Acupuncture for dysphagia in acute stroke (Review)

Xie Y, Wang L, He J, Wu T

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 3
http://www.thecochranelibrary.com

Acupuncture for dysphagia in acute stroke (Review)

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Analysis 1.1. Comparison 1 Acupuncture versus control, Outcome 1 Recovery. . . . . . . . . . . . . . 18
Analysis 1.2. Comparison 1 Acupuncture versus control, Outcome 2 Markedly improved. . . . . . . . . . . 19
Analysis 1.3. Comparison 1 Acupuncture versus control, Outcome 3 Improved. . . . . . . . . . . . . . 19
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Acupuncture for dysphagia in acute stroke (Review) i

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Acupuncture for dysphagia in acute stroke

Yue Xie1 , Liping Wang1 , Jinghua He2 , Taixiang Wu3

1 Department of Acupuncture and Moxibustion, Huguosi Hospital of Traditional Chinese Medicine, Beijing, China. 2 Department
of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA. 3 Chinese Cochrane
Centre, Chinese EBM Centre, West China Hospital, Sichuan University, Chengdu, China

Contact address: Yue Xie, Department of Acupuncture and Moxibustion, Huguosi Hospital of Traditional Chinese Medicine, No. 83
Cotton Hu Tong, Xi Cheng Qu, Beijing, 100035, China. xie11022@hotmail.com.

Editorial group: Cochrane Stroke Group.

Publication status and date: New, published in Issue 3, 2008.
Review content assessed as up-to-date: 6 February 2008.

Citation: Xie Y, Wang L, He J, Wu T. Acupuncture for dysphagia in acute stroke. Cochrane Database of Systematic Reviews 2008, Issue
3. Art. No.: CD006076. DOI: 10.1002/14651858.CD006076.pub2.

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
Background
Dysphagia after acute stroke is associated with poor prognosis, particularly if prolonged. Acupuncture has been widely used for this
complication in China. However, its therapeutic effect is unclear.
Objectives
To determine the therapeutic effect of acupuncture for dysphagia after acute stroke compared with placebo, sham or no acupuncture
intervention.
Search strategy
We searched the Cochrane Stroke Group Trials Register (last searched September 2007), the Chinese Stroke Trials Register and the
Trials Register of the Cochrane Complementary Medicine Field (last searched January 2007) and the Cochrane Central Register of
Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2007). In January 2007 we searched the following databases from
the first available date; MEDLINE, EMBASE, CINAHL, AMED, CISCOM, BIOSIS Previews, ProQuest Digital Dissertations,
Science Citation Index, ISI Proceedings, ACUBRIEFS, ACP Journal Club, Books@Ovid and Journals@Ovid, Chinese Biological
Medicine Database, Chinese scientific periodical database of VIP INFORMATION, China periodical in China National Knowledge
Infrastructure, Chinese Evidence-Based Medicine Database, Science China, Chinese Social Science Citation Index, and the Chinese
Science and Technology Document Databases. We also searched databases of ongoing trials, conference proceedings, and grey literature,
handsearched three Chinese journals and contacted authors and researchers.
Selection criteria
We included all truly randomised controlled trials that evaluated the effect of acupuncture, irrespective of type, in patients with
dysphagia within 30 day after the onset of ischaemic or haemorrhagic stroke. All types of acupuncture interventions were eligible.
The control intervention could be placebo acupuncture, sham acupuncture, or no acupuncture. The primary outcome was recovery of
normal feeding. The secondary outcomes were case fatality, deterioration, late disability, length of hospital stay, quality of life, feeding
tube removal, aspiration pneumonia and nutritional measures.
Data collection and analysis
Two review authors independently selected trials, assessed trial quality, and extracted data. Disagreements were resolved by a third
review author.
Acupuncture for dysphagia in acute stroke (Review) 1
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results

Only one trial of 66 participants was included. In the acupuncture group, 12 out of 34 participants recovered to normal feeding
(35.3%). In the control group, seven out of 32 participants recovered to normal feeding (21.9%). The relative risk of recovery was 1.61
with a 95% confidence interval of 0.73 to 3.58. No statistical significance was detected.

Authors’ conclusions

There is not enough evidence to make any conclusion about the therapeutic effect of acupuncture for dysphagia after acute stroke.
High quality and large scale randomised controlled trials are needed.

PLAIN LANGUAGE SUMMARY

Acupuncture for dysphagia in acute stroke

Better designed clinical trials are needed to prove whether acupuncture is effective for treating swallowing difficulties in patients with
stroke. Patients who have swallowing difficulties (dysphagia) as a result of their stroke are less likely to survive and be free of disability than
stroke patients who can swallow normally. Acupuncture is commonly used to treat this complication in traditional Chinese medicine
practice. We systematically reviewed currently available evidence for the use of acupuncture in treating swallowing difficulties after
acute stroke. Only one small randomised controlled trial was identified, involving 66 participants, which did not provide clear evidence
of benefit from adding acupuncture to standard Western medical treatment. Considering the small sample size and methodological
imperfections, there is insufficient evidence to determine the effectiveness of acupuncture. More research is needed.

