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Post-stroke Shoulder-Hand Syndrome
Syndrome épaule-main post-AVC
| ☆☆☆ | Evidence for effectiveness and a specific effect of acupuncture |
| ☆☆ | Evidence for effectiveness of acupuncture |
| ☆ | Limited evidence for effectiveness of acupuncture |
| Ø | No evidence or insufficient evidence |
1.1. Generic Acupuncture
1.1.1. Liu 2019 ☆
Liu S, Zhang CS , Cai Y , Guo X , Zhang AL , Xue CC , Lu C. Acupuncture for Post-stroke Shoulder-Hand Syndrome: A Systematic Review and Meta-Analysis. Front Neurol. 2019. [197941].
| Background | Shoulder-hand syndrome (SHS) is prevalent in hemiplegic patients after stroke. Potential benefits of acupuncture were shown in recent clinical trials. This systematic review aimed to comprehensively evaluate the safety and efficacy of acupuncture for SHS in stroke patients. |
| Methods | Five English databases (PubMed, Embase, CINAHL, CENTRAL, and AMED) and four Chinese databases (CBM, CNKI, CQVIP, and WanFang) were searched from their inceptions to January 2019. Randomized, controlled trials that evaluated the add-on effects of acupuncture to rehabilitation for post-stroke SHS were identified. |
| Results | Thirty-eight studies involving 3,184 participants fulfilled the eligible criteria and were included in the review. The overall meta-analysis showed that acupuncture combined with rehabilitation significantly improved motor function (upper-limb Fugl-Meyer Assessment (FMA): 34 studies, mean difference (MD) 8.01, 95% confidence interval (CI) [6.69,9.33]), and reduced pain (visual analog scale (VAS): 25 studies, MD -1.59, 95%CI [-1.86,-1.32]). It also improved activities of daily living (ADL) when compared with rehabilitation alone (ADL: 11 studies, MD 9.99, 95%CI [5.91,14.06]). However, the certainty of evidence of all these outcomes was assessed as “low.” Subgroup analyses of acupuncture stimulation types and treatment duration all showed significant add-on effects comparing with rehabilitation alone. The safety of acupuncture was unclear because there is a lack of detailed reporting of adverse events in most of the included studies. |
| Conclusions | Acupuncture therapy seems effective for motor function, pain relief and activities of daily living in stroke patients with mild SHS, when it is used in combination with rehabilitation. The low certainty of evidence downgrades our confidence in making recommendations to clinical practice. |
1.1.2. Peng 2018 ☆
Peng L, Zhang C, Zhou L, Zuo HX, He XK, Niu YM. Traditional manual acupuncture combined with rehabilitation therapy for shoulder hand syndrome after stroke within the Chinese healthcare system: a systematic review and meta-analysis. Clin Rehabil. 2018;32(4):429-39. [193285].
| Objective | To investigate the effectiveness of traditional manual acupuncture combined with rehabilitation therapy versus rehabilitation therapy alone for shoulder hand syndrome after stroke. |
| Methods | DATA SOURCES: PubMed, EMBASE, the Cochrane Library, Chinese Biomedicine Database, China National Knowledge Infrastructure, VIP Information Database, Wan Fang Database and reference lists of the eligible studies were searched up to July 2017 for relevant studies. Randomized controlled trials that compared the combined effects of traditional manual acupuncture and rehabilitation therapy to rehabilitation therapy alone for shoulder hand syndrome after stroke were included. Two reviewers independently screened the searched records, extracted the data and assessed risk of bias of the included studies. The treatment effect sizes were pooled in a meta-analysis using RevMan 5.3 software. |
| Results | A total of 20 studies involving 1918 participants were included in this study. Compared to rehabilitation therapy alone, the combined therapy significantly reduced pain on the visual analogue scale and improved limb movement on the Fugl-Meyer Assessment scale and the performance of activities of daily living (ADL) on the Barthel Index scale or Modified Barthel Index scale. Of these, the visual analogue scale score changes were significantly higher (mean difference = 1.49, 95% confidence interval = 1.15-1.82, P < 0.00001) favoring the combined therapy after treatment, with severe heterogeneity ( I2 = 71%, P = 0.0005). |
| Conclusion | Current evidence suggests that traditional manual acupuncture integrated with rehabilitation therapy is more effective in alleviating pain, improving limb movement and ADL. However, considering the relatively low quality of available evidence, further rigorously designed and large-scale randomized controlled trials are needed to confirm the results. |
1.1.3. Chau 2018
Chau JPC, Lo SHS, Yu X, Choi KC, Lau AYL, Wu JCY, Lee VWY, Cheung WHN, Ching JYL, Thompson DR. Effects of Acupuncture on the Recovery Outcomes of Stroke Survivors with Shoulder Pain: A Systematic Review. Front Neurol. 2018. [100146].
