publication bias.

Fig. 9. Funnel plot of publication bias.

therapy, acupuncture could be effective and safe for patients with PSSH.
treat them with the appropriate therapy, and ensure the value of
Nevertheless, there were shortcomings in the methodologies of the
acupuncture, whether it is used as a separate therapy or an adjuvant
previous studies, and meticulously designed studies of larger scales are
therapy.
needed in the future to draw better conclusions.
In this study, we only confirmed the short-term (less than 6 months)
effectiveness of acupuncture treatment, but we did not identify the long-
Funding
term (more than 6 months) effectiveness. The long-term effectiveness of
acupuncture therapy for the treatment of PSSH can be ascertained only if
This work was supported by the following programs:
more clinically meaningful information is obtained. In future clinical
practice, doctors could adopt acupuncture as complementary therapy in
1 Youth Program of the National Natural Science foundation of China
patient of poststroke spastic hemiplegia. Researchers can also explore
(No. 81904297).
whether acupuncture can be one kind of main therapy of poststroke by
2 General Program of the National Natural Science foundation of
design more scientific forms of randomized controlled trials.
China (No. 81774406).
3 Opening Operation of Key Laboratory of Acupuncture and Moxi­
5. Conclusion
bustion of Traditional Chinese Medicine in Guangdong. (No.
2017B030314143).
In conclusion, researchers found that as a kind of complemental

11
W. Fan et al. Complementary Therapies in Clinical Practice 40 (2020) 101176

4 Innovation Team Program of Guangdong Provincial Department of [23] S.M. Lim, J. Yoo, E. Lee, et al., Acupuncture for spasticity after stroke: a systematic
review and meta-analysis of randomized controlled trials, J. Evid. Based Compl.
Education (No. 2017KCXTD006).
Alternative Med. 2015 (2015) 1–12.
5 Scientific Research and Innovation Team Program of Guangzhou [24] J.P.T. Higgins, J. Savovi�c, M.J. Page, et al., Chapter 8: assessing risk of bias in a
University of Chinese Medicine (No. 2016KYTD03) randomized trial, in: J.P.T. Higgins, J. Thomas, J. Chandler, M. Cumpston, T. Li, M.
6 Elite Youth Education Program’ of Guangzhou University of Chinese J. Page, V.A. Welch (Eds.), Cochrane Handbook for Systematic Reviews of
Interventions Version 6.0, 2019 (updated July 2019). Cochrane, www.training.co
Medicine (No. QNYC20190106) chrane.org/handbook.
[25] J.J. Deeks, J.P.T. Higgins, D.G. Altman, Chapter 10: analysing data and
Declaration of competing interest undertaking meta-analyses, in: J.P.T. Higgins, J. Thomas, J. Chandler,
M. Cumpston, T. Li, M.J. Page, V.A. Welch (Eds.), Cochrane Handbook for
Systematic Reviews of Interventions Version 6.0, 2019 (updated July 2019).
All authors declare that they have no conflict of interests. Cochrane, www.training.cochrane.org/handbook.
[26] Z. Li, F.Y. Jiao, J. Che, et al., Clinical study of the effect of eye acupuncture
combined with opposing needling method on spastic hemiplegia after cerebral
Appendix A. Supplementary data apoplexy, J. Liaoning Univ. Tradit. Chin. Med 21 (4) (2019) 107–110 (Published in
China.).
Supplementary data to this article can be found online at https://doi. [27] G.S. Wang, C.S. Li, H.L. Qi, et al., Clinical study on acupuncture at cranial sutures
plus rehabilitation training for post-stroke spastic palsy, Shanghai J.Acup. Moxib.
org/10.1016/j.ctcp.2020.101176. 37 (1) (2018) 20–23 (Published in China.).
[28] S.H. Tan, Clinical observation on acupuncture combining bobath in the treatment
References of spastic hemiplegia after stroke, Chin.J. Integr. Med. Cerebrovascuiar Dis. 16 (20)
(2018) 3044–3047 (Published in China.).
[29] D.Y. Hu, M. Zhao, X.M. Li, Clinical study of electroacupuncture combined with
[1] J.L. Murray Christopher, T. Vos, R. Lozano, et al., Disability-adjusted life years
rehabilitation training for apoplectic spasticity hemiplegia, J. Clin. Acup. Moxib. 7
(DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic
(2017) 26–29 (Published in China.).
analysis for the Global Burden of Disease Study 2010, Lancet 380 (2012)
[30] B. Lei, F.X. Huang, J.Q. Zhang, et al., Therapy guided by Brunnstrom theory for
2197–2223.
spastic hemiplegia, chin, Manip. Rehabil. Med. 7 (2017) 29–32 (Published in
[2] Chinese early stroke rehabilitation guide, Chin. J. Neurol. (2017), 50:06.