BACKGROUND
Cerebrovascular disease was the second leading causes of death
in 1990 as indicated in the Global Burden of Disease Study (
Murray 1997). Dysphagia is one of the most important stroke-re-
lated problems (Chen 2003b), particularly if prolonged. It is asso-
ciated with stroke severity, dysphasia and lesions of the frontal and
insular cortex on brain imaging (Iizuka 2005). Between 22% to
65% of acute stroke patients are affected, depending on the time
of assessment, the diagnostic method used, and case mix (Daniels
1999; Smithard 1996; Smithard 1998a). Dysphagia resolves in
most patients within one week to one month, and persists in only
a small number of patients beyond six months (Smithard 1998b).
Dysphagia suggests a poor prognosis, and increases the risk of
chest infection, malnutrition, persistent disability, prolonged hos-
pital stay, institutionalisation on discharge, and mortality (Gordon
1987; Paciaroni 2004).
Early dysphagia management may reduce the risk of aspiration
pneumonia and assure quality care with optimal outcomes (
Odderson 1995). Treatment techniques for dysphagia may be
categorised as: direct strategies, indirect strategies, compensatory
strategies (O’Neill 2000), gastrointestinal nutrition, medication
Acupuncture for dysphagia in acute stroke (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
and surgery. Direct strategies involve modifying the feeding posi-
tion, location of food in the mouth, food consistency and feed-
ing environment, such as cold stimulation (Logemann 1991). In-
direct strategies include stimulation of the oral and pharyngeal
structures without swallowing (Lazarra 1986), such as surface elec-
tromyographic (sEMG) biofeedback (Crary 2004), or transcuta-
neous electrical stimulation (TES). Compensatory strategies make
swallowing easier usually by changing the food’s path and learn-
ing special skills, such as turning head, chin-down, nodding-like
swallowing, exchanging swallowing, and swallowing air. Gastroin-
testinal nutrition is needed only when patients have difficulties in
acquiring sufficient nutrition and involves feeding via a nasogas-
tric tube (NGT) or percutaneous endoscopic gastrostomy (PEG)
feeding tube (PEGASUS 1998). Early tube feeding might reduce
case fatality but at the expense of increasing the proportion of pa-
tients surviving with poor outcome (FOOD 2005). Early gastros-
tomy feeding is associated with a significant reduction in six-week
mortality (Norton 1996), especially for older patients because it is
relatively less invasive than surgery (Sami 2005). However, more
recent data are less clear and do not support a policy of early
initiation of PEG feeding in dysphagic stroke patients (FOOD
2
2005). NGT was found to have a better outcome than feeding with
PEG tubes (Teasell 2005), while it offered only limited protection
against aspiration pneumonia (Dziewas 2004). In addition, in the
acute stroke unit, multidisciplinary practice (Kappelle 2004) in-
volving a decision-making algorithm for dietary management ap-
pears to be effective (Runions 2004). Hence, it seems prudent to
include dysphagia-specific management as part of standard proto-
cols in stroke management (EHTAG 1999).
Acupuncture therapy has been widely used to treat stroke and its
complications, for example, dysphagia in China for at least 2000
years. Attempts to treat dysphagia caused by other reasons were
also documented, which includes cerebral trauma (Zou 2004),
motor neuron disease (Zhao 1997a) and digestive system disease
(Zhao 2001). Dysphagia after stroke pertains to the categories of
radix lingua disease after wind stroke, yinfei, and larynx obstruc-
tion, and is characterised by local symptoms in the mouth, tongue,
pharynx, and larynx in traditional Chinese medicine (TCM).
It has been reported that many types of acupuncture, includ-
ing body acupuncture, scalp acupuncture, tongue acupuncture,
ear acupuncture, abdominal acupuncture, electroacupuncture, eye
acupuncture, wrist-ankle acupuncture, cutaneous needle and mox-
ibustion with warming needle, may have benefit. Whether single
or integrated acupuncture is applied, reports suggest the treatment
easy, safe, and economic. Improvement rates diagnosed by bedside
assessment of swallowing have been reported to be as high as 80%
to 100%; with end-of-study video fluorographic swallowing stud-
ies (VFSS) showing improvement (Nowicki 2003; Zhong 2003).
The mechanism of acupuncture for acute dysphagia still remains
unknown. It is presumed that acupuncture might reconstruct the
swallowing function by stimulating the diseased muscles, nerves,
tissues, or organs. Further, acupuncture could improve the verte-
brobasilar blood supply, blood rheology, rheoencephalogram and
blood microcirculation in pseudobulbar palsy (Jiang 1992; Shi
1999), and regulate the swallowing reflex by altering regional brain
activity (Seki 2003).
Acupuncture therapy is widely used for dysphagia in acute stroke in
China and many studies have been carried out. This review aimed
to review systematically all randomised controlled trials (RCTs),
which examined the therapeutic effect of acupuncture.
OBJECTIVES
To determine the therapeutic effect of acupuncture for dyspha-
gia after acute stroke when compared with placebo, sham or no
acupuncture intervention.
METHODS
Acupuncture for dysphagia in acute stroke (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Criteria for considering studies for this review
Types of studies
We included truly randomised controlled trials; we excluded quasi-
randomised trials.
Types of participants
We included participants within 30 days of ischaemic or haem-
orrhagic stroke onset, regardless of age, sex or severity of neuro-
logical deficit. Stroke was diagnosed by computerised tomography
(CT) or magnetic resonance imaging (MRI), and conformed to
the World Health Organization definition (that is, a focal neu-
rological impairment of sudden onset, and lasting more than 24
hours (or leading to death) and of presumed vascular origin) (
Hatano 1976). We excluded subarachnoid haemorrhage and sub-
dural haematoma. Dysphagia was diagnosed either clinically or
using videofluoroscopy. We excluded trials that recruited partici-
pants who had severe mental disorders, dementia, pulmonary or
cutaneous infections, or who were in such a poor condition as to
be unable to tolerate the stimulation of acupuncture. All partici-
pants had consented to the use of acupuncture.
Types of interventions
We included trials that compared any type of acupuncture ther-
apy with placebo, sham or no intervention (neither traditional
acupuncture nor contemporary acupuncture). We included both
traditional acupuncture, in which the needles are inserted in clas-
sical meridian points, and contemporary acupuncture, in which
the needles are inserted in non-meridian or trigger points, regard-
less of the source of stimulation (for example, ear acupuncture,
scalp acupuncture, abdominal acupuncture, wrist-ankle needle,
fire needle, moxibustion with warming needle, or electrical stim-
ulation, etc). We excluded studies of acupuncture treatment with-
out needling, such as point injection, acupressure, laser acupunc-
ture, tap-pricking or cupping on pricked superficial blood vessel.
Placebo acupuncture refers to a needle attached to the skin sur-
face (not penetrating the skin but at the same acupoints) (Furlan
2005). Sham treatment refers to: (1) needle pricking on the skin
surface (needles are placed close to but not in acupuncture points)
(Furlan 2005); or (2) subliminal skin electrostimulation via elec-
trodes attached to the skin (SCSSS 1999). We excluded trials com-
paring two or more forms of acupuncture without a control group
of placebo, sham or no intervention.
Types of outcome measures
Information on the following outcome measures were sought for
