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Stroke_Emperor's College 2013_J. E. Williams, OMD

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Presentation by Dr. Williams on integrative Chinese Medicine for the treatment and management of stroke for DAOM program at Emperor's College in Santa Monica.

Presentation by Dr. Williams on integrative Chinese Medicine for the treatment and management of stroke for DAOM program at Emperor's College in Santa Monica.

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  • Who am I? L.Ac. In 1983, OMD 1985 SAMRA, Hospital rotations in Beijing stroke recovery 2 place – 1 inpatient, 1 outpatient clinic - and Shanghai College of TCM. Member STAR program Scripps Memorial in La Jolla. Member system wide rehab board Scripps Health. Weekly classes at Scripps Memorial --- employee of Scripps Health. Develop policy on acupuncture procedures and protocols, plus outcome monitors for HealthSouth, Sarasota 2005-2007.
  • Birth control pills containing synthetic estrogens and progestins increase risk for women.
  • The focus of this lecture will emphasize ischemic stroke.
  • See Harrison’s for detailed descriptions.
  • Early forms of synthetic progestins were associated with stroke in younger women. Current forms of estradiol and progesterone, particularly bio-identical forms may have cardiovascular benefits. Cancer risk remains in susceptible individuals using birth control pills and hormone replacement therapies.
  • Areas that DAOMs can integrate with allopathic medicine: prevention, comprehensive cardiovascular evaluation, recovery.
  • Cholesterol is a modified steroid, lipid molecule that serves as an essential structural component of animal cell membranes required for proper membrane permeability and fluidity. Cholesterol also serves as a precursor for the biosynthesis of steroid hormones, bile acids, and vitamin D. Cholesterol is the principal sterol synthesized by animals and is synthesized in the liver.
  • A triglyceride is an ester derived from glycerol and three fatty acids. Triglycerides are a type of blood lipid that enable the bi-directional transfer of adipose fat and blood glucose from the liver. Triglycerides are the main constituents of vegetable oil and animal fats, and a major component of human skin oils.
  • Low-density lipoprotein (LDL) is one of the five major groups of lipoproteins, which in order of size, largest to smallest, are chylomicrons, VLDL, IDL, LDL, and HDL, that enable transport of multiple different fat molecules, as well as cholesterol, within the water around cells and within the water-based bloodstream. Studies have shown that higher levels of type-B LDL particles (as opposed to type-A LDL particles) are associated with health problems, including cardiovascular disease. LDL is often informally called bad cholesterol, (as opposed to HDL particles, which are frequently referred to as good cholesterol or healthy cholesterol).
  • High-density lipoprotein (HDL) is one of the five major groups of lipoproteins, which, in order of size, largest to smallest, are chylomicrons, VLDL, IDL, LDL, and HDL, which enable the transportation of lipids (fats), such as cholesterol and triglycerides, within the water around cells, including the bloodstream. In healthy individuals, about thirty percent of blood cholesterol, along with other fats, is carried by HDL. Those with higher levels of HDL-C tend to have fewer problems with cardiovascular diseases, while those with low HDL-C cholesterol levels (especially less than 40 mg/dL or about 1 mmol/L) have increased rates for heart disease. Higher HDL levels are correlated with better cardiovascular health. Further increasing one's HDL has been found to improve cardiovascular health. Additionally, those few individuals producing an abnormal, apparently more efficient, HDL ApoA1 protein variant called ApoA-1 Milano, have low measured HDL-C levels yet very low rates of cardiovascular events even with high blood cholesterol values. Recent research suggests that high levels of HDL particles that contain apoC-III on its surface could increase the risk of future chronic heart disease.
  • Glucose (also known as D-glucose, dextrose, or grape sugar) is a simple monosaccharide found in plants. It is one of three dietary monosaccharides, along with fructose and galactose, that are absorbed directly into the bloodstream during digestion. An important carbohydrate in biology, cells use it as the primary source of energy and a metabolic intermediate. Glucose is one of the main products of photosynthesis and fuels for cellular respiration.
