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Poststroke Cognitive Impairment
Troubles cognitifs post-AVC : évaluation de l'acupuncture
| ☆☆☆ | 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. Kuang 2021
Kuang X, Fan W, Hu J, Wu L, Yi W, Lu L, Xu N. Acupuncture for post-stroke cognitive impairment: a systematic review and meta-analysis. Acupunct Med. 2021 Dec;39(6):577-588. https://doi.org/10.1177/09645284211009542
| Objectives: | The aim of this study was to evaluate the effectiveness and safety of acupuncture for the treatment of post-stroke cognitive impairment (PSCI). |
| Methods: | The Cochrane Library, Embase, Medline, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical (VIP), Wanfang, and Chinese Biological Medicine (CBM) databases were electronically searched from their inception to 10 April 2019. The Montreal Cognitive Assessment (MoCA) scale and Mini-Mental State Examination (MMSE) scale were used as outcomes to assess effectiveness with respect to cognitive function. Assessment of risk of bias (ROB) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment were performed by two reviewers independently. Data were analyzed using Review Manager (RevMan) 5.3. |
| Results: | A total of 28 trials with 2144 participants were included in the qualitative synthesis and meta-analysis. Four of the 28 trials (14%) were assessed as being at overall low ROB, 24 of the 28 trials (86%) were assessed as having overall high ROB. The quality of evidence for both MoCA and MMSE were deemed to be very low by the GRADE criteria. Results indicated that acupuncture groups may be benefiting more than non-acupuncture groups with respect to variation of MoCA scores (merged mean difference (MMD): 2.66, 95% confidence interval (CI): 2.18 to 3.13, p < 0.00001; heterogeneity: χ2 = 35.52, p = 0.0007, I2 = 63%), and the heterogeneity decreased in both subgroup analysis and sensitivity analysis. In addition, acupuncture groups might be benefiting more than non-acupuncture groups in terms of changes in MMSE score (MMD = 2.97, 95% CI = 2.13 to 3.80, p < 0.00001; heterogeneity: χ2 = 269.75; p < 0.00001; I2 = 92%), and the heterogeneity decreased in subgroup analysis. Only one RCT addressed adverse events, and the symptoms were mild and did not affect treatment and evaluation. |
| Conclusion: | Acupuncture could be effective and safe for PSCI. Nevertheless, the results should be interpreted cautiously due to the high ROB of included trials and very low quality of evidence for assessed outcomes. |
1.1.2. Zhou 2020 ☆
Zhou L, Wang Y, Qiao J, Wang QM, Luo X. Acupuncture for Improving Cognitive Impairment After Stroke: A Meta-Analysis of Randomized Controlled Trials. Front Psychol. 2020. [216106]. doi
| Objective | This meta-analysis evaluated the efficacy of acupuncture in improving cognitive impairment of post-stroke patients. |
| Design | Randomized controlled trials (RCTs) investigating the effects of acupuncture compared with no treatment or sham acupuncture on post-stroke cognitive impairment (PSCI) before December 2019 were identified from databases (PubMed, EMBASE, Ovid library, Cochrane Library, Chinese National Knowledge Infrastructure, VIP Chinese Periodical Database, Wanfang Database, and SinoMed). The literature searching and data extracting were independently performed by two investigators. Study quality was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. Meta-analyses were performed for the eligible RCTs with Revman 5.3 software. |
| Results | Thirty-seven RCTs (2,869 patients) were included in this meta-analysis. Merged Random-effects estimates of the gain of MMSE (Mini-Mental State Examination) or MoCA (Montreal Cognitive Assessment) were calculated for the comparison of acupuncture with no acupuncture or sham acupuncture. Following 2-8 weeks of intervention with acupuncture, pooled results demonstrated significant effects of acupuncture in improving PSCI assessed by MMSE (MD [95% CI] = 2.88 [2.09, 3.66], p < 0.00001) or MoCA (MD [95% CI] = 2.66 [1.95, 3.37], p < 0.00001). |
| Conclusion | The results suggest that acupuncture was effective in improving PSCI and supported the needs of more rigorous design with large-scale randomized clinical trials to determine its therapeutic benefits. |
1.1.3. Zhang 2015
