Original Research Article

Clinical Rehabilitation
1–12
Effects of transcutaneous electrical © The Author(s) 2022

acupoint stimulation on upper-limb Article reuse guidelines:

sagepub.com/journals-permissions
impairment after stroke: A DOI: 10.1177/02692155221138916
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randomized, controlled, single-
blind trial

Hewei Wang1 , Yuzhi Xiang2, Chuankai Wang3,

Yingying Wang4,5, Shugeng Chen1 , Li Ding1,
Qiang Liu1, Xiaowen Wang2, Kun Zhao2, Jie Jia1 ,
and Yao Chen2

Abstract
Objective: To evaluate the effects of transcutaneous electrical acupoint stimulation (TEAS) on upper limb
motor recovery during post-stroke rehabilitation.
Design: Single-blind, randomized controlled trial.
Setting: Four inpatient rehabilitation facilities.
Subjects: A total of 204 stroke patients with unilateral upper limb motor impairment were randomly 1:1
allocated to TEAS or sham TEAS group. Baseline demographic and clinical characteristics were comparable
between the two groups.
Interventions: Both groups received conventional physical and occupational therapies. TEAS and sham
TEAS therapy were administered to two acupoints (LI10 and TE5) with a pulse duration of 300 µs at 2
Hz on the affected forearm for 30 times over 6 weeks.
Outcome measures: The upper-extremity Fugl-Meyer score (primary outcome), manual muscle testing,
modified Ashworth scale, Lindmark hand function score, and Barthel index were evaluated by blinded
assessors at baseline, 2, 4, 6, 10, and 18 weeks.
Results: The number of patients who completed the treatment was 99 and 97 in the TEAS and the sham
group. No significant between-group difference was found in the Upper-Extremity Fugl-Meyer score,

1
Department of Rehabilitation, Huashan Hospital, Fudan Corresponding authors:
University, Shanghai, China Yao Chen, Department of Rehabilitation, Shanghai Third
2
Department of Rehabilitation, Shanghai Third Rehabilitation rehabilitation hospital, No. 100 Jiaocheng Road, Jing’an District,
Hospital, Shanghai, China Shanghai 200436, China.
3
Department of Rehabilitation Medicine, South China Hospital, Email: 1995jiangpyn@163.com
Health Science Center, Shenzhen University, Shenzhen, China
4
Department of Epidemiology, School of Public Health, Fudan Jie Jia, Department of Rehabilitation Medicine, Huashan
University, Shanghai, China Hospital, Fudan University, No. 12 Middle Wulumuqi Road,
5
Department of Epidemiology, Key Laboratory of Public Health Shanghai 200040, China.
Safety of Ministry of Education, Shanghai, China Email: shannonjj@126.com
2 Clinical Rehabilitation 0(0)

Modified Ashworth Scale, Lindmark hand function score, and Barthel Index after intervention and during
follow-up. However, the TEAS group exhibited 0.29 (95% CI 0.02 to 0.55) greater improvements in Manual
Muscle Testing of wrist extension than the sham group (p = 0.037) at 18 weeks.
Conclusions: Administration of TEAS therapy to hemiplegic forearm could not improve the upper
extremity motor recovery. However, TEAS on the forearm might provide potential benefits for strength
improvement of the wrist

Keywords
stroke, upper limb, electrical stimulation, acupuncture points, randomized controlled trial

