Anything with integrative in the title is suspect as quackery. Massage is not integrative, it is already scientific.
Rehabilitation of Post-stroke Hemiplegic Patient with Integrative Medicine
Kittiphum Ruangravevat, M.Sc., M.D.1
, Siraprapa Veerapattananon, M.Sc., M.D.1
, Sulakkana Noiprasert, Ph.D., M.D.1
,
Watchara Rattanachaisit, M.D.2
, Parichart Hongsing, Ph.D., ATTM.3
1 Department of Traditional Chinese Medicine, School of Integrative Medicine, Mae Fah Luang University,
Chiang Rai 57100, Thailand
2 Chiang Rai Prachanukroh Hospital, Chiang Rai 57000, Thailand
3 Department of Applied Thai Traditional Medicine, School of Integrative Medicine, Mae Fah Luang University,
Chiang Rai 57100, Thailand
Received 4 March 2021 • Revised 4 April 2021 • Accepted 14 April 2021 • Published online 1 May 2021
as problems with balance or coordination, weakness, and paralysis. We describe a case
in which use of integrative medicine rehabilitation for a 52-year-old female patient with
ischemic stroke suffered a right hemiplegia, resulting in persistent weakness and problems
with muscle control. The patient underwent sequential three healing processes including
physical therapy, Thai traditional massage, and acupuncture in total of 10 times, at 2 times per
week by professional practitioners. After management with this rehabilitation program, the
patient had better effects on stroke recovery evaluating by The Barthel index for activities of
daily living, Mini-Mental Status Examination (MMSE) Thai 2002 and muscle power grading.
The outcomes of the study evidence that comprehensive integrative medicinal rehabilitation
approach has multiple effects on individuals who have poststroke disability or weakness to
confer greater rehabilitative benefit.
Keywords: Rehabilitation, Poststroke, Acupuncture, Thai traditional massage
Introduction
Cerebrovascular disease or stroke
has become the top three leading cause of
mortality in non-communicable diseases
which is also the cause of disability in Thai
population1
. Ischemic stroke is the common
type of stroke which can be found in elderly
people as the report of the Thai Stroke
Registry indicating that the mean age of
patients at the onset of ischemic stroke in
Thailand is around 65 years old2
. Stroke
survivors with mobility limitation, motor
dysfunction, cognitive impairment, and
poststroke depression are unable to live
independently because of disability and
leading to physical, emotional, social, and
financial problems leading to the dramatic
impact on their quality of life (QOL)3
. Thus, the poststroke rehabilitation therapy is
recommended to improve the daily activities
and quality of life of these patients.
Ischemic stroke is a major type of
stroke in Thai population which causes by a
blockage in an artery that supplies blood to
the brain, leading to damage or even death
of brain cells4
. The damage of brain cells
typically impacts limbs and facial muscles
of stroke survivors. It’s often accompanied
by muscle pain, seizures, spasticity and
atrophy5
. The clinical study has shown that
the use of herbal medicine and acupuncture
along with conventional rehabilitation
can reduce injury level and exert a neuroprotective role in ischemic stroke patients6
.
In addition, acupuncture and Thai traditional
massage have been reported to stimulate
the sensory via multiple efferent pathways
of neural systems7, 8. However, early movement and exercise from physical therapy is
recommended to prevent a long-term
disability and promoting of neural function9
.
This case report demonstrated use of
physical therapy (conventional rehabilitation) together with Thai traditional massage
and acupuncture in a female patient suffered
from stroke. After management with
integrative approach, the patient’s neurological condition, mobility and balance have
improved drastically without significant side
effects.
Case Presentation
A poststroke 52-year-old female
(body weight, 86 kg; height, 158 cm) was
diagnosed with ischemic stroke which
caused her to have a right hemiplegia. Seven
months before stroke, she was a physically
active person, but suddenly had experienced
right-sided weakness and she was admitted
to the nearby hospital within 4 hours. After
discharge from the hospital, she visited
the local hospital for exercise therapy by
physiotherapists; however, there was no
significant improvement. Therefore, she
decided to come to Mae Fah Luang University
Hospital for rehabilitation at brain and
neurology department by integrative
medicine with a chief complaint of rightsided paralysis. She had a history of
hypertension as well as hyperlipidemia and
the physician prescribed her Enalapril 5 mg
and Simvastatin 10 mg per a day as the
antihypertensive and antihyperlipidemic
drugs, respectively. At the first visit, she
could not move her right-sided upper and
lower limbs, but she could smile and raise
her eyebrows symmetrically. She denied
a severe headache or visual disturbances.
She had a hard time for information intake
and processing such as slow thinking when
compared to the pre-stroke time. She could
communicate by talking and writing with
her left hand. The patient had elevated blood
pressure at the first to third time of visiting,
after that she had normal vital signs when
visited for the rehabilitation program.