each trial.
3
Primary outcome measure
• Resolution of dysphagia (is defined as recovery of normal
feeding, which includes solid food and water, but does not
include pureed food)
Secondary outcome measures
• Case fatality
• Deterioration (within four weeks), judged by a stroke
neurological impairment scale
• Late disability, assessed using an activities of daily living
(ADL) scale
• Length of hospital stay
• Quality of life
• Numbers of participants who were originally on feeding
tubes, who, after treatment, were able to increase their intake of
food and liquid sufficiently to no longer need a feeding tube
• Aspiration pneumonia, determined clinically or
radiographically
• Nutritional measures, for example, weight, arm
circumference, serum albumin
Search methods for identification of studies
See: ’Specialized register’ section in Cochrane Stroke Group
Electronic databases
We searched the Cochrane Stroke Group Trials Register, which
was last searched by the Review Group Co-ordinator in September
2007, the Chinese Stroke Trials Register and the Trials Register
of the Cochrane Complementary Medicine Field (last searched
January 2007) and the Cochrane Central Register of Controlled
Trials (CENTRAL) (The Cochrane Library Issue 2, 2007). In ad-
dition, in January 2007 we searched:
• MEDLINE (1966 to January 2007) (Appendix 1)
• EMBASE (1980 to January 2007)
• CINAHL (Cumulative Index to Nursing and Allied Health
Medicine) (1982 to January 2007)
• AMED (Allied and Alternative Medicine Database) (1985
to January 2007)
• CISCOM (the research database of the Research Council
for Complementary Medicine)
• BIOSIS Previews (1969 - January 2007)
• ProQuest Digital Dissertations
• Science Citation Index (1945 to January 2007)
• ISI Proceedings (1990 to January 2007)
• ACUBRIEFS (http://www.acubriefs.com/)
• ACP Journal Club (1991 to January 2007)
• Books@Ovid and Journals@Ovid Full Text
Acupuncture for dysphagia in acute stroke (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• Chinese Biological Medicine Database (CBM-disc, 1978 to
January 2007)
• Chinese scientific periodical database of VIP
INFORMATION (1989 to January 2007)
• Full text database of China periodicals in China National
Knowledge Infrastructure (CNKI), from their first publication
date to January 2007
• Chinese Evidence-Based Medicine Database
• Science China (1985 to January 2007)
• Chinese Social Science Citation Index (1998 to January
2007)
• Chinese Science and Technology Document Databases
(CSTDB) 1980 to January 2007 (http://www.wanfangdata.com)
We also searched the following databases of ongoing trials, con-
ference proceedings and grey literature.
• The Stroke Trials Directory (http://www.strokecenter.org/
trials/)
• The National Centre for Complementary and Alternative
Medicine (http://www.nccam.nih.gov/clinicaltrials/)
• The National Institute of Health Clinical Trials Database
(http://www.clinicaltrials.gov/)
• Current Controlled Trials (http://www.controlled
trials.com)
• The National Research Register (NRR) Issue 2, 2007
• China Medical Academic Conference (CMAC 1994 to
January 2007) in CMCC
• Full text database of Chinese M.D. & D.D. Dissertations
in CNKI, 1999 to January 2007
• Chinese Academic Conference Papers database (CACP)
1986 to January 2007 (http://www.wanfangdata.com)
• Chinese Dissertations database (CDDB) 1977 to January
2007 in Wanfang Data Chinainfo (http://
www.wanfangdata.com)
Handsearching
The following journals published in Chinese were hand searched
from their first publication date onwards to 2007.
• Acupuncture Research (1976 to January 2007)
• JTCM (Journal of Traditional Chinese Medicine) (1960 to
January 2007)
• New Journal of Traditional Chinese Medicine (1969 to
January 2007)
We also searched the following conference proceedings relevant to
this topic, published in Chinese.
• Annual Clinical Conference sponsored by China
Association for Acupuncture and Moxibustion (1982 to 2007)
• Superior seminar of diagnosis and treatment on
neurological disease (2005 to 2007)
• Tiantan International Stroke Conference (2004 to 2007)
4
In an effort to identify further published, unpublished and on-
going trials we searched the reference lists from trials and review
articles identified by electronic searching. We contacted authors of
identified studies and asked then to notify us of any known trials
and we also searched the Internet .
The electronic databases and references from published studies
were searched in English or Chinese, while searches of the unpub-
lished literature and journal handsearches were performed only in
Chinese.
References from published studies
The reference lists from trials and review articles selected by elec-
tronic searching were handsearched to identify further relevant
trials. Authors of identified studies were asked to notify us of any
known published or unpublished work.
Unpublished literature
Unpublished and on-going trials were identified by correspon-
dence with authors and from Internet searches.
The electronic databases and references from published studies
were searched in English or Chinese, while the unpublished liter-
ature and hand search were performed only in Chinese because no
reviewer knows other language except for English and Chinese.
Data collection and analysis
Data extraction
Two review authors (XY, WL) independently assessed all studies.
The same two review authors independently extracted eligible data
from the trial reports on to a data extraction form, cross-checked
the data, and entered them into the Review Manager software
(RevMan 4.2). We obtained missing data from the principal in-
vestigators of the trials where possible. We resolved disagreements
by discussion with a third review author (HJ). All review authors
were blinded to the identity of the groups that published the stud-
ies.
Quality assessment
We extracted the following information: randomisation process,
allocation concealment, blinding, participant dropout and loss to
follow up, intention-to-treat analysis, and explicit diagnostic and
outcome criteria. Two review authors decided which trials met
the inclusion criteria. Allocation concealment was coded as A -
adequate, B - unclear, or C - inadequate, according to the Cochrane
Handbook for Systematic Reviews of Interventions.
Blinding was not a prerequisite selection criterion, but was assessed
by: (1) whether the method of blinding was described, and (2)
Acupuncture for dysphagia in acute stroke (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
which method of blinding was used. We recorded three methods
of blinding: single, double and triple blind. They were defined
as any one, two or all three groups of participant, acupuncturist,
and assessor being blinded, respectively, and (3) we calculated the
Jadad score to assess the quality of blinding (Jadad 1996).
We only included a study when the dropout and lost to follow-
up rates were less than or equal to 10%; we regarded those whose
rates were over 10% as failed trials and excluded them (Wang
2001). We described any trials without long-term follow up in the
’Description of studies’ section.
We included trials with non-acupuncture co-interventions, such as
Western medicine, or rehabilitation, applied to both control group
and treatment group equally; otherwise we excluded confounded
trials. We sought clarification from study authors if studies initially
included did not have clear descriptions of the methodology used.
If we were unable to contact the study authors, we added the
studies to the ’Studies awaiting assessment’ section. We excluded
studies if the study authors refused or were unable to give detailed
methodological information.
Data synthesis
We used Review Manager (RevMan 4.2) for the statistical analysis.
Selection of the effect size