  • Glycated hemoglobin or glycosylated hemoglobin (A1C, or HbgA1c) is a form of hemoglobin that is used to measure the average plasma glucose concentration over prolonged periods of time. It is formed in a non-enzymatic glycation pathway by hemoglobin's exposure to plasma glucose. Normal levels of glucose produce a normal amount of glycated hemoglobin. As the average amount of plasma glucose increases, the fraction of glycated hemoglobin increases in a predictable way. This serves as a marker for average blood glucose levels over the previous approximately 5 months prior to the measurement. In diabetes mellitus, higher amounts of glycated hemoglobin, indicating poorer control of blood glucose levels, have been associated with cardiovascular disease, nephropathy, and retinopathy. Monitoring HbgA1c in type 1 diabetic patients may improve outcomes.
  • Homocysteine is a common amino acid found in the blood and is acquired mostly from eating meat. High levels are associated with increased risk for chronic inflammation, cardiovascular disease, Alzheimer’s, and bone fractures.
  • C-reactive protein (CRP) is an acute phase protein found in the blood, the levels of which rise in response to inflammation. Its physiological role is to bind to phosphocholine expressed on the surface of dead or dying cells (and some types of bacteria) in order to activate the complement system via the C1Q complex. CRP is synthesized by the liver in response to factors released by macrophages and fat cells (adipocytes). Order CRP, hs/cardiac.
  • Vitamin D is an essential vitamin that helps your body absorb calcium and phosphorus. Not enough vitamin can cause pain, hormone problems, muscle weakness, weak bones, multiple sclerosis, cardiovascular disease, cancer, and more.
  • Iron is a mineral that our bodies need to make the proteins hemoglobin and myoglobin. Hemoglobin is found in red blood cells and myoglobin is found in muscles. They help carry and store oxygen in the body. Iron is also part of many other proteins and enzymes in the body. Your body needs the right amount of iron. If you have too little iron, you may develop iron deficiency anemia. Too much iron is toxic to your body
  • High levels of a type of cholesterol known as lipoprotein(a) are associated with an increased risk for heart attacks and stroke, but the clinical implications of the finding are unclear. HighLp(a) is mostly associated with risk for heart attack. Lp(a) consists of LDL cholesterol bound to the protein apolipoprotein(a).Function of Lp(a) is not well understood. Individuals without Lp(a) or with very low Lp(a) levels seem to be healthy.
  • Fibrinogen (factor I) is a solubleglycoprotein, that is converted by thrombin into fibrin during blood clot formation. Fibrinogen is synthesized in the liver. Diagnosis of homozygous and heterozygous fibrinogen deficiency as well as dysfibrinogenemia; diagnosis of disseminated intravascular coagulation; 6-8 fibrinogen levels can be used to assess the effectiveness of thrombolytic therapy.
  • CASE STUDY http://www.plactest.com/Default.aspx?PageID=14007559&A=PrinterView
  • Methylenetetrahydrofolatereductase (MTHFR) is the rate-limiting enzyme in the methyl cycle, and it is encoded by the MTHFRgene.[2]Methylenetetrahydrofolatereductase catalyzes the conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate, a cosubstrate for homocysteineremethylation to methionine. Genetic variation in this gene may influence susceptibility to occlusive vascular disease, neural tube defects, dementia, colon cancer, and acute leukemia, because mutations in this gene are associated with methylenetetrahydrofolatereductase deficiency. Treatment is with methylcobalamin, P5P, and Methyltetrahdyrofolate.
  • The research history is highly variable with some studies favorable to acupuncture and others showing no evidence. Each study has to be scrutinized in detail for methodology and patient population. Sham acupuncture trials are not comparable to placebo controlled drug trials.
  • Preventive dosages are starting points for all patients at risk for cardiovascular disease. Therapeutic dosages, under your supervision, are double the starting dosages. Some patients may need higher. Omega-3s from sardines and anchovies, super-critical CO2 extracted (from Germany).