Received June 9, 2021; accepted October 25, 2022

Introduction therapeutic effects.13,14 In contrast, TEAS therapy

Globally, stroke is one of the most common causes
of death and long-term adult disability,1 with nearly
2.5 million annual new cases in China.2 Persistent
disability after stroke is associated with serious
upper extremity and hand impairment, as more
than half of stroke survivors are not able to regain
proper arm function even 6 months after stroke.3
Many studies have aimed at developing treatment
methods for upper limb and hand rehabilitation after
stroke and some treatments have demonstrated clear
effectiveness with ample evidence such as
constrained-induced movement therapy and robotic
therapy.4 However, constrained-induced movement
therapy is not applicable in patients with moderate
to severe impairment.5 Robotic therapy can be a
feasible alternative intervention for patients with
severe arm paresis, but robotic devices are usually
expensive.6 The efficacies of other treatment techni-
ques like mirror therapy, mental practice, and virtual
reality have not been proven with high-quality evi-
dence.4,7 Therefore, novel rehabilitation approaches
should be developed to improve upper limb motor
outcomes after stroke.
Transcutaneous electrical acupoint stimulation
(TEAS), a combination of transcutaneous electrical
nerve stimulation technique and Chinese traditional
acupuncture theory, is a potentially efficient, safe,
and low-cost therapeutic option for stroke rehabilita-
tion.8–12 Transcutaneous electrical nerve stimulation
uses low-voltage electrical currents to provoke
nerves or muscles over the skin, generating various
is usually with lower frequency (2–4 Hz), higher
intensity (to tolerance threshold), and longer pulse
width (100–400 ms).15,16 During TEAS treatment,
electrical stimulation is administered to selected acu-
points, eliciting an “acupuncture point sensation.”17
Currently, reported clinical evaluations of TEAS
therapy in stroke rehabilitation so far have mostly
found at least some evidence to suggest therapeutic
benefits in walking performance9,10 and overall
function.8 Currently, two studies focused on the
effectiveness of TEAS on the affected upper
extremity motor performance in stroke patients,
and both studies did not find that TEAS was
better than the placebo-TEAS when combined
with active training.11,12 In addition to promoting
motor recovery, TEAS also demonstrated certain
effects on relieving muscle spasticity following
brain injury.18 We also found a review article
showing the positive effects of TEAS on upper
limb functional recovery in stroke patients.19
However, all included articles were published in
Chinese, so the positive finding in this review
article suffers from possible language bias. Also,
most included RCTs did not accurately describe
the stages of stroke, and the duration and treatment
protocols of included trials varied significantly.19
Given these conflicting results about the clinical
effects of TEAS in motor recovery in patients with
brain damage, the exact therapeutic effects of
TEAS on post-stroke upper limb motor recovery
remain unclear. Therefore, this single-blind, rando-
mized controlled trial aimed to investigate whether
Wang et al.
a combination of TEAS therapy and conventional
rehabilitation methods could produce additional
benefits to stroke patients with arm and hand
motor impairments. We hypothesized that TEAS
might be effective in improving motor function,
spasticity, muscle strength, or activities of daily
living during stroke recovery.
Methods
This study was a randomized, single-blind, con-
trolled trial conducted in four inpatient rehabilitation
facilities (two rehabilitation hospitals and two com-
munity hospitals) in Shanghai, China, from January
1st, 2016 to December 31st, 2018. This study was a
subproject belonging to a large project named
‘Effects of traditional rehabilitation medicine on
stroke survivors with hand dysfunction’ funded by
the National Science & Technology Pillar Program
during the Twelfth Five-year Plan Period. The
ethical approval was obtained from the Review
Board of Ethics Committee of Huashan Hospital
and registered at the Chinese Clinical Trial Registry
(ChiCTR-IOR-15006102). This study fulfilled the
principles of the Declaration of Helsinki, and it was
conducted and reported according to the recommen-
dations of CONSORT guidelines.
At each research center, potential participants
with unilateral upper limb impairment after stroke
were consecutively screened by the physicians
(XW, KZ) for eligibility. Study participants were