We expected the randomised trials to measure both event (di-
chotomous) data and continuous data. Continuous data were ex-
pressed as mean differences (MD) or standard mean differences
(SMD). Dichotomised data were expressed as relative risks (RR).
Dichotomised data were incorporated with two levels if more ranks
appeared, such as the improved cases and cured cases as a new re-
sult, and the numbers of no improvement and little improvement
as the other. All their variabilities were expressed as 95% confi-
dence intervals (CI).
Tests for heterogeneity
We planned to assess heterogeneity using the I-squared (I2 ) statistic
according to the clinical characteristics of participants and inter-
ventions, with a value greater than 50% indicating substantial het-
erogeneity. If no substantial statistical heterogeneity was present,
we planned to synthesise the data using a fixed-effect model. Oth-
erwise we would have used a random-effects model in the meta-
analysis.
Subgroup analyses
If a sufficient number of randomised trials are identified in future,
we plan to use the I2 statistic in the subsets of trials to describe
the percentage of variability in the effect estimates that are due
to heterogeneity, then use the method outlined by Deeks et al (
Deeks 2001) to perform the following subgroups analyses relating
5
to: (1) acupuncture versus placebo; (2) acupuncture versus sham
treatment; (3) acupuncture versus no intervention.
Sensitivity analyses
If possible, we planned to perform sensitivity analyses in order to
explore the influence of the following factors on effect size:
(1) repeat the analysis excluding unpublished studies;
(2) repeat the analysis restricting studies to particular languages of
publication or particular countries.
Publication bias analyses
We plan to examine potential publication bias using a funnel plot (
Egger 1997) when enough eligible randomised trials are identified.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of ongoing studies.
We found 187 studies involving dysphagic stroke and acupunc-
ture therapy through electronic and handsearches. Only one was
included in this review. We excluded 126 studies immediately be-
cause some, if not all, of the participants were post-acute stroke
patients. Of these excluded studies, 20 included stroke patients
in the convalescent and sequel stages, 106 included mixed patient
groups and data were not presented separately for those in the
acute phase.
Twenty-eight did not specify the stroke phase of participants and
we excluded them for the following reasons: (1) 13 studies did not
have any control groups, (2) two studies compared different meth-
ods of acupuncture, (3) two studies were not randomised trials,
one allocated participants in accordance with their own choice,
the other enrolled treatment group participants from both clinic
and hospital admissions whereas control group participants were
enrolled only from clinics, which had been clarified by the investi-
gators through telephone correspondence, (4) one study compar-
ing point injection with acupuncture had a significant proportion
of participants enrolled after 30 days of stroke onset, which we
had confirmed with the investigator through telephone correspon-
dence, (5) six studies were confounded by other interventions, for
example rehabilitation exercise or point injection, (6) three studies
assessed rehabilitation exercise after acupuncture therapy, and (7)
one study listed evidence of all stroke phases in the results, indi-
cating that participants were not only acute stroke patients.
Thirty-three potentially eligible studies of acute dysphagic stroke
were identified; for more information see the ’Characteristics of
included studies’, the ’Characteristics of excluded studies’, and
Acupuncture for dysphagia in acute stroke (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
the ’Characteristics of ongoing studies’. One study is awaiting
assessment (Seki 2005).
We excluded 29 studies from the review for the following reasons:
(1) no control group was used (Bi 2004; Chen 2004; Hu 2005;
Lian 2003; Ma 2003; Wang 2003a; Wang 2004; Wei 1995; Zhao
1997b), (2) two studies compared different methods of acupunc-
ture (Bai 2007; Wang 2003b), (3) randomisation was inappro-
priate, which had been clarified by the investigators through tele-
phone correspondence (Chen 2003; He 2002; Liu 1998; Su 2004;
Wang 2003c; Xu 2001), (4) the effect of acupuncture was con-
founded by other interventions, which were traditional Chinese
herbs (Fu 2000; Liu 2004b), bloodletting (Yang 2001; Zhang
2004), hyperbaric oxygen (Zhong 2005) and rehabilitation (Fu
2004; Liu 2003; Xue 2004), (5) the dropout rate was more than
20% during the treatment period (Liu 2004a), (6) duplicate pub-
lications (Liu 2000; Yang 2002), (7) the assessed intervention was
not acupuncture (Liao 2005).
Studies included in the review
Only one trial including 66 participants met the criteria for inclu-
sion for this review (Han 2004).
Design
The included study was a single centre, randomised, open label,
controlled trial with a parallel design. Only assessors were blinded
to the intervention, so we assessed the trial as low quality based
on a Jadad score of 2 (Jadad 1996).
Participants
The included study was conducted in China. The 66 participants
were between 48 hours and six days after stroke onset (mean dura-
tion of 4.3 days). Their ages ranged from 41 to 79 years old with a
mean of 62.1 years old. Sixty-two per cent were male. The stroke
diagnosis was based on the revised definition from the Forth Chi-
nese Academic Conference on Cerebral vascular Diseases, which is
consistent with the World Health Organization definition. The di-
agnoses were confirmed by skull computerised tomography (CT)
scan concurrently.
The trial included 61 cerebral infarction patients and five cerebral
haemorrhage patients. Among the infarction patients, 23 cases
were brainstem infarction, 38 cases were involved in the brain-
stem, seven cases were combined with cerebellar infarction, 29 pa-
tients had recurring strokes. None of the participants had obvious
dysgnosia. Forty-five and 21 participants had complete and partial
bulbar palsy, respectively, which means both lower brainstem palsy
and pseudobulbar palsy. Forty-one complete bulbar palsy patients
and 16 partial bulbar patients also had hemiplegia. Among all the
participants, 62 also had facial paralysis, 61 had lingual paralysis,
and 11 had forced cry-laugh.
6
Intervention
The study compared standard Western medical treatment plus
acupuncture with standard Western medical treatment only. For
more information about the acupuncture technique, see ’Charac-
teristics of included studies’. Both the acupuncture and control
groups received nasogastric feeding as well.
Outcome measurement
The outcomes were evaluated by bedside assessment immediately
after three treatment sessions, and categorised into five grades ac-
cording to the clinical symptoms and signs of bulbar palsy, which
were (1) recovery, (2) markedly improved, (3) improved, (4) no
improvement, and (5) deterioration. There was no information
regarding the deglutition disorder or the other outcomes except
one death from aspiration pneumonia in the control group. Tele-
phone correspondence with the investigator confirmed that the
death occurred after the three treatment sessions. Long-term fol-
low up was not performed.
Risk of bias in included studies
The baseline characteristics were reported to be no different be-
tween the acupuncture and control groups. The randomisation
method was described as follows: each participant received a se-
quentially numbered, sealed opaque envelope in the sequence of
visit and the assignment was decided by odd or even number. We
rated allocation concealment as adequate (A). The trial was open