  • Serratiopeptidase (Serratia E-15 protease)is a proteolytic enzyme (protease) produced by enterobacteriumSerratia sp. E-15.[1] This microorganism was originally isolated in the late 1960s from silkwormBombyxmori L. (intestine),[2]Serratiopeptidase is present in the silkworm intestine and allows the emerging moth to dissolve its cocoon. Serratiopeptase is produced by purification from culture of Serratia E-15 bacteria.Lumbrokinase is a fibrinolyticenzyme[1] present in the earthwormLumbricus bimastus.[2] It has been investigated as an experimental antithromboticagentIsolated and purified nattokinase, an enzyme derived from a process of fermentation involving boiled soybeans and Bacillus natto. Research has shown nattokinase to support the body in breaking up and dissolving the unhealthy coagulation of blood and to support fibrinolytic activity.
  • PubMed has 10,906 citation related to exercise and stroke recovery.
  • There are several stroke scale monitoring surveys including LA, NIH, and Orpinton. http://www.strokecenter.org/professionals/stroke-diagnosis/stroke-assessment-scales/
  • This chart summarizes the number of chart reviews in relationship to specific clinical outcomes. Patient outcomes are measured before and after the termination of a course of acupuncture therapy using the Cincinnati Pre-Hospital Stroke Scale. One course consists of 1-3 times weekly acupuncture sessions over a period of 30 days. Outcomes measured include facial droop, arm drift, speech impairment, and pain. Other outcomes assessed are patient satisfaction and safety. HealthSouth 2006
  • Transcript

    • 1. STROKE An Integrative Oriental Medicine Approach To Treatment & Management J. E. Williams, OMD, L.Ac., FAAIM
    • 2. Course Objectives 1. Understand clinical aspects of stroke. 2. Understand place of acupuncture in stroke rehabilitation. 3. Learn evidence-based approach to stroke treatment. 4. Learn safe and effective integrative medicine model for stroke recovery. 5. Establish outcome model for stroke therapy.
    • 3. Course Outline • Physiologic basis for stroke • Role of OM in stroke rehabilitation • Evidence for acupuncture in stroke therapy • Chinese medicine view of stroke • Treatment methodology • Drug interactions • Demonstrations and practicum
    • 4. INTRODUCTION Stroke Prevention, Treatment, and Recovery
    • 5. Incidence of Stroke • New or recurrent strokes affect about 780,000 Americans every year. • Someone in the U.S. has a stroke every 40 seconds. • 4th leading cause of death in the U.S. • 4% of U.S. adults will have a stroke. • The annual cost of stroke care is predicted to increase from $71.55 billion in 2010 to $183.13 billion. • Stroke incidence is projected to increase the most among Hispanic men between now and 2030, and the cost of treating stroke in Hispanic women is expected to triple. • 90% of stroke patients have residual disability. • While age is the major risk factor, people who have a stroke are likely to have more than one risk factor.
    • 6. Demographics • Age: 72% are over age 65 • Gender: More common in men, but women account for about 6 in 10 stroke deaths. • Race: African-American men have more than twice the incidence of stroke than Caucasians. Hispanics and blacks not only have a higher rate of stroke incidences, but experience worse outcomes.
    • 7. STROKE PREVENTION CONTROLLABLE RISK FACTORS:  High Blood Pressure  Atrial Fibrillation  Diabetes  Smoking  High Cholesterol  Metabolic Syndrome  Atherosclerosis  Circulation Problems  Alcohol  Inactivity  Obesity  Anabolic Steroid Use CT scan slice of the brain showing a right-hemispheric ischemic stroke.