all required to sign a written informed consent
before enrolment.
Due to recruitment challenges, the original inclu-
sion criteria were modified to include participants
with a wider age range (increased from 40–80 to
18–85) and onset range (increased from 14 days–
12 months to 10 days–2 months). The recruitment
did not begin until the revised inclusion criteria
were approved by the Review Board of Ethics
Committee of Shanghai Third Rehabilitation
Hospital. The final inclusion criteria were: (1)
Medically stable; (2) First-ever cerebrovascular acci-
dent; (3) MRI or CT confirmed ischemic or hemor-
rhagic stroke; (4) Stroke onset between 10 days and
12 months; (5) 18 to 85 years of age; (6) Brunnstrom
3
stages I–V in the affected hand; (7) Intact skin on the
hemiparetic forearm.
The exclusion criteria were: (1) Patients with
significant cognitive impairment (MoCA ≤ 24);
(2) Severe shoulder or hand pain; (3) Excessive
sensory disturbance, aphasia, unilateral neglect, or
apraxia; (4) A history of serious neurological or
psychiatric diseases; (5) A history of alcohol or
drug dependence; (6) Implanted stimulators (such
as cardiac pacemaker); (7) Pregnancy.
All eligible participants who signed written
informed consent were randomized 1:1 to receive
TEAS or sham TEAS therapy, using a center-
stratified randomization procedure by computer-
generated random numbers with SPSS software
(version 25.0, Chicago, IL, USA). Randomization
was performed by a physician (YC) who was not
involved in the recruitment, data collection, and
treatment of the study. Randomization codes were
concealed in sequentially numbered opaque envel-
opes to ensure allocation concealment. The thera-
pists who delivered the conventional rehabilitation
therapy and the included patients were masked to
allocation.
Patients in both groups were subjected to con-
ventional rehabilitation which lasted for 60 min
per day, 5 days a week for 6 weeks. The conven-
tional rehabilitation included daily physical and
occupational therapies that were widely accepted,
individual-specific, and routinely practiced by
experienced therapists in each center. The interven-
tion, directed at both upper and lower extremities,
was aimed at improving skills in basic daily activ-
ities. It combined the techniques of muscle stretch-
ing, active/passive mobilization, neuromuscular
facilitation, and task-specific training. All therapists
received standardized training for consistency
before intervention and were not involved in the
group assignment and outcome measurements.
TEAS therapy was administered to two acupoints
(LI10 and TE5) on the affected forearm through a
pair of surface electrodes (40 × 26 mm) connected
to the electrical stimulator (MyoNet-COW, NCC
Medical Co Ltd., Shanghai, China) (Figure 1). The
acupoints selected in this study originated from pre-
vious reports on TEAS treatment for motor function
recovery in individuals with central nervous system
4 Clinical Rehabilitation 0(0)
Figure 1. Forearm acupoints used in this study.
injuries.11,20 TEAS treatment had a pulse width of
300 µs and a frequency of 2 Hz in the constant
mode at the maximum tolerable intensity.21 The 2
Hz modality was used because evidence indicated
that low-frequency TEAS could highly activate the
motor cortex when compared to high frequencies,
such as 100 or 120 Hz, in ischemic stroke patients.22
The sham group was administered with an identical
treatment, except that the electrical circuit of the
stimulator had been internally disconnected. That
is, the lights and screen of the stimulator were on,
but there was no real electrical stimulation.
Patients in the sham group were informed that they
might or might not feel mild tingling sensations
during treatment. TEAS or sham TEAS therapy
lasted for 30 min per session, 5 days a week for 6
weeks. The stimulation lasted for 30 min per
session because a previous study found that 30 or
60 min of neuromuscular electrical stimulation led
to similar upper limb motor function improvements
in stroke patients.23 TEAS and sham TEAS therapy
were performed by two experienced physical thera-
pists who had received standardized training on the
use of TEAS equipment before the study
intervention.
The study participants were evaluated by two
experienced assessors (HW, YX) that were
blinded to the treatment assignment at baseline,
after every 2 weeks during the treatment period,
and at 4 and 12 weeks after completion of treat-
ment. Before the assessment, a standardized assess-
ment protocol that included the patient’s position,
verbal instruction, and demonstration to the