label without placebo use in the control group. A Jadad score of
2 was assigned as the outcomes were assessed in a blinded fashion
(Jadad 1996). Dropouts, losses to follow up or intention to treat
were not stated. Telephone correspondence revealed that there
were no dropouts before the three treatment sessions were com-
pleted and participants were not followed afterwards.
Effects of interventions
Only one study of 66 participants met the inclusion criteria for
this review. We were therefore unable to perform the planned
meta-analysis, sensitivity analyses and publication bias analysis.
The clinical outcomes were assessed using a five-grade scale, in
which recovery was consistent with our pre-determined primary
outcome.
Comparison 01.01: Recovery
Thirty-four participants were randomly allocated into the
acupuncture group and 12 of them recovered to normal feeding.
The remaining 32 participants were allocated into the placebo
group and seven of them recovered to normal feeding. The re-
covery rates were 35% versus 22% respectively. Although the
Acupuncture for dysphagia in acute stroke (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
acupuncture group had a higher recovery rate than the control
group, the difference was not statistically significant (P > 0.05).
We also dichotomized the reported data and calculated a relative
risk of 1.61 for recovery in the acupuncture group relative to the
control group, with a 95% confidence interval of 0.73 to 3.58,
which implies the possibility of both harm and benefit of acupunc-
ture. No definite conclusion can be made.
Comparisons 01.02: Markedly improved and
Comparison 01.03: Improved
Another two outcomes assessed by the same scale were also re-
ported. Out of 34 acupuncture participants, 27 were reported to
be markedly improved and 33 were reported to be improved. In
the control group, the two numbers were 17 and 29 out of a total
of 32 participants. We calculated the relative risks for these two
outcomes; they were 1.49 (95% CI 1.03 to 2.16) for the markedly
improved group, and 1.07 (95% CI 0.94 to 1.21) for the improved
group. However, the effectiveness of acupuncture cannot be con-
cluded since neither of these outcomes was pre-determined in our
protocol, and the validity of the bedside scale for differentiating
dysphagia severity is unknown.
The incidence of deterioration, fatality and aspiration pneumonia
could not be compared as only one deterioration and one death
from aspiration pneumonia occurred in the control group. More-
over, the deterioration was not defined and the time of aspiration
pneumonia or death was not reported.
No information was provided on late disability, length of hospital
stay, quality of life, feed tube removal or nutritional measures.
DISCUSSION
Acupuncture has been widely used in dysphagic stroke treatment
in China and quite a few clinical studies have been carried out.
However, methodologically-sound studies are still lacking. We
only identified one randomised controlled trial, which showed
that adding acupuncture to standard Western medical treatment
was associated with an insignificant increase in full resolution of
dysphagia in the short term. Considering the small sample size,
the insignificant finding is possibly due to insufficient statistical
power. The significantly increased markedly effective rate in the
acupuncture group suggested a trend towards better outcomes.
However, it is not our pre-determined outcome and has unknown
clinical significance. Current evidence is very limited and no firm
conclusion can be made at this time.
Internal validity
The included trial was open label without placebo in the control
group. It is difficult to tell if the observed therapeutic effect was
7
distorted by performance bias and placebo response. While it is stratified by clinically relevant characteristics, such as age, type of
difficult to blind therapists in an acupuncture trial, single-blind- stroke and degree of dysphagia. It remains unclear if acupuncture
ing of the participants is possible and should be implemented. is more suitable for any particular group of patients.
The use of sham acupuncture as placebo treatment is preferable,
particularly for Chinese patients who are familiar with the general
procedure of acupuncture, although the potential effect of sham
acupuncture is still under debate, and the appropriate sham acu- Study reporting
points and techniques need to be further justified. The reporting of the included study did not fully comply with the
Consolidated Standards of Reporting Trials (CONSORT) state-
ment (Moher 2001) and the Standards for Reporting Interven-
Outcome measurement tions in Controlled Trials of Acupuncture (STRICTA) criteria (
MacPherson 2002), so that several uncertainties remain. Power
The short-term outcomes were evaluated by a bedside assessment
calculation was not stated, thus we could not estimate the chance
scale of five grades, which were recovery, markedly improved, im-
of type II error. The baseline characteristics of the acupuncture
proved, no improvement, or deterioration. The grade of recovery
and control groups were not reported separately. It is important to
was consistent with our pre-determined primary outcome and was
compare the key baseline characteristics of the two groups to eval-
found to be insignificant between the acupuncture and control
uate the success of randomisation, especially for trials with a small
groups. Although the bedside assessment has been widely used
number of participants. The type of statistical method used for
for dysphagia screening in acute stroke patients, the quality varies
comparison was not specified. The effective size and its precision
greatly depending on the included content. Without further vali-
were not summarised by the commonly used measurements, such
dation, we can not exclude the possibility of misclassification. It is
as relative risk. We dichotomized the reported data and calculated
also unknown how the possible misclassification may have biased
the relative risk. There were no dropouts during the study period,
the results.
which seems attributed to the short study period and the exclusion
Videofluoroscopic swallow study (VFSS) has been recognised as
of poor compliant patients. However, the method of poor com-
the gold standard for dysphagia diagnosis, in spite of concerns
pliance patient identification was not stated. The included study
about the radiation exposure and high cost. Recently, Han and his
did not specify the practitioner background, which the STRICTA
colleagues developed a scale according to videofluoroscopic results
criteria suggest should be reported, as the effects of acupuncture
from acute or subacute stroke patients. They found that a score of
are highly influenced by the providers’ training and experience.
47 and above out of 100 within 40 days after stroke, was associ-
ated with a significantly reduced risk of persistent dysphagia after
stroke (Han 2007). Future studies should use VFSS or another
objective and quantifiable diagnostic tool to improve the accuracy
Publication bias
of dysphagia measurements.
The ultimate goal of dysphagia therapy in acute stroke patients is Our exhaustive search identified only one study conducted in
to reduce the risk of chest infection, mortality and disability, as China. No eligible non-Chinese studies were found. It was not
well as to improve quality of life. No conclusion can be drawn on possible for us to perform a publication bias analysis. Hence, we
any of these outcomes in this study. Future studies should have could not exclude the possibility that the other studies with neg-
a follow-up time of at least three months, preferably six months ative findings remain unpublished.
to measure these clinically important outcomes (Duncan 2000;
STAIR II 2001).