    • 8. MAJOR RISK FACTORS • Hypertension • Atrial fibrillation • Diabetes • Hyperlipidemia • Symptomatic carotid stenosis • Migraine with aura
    • 9. Atrial Fibrillation (AF) • Rapid, irregular artial rhythm – may be episodal or continuous: • Palpitations • Weakness, effort intolerance • Vague chest discomfort • Dyspnea • Presyncope • Diagnosis is by ECG, and blood tests (thyroid function, glucose, lipids) • Main Risk: stroke (7%) • Other Concerns: lower cardiac output (10%) • Complicated by rheumatic valvular disorder, hyperthyroidism, hypertension, diabetes • Etiology: hypertension, cardiomyopathy, valvular disorders, hyperthyroidism, and binge alcohol drinking (“holiday heart”) • Treatment: heart rate control with drugs, prevention of embolism with anticoagulants, cardioversion procedure
    • 10. Definition Sudden onset of a neurologic deficit from a vascular mechanism: • 85% ischemic • 15% primary hemorrhage (subarachnoid and intraparenchymal) • Transient ischemic attack (TIA) “mini stroke”
    • 11. Figure 1a. (a) Schematic of brain involvement in acute stroke shows a core of irreversibly infarcted tissue surrounded by a peripheral region of ischemic but salvageable tissue referred to as a penumbra. Srinivasan A et al. Radiographics 2006;26:S75-S95 ©2006 by Radiological Society of North America
    • 12. Pathophysiology & Clinical Features • Most often due to embolic occlusion of large cerebral vessels in the heart, aortic arch, or carotid arteries. • Abrupt and dramatic onset with focal neurological symptoms. • Rarely experience pain. • Presentation is based on area of brain involved.
    • 13. TYPICAL SIGNS AND SYMPTOMS • Abrupt onset of hemiparesis, monoparesis, or quadriparesis • Acute hemisensory loss • Complete or partial hemianopia, monocular or binocular visual loss, or diplopia • Visual field deficits • Dysarthria • Ataxia • Vertigo • Nystagmus • Aphasia • Sudden decrease in the level of consciousness
    • 14. Conditions That Mimic Stroke • Brain tumors • Seizures • Migraine • Other conditions (viral or bacterial infections, gastrointestinal distress, thyrotoxicosis)
    • 15. Flow chart shows an acute stroke imaging protocol Srinivasan A et al. Radiographics 2006;26:S75-S95 ©2006 by Radiological Society of North America Ischemic Stroke
    • 16. IMAGING STUDIES • Non-contrast CT scan of the head within first few hours • Diffusion-weighted MRI also used within minutes after onset • Other imaging studies: • Angiography • Ultrasonography • Echocardiography
    • 17. STROKE THERAPIES • Thrombolytic therapy: Thrombolytics restore cerebral blood flow among some patients with acute ischemic stroke and may lead to improvement or resolution of neurologic deficits. • Antiplatelet agents: The International Stroke Trial and the Chinese Acute Stroke Trial (CAST) demonstrated modest benefit from the use of aspirin in the setting of acute ischemic stroke. • Mechanical thrombolysis: Involves the endovascular treatment of acute ischemic stroke. • Neuroprotective therapies: Many under investigation but few have shown benefits.