patient was developed. Assessors were obliged to
follow this standardized protocol and they were
trained by a senior therapist to ensure that they
could perform the assessment in a proper way.
The primary outcome measure was the
Upper-Extremity Fugl-Meyer score. Secondary
outcome measurements included muscle strength
assessment, muscle spasticity, hand function, and
activities of daily living. The following variables
were evaluated:
• The primary outcome measure was the
change in the Upper-Extremity Fugl-Meyer
Wang et al.
score from baseline to 6 and 18 weeks. It is a
valid and reliable assessment of upper limb
impairment both within and between raters
in stroke survivors,24 which consists of 33
items scored on a 3-point (0–2 points)
ordinal scale for a maximum possible score
of 66.25 Post hoc outcome measurements
of the proximal (0–42 points) and distal
(0–24 points) subscales were also performed
to examine the adjacent and remote effects of
TEAS.
• Muscle strength of wrist flexion and exten-
sion was measured by Manual Muscle
Testing on a scale from 0 (no muscle activ-
ity) to 5 (normal muscle power). Although
few studies have directly investigated the
rater reliability of Manual Muscle Testing
in stroke survivors, it has shown excellent
inter-rater reliability in trained examiners to
assess the grade of muscle weakness in a
wide range of pathologies.26
• Wrist flexors spasticity was assessed by
measuring resistance to passive wrist exten-
sion with the Modified Ashworth Scale
scored using a 6-point (0, 1, 1 + , 2, 3, 4)
scale. This scale has very good intra-rater
reliability in the assessment of upper limb
spasticity in patients with hemiparesis.27
• The grasp function of the hand was assessed
by a subscale selected from a reliable and
valid tool named the Lindmark Motor
Score.28 Patients were required to hold a
tennis ball with their fingers abducted and
flexed around the ball. It reported using a
4-point scale: 0 = cannot grasp; 1 = can
grasp but unable to hold against slight resist-
ance; 2 = can hold the ball for 5 s but release
it upon moderate resistance or the grasp
becomes uncoordinated or changed; 3 =
can hold the ball against strong resistance
for 5 s and release it in a normal way.
• Barthel Index was used to assess the
patient’s independence in basic activities of
daily living. The original 10-item scale was
used for a maximum possible score of 100.
Evidence indicates that the Barthel Index
has excellent inter-rater reliability to be an
5
appropriate outcome measure for stroke
trials and practice.29
The sample size was calculated prior to the start of
the study using a previously reported method,30
based on the assumption that the mean difference
between the two groups would be 5 points in the
Upper-Extremity Fugl-Meyer score with a
common standard deviation of 12 points in both
groups. Furthermore, we assumed that the study
would have a dropout of 10%, and the final target
sample size was 204 participants with 102 assigned
to each group when setting a power of 80% and a
significance level of 0.05.
Data was input by the EpiData software (version
3.1, the EpiData Association, JM Lauritsen) after
double-checking by trained researchers (SC, LD).
All analyses were performed by an independent stat-
istician (YW) using the SPSS software. A modified
intention-to-treat analysis was adopted: we analyzed
all assigned subjects for whom outcome data at 6
weeks were available.30 For missing data, we
moved the last data forward or, if no former value
was available, the next recorded value was used.
The student’s t-test and chi-square test were per-
formed to ensure homogeneity at baseline. The nor-
mality of data distribution was evaluated using the
Kolmogorov–Smirnov statistic. Generalized esti-
mating equations (GEEs) were used to estimate the
effects of treatment between the TEAS group and
the sham group on all outcomes. Results are pre-
sented as mean and 95% confidence intervals (CIs)
and the level of statistical significance was defined
as α = 0.05 of two-sided probability.
Results
Details of participant recruitment, allocation, and
follow-up are displayed in the flow diagram
(Figure 2). Out of the 980 stroke survivors who
were screened for eligibility, a total of 217 met
our study criteria, with 204 of them agreeing to
participate in this study. There were no differences
in baseline demographic, stroke-related, and upper
limb motor characteristics between the two
groups. The average time from stroke onset at
enrollment was 95.7 days (range, 11 to 349),
6 Clinical Rehabilitation 0(0)

