Due to advancements in the medical environment, the mortality rate for cerebrovascular diseases has decreased from 50.7 per 100,000 population in 2011 to 44.0 in 2021, and the number of survivors continues to increase proportionally in South Korea¹⁾. The total economic burden of brain disorders was USD 1.88 billion in 2008 and rose to USD 2.90 billion in 2011, representing a 54% increase. The economic burden of all diseases was USD 2.61 billion in 2008 and USD 3.62 billion in 2011, a 39% increase, which was 1.2 to 1.4 times higher than that of brain-related diseases. Therefore, there is an increasing need for cost-effective treatment methods in stroke rehabilitation²⁾.

According to the Clinical Practice Guidelines of Korean Medicine (CPG-KM) for stroke, general acupuncture, electroacupuncture, moxibustion, and herbal medicine are recommended with grades of B and C for various brain regions, including motor disorders, stiffness, cognitive disorders, swallowing disorders, speech disorders, and urination disorders. Therefore, CPG-KM suggests that Korean medicine treatments can be utilized in stroke rehabilitation management based on a relatively high level of clinical evidence³⁾. Among these, scalp acupuncture is classified under general acupuncture for scalp acupoints and is utilized in various methods during the rehabilitation phase following a stroke⁴⁾.

Standard post-stroke treatment typically includes symptomatic drug therapy, exercise therapy, occupational therapy, and speech therapy. Despite several studies indicating that integrative medicine is more effective than rehabilitation alone in enhancing motor function and quality of life in stroke patients, the use of concurrent acupuncture treatment often depends on the patient’s preferences^3,5).

Accordingly, the South Korean government has implemented a pilot project in which integrative medicine is used in primary care to reduce unnecessary expenses associated with visiting multiple medical institutions, shorten the duration of symptom recovery and healing, and improve overall treatment effectiveness.

This study simultaneously applied scalp acupuncture and rehabilitation treatments to patients admitted to a rehabilitation ward at a Korean medicine hospital under an integrative medicine system. The degree of symptom improvement was evaluated through interviews, and the results are reported herein.

1. Subjects

Among patients who received outpatient or inpatient treatment from January 1, 2020, to November 30, 2021, we targeted those who had received outpatient treatment or had been hospitalized for stroke-related symptoms within the past 10 years. Patients with hemiplegia, which made it difficult to maintain the fixed posture required for standard acupuncture treatment, were selected as subjects. These patients also needed to have a strong willingness to actively participate in treatment, agree to the combined use of scalp acupuncture, rehabilitation exercises, and electrotherapy, and have no infections or injuries at the acupuncture site. Although other patients who met these criteria visited the clinic, those who could not provide accurate data due to the timing of assessments were excluded from the study. Each patient received scalp acupuncture treatment at least twice a week, and the total number of subjects was 3.

2. Therapeutic intervention

1) Scalp acupuncture: Scalp acupuncture maps the functional localization of the cerebral cortex onto the scalp, targeting areas such as the motor, sensory, and speech regions, and stimulates the areas corresponding to the patient’s symptoms. Using sterilized stainless steel acupuncture needles (0.25×30 mm, Dong Bang Acupuncture Co., Korea), a total of four needles were inserted horizontally under the skin, with one needle placed in each of the following areas on the affected side: the upper limb motor area (the middle 2/5 of the motor area), the lower limb motor area (the upper 1/5 of the motor area), the upper limb sensory area (the middle 2/5 of the sensory area), and the lower limb sensory area (the upper 1/5 of the sensory area)⁶⁾ (Fig. 1). After placing the acupuncture needles, joint mobilization was conducted for 5 minutes each on the upper and lower limbs. No acupuncture or other Korean medicine treatments, apart from scalp acupuncture, were administered to the patients.

Fig. 1. Picture of scalp acupuncture points.

2) Rehabilitation treatment: Depending on the severity of the patient’s stroke symptoms, either complex exercise therapy (Bobath exercise)⁷⁾ or simple exercise therapy (joint mobilization) was prescribed. If there was pain in the limb joints, treatments such as hot packs, transcutaneous electrical nerve stimulation (TENS), and radiofrequency therapy (microwave) were administered in the physical therapy room. Both complex and simple exercise therapies were conducted by a physical therapist specialized in central nervous system physical therapy.

3. Evaluation

1) Manual Muscle Test (MMT): To evaluate the patient’s motor function, MMT was performed both at the initial visit and at the end of the treatment period⁸⁾.