    • 18. Drugs Used for Stroke • Anticoagulant agents: Not used for hemorrhagic stroke and studies do not support use in acute ischemic stroke • Thrombolytic agents: Tissue plasminogen activator (tPA) for ischemic stroke. • Antiplatelet agents: Aspirin – up to 325 mg per day • Neuroprotective agents: Lots of interest but no approved therapies - http://emedicine.medscape.com/article/1161422- overview#aw2aab6b3
    • 19. Drugs That Can Cause Stroke • Sumatripan, the migraine drug (Intensive Care Med, 1995; 21: 82-3). • Beta blockers (Revist Clinica Espan, 1993;192: 228-30). • Nefedipine (causing cortical blindness) (BMJ, 1992; 305: 693). • Chemotherapy or hormones given during chemotherapy (Am J Clin Onc, 1992; 15:168-73). • Contraceptive pill (Acta Neurol Belg, 1992;92: 45-7). • Oral anticoagulant therapy (The Lancet, 1991; 338: 1158). • Nasal decongestants (J Neurol, Neurosurg & Psychiatry; 1989; 52: 541-3). • Blood pressure lowering drugs (Med J Australia, 1987; 146: 412-4). • Phenylpropanolamine, a drug available over the counter in weight loss, nasal congestants and cold preparations (Am J Emerg Med, 1987; 5: 163-4). • Recreational drugs, like Ecstacy, cocaine, and methamphetamines (European Neuro, 1995; 35: 193; South Med J, 1995; 88: 352-4; Europ Neuro, 1994; 34: 16-22). • Anabolic steroids (Neuro, 1994; 44: 2405-6). • Streptokinase/subcutaneous heparin therapy, combination therapy, (Circulation,1995; 92 : 2811-8) and recombinant tissue type plasminogen activator (Circulation;1991; 83: 448-59). • Anticoagulant medication (Arch of Neuro, 1985; 42: 1033-5). • Ingesting hydrogen peroxide (Stroke; 1994;25: 1065-7).
    • 20. Hormone Replacement • Reduces risk of coronary heart disease (Hodis HN, Mack WJ 2013) • Estrogens offer neuroprotective effects (Liu R, Yang SH 2013) • N Engl J Med. 2012 Jun 14;366(24):2316-8. doi: 10.1056/NEJMe1204769.Hormonal contraceptives and arterial thrombosis--not risk-free but safe enough. Petitti DB. • Lancet Neurol. 2012 January; 11(1): 82–91.Menopause and Stroke: An Epidemiologic Review. Lynda Lisabeth, PhD and Cheryl Bushnell, MD • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615462/
    • 21. Lab Tests • Lipids – VAP profile • Glucose • Hemoglobin A1c • Homocysteine • C-Reactive Protein, cardiac/hsCRP • Lipoprotein(a) • Fibrinogen • lipoprotein phospholipase A2 (Lp-PLA2) - PLAC® Test • MTHFR gene mutations
    • 22. Cardiovascular Risk Marker Profile
    • 23. Cholesterol
    • 24. Triglycerides
    • 25. Low-Density Lipoprotein (LDL)
    • 26. High-Density Lipoprotein (HDL)
    • 27. Glucose
    • 28. Hemoglobin A1c
    • 29. Homocysteine
    • 30. C-Reactive Protein
    • 31. Vitamin D, 25-Hydroxy
    • 32. Vitamin B12 Vitamin B-12 (cobalamin) plays a role in making DNA, and helps keep nerve cells and red blood cells healthy. It is necessary for managing homocysteine levels in the body.
    • 33. Iron
    • 34. VAP Lipid Profile • Comprehensive lipid analysis • Provides stratified lipid-associated CVD risks • Supports personalized preventative care
    • 35. Lipoprotein(a) RISK VALUES Desirable < 14 mg/dL (< 35 nmol/l) Borderline 14 - 30 mg/dL (35 - 75 nmol/l) High 31 - 50 mg/dL (75 - 125 nmol/l) Very high > 50 mg/dL (> 125 nmol/l) LabCorp Reference Interval: <75 nmol/L Atherotech Desirable Level: <10 mg/dL (= “optimal” level)
