Clinical Observation on the Treatment of Spastic Paraplegia after Stroke with Different Needles ()
1. Introduction
Spastic hemiplegia following stroke is a frequent complication of both ischemic and hemorrhagic strokes. This condition arises due to upper motor neuron injury, which places the lower motor neurons in a disinhibited state, leading to increased muscle tone, heightened tendon reflexes, and impaired muscle coordination [1]. Typically, post-stroke hemiplegia emerges within three weeks after the acute event, with approximately 80% of patients developing varying degrees of limb spasticity [2]. These patients may suffer from pain in the affected muscles and restricted limb mobility, which can further result in joint contractures, deformities, and other complications [3], ultimately causing a marked decline in functional ability and quality of life. Acupuncture, through stimulation of specific acupoints, has been shown to reduce motor neuron excitability and alleviate muscle spasticity [4]. In clinical settings, the author observed that needles of different diameters produced variable therapeutic outcomes when applied to the same acupoint. Furthermore, in patients with spastic hemiplegia, needle retention during acupuncture frequently led to involuntary limb movements, resulting in needle bending, breakage, and interruption of treatment, thereby compromising therapeutic efficacy. To address these issues, the author explored a non-retention, high-intensity acupuncture technique for the management of spastic hemiplegia in stroke patients. The Qihuang needle, developed by Professor Chen Zhenhu at the First Affiliated Hospital of Guangzhou University of Chinese Medicine, features a rounded sharp tip, a hollow shaft, and a larger diameter than conventional acupuncture needles. It is distinguished by its non-retention application, fewer required acupoints, and rapid onset of action [5], effectively overcoming the limitations of traditional retained-needle acupuncture. The present study aims to evaluate the therapeutic efficacy of the Qihuang needle in treating post-stroke spastic hemiplegia and to compare its outcomes with those of conventional acupuncture. The findings are reported as follows.
2. Materials and Methods
2.1. General Information
Source of Cases: This study enrolled a total of 90 patients diagnosed with post-stroke spastic hemiplegia who were admitted to the inpatient wards and outpatient clinics of Shenhe People’s Hospital, Heyuan City, between September 2022 and August 2024. Eligible participants were randomly assigned to one of three acupuncture groups: Group 1 (Qihuang needle, 0.540 mm), Group 2 (conventional needle, 0.3540 mm), and Group 3 (0.25 × 40 mm), with 30 patients in each group. Based on preliminary experimental results (effect size d = 0.65), a two-tailed test with α = 0.05, and a power of 80%, at least 27 cases per group are required. Thus, 30 cases per group were chosen to accommodate drop-out compensation (estimated drop-out rate ≤ 10%). The baseline clinical characteristics of the patients in the three groups were comparable (P > 0.05), as detailed in Table 1.
Table 1. General data comparison (
± S) between the two groups.
Group |
age (years) |
gender (m/f/d) |
Course of stroke (Month) |
Type of stroke (Cerebral ischemia/intracerebral hemorrhage) |
Acupuncture group 1 |
63.47 ± 4.36 |
20/10 |
4.08 ± 1.37 |
19/11 |
Acupuncture group 2 |
62.79 ± 4.78 |
19/11 |
4.18 ± 1.24 |
18/12 |
Acupuncture group 3 |
63.24 ± 5.03 |
18/12 |
4.32 ± 1.28 |
19/11 |
Western Medicine Diagnostic Criteria: The diagnostic criteria for Western medicine were based on the “Guidelines for the Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack in China” [6] and the “Expert Consensus on Orthopedic Orthosis Rehabilitation Therapy for Elderly Hemiplegic Patients in China” [7].
Traditional Chinese Medicine Diagnostic Criteria: The diagnostic criteria for stroke were based on the “Standards for the Diagnosis and Efficacy Evaluation of Stroke (Trial Implementation)”.
Inclusion Criteria:
1) Meeting the above-mentioned diagnostic criteria of both Western and Traditional Chinese medicine;
2) Aged between 40 and 70 years;
3) No adverse reactions such as needle syncope during the study process;
4) Modified Ashworth Spasticity Scale grade I to III;
5) Disease duration within 3 months;
6) The study protocol was approved by the Ethics Committee of Heyuan Shenhe People’s Hospital (approval number).
Exclusion Criteria:
1) History of poliomyelitis, osteoarthropathy, or other conditions causing functional abnormalities of the affected limb;
2) Recurrent stroke or worsening of the condition;
3) Patients with skin ulceration who cannot receive acupuncture;
4) Patients with psychiatric disorders.