2) Modified Barthel index (MBI): MBI is a widely used tool for evaluating activities of daily living in stroke patients. It consists of 15 detailed items, including 9 related to personal care and 6 related to mobility. These items assess various functions such as drinking from a cup, putting on tops and bottoms, using assistive devices, body grooming, washing the face (bathing), urine disposal, stool disposal, perineal hygiene (dressing in the bathroom), transferring to a chair, transferring to a toilet, transferring to a bathtub, going up and down more than one step of stairs, walking more than 50 meters, and moving more than 50 meters in a wheelchair.

The MBI score ranges from 0 (indicating complete dependence) to 118 (indicating full independence). The index was assessed both at the time of hospitalization and at discharge, and the scores before and after treatment were compared and evaluated⁹⁾.

3) Interview: Before and after each scalp acupuncture treatment, Doctor of Korean medicine conducted interviews regarding any discomfort related to the treatment and the progress of the treatment.

4. Case Summary

1) Case 1: A 58-year-old male patient, Kim 00, was hospitalized from June 14 to June 24, 2021, for a total of 11 days. He experienced weakness in the left upper and lower limbs and dysarthria due to bilateral superior cerebellar artery (SCA), posterior inferior cerebellar artery (PICA), and right pontine infarctions that occurred on May 26, 2019. He had a medical history of diabetes.

During his hospitalization, the patient received integrative medicine, which included rehabilitation treatment, medication (Metformin hydrochloride, 1T BID / Atorvastatin calcium trihydrate, 1T BID / Clopidogrel bisulfate, 1T QD / Choline alfoscerate, 1T BID / Rebamipide, 1T BID), and scalp acupuncture treatments six times a week.

2) Case 2: A 75-year-old female patient, Ha 00, experienced left upper limb weakness due to an acute infarction in the right internal capsule (IC) and basal ganglia (BG) that occurred on August 18, 2021. She was diagnosed with hypertension in 2011. She was hospitalized for a total of 71 days, from August 20 to October 29, 2021.

During her hospitalization, she received integrative medicine, which included rehabilitation treatment, functional electrical stimulation therapy, medication (Clopidogrel resinate, 1T QD / Atorvastatin calcium trihydrate, 1T QD / Losartan potassium, 1T QD / Acetaminophen, Tramadol hydrochloride, 1T QD / Pelubiprofen, 1T QD / Nizatidine, 1T QD), and scalp acupuncture treatments twice a week.

3) Case 3: An 88-year-old female patient, Jeong 00, was hospitalized and observed for a total of 21 days, from August 24 to September 13, 2021, due to right hemiplegia resulting from an acute infarction in left corona radiata, which occurred on July 15, 2021. She was diagnosed with hypertension in 2010 and mild LCx stenosis in 2013.

Through integrative medicine, the patient received rehabilitation treatment, functional electrical stimulation therapy, medication (Bisoprolol fumarate, 1T QD / Dexlansoprazole, 1T QD / Digoxin, 0.5T QD / Azilsartan medoxomil potassium, 1T QD / Furosemide, 2T BID / Spironolactone, 0.5T QD / Rivaroxaban, 1T QD), and scalp acupuncture treatment six times a week.

5. IRB approval

This study is a retrospective observational research project based on the subjects’ electronic medical records. Research approval was obtained from the IRB of Gwangju Dongshin University Korean Medicine Hospital (review number: DSGOH_E_2021_009). Patient personal information was either deleted or de-identified. The diagnosis, treatment findings, and patient interviews necessary for the study were organized.

1. Case 1

Scalp acupuncture for the patient in case 1 began on June 18, 2021. The treatment targeted acupoints corresponding to the motor areas of the upper and lower limbs. The primary issue was difficulty in coordinating precise movements of the lower limb compared to the nearly normal upper limb, so the focus was placed on lower limb exercises.

After receiving acupuncture and exercise therapy, the patient reported, “After the treatment, I feel a bit more comfortable moving. However, my senses are still dull, and I continue to feel some discomfort.” There were no adverse events related to the scalp acupuncture treatment, such as bleeding, swelling, or bruising at the acupuncture sites.

The patient received scalp acupuncture treatment and exercise therapy six times a week during the hospitalization period. His adaptability to scalp acupuncture was high, and his satisfaction with the treatment was also high. He was discharged from the hospital on June 24, 2021. In an interview on the day of discharge, he mentioned, “It is still difficult to perform detailed movements with my arm, so I wish I could receive a little more treatment” (Fig. 2).

Fig. 2. Timeline of case 1.