| Background | Poststroke shoulder pain limits stroke survivors' physical functioning, impairs their ability to perform daily activities, and compromises their quality of life. The use of acupuncture to manage shoulder pain after a stroke is believed to free the blockage of energy flow and produce analgesic effects, but the evidence is unclear. We therefore conducted a systematic review to summarize the current evidence on the effects of acupuncture on the recovery outcomes of stroke survivors with shoulder pain. |
| Methods | Fourteen English and Chinese databases were searched for data from January 2009 to August 2017. The review included adult participants with a clinical diagnosis of ischemic or hemorrhagic stroke who had developed shoulder pain and had undergone conventional acupuncture, electroacupuncture, fire needle acupuncture, or warm needle acupuncture. The participants in the comparison group received the usual stroke care only. |
| Results | Twenty-nine randomized controlled trials were included. Most studies were assessed as having a substantial risk of bias. Moreover, due to the high heterogeneity of the acupuncture therapies examined, pooling the results in a meta-analysis was not appropriate. A narrative summary of the results is thus presented. The review showed that conventional acupuncture can be associated with benefits in reducing pain and edema and improving upper extremity function and physical function. The effects of conventional acupuncture on improving shoulder range of motion (ROM) are in doubt because this outcome was only examined in two trials. Electroacupuncture might be effective in reducing shoulder pain and improving upper extremity function, and conclusions on the effects of electroacupuncture on edema, shoulder ROM, and physical function cannot be drawn due to the limited number of eligible trials. The evidence to support the use of fire needle or warm needle acupuncture in stroke survivors with shoulder pain is also inconclusive due to the limited number of studies. |
| Conclusion | Although most studies reviewed concluded that conventional and electroacupuncture could be effective for management of shoulder pain after stroke, the very high potential for bias should be considered. Further work in this area is needed that employs standardized acupuncture treatment modalities, endpoint assessments, and blinding of treatments. |
1.1.4. Lee 2016 ☆
Lee SH, Lim SM. Acupuncture for Poststroke Shoulder Pain: A Systematic Review and Meta-Analysis.. Evid Based Complement Alternat Med. 2016. [187758].
| Objectives | To summarize and evaluate evidence for the effectiveness of acupuncture in relieving poststroke shoulder pain. |
| Methods | Seven databases were searched without language restrictions. All randomized controlled trials that evaluated the effects of acupuncture for poststroke shoulder pain compared with controls were included. Assessments were performed primarily with the Visual Analogue Scale (VAS), Fugl-Meyer Assessment (FMA), and effective rates. |
| Results | In all, 188 potentially relevant articles were identified; 12 were randomized controlled trials that met our inclusion criteria. Meta-analysis showed that acupuncture combined with rehabilitation treatment appeared to be more effective than rehabilitation treatment alone for poststroke shoulder pain, as assessed by VAS (weighted mean difference, 1.87; 95% confidence interval [CI], 1.20-2.54; <0.001); FMA (weighted mean difference, 8.70; 95% CI, 6.58-10.82; P < 0.001); and effective rate (RR, 1.31; 95% CI, 1.18-1.47; P < 0.001). |
| Conclusions | Although there is some evidence for an effect of acupuncture on poststroke shoulder pain, the results are inconclusive. Further studies with more subjects and a rigorous study design are needed to confirm the role of acupuncture in the treatment of poststroke shoulder pain. |
1.1.5. Nie 2012 ☆
Nie Wen-Bin, Liu Zhi-Shun, Zhao Hong. [Systematic review of acupuncture for treatment of post-stroke shoulder pain]. Chinese Journal of Information on Traditional Chinese Medicine. 2012;4:25-28. [186950].