Zhang Yang, Tang Wei, Song Xiao-Ge, Wu Song, Zhang Gao-Ying, Xu Hua. [Systematical review and meta-analysis of the efficacy of acupuncture and moxibustion plus cognitive rehabilitation training in treating post-stroke cognitive disorder]. Shanghai Journal of Acupuncture & Moxibustion 2015. 34(10):1013-20. (chi). [187058]
| Objective | To systematically assess the efficacy of acupuncture and moxibustion plus cognitive rehabilitation training in treating post-stroke cognitive disorder. |
| Method | A computer searched CNKI, CBM, VIP, WANFANG DATA, and Pubmed and Cochrane Library for randomized controlled trials (RCT) of acupuncture and moxibustion plus cognitive rehabilitation training for the treatment of post-stroke cognitive disorder. The reference Iiterature in the included literature was also retrieved. Retrieval time limit for both of them was from Jan. 1st 1990 to Jan. 1st 2015. Two reviewers independently selected the trials, extracted the data and assessed the quality of methodology. Meta-analysis was then performed using RevMan 5.3 software. |
| Result | Eleven trials with a total of 789 subjects were finally included. The results of Meta-analysis showed that the following aspects were better in acupuncture plus cognitive rehabilitation training than in cognitive rehabilitation training or medication alone and there were statistically significant differences: the total efficacy rate [RR=1 .58, 95% CI(1.10,2.26), P=0.011, the MMSE sc0re [M.D=2.64, 95% CI(1.78, 3.50), P'0.00001], P300 latency [MD= - 18.46, 95% CI( - 30.51, - 6.41), P=0.003], P300 amplitude [MD=l.23, 95% CI(0.82, 1 .63), P<0.0000 1] and activities of daily living (ADL) [SMD=().52, 95% CI(0.3 1, 0.73), P=0.00001]. Based on the results of a systematical review, the quality of evidence was assessed using GRADE system recommended classification method. The results showed that the level of evidence was low and the strength of recommendations was weak. |
| Conclusion | The results of Meta-analysis showed that the therapeutic effect was better in acupuncture and moxibustion plus cognitive rehabilitation training than in cognitive rehabilitation training or medication alone. Because of low quality of all the original literature, high-quality, multicenter and large-sample randomized blind controlled trials are still needed for validation. |
1.2. Special Acupuncture Techniques
1.2.1. Acupoints combination
1.2.1.1. Hu 2020 (Baihui (GV20) and Shuigou (GV26) Acupoints)
Hu Shuting. [Systematic Review and Meta-analysis of Acupuncture at Baihui (GV20) and Shuigou (GV26) Points Treatment for Post-stroke Cognitive Impairment ]. Journal of Guangzhou University of TCM. 2020. [212895].
| Objective | To systematically evaluate the clinical efficacy of acupuncture at Baihui (GV20) and Shuigou (GV26)points in treating post-stroke cognitive impairment (PSCI). |
| Methods | The randomized clinical trials (RCTs)regarding acupuncture at Baihui (GV20)and Shuigou (GV26)points treatment for PSCI were searched from China National Knowledge Infrastructure (CNKI), Wanfang database, VIP medicine information system, Chinese Biomedical Database (CBM), PubMed and the Cochrane Library. The quality of methodology in the included literatures was evaluated by Cochrane systematic assessment method, and was given Meta-analysis by Rev Man 5. 3 software. |
| Results | Ultimately, a total of 11 RCTs were included, involving 805 cases. The results of Meta-analysis showed that the experimental group was superior to the control group in the clinical effective rate[OR = 3. 15, 95%CI (1. 81, 5. 46), Z = 4. 08, P < 0. 000 1], improving the Mini-Mental State Examination (MMSE)scores [WMD=2. 21, 95%CI (1. 01, 3. 41), Z = 3. 61, P = 0. 000 3], improving the Montreal Cognitive Assessment (MoCA)scores [WMD = 1. 84, 95% CI (0. 81, 2. 88), Z = 3. 49, P = 0. 000 5]. |
| Conclusion | Acupuncture at Baihui (GV20)and Shuigou (GV26)points is effective for improving the cognitive functions in PSCI patients. However, due to the low quality of the included studies, more high-quality, large-scale and multiple-center RCTs are needed. |
1.2.1.2. Liu 2018 (Baihui (GV 20) and Shenting (GV 24) Acupoints)
Liu Fang, Yao Li-Qun, Chen Jin-Hui. [Therapeutic Efficacy of Acupuncture at Baihui (GV 20) and Shenting (GV 24) for Post-stroke Cognitive Impairment: A Systematic Review]. Shanghai Journal of Acupuncture and Moxibustion. 2018;37(1):104-111. [100878].