5) Patients did not take any muscle relaxant medications such as baclofen or eperisone, nor did they receive other forms of rehabilitation therapy during the study period.
2.2. Treatment Methods
2.2.1. Acupuncture Group 1
1) Acupoint Selection: Acupoints were selected based on the site of hemiplegia, including Jianjing, Tianjing, Waiguan, Pianli, Xuehai, Yinlingquan, Ququan, and Sanyinjiao.
2) Patient Positioning: Patients were placed in the supine position.
3) Acupuncture Technique: A 40 mm disposable sterile acupuncture needle (Qihuang needle) was selected according to the thickness of local soft tissue. Following accurate acupoint localization, the skin within a 3 - 4 cm diameter centered on the acupoint was disinfected three times with Anerdine using a cotton swab. The operator placed the thumb and index finger of the supporting hand on either side of the insertion site, while the needling hand swiftly inserted the needle vertically to the subcutaneous tissue, advancing to the bone. Upon the needle tip reaching the periosteum and the patient experiencing soreness and distension at the site, the needle handle was gently agitated, then slightly withdrawn. The Hegu needling technique was performed at a 30˚ angle along the longitudinal axis of the body. After the arrival of “Deqi”, the needle was withdrawn and the puncture site was pressed with a sterile dry cotton swab for 1 - 2 minutes. For each session, 2 - 4 acupoints were chosen according to the patient’s condition, with a maximum of 4 points. Treatments were administered once every two days, three times per week, for a total of four weeks. Qihuang acupuncture is characterized by not leaving needles in place and selecting fewer acupuncture points, eliminating the need for daily sessions. Therefore, the chosen frequency is three times a week.
2.2.2. Acupuncture Group 2 and Group 3
Acupuncture Groups 2 and 3 utilized an identical acupoint selection protocol. Group 2 used needles of specification 0.35 × 40 mm, while Group 3 used 0.25 × 40 mm needles. The selected acupoints included: Jian penetrating Biniao, Nao meeting penetrating Tianjing, Sidu penetrating Waiguan, Yangxi penetrating Pianli, Jimen penetrating Xuehai, Yinlingquan penetrating Diji, Ququan penetrating Yinbao, and Sanyinjiao penetrating Zhaohai. Local skin at the acupoint was routinely disinfected with alcohol using a cotton swab. Huánqiú brand disposable sterile acupuncture needles were used. The needle was rapidly inserted, followed by manipulation techniques such as lifting, thrusting, and rotating to elicit the needling sensation, with optimal results when the sensation was conducted downward. Needles were retained for 30 minutes per session, five times per week, over a four-week treatment course.
2.3. Observation Indicators
1) Modified Ashworth Scale (MAS): The Modified Ashworth Scale was employed to assess the degree of muscle tone in the upper and lower limbs of patients from the three groups before and after treatment, in accordance with the established grading criteria. The scale comprises six grades (0, 1, 1+, 2, 3, 4), with corresponding scores ranging from 0 to 5 (assigning 2 points to grade 1+). Higher grades indicate greater severity of limb spasticity associated with hemiplegia, whereas lower scores reflect milder spasticity.
0 points = No increase in muscle tone;
1 point = Slight increase in muscle tone;
2 points = Slight increase in muscle tone with widened resistance range;
3 points = Moderate increase in muscle tone, with consistent resistance throughout passive movement, though not to a degree that hinders joint motion;
4 points = Severe increase in muscle tone, with significantly increased resistance during passive movement and a markedly limited range of motion, allowing only partial full-range activity;
5 points: Extreme increase in muscle tone, with the affected limb being rigid, making passive movement nearly impossible.
2) Simplified Fugl-Meyer Assessment (FMA): The Fugl-Meyer Assessment was utilized to evaluate motor function in the upper and lower extremities, encompassing 50 items with a total possible score of 100. Of this, upper limb function contributes 66 points and lower limb function 34 points. Higher FMA scores are indicative of superior motor function.
Each item is scored as “cannot perform” (0 points), “partially perform” (1 point), or “fully perform” (2 points), with a total score ranging from 0 to 100 points.
3) Modified Barthel Index (MBI): The Modified Barthel Index was used to measure the patients’ abilities in activities of daily living, categorized into five levels with a maximum score of 100. Scores of 60 or above denote basic self-care capability; scores between 41 and 59 indicate moderate disability; scores between 21 and 40 signify severe disability; and scores from 0 to 20 represent extremely severe functional impairment. Higher scores correspond to greater independence in daily living activities.