Generalisation AUTHORS’ CONCLUSIONS

The study results may not be generalisable to general practice set-
tings. Firstly, acupuncture involves a very broad range of diag-
noses, techniques and treatment schedules. The effectiveness also
varies when acupuncture is applied together with different treat-
ment strategies. Secondly, the inclusion criteria were narrow. Pa-
tients with critical conditions, reduced consciousness, slight dys-
phagia symptoms or poor compliance were excluded. The eligible
patients were unlikely to represent the general population, even
in a Chinese population. The participants in this trial were not
Implications for practice
The present review included only one randomised controlled trial,
which did not indicate that acupuncture would have a positive
effect if added to standard Western medical treatment for acute
dysphagic stroke patients. Considering the small number of par-
ticipants included, flaws in methodology and reporting, as well as
the possibility of publication bias, there is insufficient evidence to
conclude that acupuncture has a therapeutic effect.

Acupuncture for dysphagia in acute stroke (Review) 8

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Implications for research
Acupuncture has been recognised as a safe and low-cost interven-
tion. No clear evidence is available to support its routine use. More
large-scale and methodologically sound trials of acupuncture for
dysphagic stroke are needed to verify its clinical value. Future trials
should overcome the limitations presented in this review. In par-
ticular, they should include enough participants to detect at least a
modest effect, participants should be blinded, sham acupuncture
should be used as the control treatment, video-fluorographic swal-
lowing study (VFSS) or another objective and quantifiable tool
should be used to assess the short-term outcome, and participants
should be followed up for at least three months to assess the clini-
cally important outcomes. In addition, the results should be anal-
ysed according to intention-to-treat principles and reported ac-
cording to the Consolidated Standards of Reporting Trials (CON-
SORT) statement and the Standards for Reporting Interventions
in Controlled Trials of Acupuncture (STRICTA) criteria.

ACKNOWLEDGEMENTS
We thank Mrs Hazel Fraser for her comments and suggestions
for this review, and for providing us with relevant trials from the
Cochrane Stroke Group Trials Register, Mrs Brenda Thomas for
her help with developing the search strategy and searching the
literature, and Professor Philip Bath for his help with improving
the readability of this review.

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∗
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12
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Han 2004

Methods RCT with parallel design

Sample = 66
Acupuncture group: 34 participants
Control group: 32 participants
Allocation concealment: sealed, opaque envelope
Blinding: single blind to the assessors
Withdrawal/drop out: none
Follow up: none
ITT analysis: not stated
Treatment duration: once daily x 7 days x 3 periods, at 2-day intervals

Participants Age: 41 to 79 years, mean 62.1 years

Males = 41, females = 25
Inclusion criteria: acute stroke patients (within 30 days after stroke onset) diagnosed by clinical diagnostic
criteria plus skull CT scan
Exclusion criteria: patients with critical conditions, reduced consciousness, throat diseases, poor compli-
ance, infections at the acupoints, and minor dysphagia and dysphasia symptoms
Degrees of dysphagia were not stated
No definite limit to neurological deficit described