China.).
[3] C. Moura Rde, M.M. Fukujima, A.S. Aguiar, et al., Predictive factors for spasticity
[31] L. Xu, M. Wang, F. Li, Acupuncture combined with rehabilitation training for the
among ischemic stroke patients, Arq Neuropsiquiatr 67 (2009) 1029–1036.
limb spasm after stroke, Chin. Acupunct. Moxibustion 37 (2017) 696–700.
[4] P.P. Urban, T. Wolf, M. Uebele, et al., Occurrence and clinical predictors of
[32] L. Xu, M. Wang, F. Li, Acupuncture combined with rehabilitation training for the
spasticity after ischemic stroke, Stroke 41 (2010) 2016–2020.
limb spasm after stroke, Chin. Acupunct. Moxibustion 37 (2017) 696–700.
[5] J. Wissel, L.D. Schelosky, J. Scott, et al., Early development of spasticity following
[33] S.F. Xu, J.H. Gu, Clinical observation of Jin’s three-needle acupuncture plus
stroke: a prospective, observational trial, J. Neurol. 257 (2010) 1067–1072.
rehabilitation for post-stroke spastic hemiplegia, Shanghai J. Acup. Moxib. 35 (2)
[6] E. Lundstr€om, A. Smits, A. Ter� ent, et al., Time-course and determinants of
(2016) 153–156 (Published in China.).
spasticity during the first six months following first-ever stroke, J. Rehabil. Med. 42
[34] L.S. Cheng, Z.Q. Li, C. Pu, To Observe the Clinical Effect of Pin Therapy Combined
(2010) 296–301.
with Exercise Therapy on Spastic Hemiplegic Stroke Patients, Health Way, 2016
[7] Q.V. Doan, A. Brashear, P.J. Gillard, et al., Relationship between disability and
(006)(Published in China.).
health-related quality of life and caregiver burden in patients with upper limb
[35] R.L. Huang, Q. Xia, Z.J. Zhu, et al., Clinical effect of acupuncture combined with
poststroke spasticity, Pharm. Manag. PM R 4 (2012) 4–10.
rehabilitation training in treatment of hemiplegia spasticity after stroke, J. Anhui
[8] American Speech-Language Hearing Association, Speech-language pathologists
Tradit. Chin. Med. Coll. 35 (4) (2016) 59–62 (Published in China.).
providing clinical services via telepractice (position statement). http://www.asha.
[36] C.Y. Wang, B.D. Xiang, C.X. Han, Observation on the clinical effect of abdominal
org/policy, 2005.
needle in the treatment of muscle spasm after stroke, Chin.Comm.Doc. 32 (22)
[9] P. Shackley, L. Shaw, C. Price, et al., Cost-effectiveness of treating upper limb
(2016) 125–126.
spasticity due to stroke with botulinum toxin type A: results from the Botulinum
[37] Chai, Qiaomai point and balanced acupuncture treatment of 71 cases of spastic
Toxin for the Upper Limb after Stroke (BoTULS) trial, Toxins 4 (2012) 1415–1426.
hemiplegia after stroke, China’s Naturopathy 23 (10) (2015) 18–19 (Published in
[10] L.D. de Jong, A. Nieuwboer, G. Aufdemkampe, Contracture preventive positioning
China.).
of the hemiplegic arm in subacute stroke patients: a pilot ran- domized controlled
[38] S.F. Hao, F. Li, X.T. Lv, Abdominal acupuncture combined with rehabilitation
trial (published correction appears in Clin Rehabil 2010;24:767, Clin. Rehabil. 20
training to treat spastic paralysis in the recovery period of cerebral infarction,
(2006) 656–667.
China’s Naturopathy 23 (5) (2015) 21–23 (Published in China.).
[11] S.K. Sabut, C. Sikdar, R. Kumar, et al., Functional electrical stimulation of
[39] X.M. Xing, B. Yang, F. Li, et al., Acupuncture and moxibustion combined with
dorsiflexor muscle: effects on dorsiflexor strength, plantarflexor spasticity, and
rehabilitation treatment of 30 cases of spastic hemiplegia after ischemic stroke,
motor recovery in stroke patients, NeuroRehabilitation 29 (2011) 393–400.
Liaoning J. Tradit. Chin. Med. 42 (3) (2015) 595–597 (Published in China.).
[12] J.M. Meythaler, W. Clayton, L.K. Davis, et al., Orally delivered baclofen to control
[40] J.X. Li, Clinical observation on treatment of spastic hemiplegia after stroke by
spastic hypertonia in acquired brain injury, J. Head Trauma Rehabil. 19 (2004)
penetrating, China’s Naturopathy 9 (2015) 17–18 (Published in China.).