2.4. Statistical Analysis
Data from 90 patients with post-stroke spastic hemiplegia were entered into SPSS version 13.0 for statistical analysis. Categorical data were analyzed using the χ2 test. Comparisons between the treatment and control groups were conducted using independent samples t-tests, while pre- and post-treatment comparisons within groups employed paired t-tests. A P-value of less than 0.05 was considered indicative of statistical significance.
3. Results
3.1. Comparison of MAS Scores before and after Treatment between Groups
Prior to treatment, multiple comparisons using the Student-Newman-Keuls (SNK) test revealed no statistically significant differences in MAS scores among the three groups (P > 0.05), demonstrating baseline comparability. After four weeks of intervention, all three groups exhibited reductions in MAS scores compared to baseline. Paired t-test results indicated that the changes in upper limb MAS scores before and after treatment were statistically significant (P < 0.05). Furthermore, post hoc SNK analysis showed that Group 1 (acupuncture) had significantly lower MAS scores than Groups 2 and 3 (P < 0.05), while no significant difference was observed between Groups 2 and 3 (P > 0.05) in Table 2.
Table 2. The MAS scores of the three groups of patients with spastic hemiplegia of the upper limb before treatment and after 4 weeks of treatment.
Group |
Number of Cases |
Before treatment |
After treatment |
t-value |
P-value |
Acupuncture group 1 |
30 |
3.04 ± 0.52 |
1.47 ± 0.68 |
12.20 |
<0.001 |
Acupuncture group 2 |
30 |
3.07 ± 0.58 |
2.33 ± 1.09 |
3.14 |
<0.05 |
Acupuncture group 3 |
30 |
3.05 ± 0.60 |
2.35 ± 1.03 |
2.45 |
<0.05 |
F-number |
|
1.986 |
11.44 |
|
|
P-value |
|
0.143 |
0.000 |
|
|
According to the results of the Student-Newman-Keuls (SNK) multiple comparison test, there were no statistically significant differences in the lower limb MAS scores among the three patient groups prior to treatment (P > 0.05), indicating that the groups were comparable at baseline. After four weeks of intervention, all three groups exhibited a reduction in lower limb MAS scores compared to their pre-treatment values (P < 0.05). Paired t-test analysis confirmed that these pre- and post-treatment changes in lower limb MAS scores were statistically significant (P < 0.05). Moreover, SNK multiple comparison further revealed that the MAS score in acupuncture group 1 was significantly lower than those in acupuncture group 2 and group 3 (P < 0.05), whereas no significant difference was observed between acupuncture group 2 and group 3 (P > 0.05) in Table 3.
Table 3. The comparison of MAS scores of patients with spastic hemiplegia of lower limbs before treatment and after 4 weeks of treatment in the three groups.
Constituencies |
Number of cases |
Before treatment |
After treatment |
t-value |
P-value |
Acupuncture group 1 |
30 |
1.91 ± 0.48 |
0.84 ± 0.24 |
10.95 |
<0.001 |
Acupuncture group 2 |
30 |
1.88 ± 0.48 |
1.32 ± 0.31 |
7.043 |
<0.001 |
Acupuncture group 3 |
30 |
1.92 ± 0.49 |
1.36 ± 0.33 |
5.37 |
<0.001 |
F-number |
|
0.052 |
9.135 |
|
|
P-value |
|
0.949 |
<0.000 |
|
|
3.2. Comparison of FMA Scores among the Three Patient Groups before and after Treatment
The SNK multiple comparison test indicated that there were no statistically significant differences in baseline FMA scores among the three patient groups prior to treatment (P > 0.05), confirming group comparability. After four weeks of treatment, FMA scores in all groups increased significantly compared to baseline (P < 0.05), with paired t-test results demonstrating statistically significant improvements in FMA scores pre- and post-treatment (P < 0.05). Furthermore, the SNK multiple comparison test revealed that Group 1 (acupuncture) exhibited significantly higher post-treatment FMA scores than both Group 2 and Group 3 (P < 0.05), while no significant difference was observed between Group 2 and Group 3 (P > 0.05). Detailed results are presented in Table 4.
Table 4. The comparison of FMA before and after treatment of patients with spastic hemiplegia after stroke in the three groups (scores,
± S).