Interventions Both groups received nasogastric feeding plus standard Western medical treatment. The acupuncture
group also received scalp acupuncture, neck acupuncture and electroacupuncture.
Acupoints: both sides of the balance areas, both sides of the lower third of the motor areas, both sides of
the third speech areas, both sides of the swallowing points and supply-blood points (based on investigators’
experience and the locations were not specified), RN 23, ST 9 (both sides), GB 20 (both sides), DU 16
Procedures:
(1) Swallowing points, ST 9 and RN 23 were needled in a semi-supine or sitting position. Needles were
manipulated for half minute after De Qi sensation, and quickly withdrawn.
(2) Patient changed to the appropriate position, and GB 20, DU 16 and supply-blood points were needled.
The needles were manipulated for half minute after De Qi sensation and retained for 30 minutes, during
which the needles were manipulated twice for 2 minutes each.
(3) Scalp needles were inserted horizontally into 1.2 cun under epicranial aponeurosis.
(4) The homolateral balance area (cathode) and motor area (anode) were electrified with a low frequency
(30 times per second) sparse-dense wave for 30 minutes. The same procedure was applied to the other
side at the same time.
All the neck and scalp needles were manipulated with reinforcing or reducing method according to the
dialectical theory of traditional Chinese medicine.
Length of application: 30 minutes
Length of session: 7 days
Interval: 2 days between sessions
Total number of treatment sessions: 3
All 3 sessions were considered as a whole acupuncture treatment unit
Instruments: fine needle, 30 x 45 mm
No information on acupuncturist’s background

Acupuncture for dysphagia in acute stroke (Review) 13

Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Han 2004 (Continued)

The De Qi sensation: yes

Outcomes Bedside assessment of dysphagia immediately after 3 treatment sessions.

(1) Recovery: the complete resolution of dysphagia and dysarthria, i.e. resumption of normal feeding and
normal speech
(2) Markedly improved: nearly complete resolution of dysphagia and dysarthria, i.e. resumption of normal
feeding with occasional bucking and normal speech with slight dysarthria
(3) Improved: partial resolution of dysphagia and dysarthria, i.e. resumption of feeding in the lying position
without a nasogastric feeding tube but swallow difficulty remains in the sitting position; relatively poor
resolution of dysarthria
(4) No improvement: slight change or no change in dysphagia, bucking and dysarthria
Deterioration was not defined

Notes Setting: both inpatients and outpatients were from the Peoples Hospital in Qi County, Henan Province,
China
Acupuncture group
• Recovery: 12 participants
• Markedly improved: 15 participants
• Improved: 6 participants
• Ineffective: 1 participant
• Deterioration: 0 participants
Control group
• Recovery: 7 participants
• Markedly improved: 10 participants
• Improved: 12 participants
• Ineffective: 2 participants
• Deterioration: 1 participant

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

CT: computerised tomography

cun: cuneus (wedge)
DU 16: Fengfu
GB 20: Feng Chi
ITT: intention to treat
RN 23: Lianquan
RCT: randomised controlled trial
ST 9: Ren Ying

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Characteristics of excluded studies [ordered by study ID]

Bai 2007 Different methods of acupuncture were compared: 111 cases divided into 3 groups were treated with 3 different
manipulating methods on RN 23

Bi 2004 No control group was used

Chen 2003 Randomisation was not performed properly

Chen 2004 No control group was used

Fu 2000 Acupuncture plus traditional Chinese herbs were compared with the control group

Fu 2004 Acupuncture plus rehabilitation were compared with the control group

He 2002 No randomisation. Participants were allocated to 2 groups according to the odd number or even number of visit date,
i.e. all patients that attended on the same day were assigned to the same group whatever the total numbers of visits
in that day.

Hu 2005 No control group was used

Lian 2003 No control group was used

Liao 2005 Comparing rehabilitation exercise versus no rehabilitation exercise based on acupuncture plus bloodletting.

Liu 1998 Randomisation was not performed properly. The author, when asked how 54 cases were allocated into the treatment
group while 30 cases into the control group, could not describe the method of randomisation at all

Liu 2003 Acupuncture plus rehabilitation were compared with the control group

Liu 2004a The drop-out rate was more than 20% of total participants during the treatment period

Liu 2004b Acupuncture plus traditional Chinese herbs and Western medicine were compared with the control group

Ma 2003 No control group was used

Su 2004 No randomisation. Participants were allocated to 2 groups according to the odd number or even number in their visit
sequence and 1 group of patients was further assigned into 3 subgroups by their baseline characteristics for 3 different
treatments, and the other group received all 3 treatments at the same time

Wang 2003a No control group was used

Wang 2003b Different methods of acupuncture were compared: 30 cases were needled with 6 neck points in the treatment group,
the other 30 cases were needled with 2 neck points in the control group

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(Continued)

Wang 2003c Randomisation was not performed properly: the author stated that she might have used some kind of sequence that
she could no longer remember

Wang 2004 No control group was used

Wei 1995 No control group was used

Xu 2001 No randomisation was performed. Participants were allocated to 2 groups according to the odd number or even
number in visit sequence confirmed by the author. However, the author could not explain why the total number in
the control group was 4 less than in the treatment group, while no withdrawals or losses to follow up happened

Xue 2004 Acupuncture plus rehabilitation were compared with the control group

Yang 2001 Acupuncture plus bloodletting were compared with the control group

Zhang 2004 Acupuncture plus bloodletting were compared with the control group

Zhao 1997b No control group was used

Zhong 2005 Acupuncture plus hyperbaric oxygen were compared with the control group

RN 23: Lianquan

Characteristics of ongoing studies [ordered by study ID]

Heng 1999

Trial name or title Acupuncture adjuvant therapy for dysphagia due to recent stroke. NMRC’s Clinical Trials and Epidemiology
Research Unit, Singapore. Annual Report 1999

