The effect of new scalp acupuncture on qi, 5 elements and acupuncture of meridians in patients with chronic stroke – pilot study

1.Student of the Graduate Program in Rehabilitation Sciences of the Institute of Motricity Sciences, Universidade Federal de Alfenas, Alfenas-MG, Brazil. ORCID: https://orcid.org/0000-0002-9510-0017 2.Professor of the Graduate Program in Rehabilitation Sciences of the Institute of Motricity Sciences, Universidade Federal de Alfenas, Alfenas-MG, Brazil. ORCID: https://orcid.org/0000-0002-1255-8429 3.Physical therapist graduated from the Universidade Federal de Alfenas, Alfenas-MG, Brazil. ORCID: https://orcid.org/0000-0002-3613-2916 4.Professor of the Graduate Program in Rehabilitation Sciences of the Institute of Motricity Sciences, Universidade Federal de Alfenas, Alfenas-MG, Brazil. ORCID: https://orcid.org/0000-0002-0672-7804 5.Professor of the Graduate Program in Rehabilitation Sciences of the Institute of Motricity Sciences, Universidade Federal de Alfenas, Alfenas-MG, Brazil. ORCID: https://orcid.org/0000-0001-6479-9550 6.Student of the Graduate Program in Rehabilitation Sciences of the Institute of Motricity Sciences, Universidade Federal de Alfenas, Alfenas-MG, Brazil. ORCID: https://orcid.org/0000-0002-7971-2400 7.Professor of the Physical Therapy at the Universidade do Vale do Sapucaí (UNIVAS), Pouso Alegre-MG, Brazil. OCID: https://orcid.org/0000-0001-8836-1094 8.Professor of the Graduate Program in Rehabilitation Sciences of the Institute of Motricity Sciences, Universidade Federal de Alfenas, Alfenas-MG, Brazil. ORCID: https://orcid.org/0000-0002-9959-3269


INTRODUCTION
Stroke is defined as the sudden interruption of cerebral vascular flow that leads to brain lesions and damage to neurological functions 1 . It is a major public health issue due to its high incidence and great impact on the population.
Stroke is one of the four leading causes of death worldwide, as well as one of the most disabling illnesses [2][3][4] .
Individuals affected by this condition often experience loss of autonomy, dependence in activities of daily living, and social disruption, possibly leading to a reduced quality of life [5][6] . Most survivors present residual sensory-motor deficits that interfere with the performance of functional activities [7][8][9] and are correlated to the lesion size, location, and area 10 .
Clinical studies that administered acupuncture therapy suggest that needle insertion reorganizes and balances chemical mediators, boosting brain function and consequently rebounding in sensory-motor and visceral responses, cognitive processes, sleep, and emotion [11][12][13] . In the East it involves stimulation at certain points, to flow Qi through the meridians. These effects comply with the philosophical principles of traditional Chinese medicine (TCM), whose goal is to restore the Yin-Yang balance 11 .
When administered after cerebral ischemia in rats, the electroacupuncture enhanced motor cortex excitability and enabled motor function recovery 14 .
According to Chinese thought, everything that exists in the universe has these two aspects: yin and yang. In  16 . By measuring the conductivity of each meridian, we can verify energetic excesses or deficiencies 17 .
The theory of the five elements (wood, fire, earth, metal, and water) is another aspect analysed in TCM, it serves to categorize all things in nature as well as correlate them to five physiological systems centred on the organs and viscera of the human body through the meridians (Livergallbladder; heart -small intestine; stomach -spleen; lung -large intestine and kidney -bladder) 16 .
Scalp acupuncture (SA) is a specialized acupuncture technique used to stimulate specific areas of the scalp, able to harmonize and regulate the functional activities of the brain and body 17 . A review with meta-analyses that included only clinical trials with ischemic stroke that applied AE bilaterally and unilaterally showed improvements in neurological deficits when compared to the control group 18 .
However, these were insufficient reports due to poor methodological quality. Two patients refused to participate in the study.

Assessment tools
The mini-mental state examination (MMSE), the Fugl-Meyer motor assessment scale (FMA), and electrodiagnostic instrument for energy profile were used for evaluation.

Mini-mental state examination (MMSE)
The MMSE was used to assess patients' cognitive abilities. This instrument allows cognitive assessment based on different parameters 20 , such as temporal orientation, spatial orientation, memory, attention and calculation, evocation, language, and visual-constructive ability. Its maximum score is 30 points, indicating a better cognitive ability 21 . MMSE cut-off score is adjusted by education level: for over 7 years of education, cut-off point is 28; from 4 to 7 years, it is 24; for 1 to 3 years, 23; and 19 for illiterate 22 .

Statistical Analysis
Descriptive statistics were used to characterize sample, mean, standard deviation, and percentage. The Shapiro-Wilk test and paired t-test were used to test data normality. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) v. 20.0. Table 1 shows the anthropometric and clinical data of the participants. We found a male predominance and a higher incidence of ischemic stroke.      Table 4 shows the values of the mean, standard deviation, and p value of the elements of organs and viscera of the studied population. There was a significant difference left LU (p=0,03), right PC (p=0.01), left SI (p=0.03), and right SP (p=0.00).

DISCUSSION
TCM characterizes the pathophysiology of stroke as the   In TCM, brain diseases are considered systemic, rather than disorders of a single organ, their treatment aims to normalize not only the organs, but also the balance of functional interaction between the organs 32 . Clinical research shows that application of AE (motor area) can increase cerebral blood flow, reduce the focus of infarction, and promote the establishment of cerebral collateral circulation 35,36 .
AE can increase the blood supply in the cerebral cortex, increases the metabolite level of brain cells, activates potential neurons, and promotes the formation of brain synapses 37 .
AE YNSA promotes improvement in function, pain, quality of life 38 and muscle tone, with activation in the motor cortex, premotor area, and supplementary motor area, in stroke patients 39 .
Yin represents decreased Qi activity, which suggests rest and negative polarity, indicating parasympathetic action 40 . It is noted in the present study, that this reduction of yin was found, suggesting better vagal action and energetic balance.
The fire element is a constituent of the 5 elements, characterized as hot, light, and movement 40 . The overload of this element may be the condition of the stroke patient 30 .
The result found in the present study, regarding this question indicated that the EA promoted a reduction of this element, suggesting an energy balance in this element.
Another variable addressed in this study was the organs and viscera, among them is LU, PC and SP. When there is a deficiency of Qi of these structures, it indicates symptoms of contracture or impotence of the muscles, and as for the SP, it indicates muscle fatigue and edema 41 . These data correlate to the characteristic clinical picture of the stroke. All these analyzed variables had a reduction after the application of YNSA EA.
The limitations found in the present study were absence of a control group -for a better comparison of the data, limited sample size -due to the difficulty in contacting the patients and difficulty in recruitment, and lack of use of the sensory-motor scale after the intervention. Follow-up and a longer time of intervention are suggested.
It is hoped that this study can generate a contribution for future research.

CONCLUSION
It is concluded that AE YNSA can promote Qi balance, reduction in the fire element and reduction in the action of some acupuncture meridians in chronic stroke patients in the analysed sample.