    • 36. Fibrinogen • Fibrinogen is a protein produced by the liver that helps stop bleeding by encouraging blood clot formation. • Association between elevated fibrinogen levels and increased risk for atherosclerotic vascular disease. • Reference interval: 193−507 (LabCorp)
    • 37. PLAC® Test http://www.plactest.com/ • Predicts risk of acute heart attack or stroke more accurately than do traditional markers of cardiovascular risk. • Measures levels of the enzyme lipoprotein phospholipase A2 (Lp-PLA2). • Lp-PLA2 triggers a chain of events resulting in endothelial dysfunction in the blood vessel wall that sets the stage for atherosclerosis, plaque accumulation, and rupture. • Lp-PLA2 is found in high concentration in atherosclerotic plaques that are ready to rupture, causing heart attack or stroke. • Lp-PLA2 reflects inflammation in the atherosclerotic plaque and its activity is associated with macrophages. • Levels of Lp-PLA2 rise in individuals at risk for acute heart attack and stroke. • As sensitive and more specific for acute cardiovascular risk than other more widely used cardiovascular risk markers. • To monitor response to diet, statins, and other treatments. Normal range < 200 ng/dL
    • 38. MTHFR Gene Mutation • The official name of this gene is “methylenetetrahydrofolate reductase.” • At least 40 mutations in the MTHFR gene have been identified in people with homocystinuria. • Most common 2 mutations are A1298C and C677T each refer to variants in a MTHFR gene in our DNA. • Around 30% of Europeans, 10% of Africans, and 50% of Chinese people have the C677T version of the MTHFR gene. http://www.youtube.com/watch?v=QRHif2aVPvw#t=64
    • 39. Solving stroke one piece at a time. Putting the Pieces Together
    • 40. CHINESE MEDICINE How the ancients viewed stroke
    • 41. Degree of Attack • Mild: Wind attacking network channels – Zhong Luo • Moderate: Wind attacking channels – Zhong Jing • Severe: Wind attacking organs – Zhong Fu & Zhong Zang
    • 42. TCM Etiology • Yin deficiency of liver and kidney failing to control yang: lack of qi and blood, and too much rising heat Age plays a significant role • Explosive anger damaging liver yin • Chronic stress and emotional repression causing liver qi stagnation, transforming to heat, stirring up liver wind • Excess alcohol and fatty foods • External “wind” attacking channels and vessels • Excess yang constitution associated with hyperactivity of liver yang
    • 43. Point Selection • Classic Basic Points: • Ren Zhong GV26 • Jia Che ST6 • Bai Hui GV20 • He Gu LI4 • For “Tense” Type: • GV26 + GV20 • Bleed 12 “well points” • Yong Quan KI1 • For “flaccid” Type: • CV4, 6, 8, 17 • ST36 • GV4, 26, 20 • BL 15, 23
    • 44. Dr. Shi Xue-min’s Points • PC6, GV26, SP6 • Neiguan confluent point 8 extra meridians and luo point of the PC channel • Renzhong is the confluent point of the GB channel, controls yang of the whole body • Sanyinjiao nourish liver and kidney • Additional Points: HT1, LU5, BL40, LI4, GB20, TH17, GB12
    • 45. Variation of Strategies • Based on affected side • Based on associated organ and/or meridian dysfunction • Scalp needling • Local area needling • Electro-stimulation • Point selection of different masters
    • 46. ACUPUNCTURE FOR STROKE From Art to Science
    • 47. Acupuncture Contradictions • No known contradiction for using acupuncture for stroke patients after initiation emergency measures. • Precaution with anticoagulants and antiplatelet drugs. • Precaution in older and very weak patients.