Investigation
Blood chemistry tests were examined
at the first and tenth time of the rehabilitation program, including HbA1c, eAG,
fasting plasma glucose, total cholesterol,
triglycerides, LDL-cholesterol, and
HDL-cholesterol. The Barthel index for
activities of daily living, Mini-Mental
Status Examination (MMSE) Thai 2002
and muscle power grading were evaluated
at the first, fifth and tenth time of the
rehabilitation program.
Treatment
The rehabilitation program was
designed by the hospital for disability
patients after stroke by integrating three
medical professional fields including
physical therapy, applied Thai traditional
medicine and traditional Chinese medicine.
The patients with disability after stroke
(less than a year) who don’t need any
intensive care monitoring by physicians
with medically stable can apply for this
integrative medicine rehabilitation program.
In this study, all the techniques for the
treatments were accepted as clinical care.
The combination of three healing processes
were delivered to the patient in the same
sequence for ten times, two times per
week. Initiation of the activity began with
a physical therapy including exercise in
the hospital gym with some equipments to
improve mobility coordination, strengthen
muscles and regain range of motion. This
session was last for an hour under the
supervision and monitoring by physiotherapists. In the next session, the patient received
Thai traditional massage (Table 1). Following
this, a hot herbal compress was applied to
the same massage areas for approximately
40 min. The main ingredient of the herbal
compress is Zingiber cassumunar rhizome.
After that, the patient was taken through the
regime of traditional Chinese medicine using
acupuncture. The 0.25x40 mm fine needles
were inserted into specific 11 acupuncture
points (Table 2) based on YangMing
meridian lines and Dumai channel of the
weak or painful area for 30 min.
Table 1 Step, area and duration of Thai traditional massage treatment
Step Area and duration
1 Apply pressure on the right leg (beginning from lower leg to upper leg then
return to lower leg) and right ankle (press at anterior of ankle joint) for 6 min
2 Apply pressure on the back (along erector spinae muscle from L5 to C7) for 9 min
3 Apply pressure on the lateral side of the right leg (beginning from gluteal area
to lateral side of upper and lower leg) for 5 min
4 Apply pressure on the medial side of the right leg (beginning from medial side
of upper leg to lower leg) for 5 min
5 Apply pressure on the medial side of the right arm (beginning from middle of
medial side of upper arm to anterior of wrist) for 5 min
6 Apply pressure on the lateral side of the right arm (beginning from middle of
lateral side of upper arm to middle of lower arm) for 5 min
7 Apply pressure on the right shoulder (upper part of back at posterior shoulder)
for 5 min
8 Apply pressure on the right shoulder (lateral side of lower neck and posterior of
shoulder) for 5 min
Table 2 Eleven acupuncture points and areas
Point Areas
BaiHui Insert the needle at the top of the head at midpoint of the posterior
hairline.
TongTian Insert the needle at the midline of the anterior hairline, lateral to the
midline.
Point Areas
FengFu Insert the needle at the midline of the nape of the neck, above the
midpoint of the posterior hairline.
JianYu Insert the needle at the upper border of the deltoid muscle, in the anterior
border of the acromion of the right arm.
QuChi Insert the needle at the midpoint between the lateral end of the transverse
cubical crease and the lateral epicondyle of the humerus of the right arm.
WaiGuan Insert the needle at the dorsal aspect of the forearm, above the transverse
crease of the dorsum of the wrist of the right arm.
HeGu Insert the needle at the dorsum of the hand, midway between thumb
and point fingers of the right hand
HuanTiao Insert the needle at the junction of lateral 1/3 and medial 2/3 of the line
linking the prominence of greater trochanter and the sacro-coccygeal
hiatus of the right buttock.
YangLingQuan Insert the needle at the depression anterior and inferior to the small
head of the fibula of the right leg.
ZuSanLi Insert the needle at the lateral to the anterior crest of the tibia of the
right leg.
JieXi Insert the needle at the midpoint of the transverse crease of the ankle
joint, between the tendons of m. extensor digitorum longus and hallucis
longus of the right leg.
Results
After the patient completed five weeks
of the program, most of her blood chemistry
profiles were at normal range at the tenth
time of the program, except HbA1c (6.5%),
eAG (140.8 mg/dL), fasting plasma glucose
(109 mg/dL) (Table 3). Therefore, she was
recommended to the physician to monitor
and manage her diabetes. Additionally,
she was managed to continue with
antihypertensive and antihyperlipidemic
drugs including Enalapril 5 mg and
Simvastatin 10 mg per a day to reduce
long-term cardiovascular as well as
cerebrovascular mortality and morbidity
after stroke10. The evaluations of Barthel
index and muscle power grading revealed
her improvement, especially the weakened
right-sided leg and arm as shown in Table 4.