101–108.
[41] S.L. Si, Clinical observation on treating 60 cases of spastic hemiplegia following
[13] J.M. Meythaler, S. Guin-Renfroe, A. Johnson, et al., Prospective assessment of
stroke by balance acupuncture therapy, Clin. J. Chin. Med. 6 (10) (2014), 37-38þ
tizanidine for spasticity due to acquired brain injury, Arch. Phys. Med. Rehabil. 82
41(Published in China.).
(2001) 1155–1163.
[42] H.T. Yang, L.X. Zhuang, Y. Liu, Clinical studies of Jin’s three-needle therapy on
[14] D.A. Gelber, D.C. Good, A. Dromerick, et al., Open- label dose-titration safety and
spastic hemiplegia after stroke and mutual influence between rehabilitation
efficacy study of tizanidine hydrochloride in the treatment of spasticity associated
training, Liaoning J. Ttadit. Chin. Med 40 (11) (2013) 2349–2351 (Published in
with chronic stroke, Stroke 32 (2001) 1841–1846.
China.).
[15] L. Zhang, J.Q. Fang, Effect of acupuncture and moxibustion on limb motor function
[43] H.T. Yang, L.X. Zhuang, Y. Liu, Clinical studies of Jin’s three-needle therapy on
and activities of daily living in elderly patients with spastic hemiplegia after stroke,
spastic hemiplegia after stroke and mutual influence between rehabilitation
Chin. J. Gerontology 17 (2017) 4222–4223 (Published in China.).
training, Liaoning J. Ttadit. Chin. Med 40 (11) (2013) 2349–2351 (Published in
[16] B.X. Zhang, J.S. Zhang, S.H. Ma, Clinical observation on treatment of apoplectic
China.).
hemiplegia with acupuncture combined with neural stem block, J. New Chin. Med.
[44] H.T. Yang, L.X. Zhuang, Y. Liu, Efficacy observation on post-stroke spastic
(2011), 03:97-99 (Published in China.).
hemiplegia treated with temporal three-needle and spastic three-needle therapy,
[17] X.M. Xing, B. Yang, F. Li, et al., Acupuncture and moxibustion combined with
Chin. Acupunct. Moxibustion 33 (10) (2013) 889–892 (Published in China.).
rehabilitation treatment of 30 case of spastic hemiplegia after ischemic stroke,
[45] H.T. Yang, L.X. Zhuang, Y. Liu, Efficacy observation on post-stroke spastic
Liaoning J. Tradit. Chin. Med. (2015), 03:595-597 (Published in China.).
hemiplegia treated with temporal three-needle and spastic three-needle therapy,
[18] Y.F. Arthur, W.M. David, B. Bonnie, et al., Acupuncture’s role in solving the opioid
Chin. Acupunct. Moxibustion 33 (10) (2013) 889–892 (Published in China.).
epidemic: evidence, cost-effectiveness, and care availability for acupuncture as a
[46] H.T. Yang, L.X. Zhuang, Y. Liu, Treatment of 32 cases with spastic hemiplegia after
primary, non-pharmacologic method for pain relief and management—white paper
stroke by using three-needle and three-needle combined rehabilitation training,
2017, J. Integrative Med 6 (2017) 411–425.
J. Anhui Tradit. Chin. Med. Coll. 32 (4) (2013) 48–51 (Published in China.).
[19] T.J. Chien, C.Y. Liu, C.J. Fang, The effect of acupuncture in breast cancer-related
[47] H.T. Yang, L.X. Zhuang, Y. Liu, Treatment of 32 cases with spastic hemiplegia after
lymphoedema (BCRL): a systematic review and meta-analysis, Integr. Canc. Ther.
stroke by using three-needle and three-needle combined rehabilitation training,
18 (2019).
J. Anhui Tradit. Chin. Med. Coll. 32 (4) (2013) 48–51 (Published in China.).
[20] H. Li, H. Liu, C. Liu, et al., Effect of ‘‘Deqi’’ during the study of needling ‘‘Wang’s
[48] F.F. Yu, X.H. Zheng, K.X. Zeng, Clinical observation on 32 cases of spastic
Jiaji’’ acupoints treating spasticity after stroke, Evid. base Compl. Alternative Med.
hemiplegia after ischemic stroke treated by acupuncture, Yunnan J. Tradit. Chin.
(2014) (Published in China.).
Med. and Mater. Med. (7) (2013) 50–52 (Published in China.).
[21] H.Y. Sun, Study on the treatment of stroke hemiplegia with therapy of skin needles,
[49] J.Y. Lang, L.X. Zhuang, J. He, Randomized controlled study on Jin’s three needle
Beijing Univ. Chin. Med. (2003) (Published in China.).
therapy on spastic hemiplesia after ischemic stroke, Shanghai J. Acup. and Moxib.