| Objectives | To evaluate the effectiveness of acupuncture therapy on post-stroke shoulder pain. |
| Methods | The review assessed the methodological quality of all eligible randomized or quasi-randomized trials of acupuncture for the treatment of post-stroke shoulder pain that identified by computerized and hand searches of the literature. The data was analysed by Review Manager software program. |
| Results | The evidence from randomised controlled trials so far confirmed that acupuncture therapy was effective in treating shoulder pain after stroke and benefited for limb motor recovery. But the quality of involved literature was low. |
| Conclusions | Acupuncture is effective in treating post-stroke shoulder pain, but the possibity of selection bias and measurement bias reduced the reliability of conclusion. |
1.1.6. Lee 2012 ☆
Lee JA, Park SW, Hwang PW, Lim SM, Kook S, Choi KI, Kang KS.. Acupuncture for shoulder pain after stroke: a systematic review. J Altern Complement Med. 2012. 18(9):818-23. [157513].
| Objectives | Shoulder pain, for which acupuncture has been used, is a common complication after a stroke that interferes with the function of the upper extremities. The aim of this systematic review is to summarize and evaluate the effects of acupuncture for shoulder pain after stroke. |
| Methods | Randomized controlled trials (RCTs) involving the effects of acupuncture for shoulder pain, published between January 1990 and August 2009, were obtained from the National Libraries of Medicine, MEDLINE(®), CINAHL, AMED, Embase, Cochrane Controlled Trials Register 2009, Korean Medical Database (Korea Institute of Science Technology Information, DBPIA, KoreaMed, and Research Information Service System), and the Chinese Database (China Academic Journal). |
| Results | Among the 453 studies that were obtained (300 written in English, 137 in Chinese, and 16 in Korean), 7 studies met the inclusion criteria for this review. All of them were RCTs published in China and reported positive effects of the treatment. The quality of the studies was assessed by the Modified Jadad Scores (MJS) and the Cochrane Back Review Group Criteria List for Methodologic Quality Assessment of RCTs (CBRG); the studies scored between 2 and 3 points on MJS, and between 4 and 7 points on CBRG. |
| Conclusions | It is concluded from this systematic review that acupuncture combined with exercise is effective for shoulder pain after stroke. It is recommended that future trials be carefully conducted on this topic. |
1.1.7. Lu 2009 ☆
Lu Yin-Ming, Fu Li-Xin, Mu Jiao, Xu Hong-Jun, Qi Ying-Zhou. [Acupuncture for post stroke shoulder hand syndrome: a systematic review]. Chinese Journal of Evidence-Based Medicine. 2009;9(9):976-8. [166899].
| Objective | To assess the therapeutic effect of acupuncture for shoulder hand syndrome after stroke. |
| Methods | We searched MEDLINE (1966 to Sep. 2008), EMbase (1980 to Sept. 2008), CBM (1978 to Sept. 2008), VIP (1989 to Sept. 2008), WANFANG Database (1998 to Sept. 2008), CNKI (1979 to Sept. 2008) and handsearched relevant journals and conference proceedings. We included all randomized controlled trials (RCTs) and quasi-RCTs of acupuncture treatment for patients with shoulder hand syndrome. We evaluated the internal validity of the RCTs and quasi-RCTs. If all included trials were of high quality and homogeneity, then the meta-analysis was conducted. |
| Results | Three RCTs were identified but due to the defects in quality and clinical differences between the trials, data from these trials were not combined through meta-analysis, and a descriptive analysis was performed. The results showed that acupuncture was effective for treating shoulder hand syndrome. |
| Conclusions | The results of our review suggest that acupuncture may be effective for treating houlder hand syndrome, but because of the defects in the methodological quality of included trials, further large sample, double-blind RCTs are urgently needed. |
1.2. Special Acupuncture Techniques
1.2.1. Electroacupuncture
1.2.1.1. Wei 2019
Wei X, He L , Liu J , Ai Y , Liu Y , Yang Y , Liu B. Electroacupuncture for Reflex Sympathetic Dystrophy after Stroke: A Meta-Analysis. J Stroke Cerebrovasc Dis. 2019;28(5):1388-1399. [198018].