Group |
Number of examples |
Before treatment |
After treatment |
t-value |
P-value |
Acupuncture 1 group |
30 |
40.34 ± 13.21 |
70.45 ± 6.78 |
8.752 |
<0.001 |
Acupuncture 2 group |
30 |
39.89 ± 14.01 |
55.31 ± 9.49 |
5.173 |
<0.001 |
Acupuncture 3 group |
30 |
40.25 ± 13.11 |
52.69 ± 9.68 |
3.682 |
<0.001 |
F-number |
|
0.471 |
7.29 |
|
|
P-value |
|
0.626 |
0.001 |
|
|
3.3. Comparison of MBI Differences among the Three Patient Groups before and after Treatment
According to the results of the Student-Newman-Keuls (SNK) multiple comparison test, there were no statistically significant differences in pre-treatment MBI scores among the three groups (P > 0.05), confirming baseline comparability. After four weeks of treatment, MBI scores in all groups showed significant increases compared to baseline (P < 0.05). Paired t-test analysis further indicated that these pre- and post-treatment changes in MBI scores were statistically significant (P < 0.05). Additionally, SNK multiple comparison revealed that Group 1 (acupuncture) exhibited significantly higher post-treatment MBI scores than both Group 2 and Group 3 (P < 0.05), while no significant difference was observed between Groups 2 and 3 (P > 0.05). Details are presented in Table 5.
Table 5. The comparison of MBI before and after treatment of patients with spastic hemiplegia after stroke in the three groups (scores,
± S).
Group |
Number of Cases |
Before treatment |
After treatment |
t-value |
P-value |
Acupuncture group 1 |
30 |
38.63 ± 16.78 |
89.08 ± 14.51 |
14.946 |
<0.001 |
Acupuncture group 2 |
30 |
38.36 ± 16.91 |
63.15 ± 14.41 |
5.452 |
<0.001 |
Acupuncture group 3 |
30 |
37.99 ± 16.87 |
59.39 ± 14.55 |
4.50 |
<0.001 |
F-number |
|
0.265 |
47.17 |
|
|
P-value |
|
0.768 |
<0.000 |
|
|
3.4. Results Comparison of Overall Efficacy Rates among the Three Groups
The overall efficacy rate in acupuncture group 1 was significantly higher than that in acupuncture group 2 (P < 0.05), and also significantly higher than that in acupuncture group 3 (P < 0.05). In contrast, no statistically significant difference was observed in the overall efficacy rates between acupuncture group 2 and acupuncture group 3 (P > 0.05). Detailed data are presented in Table 6.
Table 6. No statistically significant difference observed in the overall efficacy rates between acupuncture group 2 and acupuncture group 3 (P > 0.05).
Group |
Number of Cases |
Basic Healing (Example) |
Significant progress (examples) |
Progress (example) |
Invalid (example) |
Overall effective rate (%) |
Acupuncture group 1 (Qihuang group) |
30 |
10 |
12 |
15 |
3 |
90 |
Acupuncture 2 sets (0.35 × 40 mm) |
30 |
8 |
5 |
8 |
10 |
66.6 |
3 groups of acupuncture (0.25 × 40 mm) |
30 |
3 |
4 |
12 |
11 |
63 |
Note: The χ2 test results indicated a statistically significant difference in the efficacy rates among the three needle types for treating post-stroke spastic hemiplegia (χ2 = 4.812, P < 0.05). Specifically, the efficacy rate in acupuncture group 1 was significantly higher than that in acupuncture group 2 (χ2 = 5.963, P < 0.05), and also higher than that in acupuncture group 3. However, there was no statistically significant difference in efficacy rates between acupuncture group 2 and group 3 (χ2 = 0.073, P > 0.05).
4. Discussion
The present study was designed to compare the therapeutic efficacy of different acupuncture needles in the management of post-stroke spastic hemiplegia, with the aim of providing scientific evidence to inform needle selection for patients with post-stroke hemiplegia. The findings indicate that all three groups—acupuncture group 1 (Qihuang needle, 0.540 mm), acupuncture group 2 (0.3540 mm), and acupuncture group 3 (0.25 × 40 mm)—were effective in alleviating symptoms of post-stroke spastic hemiplegia. Notably, the Qihuang needle group demonstrated superior outcomes in terms of motor function, activities of daily living, and muscle tone when compared to the two groups utilizing thinner conventional needles. However, no significant difference was observed between the two conventional acupuncture groups, suggesting that minor differences in needle diameter may not translate into discernible differences in clinical efficacy. The use of the larger-diameter, single-use sterile Qihuang needle resulted in a marked improvement in patient symptoms, whereas the therapeutic effects of conventional needles with only slight diameter differences were comparable. The superiority of the Qihuang needle may be attributed not only to its larger diameter and increased stimulation but also to its functional resemblance to the small needle-knife. Beyond acupoint stimulation, the Qihuang needle is employed with the Hegu puncture technique, which facilitates the release of soft tissue adhesions and enhances local blood circulation, thereby contributing to reduced muscle tone and alleviation of spasticity [8]. Before treatment, factors such as age, gender, course of the disease, type of stroke, MAS scores, FMA scores, and Barthel scores were statistically comparable across the groups (P > 0.05), indicating these factors did not affect the differences in treatment outcomes. However, the presence of comorbidities like hypertension, diabetes, and hyperlipidemia in stroke patients could influence the specific effects of acupuncture in improving post-stroke spasticity.