    • 48. Research: PubMed 547 Citations for Acupuncture and Stroke • Clinical experience is favorable for improving stroke patient outcomes. • Patient reports are favorable for improvement in wellbeing, anxiety, and pain in post-stroke recovery. • Earlier studies were favorable for use of acupuncture to treat post-stroke symptoms and to support recovery • Recent studies do not support efficacy of acupuncture for sub- acute stroke or post-stroke recovery. (Sze FK, et al 2002) • Acupuncture may help motor recovery in chronic stroke survivors. (Zhang H, et al 2013)
    • 49. Figure 4. PET (positron emission tomography) images reveal an abnormal pattern of neural activation (right) during a finger manipulation task (see Figure 3) performed by the stroke-affected hand of patients who had experienced a stroke to the motor cortex in one hemisphere of the brain (lesion). Abnormal neural activity (in the premotor cortex and the supplementary motor area) on the unlesioned side of the brain suggests that these areas have learned to compensate for the damaged motor cortex on the lesioned side. Performance of the task by the unaffected hand shows a normal pattern of activity (left). http://www.americanscientist.org/my_amsci/restricted.aspx?act=pdf&id=2900445295912 Brain Plasticity and Recovery from Stroke 200 Brain Plasticity Theory
    • 50. Brain Plasticity & Neurorestorative Therapies in Stroke Recovery Brain Plasticity and Stroke Rehabilitation The Willis Lecture. Stroke. 2000; 31: 223-230 Barbro B. Johansson, MD, PhD http://stroke.ahajournals.org/content/31/1/223.long • Enriched environmental setting including more social interactions • Growth factors: fibroblast growth factor (bFGF), nerve growth factor (NGF), insulin growth factor-1 (IGF-1) • Brain immune cell modulating factors • Neuroregenesis and stem cells
    • 51. Auton Neurosci. 2010 Oct 28;157(1-2):9-17 Epub 2010 May 7. Neurotrophins and acupuncture. Manni L, et al The aim of this review is to report recent findings and ongoing studies on the effects of acupuncture on endogenous biological mediators, in particular on neurotrophins such as nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF). Acupuncture is a therapeutic technique and is a part of Traditional Chinese Medicine (TCM). Neurol Res. 2008 Nov;30(9):985-9. The influence of electro-acupuncture on neural plasticity in acute cerebral infarction. Ren L, et al. To observe the effect of electro-acupuncture (EA) on dendritic spine and ephrin-A5 and to investigate the action of EA on neural plasticity after acute cerebral ischemic infarction. It is possibly the regulation of the ephrin-A5 expression by which EA treatment improves the neural plasticity at the peri- infarct cerebral cortex in acute cerebral ischemia rat. There may be a time window in EA treatment for acute cerebral ischemia. Acupuncture & Brain Plasticity
    • 52. Evid Based Complement Alternat Med. 2012. Effects of Electroacupuncture at Head Points on the Function of Cerebral Motor Areas in Stroke Patients: A PET Study. Fang Z, et al. Positron emission tomography (PET) is used to observe the cerebral function widely and is a good method to explore the mechanism of acupuncture treatment on the central nervous system. By using this method, we observed the cerebral function of 6 patients suffering from ischemic stroke after receiving EA treatment at Baihui(GV20) and right Qubin(GB7). We concluded that EA was very helpful for the cerebral motor plasticity after the ischemic stroke. • “Glucose metabolism changed significantly on primary motor area (M1), premotor cortex (PMC), and superior parietal louble (LPs)”.
    • 53. INTEGRATIVE THERAPIES
    • 54. Healthy Lifestyle • Plant-based, anti-inflammatory diet • Regular exercise • Stress management • “Changes in lifestyle and pharmacological treatment for hypertension, diabetes mellitus and dyslipidemia, according to criteria of primary and secondary prevention, are recommended for preventing ischemic stroke.” • Neurologia. 2012 Epub 2011 Sep 3. • Guidelines for the preventive treatment of ischaemic stroke and TIA . Update on risk factors and life style.