| Background | Reflex sympathetic dystrophy (RSD) is the common complication among stroke and cerebral injury patients, which is lack of safe and effective treatment. Electroacupuncture (EA) may potentially be a reliably therapy, but the evidence is insufficiency. |
| Methods | Cochrane Library, MEDLINE, Embase, Chinese National Knowledge Infrastructure, Wan Fang Data, the Chinese Biology Medicine disc, etc., were searched, until July 20, 2018. We included random control trials that contrast EA with conventional rehabilitation therapy for the treatment of RSD. Main outcomes were visual analog scale score and Fugl-Meyer upper limb motor function scoring scale, other outcomes such as Barthel index, and hand swelling score were also collected. Data in included studies were extracted into an excel and pooled by Stata/MP 14.1. |
| Results | We incorporated 13 studies involving 1040 RSD patients and outcomes were from 2 to 6 weeks' follow-up. The analgesic effect between 2 groups had statistically significant difference (weighted mean difference [WMD] = -1.122, 95% confidence interval [CI] [-1.682 to -.562], P = .000], a statistical difference existed in improving dysfunction between 2 groups: (WMD = 6.039, 95% CI [2.231-.916], P = .000). EA groups had a better effect on improving activities of daily life abilities (WMD = 12.170, 95% CI [6.657-17.682], P < .00011] and better detumescence effect (WMD = -.800, 95% CI [-1.972 to -.212], P = .000] contrast to conventional rehabilitation therapy. |
| Conclusions | This meta-analysis supports that EA has a positive effect on alleviating pain, improving limb dysfunction, and promoting activities of daily living. On account of moderate-quality random control trials and high heterogeneity, further high-quality studies are imperative to optimize the EA treatment program. |
1.2.2. Jin's three needles puncture
1.2.2.1. Li 2017
Li Jun - Ping, Zhuang Li - Xing, He Jun. [Systematic Review of Jin's 3 needle Therapy for Shoulder Hand Syndrome after Stroke]. Journal of Clinical Acupuncture and Moxibustion. 2016;32(11):66. [188590].
| Objective | To evaluate the curative effect and status of Jin' s 3-needle therapy in the treatment of shoulder hand syndrome(SHS) after stroke. |
| Methods | A systematic retrieval has been taken in Chinese National Knowledge Infrastructure, Chinese biomedical literature database, VIP journal full text database, Wanfang database, MEDLINE, Cochrane Library and Springer. Collect RCT literatures concerning the treatment of SHS after stroke with Jin's 3 -needle therapy. Characteristics of these literatures would be summarized. Risk and bias in them would be evaluated too. Meta-analysis would be made on the similar researches. If a single Literature was special to make Meta-analysis, a descriptive analysis would be performed on it. |
| Results | Totally 15 researches were included. It showed that Jin's 3 needle therapy had the same efficacy as rehabilitation; Jin's therapy was superior to Xunjing Yuanqudong therapy; Jin's therapy combined with rehabilitation training was more effective than simple rehabilitation training. The efficacy of a variety of treatments including Jin's 3 - needle therapy was better than a simple therapy or certain types of therapies. The quality of the evidence was generally low, and the recommended levels were not intensified. |
| Conclusion | Jin's 3 - needle therapy is effective to treat shoulder hand syndrome after stroke and is worthy of promotion. |
1.2.3. Bee Acupuncture
1.2.3.1. Lim 2015 ☆
Lim SM, Lee SH. Effectiveness of bee venom acupuncture in alleviating post-stroke shoulder pain: a systematic review and meta-analysis. J Integr Med. 2015. 13(4):241-7. [183381]
| Background | Shoulder pain is a common complication of stroke. Bee venom acupuncture (BVA) is increasingly used in the treatment of post-stroke shoulder pain. |
| Objective | To summarize and evaluate evidence on the effectiveness of BVA in relieving shoulder pain after stroke. |