Methods

Participants Patients with a neurological event in the preceding 7 days consistent with an acute stroke determined clinically
or radiologically Difficulty in swallowing due to the stroke
Clinically alert, can sit upright, and understand dysphagia testing
Dysphagia testing: participant has at least one of the following signs after drinking 90 ml of water:
(1) drooling/leakage from corner(s) of mouth;
(2) cough (instant or delayed up to 2 minutes after swallowing);
(3) wet voice;
(4) time taken more than 5 seconds to swallow the 90 ml of water
Penetration/ aspiration of barium on Video-fluorographic Swallowing Study (VFSS)
Age less than 80 years
Informed consent

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Heng 1999 (Continued)

Interventions True acupuncture versus sham acupuncture

Outcomes Unclear

Starting date 1999

Contact information Derrick Heng, Ministry of Health, Clinical Trials & Epidemiology Research Unit, 10 College Road, Singapore,
169851. Tel: (65) 220 1463 Ext. 128; Fax: (65) 220 1475; Email: derrickh@cteru.gov.sg

Notes

Heng 2001

Trial name or title SQACU01 - A randomised trial of acupuncture as adjuvant therapy for dysphagia due to recent stroke

Methods

Participants Patients with a neurological event in the preceding 7 days consistent with an acute stroke determined clinically
or radiologically
Difficulty in swallowing due to the stroke
Clinically alert, can sit upright, and understand dysphagia testing
Dysphagia testing: participant has at least one of the following signs after drinking 90 ml of water:
(1) drooling/leakage from corner(s) of mouth;
(2) cough (instant or delayed up to 2 minutes after swallowing);
(3) wet voice;
(4) time taken more than 5 seconds to swallow the 90 ml of water
Penetration/aspiration of barium on Video-Fluorographic Swallowing Study (VFSS)
Age less than 80 years
Informed consent

Interventions True acupuncture 16 sessions versus sham acupuncture

Outcomes The proportion of participants requiring tube feeding at 3 and 6 months after stroke with dysphagia
The number of hospital readmissions for pneumonia in the first 6 months after stroke with dysphagia
Mortality in the first 6 months after stroke with dysphagia

Starting date 2001

Contact information Derrick Heng, Ministry of Health, Clinical Trials & Epidemiology Research Unit, 10 College Road, Singapore,
169851. Tel: (65) 220 1463 Ext. 128; Fax: (65) 220 1475; Email: derrickh@cteru.gov.sg

Notes

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES

Comparison 1. Acupuncture versus control

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Recovery 1 66 Risk Ratio (M-H, Fixed, 95% CI) 1.61 [0.73, 3.58]
2 Markedly improved 1 66 Risk Ratio (M-H, Fixed, 95% CI) 1.49 [1.03, 2.16]
3 Improved 1 66 Risk Ratio (M-H, Fixed, 95% CI) 1.07 [0.94, 1.21]

Analysis 1.1. Comparison 1 Acupuncture versus control, Outcome 1 Recovery.

Review: Acupuncture for dysphagia in acute stroke

Comparison: 1 Acupuncture versus control

Outcome: 1 Recovery

Study or subgroup Acupuncture Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Han 2004 12/34 7/32 100.0 % 1.61 [ 0.73, 3.58 ]

Total (95% CI) 34 32 100.0 % 1.61 [ 0.73, 3.58 ]

Total events: 12 (Acupuncture), 7 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.18 (P = 0.24)

0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 Analysis 1.2. Comparison 1 Acupuncture versus control, Outcome 2 Markedly improved.

Review: Acupuncture for dysphagia in acute stroke

Comparison: 1 Acupuncture versus control

Outcome: 2 Markedly improved

Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Han 2004 27/34 17/32 100.0 % 1.49 [ 1.03, 2.16 ]

Total (95% CI) 34 32 100.0 % 1.49 [ 1.03, 2.16 ]

Total events: 27 (Treatment), 17 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 2.14 (P = 0.032)

0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control

Analysis 1.3. Comparison 1 Acupuncture versus control, Outcome 3 Improved.

Review: Acupuncture for dysphagia in acute stroke

Comparison: 1 Acupuncture versus control

Outcome: 3 Improved

Study or subgroup Treatment Control Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Han 2004 33/34 29/32 100.0 % 1.07 [ 0.94, 1.21 ]

Total (95% CI) 34 32 100.0 % 1.07 [ 0.94, 1.21 ]

Total events: 33 (Treatment), 29 (Control)
Heterogeneity: not applicable
Test for overall effect: Z = 1.07 (P = 0.29)

0.1 0.2 0.5 1 2 5 10

Favours treatment Favours control

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
APPENDICES

Appendix 1. MEDLINE search strategy

The following search strategy, including a combination of controlled vocabulary and free text terms, was used for MEDLINE and
modified for other databases.

MEDLINE (Ovid)
1. deglutition disorders/ or deglutition/
2. (deglutition or dysphag$ or swallow$).tw.
3. 1 or 2
4. acupuncture/
5. acupuncture therapy/
6. acupuncture points/
7. acupuncture, ear/
8. electroacupuncture/
9. meridians/
10. (acupuncture or electroacupuncture or electro-acupuncture or acupoint$).tw.
11. ((meridian$ or non-meridian or trigger) adj10 point$).tw.
12. or/4-11
13. 3 and 12

WHAT’S NEW
Last assessed as up-to-date: 6 February 2008.

17 March 2008 Amended Converted to new review format.

HISTORY
Protocol first published: Issue 3, 2006
Review first published: Issue 3, 2008

CONTRIBUTIONS OF AUTHORS
Yue Xie conceived the idea for the review, performed searches, data extraction and checking, drafted and revised the review.
Liping Wang performed handsearches, extracted and checked the data.
Jinghua He participated in study selection and revised the review.
Taixiang Wu gave general advice on this review.

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DECLARATIONS OF INTEREST
None known

SOURCES OF SUPPORT

Internal sources

• Chinese Cochrane Centre, China.

External sources

• No sources of support supplied

INDEX TERMS

Medical Subject Headings (MeSH)

Acupuncture Therapy [∗ methods]; Deglutition Disorders [∗ therapy]; Stroke [∗ complications]; Treatment Outcome

MeSH check words

Humans

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Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.