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Critical Appraisal

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Critical Appraisal

INTRODUCTION

A clinical disease known as a stroke may occur either when there is a disruption in the

oxygen flow to the brain or when a sudden bleeding occurs in the brain. Ischemic stroke,

hemorrhagic (TIA) stroke, and transient ischemic attack are the three distinct forms of stroke

that may occur. Strokes may occur in people of any age, although the risk is highest for

children less than one-year-old and adults. Compared to women, males have a higher chance of

stroke at a younger age, and this risk rises with increasing age in adults (Anand & Klein 2021).

Conditions such as high blood pressure, diabetes, high cholesterol, atrial fibrillation, and

smoking behaviors are seen in the adult group with the most significant risk. This cohort also

has the highest mortality rate.

Patients who have had a stroke want pain relief and other relief from the discomfort

caused by their condition, and therapeutic procedures such as acupuncture may provide this

relief. Pain management based on traditional Chinese medicine may be accomplished via

acupuncture (MacPherson & Charlesworth 2020). It includes penetrating the patient’s skin

using fine needles at specific locations on the patient’s body. Patients who have had a stroke

are given this treatment in the hopes that it would enhance their balancing function, increase

their muscular strength, and decrease their spasticity. Patients with diseases brought on by a

stroke, such as a paralysis, depression, and difficulties swallowing and speaking, may benefit

from acupuncture treatment, which assists them in recovering their independence. It is possible

for people who have had a stroke to make a full recovery in less time if the treatment is

appropriately done.
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PICOT Question: In adult patients with stroke (Population), how effective is acupuncture

(Intervention) compared to regular medication (Comparison) in recovering after post

treatment pain (Outcome) during the recovery time (Time)?

Background of the studies

Globally, stroke is one of the leading causes of death and disability. Current treatments for

stroke are ineffective. In China, acupuncture is often utilized to aid the recovery of stroke

patients. Few well-designed randomized controlled studies have been conducted to assess the

efficacy of acupuncture in acute stroke rehabilitation. All 328 patients will be identified as

having acute cerebral apoplexy. It aims to randomly assign patients to either an “intervention”

or a “control” group (acupuncture with conventional Western treatment for 2 weeks, followed

by 22 weeks of secondary preventative care) (standard Western care plus secondary prevention

care for two weeks). Significant success indicators are the Barthel Index and the Stroke-

Specific Quality of Life. In recent decades, China’s healthcare system has seen significant

transformations due to the country’s rapid economic growth. Despite these advancements,

stroke continues to be the leading cause of death and disability in China, but the disease is now

killing fewer people. Stroke is a global disease. However, the great majority of stroke deaths

and disability-adjusted life years lost (about 85% and 87%, respectively) occur in low- and

middle-income countries. In China, there are 89.6-314 cases of stroke per 100,000 men and

76.7-212.2 points per 100,000 women. In urban areas, 127.96 persons per 100,000 perish from

a stroke, but only 115.2 per 100,000 die in rural areas.

Poor management of vascular risk factors and a lack of access to acute and primary care are

commonly blamed for the high mortality and disability rates after stroke. In low- and middle-
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income countries, secondary prevention, another critical potential treatment for stroke, is

almost nonexistent. Despite the availability of effective medications, treating a stroke remains

challenging. In situations of hemorrhagic or ischemic strokes, current stroke therapies focus on

avoiding more bleeding or restoring blood flow. These therapies do not improve stroke

sufferers’ long-term recovery or quality of life. Due to the risk of bleeding, thrombolytic

treatment may only be provided within three hours after a stroke.

In China, stroke symptoms were treated with acupuncture over 3000 years ago. Numerous

recent trials have shown its effectiveness in treating stroke. The effect size was underestimated

due to methodological errors in the clinical trials, such as preliminary statistical analysis,

failure to detect changes in baseline stroke severity, and inappropriate assessment time.

Consequently, acupuncture may be more beneficial than previously anticipated for enhancing

the stroke process after a minor stroke. The research aims to determine if acupuncture can

improve stroke patients’ quality of life and long-term rehabilitation. The NIH Stroke Scale and

the Modified Rankin Scale are two secondary outcome indicators. All assessments will be

repeated at the beginning of the research and 4, 12, and 24 weeks afterward. This investigation

will enhance comprehensive stroke therapy protocols.

HOW THE ARTICLES SUPPORT THE STUDY

The first section, which summarizes the current state of the clinical ailment known as stroke, is

in many ways related to the PICOT problem. More information on acupuncture’s possibly

dangerous effects is provided below. This paper outlines the educational prerequisites for

working in high-crime healthcare areas. Quantitative: Relies on information that can be

converted into a numerical figure to provide insight into the questioned quantity. Extrapolating
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results from a large sample to the whole population is a standard method in qualitative research.

To convey information about the amount being addressed, it uses numerical symbols.