| Methods | Search strategy: Nine databases, namely MEDLINE, EMBASE, the Cochrane Library, the China National Knowledge Infrastructure (CNKI), the Japan Science and Technology Information Aggregator, Electronic (J-STAGE), and four Korean medical databases, namely, the National Assembly Library, the Research Information Service System, the National Discovery for Science Leaders, and OASIS, were searched from their inception through August 2014 without language restrictions. Inclusion criteria: Randomized controlled trials (RCTs) were included if BVA was used at acupoints as the sole treatment, or as an adjunct to other treatments, for shoulder pain after stroke. Data extraction and analysis: Two review authors independently selected trials for inclusion, assessed methodological quality and extracted data. |
| Results | A total of 138 potentially relevant articles were identified, 4 of which were RCTs that met our inclusion criteria. The quality of studies included was generally low, and a preponderance of positive results was demonstrated. All four trials reported favorable effects of BVA on shoulder pain after stroke. Two RCTs assessing the effects of BVA on post-stroke shoulder pain, as opposed to saline injections, were included in the meta-analysis. Pain was significantly lower for BVA than for saline injections (standardized mean difference on 10-cm visual analog scale: 1.46 cm, 95% CI=0.30-2.62, P=0.02, n=86). |
| Conclusion | This review provided evidence suggesting that BVA is effective in relieving shoulder pain after stroke. However, further studies are needed to confirm the role of BVA in alleviating post-stroke shoulder pain. Future studies should be conducted with large samples and rigorous study designs. |
1.2.4. Acupuncture combined with Chinese Materia Medica Iontophoresis
1.2.4.1. Li 2020
Li Nirong. [Systematic Analysis of Clinical Efficacy of Chinese Materia Medica Iontophoresis Combined with Acupuncture for Stroke Shoulder-Hand Syndrome]. Journal of Hunan University of Chinese Medicine. 2020. [212930].
| Objective | To systematically evaluate the clinical efficacy of Chinese materia medica iontophoresis combined with acupuncture for the treatment of stroke shoulder-hand syndrome from evidence-based. |
| Methods | The databases of VIP, Wanfang, CNKI, CBM, PubMed, Cochrane library, Science Direct, etc. were searched, and the journal in the library of Hunan University of Chinese Medicine were manually retrieved for literatures on the randomized controlled literature on the clinical efficacy of Chinese materia medica iontophoresis combined with acupuncture for stroke shoulder-hand syndrome. Data was extracted and analyzed using RevMan 5. 3 software. |
| Results | A total of 7 studies were included, involving504 patients with stroke shoulder-hand syndrome. Meta-analysis showed that compared with the control group, Chinese materia medica iontophoresis combined with acupuncture can improve the total clinical efficiency by 22% [RR=1. 22, 95% CI (1. 11, 1. 35), Z=3. 94, P<0. 000 1], relieve pain [MD=-1. 55, 95% CI (-2. 08, -1. 02), Z=5. 72, P<0. 000 01], enhance the motor function of the affected limbs [MD=6. 01, 95%CI (5. 15, 6. 87), Z=13. 73, P<0. 000 01], and improve patients' ability of daily activities [MD=9. 07, 95% CI (5. 95, 12. 19), Z=5. 69, P<0. 000 01]. |
| Conclusion | Chinese materia medica iontophoresis combined with acupuncture for the treatment of shoulder-hand syndrome has a significant effect, can effectively relive pain, improve patient's motor function and quality of life, and is conducive to the promotion and application of featured technology of traditional Chinese medicine. |
2. Overviews of Systematic Reviews
2.1. Choi 2022
Choi TY, Jun JH, Lee HW, Yun JM, Joo MC, Lee MS. Traditional Chinese Medicine Interventions in the Rehabilitation of Cognitive and Motor Function in Patients With Stroke: An Overview and Evidence Map. Front Neurol. 2022 May 17;13:885095. https://doi.org/10.3389/fneur.2022.885095
| Objective | Evidence mapping of systematic reviews (SRs) systematically and comprehensively identifies, organizes, and summarizes the distribution of scientific evidence in a field. The aim of this evidence map is to provide a synopsis of the best clinical practices and interventions in stroke rehabilitative care and to identify areas with a paucity of evidence to guide future research. |