| Objective | To evaluate the clinical efficacy of acupuncture at Baihui (GV 20) and Shenting (GV 24) in treating post-stroke cognitive impairment (PSCI) by using the systematic review method. | |
| Method | Via computer, Chinese Journal Full-text Database, Wanfang, China Biology Medicine disc (CBMdisc),Chinese Science and Technology Periodical Database, Pub Med, Foreign Evidence-Based Medicine(FEMB), the Cochrane Library were retrieved. Chinese Acupuncture and Moxibustion and Shanghai Journal of Acupuncture-moxibustion were manually retrieved. Randomized controlled trials published before Jan 31 st of 2013 on acupuncture at Baihui (GV 20) and Shenting (GV 24) in treating PSCI, both in Chinese and English, were collected. The required data were extracted, then were evaluated according to the criteria of Cochrane systematic review and underwent meta-analysis by using Rev Man 5.0. | |
| Results | Twenty-two clinical trials were finally recruited, including 1 637 subjects. The meta-analysis showed that acupuncture at acupoints including Baihui (GV 20) and Shenting (GV 24) produced a more significant rehabilitation result compared to single rehabilitation training or medication. The comparison of Mini-Mental State Examination(MMSE) score showed: [WMD=3.37, 95%CI(1.70, 5.05), P<0.00001]; the comparison of P300 latency: [WMD=1.22, 95%CI(0.84, 1.59), P<0.00001]. Severe adverse reactions were not discovered. | |
| Conclusion | Acupuncture at Baihui (GV 20) and Shenting (GV 24) can effectively improve the cognitive function of PSCI patients. However, the diagnostic criteria and evaluation indexes are expected to be unified and standardized, and the clinical trials on acupuncture intervening PSCI are required to be further improved methodologically. | |
1.2.2. electroacupuncture
1.2.2.1. Zhan 2017
Zhan J, Wang X, Cheng N, Tan F. [Electroacupuncture for post stroke cognitive impairment: a systematic review and Meta-analyses]. Chinese Acupuncture and Moxibustion. 2017;37(10):1119-25. 165857[165857].
| Objective | To systematically evaluate the efficacy and safety of electroacupuncture (EA) for post stroke cognitive impairment (PSCI). |
| Methods | The randomized clinical trials (RCTs) regarding EA for PSCI published before October of 2016 were researched in China National Knowledge Infrastructure (CNKI), Chinese Biomedical Database (CBM), WanFang database, VIP medicine information system, PubMed and Cochrane Library. The literature screening and information extraction was conducted by two independent reviewers. The quality assessment was performed based on the guidance of the Cochrane Reviewers' Handbook, and Meta-analyses was performed by using RevMan 5. 3 software. |
| Results | Totally 14 RCTs were included, involving 896 PSCI patients. The results of Meta-analyses showed the EA group was superior to the control group in improving the MMSE [MD =1. 78, 95% CI (0. 24, 3. 32), P =0. 02], the MoCA [MD=1. 92, 95% CI (0. 96, 2. 88), P<0. 000 1], P300 latency [MD =-11. 01, 95% CI (-18. 91, -3. 11), P =0. 000 6], P300 amplitude [MD=1. 56, 95% CI (1. 14, 1. 98), P<0. 000 01], FMA score [MD =10. 74, 95% CI (2. 67, 18. 82), P =0. 009] and the clinical effective rate [RR =1. 37, 95% CI (0. 98, 1. 91), P =0. 06]. However, the comparison of BI score in both group had no significant differences [MD =6. 38, 95% CI (-2. 41, 15. 18), P =0. 15]. |
| Conclusion | This Meta-analyses confirmed EA is effective and safe for PSCI, which could improve cognitive function and motor function. However, because of low quality of the included studies, more well-designed multicenter RCTs are needed |
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. |
2.2. Li 2022
Li L, Yang L, Luo B, Deng L, Zhong Y, Gan D, Wu X, Feng P, Zhu F. Acupuncture for Post-Stroke Cognitive Impairment: An Overview of Systematic Reviews. Int J Gen Med. 2022 Sep 13;15:7249-7264. https://doi.org/10.2147/IJGM.S376759. https://pubmed.ncbi.nlm.nih.gov/36124104; PMCID: PMC9482408.