As a consequence, there are now significantly more documented instances of stroke. Several

modern solutions are being developed to enhance emergency treatment, prevention, and

rehabilitation(Liu et al., 2019). In Eastern medicine, acupuncture is often used to speed up

stroke recovery. In a meta-analysis of randomized clinical trials, inadequate evidence was

found to support the use of acupuncture for stroke-related functional rehabilitation. In contrast,

acupuncture was shown to have no significant benefits in a recent randomized controlled trial

for post-stroke repair. These results have contributed to the ongoing dispute despite hundreds of

years of data from traditional Chinese medicine supporting the use of acupuncture for stroke

survivors.

The occupational therapist’s ability to choose and manage acupoints determines whether

acupuncture treatment is successful or not. The occupational therapists who participated in this

experiment all had a great deal of acupuncture expertise and had been actively treating stroke

patients for at least ten years before the study began. The study’s acupoints were selected

because they are a component of a complex, 60-year-old stroke rehabilitation program. To

maintain uniformity, each occupational therapist will get intensive training in acupoint

selection and standardized procedures (Waelveerakup et al., 2019). The requirements of this

STRICTA have all been satisfied (Standards for Reporting Interventions in Controlled Trials of

Acupuncture).

The severity of the illness determines how well acupuncture treats stroke. Very severe strokes,

particularly those that cause extensive brain damage, may not respond to therapy [20,21]. The

most effective treatment for less powerful strokes may be acupuncture. A moderately severe
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acute stroke without substantial deformities (NIHSS score between 4 and 21; Glasgow coma

score more than or equal to 7; modified Rankin Scale [mRS] score or = 1) is required for

patients to be included in this research.

After a stroke, regaining lost skills may be a drawn-out process that takes weeks or months—an

instant reaction to acupuncture could occur. Because of the timing of the studies’ evaluations,

previous research on the efficacy of acupuncture yielded erratic outcomes (in most cases, 2–3

weeks after stroke). Following treatment, the patient should have evaluations at least four

weeks every three to six months. When planning our study, we considered the average recovery

time for stroke patients. We will take measures before and after acupuncture treatments at

weeks 0, 4, 12, and 24 (Su et al.,2020).. Patients’ self-reported quality of life will be the

primary outcome measure in this research, and it will be assessed at baseline, weeks 4, 12, and

24, as well as 24 weeks following the end of therapy. Measures like the NIHSS and Mrs are

used to determine the degree of neurological impairment, disability, and dependency on ADLs.

Few acupuncturists have studied stroke patients’ quality of life, including factors like reliance

on daily living activities, eating, dressing, and bowel and bladder continence, despite the notion

that acupuncture significantly impacts motor function rehabilitation. The BI and SS-QOL

questionnaires will be used to evaluate people’s well-being.

METHODS OF STUDIES

This is a randomized controlled trial with many sites. The researchers will compare the efficacy

of acupuncture combined with Western medicine treatments for stroke to that of standard

Western medicine therapy when administered alone during the acute phase, defined as the first

twenty-four weeks following a stroke. The primary outcome measures will be the Barthel Index

(BI) and the Stroke-Specific Quality of Life (SS-QOL), while the secondary outcome measures
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will be the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale

(mRS). The Epidemiological Research Center at Beijing University’s Third Affiliated Hospital

will undertake the statistical analysis.

An analysis of variance will be performed after confirming the normality of the quantitative

data distribution. In addition to the standard deviation, we give the mean score of the data in

numerical form. For the study of non-parametric data, the Wilcoxon test with repeated

measurements will be used. Once the dust has cleared, the findings of a census are often

conveyed using percentages or frequency counts. If the outcome variables are two-way, two-

by-two contingency tables, chi-square tests or Fisher exact probability tests will be performed.

If the data is organized in a one-directional, two-by-four grid, a ridit analysis will be performed.

SPSS version 13.0 will be used for the statistical analysis (SPSS, Chicago, IL, USA). All

statistical tests are performed on the premise that the data has two plausible explanations, and

the p-value threshold for statistical significance is set at 0.05 or below.

RESULTS

Summary of key findings

 A familiarity with the current level of knowledge on the incidence of strokes across the

globe.

 • Here, we report a revised meta-analysis of acupuncture’s effect size for conditions

related to chronic pain based on data from individual patients.

 • A caretaker who is learning about the needs of stroke patients

 • An increasing number of documented stroke occurrences. Multiple initiatives aim to

enhance emergency care, prevention, and rehabilitation.

 If you are experiencing constant discomfort, acupuncture might be a lifesaver.

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 Patients who have had a stroke need special attention.

 Evidence supports the usefulness and safety of acupuncture therapy.

 • Acupuncture may help people who have had an ischemic stroke by influencing several

processes essential to the central nervous system.

 •

 A review of the evidence for and against the use of acupuncture in rehabilitating stroke

victims and their loved ones.

 There is some evidence that acupuncture may mitigate the unfavorable effects of

addiction. After recovering from a stroke, patients may have global and localized brain

function abnormalities. On the other hand, there seem to be no obvious negative

implications.

 Our findings suggest that acupuncture’s ability to modulate many central nervous

system-based processes may lessen the likelihood of an ischemic stroke.