| Methods | PubMed, EMBASE, CDSR, six Korean databases, and two Chinese databases were searched for SRs evaluating the effectiveness of any stroke rehabilitation intervention through October 2021. The quality of the SRs was assessed using AMSTAR 2. A bubble plot was used to graphically display clinical topics, the number of articles, the number of patients included, confidence, and effectiveness. |
| Results | In total, ninety-five SRs were identified; however, after methodological analysis, only 48 had sufficient quality to be included. In total, forty-eight SRs were included in the evidence mapping. The overall search identified SRs from 2015 to 2021. A total of four SRs focused on post-stroke cognitive impairment, whereas the other forty-four SRs focused on post-stroke motor function. In total, nineteen different traditional Chinese medicine (TCM) intervention modalities were included. Acupuncture was the most commonly used treatment. Overall, the quality of the included SRs was low or very low. Most SRs concluded that TCM interventions may have potential benefits in stroke rehabilitation. The results were more promising when acupuncture was used for shoulder-hand syndrome. |
| Conclusions | However, the identified reviews cautioned that firm conclusions cannot be drawn. The evidence map provides a visual overview of the research volume and content involving TCM interventions in stroke rehabilitation. Evidence mapping can facilitate the process of knowledge translation from scientific findings to researchers and policymakers and possibly reduce waste in research. |
| | POST-STROKE SHOULDER-HAND SYNDROME |
3. Clinical Practice Guidelines
⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence) |
3.1. Brazilian Academy of Neurology 2022 Ø
Minelli C, Bazan R, Pedatella MTA, Neves LO, Cacho RO, Magalhães SCSA, Luvizutto GJ, Moro CHC, Lange MC, Modolo GP, Lopes BC, Pinheiro EL, Souza JT, Rodrigues GR, Fabio SRC, Prado GFD, Carlos K, Teixeira JJM, Barreira CMA, Castro RS, Quinan TDL, Damasceno E, Almeida KJ, Pontes-Neto OM, Dalio MTRP, Camilo MR, Tosin MHS, Oliveira BC, Oliveira BGRB, Carvalho JJF, Martins SCO. Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I. Arq Neuropsiquiatr. 2022 Jun;80(6):634-652. https://doi.org/10.1590/0004-282X-ANP-2021-0354
| Painful shoulder : Acupuncture, as an adjunctive treatment, has an uncertain value. (Recommendation IIb-B) |
3.2. Stroke Foundation (Australia, New-Zealand) 2022 ⊕
Australian and New Zealand Clinical Guidelines for Stroke Management - Chapter 6: Managing complications. https://app.magicapp.org/#/guideline/WE8wOn
| For stroke survivors with shoulder pain, acupuncture in addition to comprehensive rehabilitation may be used to reduce pain. (Liu et al 2019 [98]) [Weak recommendation]. |
3.3. Japan Stroke Society (JSS, Japan) 2021 ⊕
The Japan Stroke Society. [Japanese Guidelines for the Management of Stroke, 2021] . Kyowa Kikaku Co. Ltd.; 2021 [in Japanese] .
Cited by Okawa Y, Yamashita H, Masuyama S, Fukazawa Y, Wakayama I. Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture. Integr Med Res. 2022 Sep;11(3):100838. https://doi.org/10.1016/j.imr.2022.100838
| Recommended for complex regional pain syndromes, in conjunction with training. |
3.4. Canadian Partnership for Stroke Recovery (CPSR, Canada) 2018 ⊕
Evidence-based review of stroke rehabilitation: 18th edition, Canadian Partnership for Stroke Recovery (CPSR). 2018. [197578]. URL/
| Hemiplegic Shoulder. There is Level 1a evidence that acupuncture reduces pain, increases range of motion, and improves motor function in the hemiplegic shoulder when compared to conventional therapy. There is Level 1b and Level 2 evidence that massage therapy, alone or with acupuncture, reduces hemiplegic shoulder pain. There is limited Level 1b evidence that a combination of acupressure and aromatherapy is more effective than dry acupressure in reducing hemiplegic shoulder pain. |
3.5. American Heart Association/American Stroke Association (AHA, ASA, USA) 2016 Ø
Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD et al. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98-e169. [198716].
| Usefulness of acupuncture as an adjuvant treatment for hemiplegic shoulder pain is of uncertain value. Iib B. |