| Background | Post-stroke cognitive impairment (PSCI) is one of the most common complications after stroke. In recent years, as a complementary alternative therapy, many systematic reviews (SRs) and meta-analysis (MAs) have reported the efficacy and safety of acupuncture in improving cognitive function in patients with PSCI, but the quality of evidence is unknown and therefore needs to be evaluated comprehensively. |
| Aim | We aimed to evaluate the SRs of acupuncture for patients with PSCI, to summarize the evidence quality of SRs to provide scientific evidence. |
| Methods | We searched for relevant SRs and MAs in seven databases up to March 22, 2022. Two reviewers independently completed literature retrieval, screening, and data extraction. We used A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) to evaluate the methodological quality; the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool to determine the strength of evidence; and the ROBIS tool to assess RoB. |
| Results | We identified 14 SRs. The methodological quality of all SRs was low (2/14) or very low (12/14). GRADE results showed 13 were moderate quality (26%), 5 were low quality (10%), and 32 were very-low quality (64%). RoB showed that one SR had a low risk and 13 had a high risk. Moderate quality results showed that combined acupuncture therapy was superior to western medicine or cognitive rehabilitation training in improving cognitive function, the total response rate, and the daily living ability of patients with PSCI. |
| Conclusion | Based on the evidence, acupuncture appears to be effective and safe in improving cognitive function for patients with PSCI, but the overall quality of SRs is not high. High-quality randomized controlled trials are needed to confirm the effectiveness and safety of acupuncture on the cognitive function of patients with PSCI. |
2.3. Hung 2019
Hung CY, Wu XY, Chung VC, Tang EC, Wu JC, Lau AY. Overview of systematic reviews with meta-analyses on acupuncture in post-stroke cognitive impairment and depression management. Integr Med Res. 2019;8(3):145-159. [199813].
| Background | Acupuncture has been using as an alternative non-pharmacological therapy in the management of post stroke depression and cognitive impairment but its effectiveness and safety remain controversial. We conducted an overview of systematic reviews with meta-analyses to evaluate the evidence on the effect of acupuncture in the treatment of stroke with conventional medicine intervention. |
| Methods | Systematic reviews summarized the treatment effects of acupuncture for post stroke cognitive impairment and post stroke depression were considered eligible. Methodological quality of included systematic reviews was assessed using A Measurement Tool to Assess systematic Reviews 2 (AMSTAR 2). |
| Results | Four systematic reviews on post stroke cognitive impairment and ten systematic reviews on post stroke depression with good methodological quality were included. Meta-analyses revealed that acupuncture plus cognitive rehabilitation; and acupuncture or moxibustion plus cognitive rehabilitation, versus cognitive rehabilitation demonstrated statistically significant increase in Mini-Mental State Examination scores in compared to cognitive rehabilitation after 4 weeks treatment [Pooled weighted mean difference (WMD) = 3.14, 95% confidence interval (CI) = 2.06 to 4.21, I2 = 36%]; and (Pooled WMD = 3.22, 95% CI = 2.09 to 4.34, I2 = 0%). Furthermore, acupuncture versus antidepressant demonstrated statistically significant improve depression measured by increasing in 17-item Hamilton Depression Rating Scale in comparing to cognitive rehabilitation after 2 weeks treatment (Pooled WMD= -2.34, 95% CI= -3.46 to -1.22, I2 = 5%). Acupuncture usage was not associated with increased risk of adverse events. |
| Conclusions | Acupuncture is safe and improves cognitive function and depressive disorder without obvious serious adverse events for post stroke patients. |
3. Clinical Practice Guidelines
| ☆☆☆ | 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 |
3.1. Brazilian Academy of Neurology (BAN, Brazil) 2022 ⊕
Minelli C, Luvizutto GJ, Cacho RO, Neves LO, Magalhães SCSA, Pedatella MTA, Mendonça LIZ, Ortiz KZ, Lange MC, Ribeiro PW, Souza LAPS, Milani C, Cruz DMCD, Costa RDMD, Conforto AB, Carvalho FMM, Ciarlini BS, Frota NAF, Almeida KJ, Schochat E, Oliveira TP, Miranda C, Piemonte MEP, Lopes LCG, Lopes CG, Tosin MHS, Oliveira BC, Oliveira BGRB, Castro SS, Andrade JBC, Silva GS, Pontes-Neto OM, Carvalho JJF, Martins SCO, Bazan R. Brazilian practice guidelines for stroke rehabilitation: Part II. Arq Neuropsiquiatr. 2022 Jul;80(7):741-758.. https://doi.org/10.1055/s-0042-1757692
.
| Cognition: Acupuncture associated with cognitive rehabilitation can be employed (Recommendation IIa-A) |
3.2. 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/
| Post-Stroke Cognitive Disorders. There is level 1b and level 2 evidence that acupuncture can be an effective intervention in the remediation of cognitive deficits, There is level 1b evidence that acupuncture combined with nimodipine can improve cognitive functioning short term. There is level 1b evidence that electroacupuncture may improve attention, praxis, perception and orientation, but not thinking, organization memory and mental health. |