    • 55. Dr. Weil’s Anti-Inflammatory Food Pyramid
    • 56. Foundational Nutritional Supplements • Omega-3 Fatty Acids, high EPA 1,000 mg • Folic Acid as L-5-Methyltetrahydrofolate 400 mcg • Alpha Lipoic Acid 200 mg • Vitamin B6 as Pyridoxal-5’-Phosphate (P5P) 50 mg • Vitamin B12 as methylcobalamin 1,000 mcg • Vitamin E, high gamma with mixed tocopherols 400 IU • Selenium as selenomethionine 200 mcg • Coenzyme Q10 250-600 mg • Multivitamin and mineral with polyphenols
    • 57. Antioxidants “...reactive oxygen species (ROS) and reactive nitrogen species (RNS) is a common underlying mechanism of many neuropathologies.” Curr Med Chem. 2008;15(4):404-14. Antioxidants and free radical scavengers for the treatment of stroke, traumatic brain injury and aging. Slemmer JE, Shacka JJ, Sweeney MI, Weber JT. Antioxidant reduce cell damage by countering the dangerous effects of free radicals produced when the body processes oxygen: • Vitamins C, E, A • Betacarotene • Glutathione • SOD
    • 58. Lowering CRP • Wild blueberry (vaccinium angustifolium) • Cranberry (vaccinium macrocarpon) Pomegranate (punica granatum) 50 mg whole fruit extract standardized to contain 40% punicosides • Lipolytic Enzymes • Serrapeptase, Nattokinase, Lipase • Protease Enzymes • Protease (derived from Serratia, B. subtilis and A. oryzae)
    • 59. Specialized Supplements • Lumbrokinase 600,000 IU (40 mg): 1-2 capsules daily with or without food • Serrapeptase Enzyme (Peptizyme SP®) 10 mg (providing 20,000 units of proteolytic enzyme activity): 1 capsule three times daily without food • Nattokinase NSK-SD (soy) 2000 FU (100 mg): 1 soft gel capsule twice daily with or without food Use with caution. May be contraindicated with concurrent Coumadin use.
    • 60. Benefits of Exercise • Elevated Aerobic Fitness Sustained Throughout the Adult Lifespan Is Associated With Improved Cerebral Hemodynamics (2013) • Phys Ther. 2013 Promoting Neuroplasticity for Motor Rehabilitation After Stroke: Considering the Effects of Aerobic Exercise and Genetic Variation on Brain- Derived Neurotrophic Factor. Mang CS, Campbell KL, Ross CJ, Boyd LA.
    • 61. LosAngelesPrehospital StrokeScale(LAPSS) Page  62
    • 62. QUARTERLY AUDITS 1st 2nd 3rd 4th YTD Ave. OUTCOMES DATA Total Number of patients treated % of audits completed > or = 20% Avg. pain level pre-treatment 1 10 Avg. Pain level post-treatment 1 10 Duration of pain reduction post-treatment (hrs. or days) Los Angeles Stroke Screen pre-treatment 0 +4 Los Angeles Stroke Screen post-treatment 0 +4 Patient satisfaction (scale of 1-5) > or = 4 Number of unexpected complications and adverse events Number of complaints Number of phone calls ACUPUNCTURE QUALITY MONITORS: HealthSouth
    • 63. Help Patients Prevent All Forms of Cardiovascular Disease “Up to 80 percent of all strokes can be prevented—start reducing risk now.”
    • 64. Clinical Strategies • Evaluation & Diagnostics • Management of Risk Factors: lower blood pressure, lower homocysteine, lower CRP, improve vitamin D3 status, normalize thyroid function • Lifestyle Modifications: stop smoking, reduce alcohol or stop drinking, regular moderate exercise, plant-based anti-inflammatory diet • Acupuncture • Consider herbal therapies
    • 65. Case Study: Stroke Page  66 40-year-old male executive, non-smoker, healthy diet, black belts in karate and hapkido. Only one of two professional football players to suffer a massive heart attack during a game. Fully recovered. Onset was severe headache, unrelenting for 6-8 hours. Tried acupuncture without relief. MD prescribed prednisone without relief. At 12 hours, numbness in thumb and first finger. Rapidly progressed to hemiparesis. ER diagnosed ischemic stroke. Patient requested acupuncture in hospital, which was denied. Within a week after discharge, he was brought to my office in a wheel chair. Treatments were every other day for one month, then twice weekly for three months. Patient made consistent and steady progress. Within two years, achieved 95% full use of upper limbs, and 100% use of lower limbs and speech. Slight memory impairment persisted, but by the end of four years he had full normal cognitive ability.
    • 66. Page  67 Integrating Therapies Integrative Medicine including Acupuncture Physical Medicine Western Emergency Medicine

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