Figure 2. CONSORT flow diagram for enrollment and outcomes.

with 72, 92, and 40 patients at acute (35.3%), sub-
acute (45.1%), and chronic (19.6%) stages. The
baseline means upper-extremity Fugl-Meyer
score was 15.2 (range, 0 to 62), with 154
(75.5%) patients being severely impaired (0 to
22 points)31 (Table 1).
Primary outcome: At the end of treatment,
the mean change in the upper-extremity
Fugl-Meyer score from baseline was higher in
the TEAS group, however, the between-group
differences were not significant (difference:
1.62 points, 95% CI: −1.16 to 4.40, p =
0.254). Post hoc analysis also did not reveal
any significance in the distal and proximal sub-
scales. At 18 weeks, the between-group differ-
ences in the Upper-Extremity Fugl-Meyer
score and its subscales were still not significant
(Table 2).
Wang et al. 7

Table 1. Baseline characteristics of the patients.

TEAS therapy (n = 102) Sham TEAS therapy (n = 102) P value

Sex
Male 77 (75.5%) 72 (70.6%) 0.430
Female 25 (24.5%) 30 (29.4%)
Age (years) 60.6 ± 12.5 61.9 ± 10.5 0.439
Stroke type
Infarction 68 (66.7%) 71 (69.6%) 0.652
Hemorrhage 34 (33.3%) 31 (30.4%)
Stroke side
Right 60 (58.8%) 56 (54.9%) 0.572
Left 42 (41.2%) 46 (45.1%)
Stroke location
Cortical 13 (12.7%) 13 (12.7%) 0.919
Subcortical 55 (53.9%) 52 (51.0%)
Cerebellar 0 (0.0%) 1 (1.0%)
Brainstem 3 (2.9%) 5 (4.9%)
Multiple 31 (30.4%) 31 (30.4%)
Time since stroke (days) 95.6 ± 97.6 95.7 ± 90.8 0.995
Stage at inclusion
Acute (0–30d) 35 (34.3%) 37 (36.3%) 0.925
Subacute (31–180d) 46 (45.1%) 46 (45.1%)
Chronic (>180d) 21 (20.6%) 19 (18.6%)
Severity at inclusion (FMA-UE)
Mild (48–66) 3 (2.9%) 9 (8.8%) 0.178
Moderate (23–47) 21 (20.6%) 17 (16.7%)
Severe (0–22) 78 (76.5%) 76 (74.5%)
FMA-UE (total) 14.8 ± 12.4 15.6 ± 16.2 0.701
FMA-UE (proximal) 11.5 ± 9.2 11.8 ± 10.8 0.850
FMA-UE (distal) 3.3 ± 5.3 3.8 ± 6.1 0.525
Brunnstrom stage
Arm 2.0 ± 1.1 2.0 ± 1.1 0.950
Hand 1.8 ± 1.1 1.8 ± 1.1 0.854
NIHSS 8.4 ± 4.7 8.6 ± 5.0 0.762
MMT (wrist flexion) 1.0 ± 1.2 1.1 ± 1.4 0.786
MMT (wrist extension) 0.9 ± 1.1 1.0 ± 1.4 0.738
MAS (wrist flexion) 0.8 ± 0.9 0.7 ± 0.8 0.097
Hand function (Lindmark) 0.5 ± 0.8 0.4 ± 0.8 0.486
BI 42.3 ± 17.0 41.3 ± 21.1 0.726
Values are numbers or mean ± standard deviation.
FMA-UE: upper-extremity Fugl-Meyer assessment; NIHSS: National Institute of Health stroke scale; MMT: manual muscle testing; MAS:
modified Ashworth scale; BI: Barthel index.

Secondary outcomes: At 6 weeks, both groups
exhibited significant improvements in Manual
Muscle Testing scores (wrist flexion/extension),
Lindmark hand function scores, and Barthel Index
scores when compared to the baseline. However,
there were no significant between-group differences
for all these outcomes. At 18 weeks, patients in the
TEAS group exhibited higher MMT scores in wrist
extension when compared to the sham group (dif-
ference: 0.29 points, 95% CI: 0.02 to 0.55, p =
0.037). There were no significant between-group
differences in other outcomes. Regarding wrist
8 Clinical Rehabilitation 0(0)

flexor spasticity, no significant changes from base-

P value

0.295
0.324
0.349
0.104
0.037
0.205
0.557
0.680
line were found in both groups at 6 and 18 weeks

0.03 (−0.12 to 0.19) 0.18 (0.02 to 0.33) −0.14 (−0.36 to 0.08)

0.69 (0.54 to 0.84) −0.06 (−0.28 to 0.15)
(Table 2).

