This study followed the standard protocol items of the Recommendations for Interventional Trials (SPIRIT) and CONSORT statement. Detailed methods of this study have been reported previously .
This study was an outcome assessor-blinded single-center randomized controlled pilot clinical trial with a 1:1:1:1 allocation ratio. Participants (n = 60) who fit the inclusion criteria were randomly allocated to the control group (n = 15), SA group (n = 15), rTMS group (n = 15), and SAEM-CS group (n = 15). All groups received CSRT twice per day, five times per week, for a total of 15 times over the course of a 3-week hospitalization period at Chonnam National University Hospital. In addition, the SA group received SA therapy, the rTMS group received rTMS therapy, and the SAEM-CS group received SAEM-CS therapy once per day. Outcome measures were determined at baseline (week 0), 3 weeks after the first intervention (week 3), and 4 weeks after completion of the intervention (week 7). The study design is summarized in Figure 1.
This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Chonnam National University Hospital (CNUH-2015-114). This trial was registered at cris.nih.go.kr (registration number: KCT0001768). All patients provided written informed consent before participating in this study.
To achieve adequate participant enrollment to reach the target sample size, all CI patients who finished treatment for early acute stage CI at the Department of Neurology of Chonnam National University Hospital were screened by physical and rehabilitation medicine doctors. Patients who received an explanation regarding this study from the clinical research coordinator and who voluntarily signed a consent form were transferred to the Department of Physical and Rehabilitation Medicine to participate in this study. The clinical research coordinator continuously monitored the medical conditions of enrolled participants for improved adherence to intervention protocols.
There were six inclusion criteria: (1) age older than 19 years; (2) incipient CI confirmed by computed tomography or magnetic resonance imaging examination; (3) CI that resulted in motor and sensory disorders within 1 month of study onset; (4) could undergo rehabilitation therapy after hospitalization at the Department of Physical and Rehabilitation Medicine of Chonnam National University Hospital; (5) modified Rankin scale (mRS) score of 2–4; and (6) voluntarily signed an informed consent form.
Subjects whose general condition was not fit for SA and rTMS therapies were excluded. Detailed exclusion criteria were as follows: (1) prior history of brain lesion (e.g., stroke, serious mental illness, loss of consciousness accompanied by head trauma, brain surgery, or seizure disorder); (2) presence of other serious illnesses (e.g., cancer, Alzheimer’s disease, epilepsy, head trauma, or cerebral palsy); (3) transient ischemic attack; (4) contraindications to electromagnetic stimulation (e.g., metal implants in the brain, implanted electronic devices in the body such as nondetachable ferromagnetic metals, metal-sensitive implants less than 30 cm away from the brain such as cochlear implants, pacemakers, aneurysm clips or coils, stents, bullet fragments, deep brain stimulation, vagus nerve stimulators, jewelry, or hairpins); (5) continuous convulsion symptoms; (6) previous craniectomy or shunt surgery; (7) increased intracranial pressure symptoms such as headache, vomiting, or nausea; (8) seizure disorder or epilepsy after CI; (9) prior history of stroke accompanied by a clear clinical sign; (10) contraindications to SA (e.g., scalp scarring, inflammation from scalp injury, infection in the treatment region, inability to stop blood flow due to clotting disturbances such as hemophilia, serious unusual response after acupuncture treatment); (11) pregnant or breastfeeding; (12) disagreement with informed consent; and (13) scheduled for surgery within 2 weeks.
Randomization and blinding
After signed informed consent and baseline measurements were obtained, random allocation software (developed by M. Saghaei, MD, Department of Anesthesia, Isfahan University of Medical Sciences, Isfahan, Iran) was used to assign a serial number to the 60 research volunteers and to randomly allocate 15 of them to each group. The serial number codes were inserted in sealed opaque envelopes, kept in a double-locked cabinet, and opened in the presence of the patient and a guardian.
We had no choice but to adopt a single outcome assessor blinding approach because sham treatment was impossible due to the characteristics of SA, which included scalp penetration. During the study, the assessor was blinded to group assignments, and data analysts without conflicts of interest were involved in this study.
A clinical research coordinator generated the allocation sequence, enroll participants, and assign participants to interventions.
All participants underwent conventional stroke rehabilitation therapy (CSRT), which focused on practicing fine and gross motor movements, activities of daily living, task-oriented therapeutic exercises, and muscular electrical stimulation therapy as needed. Training for swallowing and improving language was also performed for dysarthria. These sessions were conducted for 30 minutes (excluding Saturdays and Sundays) twice daily for 3 weeks for a total 15 times. SA, rTMS, and SAEM-CS therapies were conducted once daily for 20 minutes (excluding Saturdays and Sundays) for 3 weeks for a total of 15 times.
SA was conducted as follows: one or two needles were horizontally inserted approximately 3 cm into the lesion site and upper limb regions of MS6 (line connecting GV21 and GB6) and MS7 (line connecting GV20 and GB7) in the directions from GV21 to GB6 and from GV20 to GB7 . Manual stimulation and electroacupuncture were not applied, and the needles (KOS 92 nonmagnetic steel acupuncture needles, size 0.25 mm × 30 mm, product no. A84010.02; Dongbang Acupuncture, Inc., Boryeong, Republic of Korea) were left in position for 20 minutes (Table 1).