The Mini-Mental Status Examination
(MMSE-Thai 2002) indicated the normality
of her cognitive function at the end of the
program.
, Siraprapa Veerapattananon, M.Sc., M.D.1
, Sulakkana Noiprasert, Ph.D., M.D.1
,
Watchara Rattanachaisit, M.D.2
, Parichart Hongsing, Ph.D., ATTM.3
1 Department of Traditional Chinese Medicine, School of Integrative Medicine, Mae Fah Luang University,
Chiang Rai 57100, Thailand
2 Chiang Rai Prachanukroh Hospital, Chiang Rai 57000, Thailand
3 Department of Applied Thai Traditional Medicine, School of Integrative Medicine, Mae Fah Luang University,
Chiang Rai 57100, Thailand
Received 4 March 2021 • Revised 4 April 2021 • Accepted 14 April 2021 • Published online 1 May 2021
Abstract:
Numerous of stroke survivors are suffering from the body function impairments suchas problems with balance or coordination, weakness, and paralysis. We describe a case
in which use of integrative medicine rehabilitation for a 52-year-old female patient with
ischemic stroke suffered a right hemiplegia, resulting in persistent weakness and problems
with muscle control. The patient underwent sequential three healing processes including
physical therapy, Thai traditional massage, and acupuncture in total of 10 times, at 2 times per
week by professional practitioners. After management with this rehabilitation program, the
patient had better effects on stroke recovery evaluating by The Barthel index for activities of
daily living, Mini-Mental Status Examination (MMSE) Thai 2002 and muscle power grading.
The outcomes of the study evidence that comprehensive integrative medicinal rehabilitation
approach has multiple effects on individuals who have poststroke disability or weakness to
confer greater rehabilitative benefit.
Keywords: Rehabilitation, Poststroke, Acupuncture, Thai traditional massage
Introduction
Cerebrovascular disease or stroke
has become the top three leading cause of
mortality in non-communicable diseases
which is also the cause of disability in Thai
population1
. Ischemic stroke is the common
type of stroke which can be found in elderly
people as the report of the Thai Stroke
Registry indicating that the mean age of
patients at the onset of ischemic stroke in
Thailand is around 65 years old2
. Stroke
survivors with mobility limitation, motor
dysfunction, cognitive impairment, and
poststroke depression are unable to live
independently because of disability and
leading to physical, emotional, social, and
financial problems leading to the dramatic
impact on their quality of life (QOL)3
. Thus, the poststroke rehabilitation therapy is
recommended to improve the daily activities
and quality of life of these patients.
Ischemic stroke is a major type of
stroke in Thai population which causes by a
blockage in an artery that supplies blood to
the brain, leading to damage or even death
of brain cells4
. The damage of brain cells
typically impacts limbs and facial muscles
of stroke survivors. It’s often accompanied
by muscle pain, seizures, spasticity and
atrophy5
. The clinical study has shown that
the use of herbal medicine and acupuncture
along with conventional rehabilitation
can reduce injury level and exert a neuroprotective role in ischemic stroke patients6
.
In addition, acupuncture and Thai traditional
massage have been reported to stimulate
the sensory via multiple efferent pathways
of neural systems7, 8. However, early movement and exercise from physical therapy is
recommended to prevent a long-term
disability and promoting of neural function9
.
This case report demonstrated use of
physical therapy (conventional rehabilitation) together with Thai traditional massage
and acupuncture in a female patient suffered
from stroke. After management with
integrative approach, the patient’s neurological condition, mobility and balance have
improved drastically without significant side
effects.
Case Presentation
A poststroke 52-year-old female
(body weight, 86 kg; height, 158 cm) was
diagnosed with ischemic stroke which
caused her to have a right hemiplegia. Seven
months before stroke, she was a physically
active person, but suddenly had experienced
right-sided weakness and she was admitted
to the nearby hospital within 4 hours. After
discharge from the hospital, she visited
the local hospital for exercise therapy by
physiotherapists; however, there was no
significant improvement. Therefore, she
decided to come to Mae Fah Luang University
Hospital for rehabilitation at brain and
neurology department by integrative
medicine with a chief complaint of rightsided paralysis. She had a history of
hypertension as well as hyperlipidemia and
the physician prescribed her Enalapril 5 mg
and Simvastatin 10 mg per a day as the
antihypertensive and antihyperlipidemic
drugs, respectively. At the first visit, she
could not move her right-sided upper and
lower limbs, but she could smile and raise
her eyebrows symmetrically. She denied
a severe headache or visual disturbances.
She had a hard time for information intake
and processing such as slow thinking when
compared to the pre-stroke time. She could
communicate by talking and writing with
her left hand. The patient had elevated blood
pressure at the first to third time of visiting,
after that she had normal vital signs when
visited for the rehabilitation program.