17.33 (14.94 to 19.73) 15.52 (13.10 to 17.93) 1.82 (−1.59 to 5.22)

10.65 (9.31 to 11.98) 9.69 (8.34 to 11.04) 0.96 (−0.94 to 2.85)
5.82 (4.54 to 7.11) 0.86 (−0.94 to 2.67)
1.04 (0.83 to 1.25) 0.24 (−0.05 to 0.53)

23.54 (20.85 to 26.22) 22.73 (20.02 to 25.44) 0.08 (−3.01 to 4.62)

0.29 (0.02 to 0.55)
Findings from the longitudinal GEEs analyses

Mean difference
of the primary outcome within each group

Values are mean (95% CI). FMA-UE: upper-extremity Fugl-Meyer assessment; MMT: manual muscle testing; MAS: modified Ashworth scale; BI: Barthel index.
showed that both groups demonstrated significant

(95% CI)
improvements along the 18 weeks in total (both p
< 0.001), proximal (both p < 0.001), and distal
(both p < 0.001) score of the upper-extremity

0.84 (0.64 to 1.03)

Sham TEAS therapy
Fugl-Meyer assessment. This result means that 6
weeks of conventional rehabilitation combined

Changes from baseline to 18 weeks

with TEAS/sham TAES therapy can significantly

(n = 97)
improve the upper limb motor function in stroke
patients. The changes in primary and secondary
outcomes during the 18-week study period com-

6.69 (5.42 to 7.96)

1.28 (1.08 to 1.49)
1.12 (0.93 to 1.31)

0.63 (0.47 to 0.78)

pared to the baseline are presented in the
Supplementary Material. Overall, the longitudinal

TEAS therapy
GEEs analyses did not show any significant

P value (n = 99)
between-group difference.
The TEAS interventions in this study were not
associated with any serious adverse events or side

0.254
0.535
0.131
0.198
0.317
0.363
0.836
0.327
effects. The treatment compliance was excellent,
with a total of 196 (96.1%) participants completing

0.06 (−0.06 to 0.18) 0.14 (0.02 to 0.27) −0.07 (−0.25 to 0.09)

Hand function (Lindmark) 0.47 (0.34 to 0.61) 0.49 (0.36 to 0.63) −0.02 (−0.21 to 0.17)
12.58 (10.62 to 14.53) 10.96 (8.98 to 12.93) 1.62 (−1.16 to 4.40)
7.78 (6.62 to 8.93) 7.26 (6.09 to 8.42) 0.52 (−1.12 to 2.16)
4.80 (3.80 to 5.80) 3.70 (2.69 to 4.71) 1.10 (−0.33 to 2.52)
0.80 (0.64 to 0.96) 0.65 (0.49 to 0.81) 0.15 (−0.08 to 0.37)
0.68 (0.53 to 0.83) 0.57 (0.41 to 0.72) 0.11 (−0.11 to 0.32)

1.53 (−1.53 to 4.59)

their assigned treatment interventions, while 189
Sham TEAS therapy Mean difference

(92.6%) participants received all assessments

during follow-up. Reasons for withdrawal are pro-
(95% CI)

vided in the flow diagram (Figure 2).

Discussion 15.76 (13.60 to 17.91) 14.23 (12.05 to

The major finding of this multicenter, randomized,

16.40)
Changes from baseline to 6 weeks

single-blind, controlled study was that 6 weeks of

(n = 97)
Table 2. Changes in primary and secondary outcomes.