 Acupuncture may have beneficial and harmful results for patients, stroke survivors, and

those who have had a stroke..

ETHICAL CONSIDERATION

The following healthcare ethical principles have been considered

Principles of voluntariness, informed consent, and community agreement

All of the advantages and disadvantages of participating in research must be communicated to

participants. All participants were told that they might withdraw their permission for continued

study involvement at any moment. When conducting research on a population to treat them, the

norms of voluntariness and informed consent should be applied to each individual participant
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and the population as a whole. If a person lacks the mental ability to offer informed consent, a

guardian who is legally competent of acting on their behalf should do so.

Principles of non-exploitation

All possible psychological and physical hazards must be adequately addressed to the

participants. Human subjects studies should have a mechanism in place to repay people who are

damaged due to the study. This might involve insurance or another technique. Participants’

names and data will be kept as private as possible from the general public (except when

required for legal reasons). This is done to ensure that no one who assisted with the research is

put at a disadvantage, discriminated against, or stigmatized as a result of their participation

(Prasetyanto & Yona 2019). All feasible steps are taken to ensure that research participants and

the general public are not threatened, that no unintended consequences of the study occur that

cannot be managed, and that the study yields the greatest amount of benefit. Interim reviews

and early discontinuation of the trial are required to avoid additional harm if it is discovered

that either the active or control intervention arm is associated with greater risks.

Principles of professional competence

The researchers are qualified to conduct the study or experiment, will do so with complete

honesty and objectivity, and have been instructed on the relevant ethical problems. A research

or experiment may be deemed fair, honest, impartial, and transparent if all participants disclose

all possible conflicts of interest and participation details. Full and complete records of the study

should be maintained for as long as is required or deemed appropriate for post-research

monitoring, research evaluation, subsequent research, and, if necessary, scrutiny by the relevant

legal and administrative agency.

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The findings of the research will be widely disseminated via publication in journals with peer

review and other open venues. This would help to harmonize the body of scientific information

in the field and put an end to research that puts individuals in risk of being repeated.

Everyone engaging in medical research, regardless of position, has a professional and ethical

commitment to guarantee compliance with all relevant standards, guidelines, and prescriptions.

This category include both financial and research institutes. Frequent examination and

reevaluation of research is necessary to preserve its quality.

Compliance with research regulations

Throughout the inquiry, Medical Research Council Ethics Guidelines are being followed. On

January 22, 2019, the Beijing Hospital for Traditional Chinese Medicine’s Study Ethical

Committee authorized this research and issued a scientific review. Before they begin,

participants will be informed in writing and verbally about the study’s methods and time

commitment. All patients diagnosed with acute ischemic stroke who are admitted to the

Neurology Departments of Beijing Shunyi District Hospital and Beijing Pinggu District

Hospital will be eligible for recruitment. Patients of any age who have experienced a recent

(within 14 days) clinically and CT/MRI-confirmed ischemic stroke and are capable of

providing informed consent will be evaluated for inclusion.

Conclusion

Based on pain intensity and impairment measurements gathered at both immediate and short-

term follow-up, researchers discovered that real acupuncture is more effective than sham

acupuncture for treating mechanical neck pain. The researchers reached this result after

comparing the impact of the two acupuncture procedures on pain and functional impairment

measurements. Although the data were insufficient to establish definite conclusions, the
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evidence suggests to the similarity of needle-based acupuncture/dry needling therapies and

sham treatments in the management of pain in patients with mechanical neck discomfort. Based

on the little evidence available, it seems that acupuncture treatments are more successful than

wait list therapies and sham treatments in the short and medium term.
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References

Anand, P., & Klein, J. P. (2021, October). Inpatient consultations in neurology. In Seminars in

Neurology (Vol. 41, No. 05, pp. 475-476). Thieme Medical Publishers, Inc.

MacPherson, H., & Charlesworth, K. (2020). The challenges of evaluating specific and

nonspecific effects in clinical trials of acupuncture for chronic pain. Medical

Acupuncture, 32(6), 385-387.

Waelveerakup, W., Lapvongwatana, P., Leelacharas, S., & Davison, J. (2019). Factors

predicting stroke pre-hospital delay behavior intention among people with high risk of

stroke. Pacific Rim International Journal of Nursing Research, 23(3), 271-284.

Prasetyanto, D., & Yona, S. (2019). Meridian acupuncture in stroke rehabilitation: a literature

review. International Journal of Nursing and Health Services (IJNHS), 2(2), 48-54.

Su, X. T., Wang, L., Ma, S. M., Cao, Y., Yang, N. N., Lin, L. L., ... & Liu, C. Z. (2020).

Mechanisms of acupuncture in the regulation of oxidative stress in treating ischemic

stroke. Oxidative medicine and cellular longevity, 2020

Liu, S., Zhang, C. S., Cai, Y., Guo, X., Zhang, A. L., Xue, C. C., & Lu, C. (2019). Acupuncture

for post-stroke shoulder-hand syndrome: a systematic review and meta-

analysis. Frontiers in neurology, 10, 433.