Investigation
Blood chemistry tests were examined
at the first and tenth time of the rehabilitation program, including HbA1c, eAG,
fasting plasma glucose, total cholesterol,
triglycerides, LDL-cholesterol, and
HDL-cholesterol. The Barthel index for
activities of daily living, Mini-Mental
Status Examination (MMSE) Thai 2002
and muscle power grading were evaluated
at the first, fifth and tenth time of the
rehabilitation program.
Treatment
The rehabilitation program was
designed by the hospital for disability
patients after stroke by integrating three
medical professional fields including
physical therapy, applied Thai traditional
medicine and traditional Chinese medicine.
The patients with disability after stroke
(less than a year) who don’t need any
intensive care monitoring by physicians
with medically stable can apply for this
integrative medicine rehabilitation program.
In this study, all the techniques for the
treatments were accepted as clinical care.
The combination of three healing processes
were delivered to the patient in the same
sequence for ten times, two times per
week. Initiation of the activity began with
a physical therapy including exercise in
the hospital gym with some equipments to
improve mobility coordination, strengthen
muscles and regain range of motion. This
session was last for an hour under the
supervision and monitoring by physiotherapists. In the next session, the patient received
Thai traditional massage (Table 1). Following
this, a hot herbal compress was applied to
the same massage areas for approximately
40 min. The main ingredient of the herbal
compress is Zingiber cassumunar rhizome.
After that, the patient was taken through the
regime of traditional Chinese medicine using
acupuncture. The 0.25x40 mm fine needles
were inserted into specific 11 acupuncture
points (Table 2) based on YangMing
meridian lines and Dumai channel of the
weak or painful area for 30 min.
Table 1 Step, area and duration of Thai traditional massage treatment
Step Area and duration
1 Apply pressure on the right leg (beginning from lower leg to upper leg then
return to lower leg) and right ankle (press at anterior of ankle joint) for 6 min
2 Apply pressure on the back (along erector spinae muscle from L5 to C7) for 9 min
3 Apply pressure on the lateral side of the right leg (beginning from gluteal area
to lateral side of upper and lower leg) for 5 min
4 Apply pressure on the medial side of the right leg (beginning from medial side
of upper leg to lower leg) for 5 min
5 Apply pressure on the medial side of the right arm (beginning from middle of
medial side of upper arm to anterior of wrist) for 5 min
6 Apply pressure on the lateral side of the right arm (beginning from middle of
lateral side of upper arm to middle of lower arm) for 5 min
7 Apply pressure on the right shoulder (upper part of back at posterior shoulder)
for 5 min
8 Apply pressure on the right shoulder (lateral side of lower neck and posterior of
shoulder) for 5 min
Table 2 Eleven acupuncture points and areas
Point Areas
BaiHui Insert the needle at the top of the head at midpoint of the posterior
hairline.
TongTian Insert the needle at the midline of the anterior hairline, lateral to the
midline.
Point Areas
FengFu Insert the needle at the midline of the nape of the neck, above the
midpoint of the posterior hairline.
JianYu Insert the needle at the upper border of the deltoid muscle, in the anterior
border of the acromion of the right arm.
QuChi Insert the needle at the midpoint between the lateral end of the transverse
cubical crease and the lateral epicondyle of the humerus of the right arm.
WaiGuan Insert the needle at the dorsal aspect of the forearm, above the transverse
crease of the dorsum of the wrist of the right arm.
HeGu Insert the needle at the dorsum of the hand, midway between thumb
and point fingers of the right hand
HuanTiao Insert the needle at the junction of lateral 1/3 and medial 2/3 of the line
linking the prominence of greater trochanter and the sacro-coccygeal
hiatus of the right buttock.
YangLingQuan Insert the needle at the depression anterior and inferior to the small
head of the fibula of the right leg.
ZuSanLi Insert the needle at the lateral to the anterior crest of the tibia of the
right leg.
JieXi Insert the needle at the midpoint of the transverse crease of the ankle
joint, between the tendons of m. extensor digitorum longus and hallucis
longus of the right leg.
Results
After the patient completed five weeks
of the program, most of her blood chemistry
profiles were at normal range at the tenth
time of the program, except HbA1c (6.5%),
eAG (140.8 mg/dL), fasting plasma glucose
(109 mg/dL) (Table 3). Therefore, she was
recommended to the physician to monitor
and manage her diabetes. Additionally,
she was managed to continue with
antihypertensive and antihyperlipidemic
drugs including Enalapril 5 mg and
Simvastatin 10 mg per a day to reduce
long-term cardiovascular as well as
cerebrovascular mortality and morbidity
after stroke10. The evaluations of Barthel
index and muscle power grading revealed
her improvement, especially the weakened
right-sided leg and arm as shown in Table 4.
The Mini-Mental Status Examination
(MMSE-Thai 2002) indicated the normality
of her cognitive function at the end of the
program.
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