TEAS on the forearm acupoints did not demon-

strate better effects than sham TEAS on upper
limb motor recovery when combined with conven-
tional rehabilitation. We also found that TEAS
TEAS therapy

might contribute to the increase of wrist extension

strength at 12 weeks after treatment, although the
(n = 99)

absolute between-group difference was small and

of weak significance.
Acupuncture therapy is an important supple-
MMT (wrist extension)

ment to conventional stroke rehabilitation in

MMT (wrist flexion)
FMA-UE (proximal)

MAS (wrist flexion)

China.32 However, acupuncture therapy is asso-

FMA-UE (distal)
FMA-UE (total)

ciated with limitations, such as possible risks of

broken needles and infection, heavy dependence
on the therapist’s skill, as well as lack of standard-
ization and reproducibility.32 Transcutaneous
BI
Wang et al.
electrical nerve stimulation has been proved to
improve hand-related function in patients with
spinal cord injury33 and stroke.34,35 Prolonged
periods of peripheral sensory stimulation contri-
butes to increasing the excitability of the cortico-
motor excitability.36 As a combination of transcuta-
neous electrical nerve stimulation and acupuncture,
the TEAS is non-invasive and safe,9,20 and it is
equipped with built-in therapeutic parameters that
make it standardized in clinical practice.37 To the
best of our knowledge, our study represents the
largest clinical trial of TEAS on upper limb recov-
ery in stroke patients.
Primary outcome measurements revealed that 6
weeks of TEAS intervention brought a mean
improvement of more than 10 points in the upper-
extremity Fugl-Meyer scores in both groups.
However, the longitudinal analyses showed that
the between-group differences were not statistically
significant. Subgroup analysis of proximal and
distal scores of the upper-extremity Fugl-Meyer
assessment also did not reveal any significant
between-group difference. This negative finding
was consistent with two previous TEAS studies
with similar design.12 Alwhaibi et al.12 compared
the therapeutic effects of TEAS (applied to LI11
and LI4) and sham TEAS on upper limb motor
recovery in chronic stroke patients. The results
indicated that adding TEAS to task-specific training
did not further improve the upper-extremity
Fugl-Meyer score and Box and Block Test
Interestingly, the activity of the motor area (C3)
in the TEAS group increased significantly com-
pared with the sham group, suggesting that the
degree of cortical remodeling was not enough to
cause significant changes in motor recovery. In
another study conducted by Christina et al., 73
stroke patients were randomized to TEAS
(applied to LI4, LI10, LI11, and LI15),
placebo-TEAS, and control group.11 The results
showed that all between-group differences in
Action Research Arm Test and hand strength
were not significant except that the TEAS group
demonstrated greater improvements in hand grip
and pinch strength than the control group. In sum,
based on our findings and previous evidence, we
suggest that adding TEAS to conventional
9
rehabilitation may not bring additional improve-
ments to the upper extremity and hand function.
It is also possible that the functional enhancements
derived from the TEAS treatment protocol were too
small to show any significant effect. However, our
result should not be generalized to all stroke popu-
lations since most participants (75%) had severe
dysfunction. In future studies, stroke patients with
mild and moderate upper limb motor impairments
should be recruited and studied respectively.
In this study, the only significant between-group
difference was noted in Manual Muscle Testing of
wrist extension at 18 weeks. This result suggested
that TEAS might be beneficial to muscle weakness,
with the effects being confined to muscles adjacent
to the acupoints that are stimulated. This finding is
consistent with the results reported by other TEAS
studies.9–11 Yan et al.9 found that 3 weeks of daily
TEAS treatment at the acute phase to 4 acupoints
(St36, Lv3, GB34, and Bl60) of the hemiplegic
lower leg significantly increased dorsiflexor
strength. A case study of a chronic stroke patient
also showed that a 4-week home program consist-
ing of TEAS therapy and task-related training
could effectively improve dorsiflexor strength,
gait velocity, and walking edurance.10 There are
several possible mechanisms. First, the LI10 and
TE5 acupoints are adjacent to extensor carpi radia-
lis and finger extensors, respectively. Six weeks of
low-frequency electrical stimulation might partially
reverse or slow down the atrophy process of these
two muscles.38–40 Second, previous studies
reported that prolonged peripheral electrical stimu-