2. Case 2

Case 2 involved a patient admitted to our hospital on the second day of illness. The patient initially had almost no movement in either the upper or lower limbs. Scalp acupuncture was performed on acupoints corresponding to the motor areas of the upper and lower limbs. Following acupuncture, joint mobilization was carried out for 5 minutes each on the upper and lower limbs.

After starting acupuncture treatment, the patient reported, “I couldn’t stand before, but now I have strength in my legs, so I can stand for a while. The third and fourth fingers on the left have started to bend.” There were no adverse reactions to the scalp acupuncture treatment, such as bleeding, swelling, or bruising at the acupuncture sites.

Case 2 was a patient who received scalp acupuncture treatment twice a week during hospitalization. The patient actively participated in exercise therapy, including self-walking exercises using a walker and a cane, and expressed high satisfaction with the scalp acupuncture treatment. In an interview on the day of discharge, the patient remarked, “My arm and leg strength has improved significantly. Although I couldn’t walk at first, I can now walk with a cane. The third and fourth fingers can also be moved separately. I found that while I had to lie still for acupuncture on my limbs, scalp acupuncture was beneficial because it was performed while I was exercising, which made it easier to feel the strength in my limbs more effectively” (Fig. 3).

Fig. 3. Timeline of case 2.

3. Case 3

Case 3 was an elderly patient who could not move her right upper and lower limbs at all (MMT: Upper limb Gr 1-, lower limb Gr 1-) (Table 1). She also had heart failure, leading her guardian to be concerned about potential energy loss during acupuncture treatment at the start of scalp acupuncture. Scalp acupuncture was performed on the acupoints of the motor areas of the upper and lower limbs. After acupuncture placement, joint mobilization was performed for 5 minutes each on the upper and lower limbs.

As the right shoulder was difficult to exercise due to a fracture, elbow exercises were performed approximately 10 times. During scalp acupuncture treatment, the patient reported that the center of her head was fine, but the outside was painful. After scalp acupuncture, there was no pain or abnormal sensation. During the mid-treatment interview, Case 3 complained of poor intake (1∼2 spoonfuls of porridge for 3 meals), poor sleep (waking up every 1∼2 hours due to chest pain and difficulty breathing), and difficulty distinguishing people (failing to recognize her children). On the day of discharge, she was able to drag her arm on the floor and hold it for a while in a lying position with her knees bent and brought together (Fig. 4).

Fig. 4. Timeline of case 3.

Stroke is a disease that impairs functions such as cognitive, motor, sensory, swallowing, and excretory functions. Therefore, stroke rehabilitation involves experts from various fields working together to restore the patient’s functionality¹⁰⁾.

Rehabilitation treatment for stroke patients begins as soon as the patient is medically and neurologically stable. Initially, the goal is to prevent complications such as deep vein thrombosis, bedsores, joint contractures, constipation, and pneumonia. Ultimately, the aim is to restore the patient’s function, prevent further complications, and facilitate their return to society. Rehabilitation training is tailored to the patient’s needs and symptoms, including exercises for upper and lower limb strength, sensory impairments, swallowing difficulties, urination and defecation, communication, and cognitive function. In Korean medicine, rehabilitation for stroke patients includes acupuncture, moxibustion, electroacupuncture, herbal medicine, pharmacopuncture, and Chuna manual therapy (CMT), depending on the patient’s clinical condition.

Integrative medicine combines complementary and alternative medicine (such as Korean medicine) with modern medicine for diagnosis and treatment, leveraging the advantages of each approach. Currently, integrative medicine for stroke patients includes intravenous thrombolysis, intra-arterial thrombolysis, neurosurgery, acupuncture, moxibustion, electroacupuncture, and herbal medicine, tailored to the needs of each patient.

According to a report from a domestic cooperative hospital, 5,957 patients (45.5%) out of 13,104 hospitalized patients received integrative medicine treatment for 6 years. In 2007, more than 50% of patients in South Korea received integrative treatment. However, from 2008 to 2011, although the total number of hospitalized patients increased, the proportion of those receiving integrative medicine treatment decreased¹¹⁾.

Although patients show a strong preference for Korean medicine treatment for stroke, a standardized model for integrative medicine has not yet been developed in South Korea. This is due to differences in approaches to the disease and a lack of mutual understanding on treatment methods. In a study that compared and analyzed the treatment effects of stroke patients using data from the integrated registration system for brain disease rehabilitation, it was reported that patients who received integrative medical treatment were more satisfied with their stroke rehabilitation and experienced greater functional recovery⁵⁾. Another study reported that the group receiving integrative medical treatment performed better in daily life activities after discharge compared to the group that did not receive such treatment¹²⁾.