The rTMS was conducted as follows: a 70-mm figure-8 coil and a Magstim Rapid stimulator (Magstim Co., Dyfed, UK) were used to deliver 1 Hz of rTMS to the skull of the contralesional hemisphere at the site that elicited the largest motor-evoked potentials (MEPs) in the first dorsal interosseous (FDI) muscle of the unaffected upper limb. One LF-rTMS session consisted of 1200 pulses and lasted for 20 minutes. Stimulation intensity was set to 80% of the motor threshold of the FDI muscle, which was defined as the lowest intensity of stimulation that provokes MEPs. All patients sat in a reclining wheelchair and were asked to relax as much as possible with their heads strapped to a headrest .
The SAEM-CS was conducted as follows: the aforementioned SA and LF-rTMS therapies were performed simultaneously. After SA treatment of MS6 and MS7 on the lesion side, LF-rTMS stimulation was conducted on the contralateral hemisphere for 20 minutes.
The primary outcome was motor function, and the secondary outcomes were cognitive function, activities of daily living, walking, quality of life, and stroke severity. Primary and secondary outcome assessments were conducted at baseline (before intervention), 3 weeks after the first intervention, and 4 weeks after completion of intervention (except Korean Mini Mental State Examination [K-MMSE], American Speech-Language-Hearing Association National Outcome Measurement System Swallowing Scale [ASHA-NOMS], and functional ambulatory category [FAC]).
The primary outcome was assessed via changes in the Fugl‐Mayer assessment (FMA) scale scores for motor function. The FMA scale was developed as the first quantitative evaluation instrument for measuring sensorimotor stroke recovery and included an assessment of the upper extremities (33 items; score range, 0-66) and lower extremities (17 items; score range, 0-34) .
Secondary outcome measures were assessed via changes in the National Institutes of Health Stroke Scale (NIHSS) score, modified Barthel index (MBI), functional independent measurement (FIM) score, K-MMSE score, ASHA-NOMS score, FAC, European Quality of Life-5 Dimensions (EQ-5D), modified Ashworth scale (MAS) score, hand grip strength test, MEPs, mRS score, and 9-hole peg test (9HPT).
The NIHSS, which was developed by the United States National Institutes of Health, is a standardized stroke severity scale used to describe the neurological deficits of stroke patients, and it strongly predicts the likelihood of a patient’s recovery after stroke . The MBI is a scale that measures 10 basic aspects of daily life activities related to self-care and mobility . The FIM is an assessment of everyday movement performance that evaluates 13 detailed items of motor FIM and five detailed items of cognitive FIM . The MMSE is a brief 30-point questionnaire that is used to screen for cognitive impairment. In this study, we used the K-MMSE . The ASHA-NOMS is a seven-stage dysphagia scale developed by the American Speech-Language-Hearing Association to evaluate the severity of dysphagia . The FAC was designed to evaluate walking ability, which is categorized into six ranks . The EQ-5D is a generic instrument for describing and valuing health-related quality of life . The MAS assesses muscles by measuring spasticity in the wrist and elbow joints while the joints are maximally bent . The hand grip strength test evaluates muscle strength in the hands .
In this study, MEPs were evoked by stimulating the primary motor cortex representing hand grip muscles without pain. Then, responses of the FDI muscle were observed. MEPs are useful for predicting functional recovery after CI. The latency and amplitude of the MEP responses were recorded . The mRS is a six-point ordinal hierarchical scale that describes global disability and focuses on mobility . The 9HPT is useful for measuring the dexterity of relatively well-recovered patients .
Sample size calculation was detailed in our study protocol . We performed per-protocol analysis for the assessment of efficacy and a supplementary full analysis set. Analysis was performed by blinded biostatisticians using SPSS version 20.0 software (SPSS Inc., Chicago, IL, USA) using two-sided significance tests with a 5% significance level. Continuous variables were presented as means and standard deviations (SD), and categorical variables were presented as count frequencies and percentages.
Baseline data were collected and compared by first using the independent k-sample Kruskal-Wallis test, nonparametric tests, and χ2 test. Differences between all outcome value changes (week 0 vs. week 7) in the four groups were compared by the two related samples test and the Wilcoxon signed-rank test (nonparametric tests). Values of FMAUE, FMA lower extremity (FMALE), FMA total, NIHSS, MBI, FIM, 9HPT, AHSA-NOMS, FAC, mRS, EQ-5D, K-MMSE, MAS elbow, and MAS ankle were compared by repeated-measures analysis of variance (ANOVA) across two to three testing time points (week 0, week 3, week 7). An F test was conducted to detect differences between therapies, and the Scheffé post hoc test was conducted to identify groups. Differences between two groups of outcome value changes (week 0 vs. week 7 and week 0 vs. week 3; significant changes were observed in the ANOVA and the Scheffé post hoc test) were compared by the two independent samples test and the Mann-Whitney U test (nonparametric test).