lation leads to reinforced sensory inputs to the
sensory cortical representation, which may facili-
tate motor outputs of the muscles innervated by
these sensory-motor areas.22,41 However, whether
acupoint stimulation of the LI10 and TE5 during
TEAS therapy can improve muscle strength in
stroke survivors through a mechanism different
from transcutaneous electrical nerve stimulation
remains to be further studied.
In this study, there were no statistical
between-group differences in other outcomes.
Although previous TEAS studies reported some
positive results in relieving spasticity in patients
with brain damage,9,10,18 they all applied 100 Hz
10
rather than 2 Hz electrical stimulation. Direct evi-
dence is from a randomized controlled trial in
brain injury patients which showed that 4 weeks
of TEAS at 100 Hz to four acupoints (L14,
LU10, ST36, and BL57) could significantly
relieve wrist spasticity while 2 Hz and sham
TEAS therapy did not.18 In addition, the TEAS
group did not show any superiority in the
Lindmark hand function test and Barthel Index.
It is probably attributed to the floor effects of
these two scales since 75% of participants were
with severe impairments. Moreover, the relatively
wide standard deviations might be another reason
for these negative results.
The strengths of this study included the high
compliance rates, extended follow-up period,
and the absence of adverse events. However, this
study is also associated with several limitations.
Although the sample size was based on statistical
calculation, the relatively loose inclusion criteria
caused large standard deviations in all outcomes.
In addition, this study demonstrated the ceiling
effect for some outcomes. Furthermore, the treat-
ment dose, defined as the combination of different
parameters including treatment frequency, inten-
sity, and duration, should also be investigated.23
Lastly, according to the theory of acupoint com-
patibility, when two or more acupoints are
selected, the synergy between the acupoints is
strengthened.42 After we compared all the posi-
tive and negative studies of TEAS on stroke
rehabilitation, we found that the compatibility
of four acupoints demonstrated greater effects
than two acupoints.8–12 Thus, future studies
should evaluate the optimum compatibility of
acupoints.32
In conclusion, adding 6 weeks of TEAS therapy
(applied to LI10 and TE5) to conventional rehabili-
tation could not improve the upper extremity motor
recovery in stroke patients. However, our study
found positive effects of TEAS on the strength of
wrist extension at 12 weeks after treatment comple-
tion. Future studies should investigate the effects of
different treatment doses and acupoints compatibil-
ities in patients with mild and moderate impair-
ments, respectively. More sensitive assessments
such as Wolf Motor Function Test or Action
Clinical Rehabilitation 0(0)
Research Arm Test should also be included in the
future.
Clinical messages
• Adding 6 weeks of TEAS therapy to two
acupoints (LI10 and TE5) on the affected
forearm did not bring additional benefits
to upper extremity motor recovery as mea-
sured by the upper-extremity Fugl-Meyer
score in stroke patients.
• TEAS therapy might contribute to the
improvement of arm muscle strength with
the effects being confined to muscles adja-
cent to the acupoints that are stimulated.
• Future studies should investigate the influ-
ence of the treatment dose and acupoints
compatibility on TEAS therapy in stroke
patients with mild and moderate impair-
ments, respectively.
Acknowledgments
The authors thank all patients and therapists who partici-
pated in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
This trial was financially supported in part by the General
Research Project of Shanghai Municipal Health and
Family Planning Commission (Grant Nos. 202040034
and 201540197); in part by the Medical research
project of Shanghai Jing’an District Health
Commission and District Science and Technology
Commission (Grant No. 2020MS17); in part by the
Key Subjects Construction Program of the Health
System in Jing’an District (No. 2021PY04); in part by
the National Key R&D Program of China (Grant No.
2018YFC2002301); in part by the China National
Nature Science Young Foundation (Grant No.
82102665); and in part by Shanghai Sailing Program
(No. 21YF1404600). The authors have no financial con-
flicts of interest.
Wang et al.
ORCID iDs
Hewei Wang https://orcid.org/0000-0001-7632-0607
Shugeng Chen https://orcid.org/0000-0003-1886-9233
Jie Jia https://orcid.org/0000-0002-4516-4629
Supplemental Material
Supplemental material for this article is available online.
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