Scalp acupuncture simultaneously stimulates the motor reflex area of the scalp and accelerates the recovery of neural function in the affected area through the patient’s movements. Therefore, retaining the needles during scalp acupuncture while the patient actively or passively performs rehabilitation exercises can accelerate the recovery of limb function, speech, and sensory abilities. Recent studies have shown that scalp acupuncture helps improve cerebrovascular circulation, promotes brain cell metabolism and the expression of neurotrophic factors, and can particularly activate specific motor function areas in the cerebral cortex, leading to partial or complete recovery of brain function⁴⁾.

In these cases, there was a positive change in the course of treatment, even though short-term treatment was administered years after the onset of the stroke. Notable improvement in MMT and MBI was observed, especially in the patient who visited the hospital immediately after the onset. In the case of chronic patients, although the improvement in MMT and MBI was not significant, all patients reported high satisfaction with the treatment in their interviews. Generally, stroke recovery is most active within the first three months after onset and can continue up to two years. In the case of Case 1, recovery was slower because more than two years had passed since the stroke occurred. In Case 2, treatment began just two days after the stroke during the acute phase, and with the longest treatment duration, this resulted in the best outcomes. In Case 3, treatment started about a month and a half after the stroke diagnosis, but due to the patient’s poor overall condition, including reduced food intake, decreased energy, and sleep difficulties, the scalp acupuncture did not appear to have a significant effect. A study conducted on subacute stroke patients in China showed better outcomes in the group that combined rehabilitation treatment with Chinese medicine treatment compared to those who received only rehabilitation treatment, supporting the results of this study¹³⁾.

According to a 2021 study by Xiaoli Hu⁴⁾, when comparing the Modified Barthel Index (MBI) before and one month after treatment between a group that received only exercise therapy and another that received both exercise therapy and scalp acupuncture, the group that received only exercise therapy showed little change in MBI (34.67±12.452 vs. 30.00±12.25; p>0.05). However, the group that received both exercise therapy and scalp acupuncture showed a significant difference (37.67±9.714 vs. 31.00±9.51; p<0.01). Although this study did not evaluate patients who did not receive scalp acupuncture, a comparison based on other studies suggests that patients receiving scalp acupuncture may experience better recovery outcomes than those who do not.

Patients’ expectations and preferences for scalp acupuncture treatment were high, leading to active participation in the treatment. Elderly patients with chronic diseases such as heart failure showed particularly high satisfaction rates. This is due not only to the effectiveness of scalp acupuncture treatment but also to its convenience. Patients who find it difficult to receive general acupuncture treatment due to challenges in maintaining a position show higher satisfaction with scalp acupuncture.

A series of rehabilitation treatments, including scalp acupuncture and medication, are established practices that do not require approval for new medical technologies. These treatments can be implemented immediately and are expected to produce synergistic effects. This case report, which demonstrates improvement through convergent collaborative treatment, provides hope for the effectiveness of integrative medicine for stroke patients. It is anticipated that such approaches will contribute to shortening the treatment period for stroke patients, improving symptoms in those with post-stroke sequelae, and reducing associated economic costs. If future research includes studies where scalp acupuncture from Korean medicine is administered concurrently with conventional rehabilitation treatments within the same clinical setting, it could lead to the development of a new, integrated rehabilitation treatment model.

Although this study is the first report on integrative medicine utilizing scalp acupuncture, confirming the treatment effects was challenging due to the chronic condition and sequelae of stroke. Additionally, there is a limitation in that only one patient was reported in the acute and subacute stages. Therefore, based on this study, there is a need for ongoing research on standardized integrative medicine protocols for stroke, incorporating scalp acupuncture.

Based on the integrative medicine system, scalp acupuncture and rehabilitation treatments were administered to three patients with post-stroke sequelae. The results demonstrated significant improvements in MMT and MBI in the acute phase of stroke. However, in cases of chronic stroke, the degree of improvement was modest. Despite this, all patients reported very high satisfaction with the treatment in their interviews.

The authors express their sincere thanks to the staff at Dongshin University Gwangju Korean Medicine Hospital and AICC (Acupuncture Treatment by ICT Convergence Research Center) for their support.

This work is supported by the National Research Foundation of Korea (NRF) funded by the Ministry of Science and ICT (No. 2022M3A9B6017813 and NRF-2020R1A2C2009926).

The authors can provide upon reasonable request.

The authors have declared that no conflicts of interest exists.