The origins of acupuncture therapy can be traced back to the Stone Age, as documented in Shuowen Jiezi: “Bian refers to treating diseases by pricking with stones” [9]. According to the Huangdi Neijing, needles were classified and named—such as round needle, spoon needle, lance needle, sharp needle, sword needle, round-sharp needle, long needle, filiform needle, and large needle—based on their distinct therapeutic functions [10]. By the Ming and Qing dynasties, only filiform and sharp needles remained in clinical use [11]. As manufacturing techniques advanced, needle production became increasingly sophisticated. In 1953, Cheng Dan’an established China’s first national needle manufacturing plant, which standardized the shape, size, and length of filiform needles, thus enabling industrial-scale production. Following this standardization, clinicians typically selected filiform needles of varying lengths according to anatomical location, pain threshold, or clinical experience, often overlooking the significance of needle thickness. The morphology of acupuncture needles is a critical determinant of therapeutic efficacy. Presently, the use of filiform needles is characterized by uniform morphology, whereas other acupuncture techniques employ a wider variety of needle forms [12]. The choice of needle should be tailored to the specific pathology: thick fire needles are suitable for incision and pus drainage, long needles can reach areas inaccessible to short needles, and small needle knives can release tissue adhesions beyond the capability of standard filiform needles. However, most modern acupuncturists rely solely on standard filiform needles, which may diminish the therapeutic benefits associated with other needle types. In the author’s view, the clinical efficacy of acupuncture is closely linked to the technique of needle manipulation, the diameter of the needle, and the physical characteristics of the applied stimulus. Factors such as the mechanical properties of the instrument (geometric configuration), the mechanical dynamics of the needling process (amplitude, frequency, velocity changes), and the physical properties of the target tissue all significantly influence the biomechanical process and therapeutic outcomes of acupuncture [13]. The Qihuang needle, with its larger diameter, more readily elicits the characteristic sensations of soreness, numbness, distension, and heaviness (deqi), delivers a stronger mechanical stimulus, effectively activates local sensory receptors, enhances neural signal transmission, and better modulates neuromuscular function. Xie Yufeng et al. [14] demonstrated that, in the treatment of cervicogenic headache, filiform needles with a diameter of 0.45 mm provided superior improvements in short-form McGill pain questionnaire scores compared to 0.3 mm needles. Thicker needles deliver greater stimulation, more effectively activate local meridian qi, promote the circulation of qi and blood, and can facilitate the release of adhesions, thereby yielding enhanced therapeutic effects.
It is well recognized that the therapeutic efficacy of acupuncture is intimately associated with various factors, including manipulation techniques, characteristics of the needles (such as length, diameter, and shape), and the duration of needle retention. The present study specifically investigates the clinical efficacy of acupuncture using needles of varying diameters. In clinical practice, achieving therapeutic outcomes through acupuncture is not solely dependent on maximizing the intensity of stimulation; rather, the degree of stimulation should be judiciously tailored to the patient’s age, physical constitution, type of disease (whether involving meridians or internal organs), and specific syndrome differentiation [15]. It should be emphasized that the present study is limited by its small sample size and the absence of a multicenter research design. Therefore, the efficacy of larger-diameter needles in patients recovering from ischemic stroke warrants further validation through larger-scale clinical studies. Considering acupuncture’s sustained effects is crucial for its clinical utility. Given our study’s current limitations, we plan to increase the frequency of rehabilitation assessments in future studies, evaluating MAS, simplified FMA scores, and Barthel scores at 3 and 6 months post-intervention to compare differences at various time points against the end of the intervention.
Funding
Heyuan City Science and Technology Program Project Application Project, Project Number: 220926151602090.