[22] S. Park, S. Yi, J.A. Lee, et al., Acupuncture for the treatment of spasticity after
32 (6) (2013) 440–443 (Published in China.).
stroke: a meta-analysis of randomized controlled trials, J. Alternative Compl. Med.
20 (9) (2014) 672–682.

12
W. Fan et al.
[50] J.Y. Lang, L.X. Zhuang, J. He, Randomized controlled study on Jin’s three needle
therapy on spastic hemiplesia after ischemic stroke, Shanghai J. Acup. and Moxib.
32 (6) (2013) 440–443 (Published in China.).
[51] Y.Q. Lu, H.T. Yang, L.X. Zhuang, et al., A clinical observation on Jin’s three-needle
therapy combined with rehabilitation for 40 cases of post-stroke spastic
hemiplegia, J. Tradit. Chin. Med. 54 (12) (2013) 1034–1037 (Published in China.).
[52] Y.Q. Lu, H.T. Yang, L.X. Zhuang, et al., A clinical observation on Jin’s three-needle
therapy combined with rehabilitation for 40 cases of post-stroke spastic
hemiplegia, J. Tradit. Chin. Med. 54 (12) (2013) 1034–1037 (Published in China.).
[53] W. Gu, C.Y. Li, X.X. Jin, et al., Clinical observation on acupuncture treatment of
spastic hemiplegia after stroke, J. Sichuan Tradit. Chin. Med. 5 (2013) 132–133
(Published in China.).
[54] S. Tong, L. Su, H.B. Lv, et al., Therapeutic effect of acupuncture at key points
combined with rehabilitation on hemiplegia after cerebral infarction, Chin.
Acupunct. Moxibustion 5 (2013) 399–402 (Published in China.).
[55] J.Y. Lang, L.X. Zhuang, C. Jia, et al., Clinical observation on the treatment of
ischemic stroke and hemiplegia with Jin’s triple needles combined with
rehabilitation therapy, J. Guangzhou Univ. Tradit. Chin. Med. 4 (2011) 369–373
(Published in China.).
[56] J.Y. Lang, L.X. Zhuang, C. Jia, et al., Therapeutic effect of Jin’s three-needle
therapy combined with rehabilitation therapy for spastic hemiplegia after ischemic
stroke, Guangzhou Univ. Tradit. Chin. Med. 28 (4) (2011) 369–373 (Published in
China.).
[57] R.J. Jin, T.M. Zhu, Q. Wang, Clinical observation on spastic paralysis caused by
cerebral infarction treated by electric stimulation on acupuncture of antagonistic
13
Complementary Therapies in Clinical Practice 40 (2020) 101176
muscles and facilitation techniques, J.Chengdu Univ. Tradit. Chin. Med. 33 (3)
(2010) 9–12 (Published in China.).
[58] R.J. Jin, T.M. Zhu, Q. Wang, Clinical observation on spastic paralysis caused by
cerebral infarction treated by electric stimulation on acupuncture of antagonistic
muscles and facilitation techniques, J. Chengdu Univ. Tradit. Chin. Med. 33 (3)
(2010) 9–12 (Published in China.).
[59] X. Chen, Y.F. Chen, M. Mao, et al., Acupuncture therapy combined with
contemporary rehabilitation techniques for treatment of hemiplegia and spasticity
caused by apoplexy, J. Chengdu Univ. Tradit. Chin. Med. 1 (2010) 27–29
(Published in China.).
[60] R.J. Sun, A Clinical Study on the Treatment of “Jin Gou Diao Yu” Acupuncture for
Spastic Paralysis after Ischemic Stroke, D. Gansu university of traditional Chinese
medicine, 2017 (Published in China).
[61] F.J. Lu, The Combination of Acupuncture Bobath Therapy Tendon Junction of
Spastic Paralysis after Stroke Clinical Efficacy, D. Heilongjiang university of
traditional Chinese medicine, 2011 (Published in China).
[62] J.W. Carolee, S. Joel, A. Ross, et al., Guidelines for adult stroke rehabilitation and
recovery: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association, Stroke 47 (2016) 98–169.
[63] L. Yu, P.X. Wu, A meta-analysis of clinical effect of warm acupuncture on spastic
hemiplegia patients after stroke, Chin. Nurs. Res. 13 (2019) 2247–2252 (Published
in China.).
[64] Y. Li, Acupuncture and moxibustion for spastic paralysis after stroke: a systematic
review and meta-analysis of randomized controlled trials, Heilongjiang Univ. Chin.
Med. (2017) (Published in China.).