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Discover Medicine
Review
Complementary therapies forstroke towardsneurorecovery
AnirbanBarik1· ChetsiShah2· GautamKarmarkar1· JyotMotivaras1· TanishaMajumdar1,3· BijoyaniGhosh1·
NikitaRana1· AishikaDatta1· HeliShah4· SudhirShah5· PallabBhattacharya1
Received: 15 July 2024 / Accepted: 10 March 2025
© The Author(s) 2025 OPEN
Abstract
Background and purpose Despite rapid advances in stroke management and rehabilitation therapy, no eective treatment
is available for the later recovery phase following stroke. Therefore, complementary and alternative medicine system
(CAM) has emerged as promising adjunct therapy for stroke management. CAM has its own cultural and philosophical
aspects with dierent societies that drive as an inspiration and perception of less harmful and more eective strategies
for stroke rehabilitation. However, robust scientic studies are required to establish CAM as an alternative therapy adjunct
to conventional stroke treatment.
Methods A thorough literature search was performed using standard web databases such as PubMed, Google Scholar,
ResearchGate, Scopus using ‘complementary and alternative medicine in stroke’ as the major keyword. Research and
review articles containing latest preclinical and clinical studies were primarily included in this review. Moreover, dierent
stroke treatment strategies mentioned in ancient scriptures were also considered.
Result CAM therapy is parallelly practiced along with clinically approved stroke therapy worldwide. It has been also
reported benecial on post-stroke neurorehabilitation in dierent population-based studies.
Conclusion Currently, CAM suers various limitations, including dened end-point, clear outcomes, the exact mechanism
of action, and proper assessment of the patient’s physical and emotional needs. Nevertheless, CAM is being used to treat
various diseases globally. However, their usage pattern diers according to a population’s geography and socio-cultural
background. The review briey discusses dierent CAM used as stroke rehabilitation therapy and their promising role in
adjunct stroke management strategies.
Keywords Complementary medicine· Alternative medicine· Stroke· Rehabilitation· Adjunctive therapy
1 Introduction
Stroke is the second leading cause of death worldwide, accounting for 6.55 million fatalities in 2019—or around 11.6%
of all deaths [1–3]. A stroke occurs when the brain’s blood flow gets reduced due to interruption [4]. It is caused due
to blocked or broken arteries supplying blood, oxygen, and nutrients to or within the brain. In 2019 the projected
number of incidents and prevalent strokes were 12.22million (70% increment from 1990) and 101.47million (85%
increment from 1990), respectively [1]. Stroke has been identified to be the third major contributor to disability
* Pallab Bhattacharya, pallab.bhu@gmail.com; pallab.bhattacharya@niperahm.res.in | 1Department ofPharmacology andToxicology,
National Institute ofPharmaceutical Education andResearch (NIPER), Ahmedabad,Gandhinagar382355, Gujarat, India. 2Department
ofNeurology, Sumandeep Hospital, Vadodara, Gujarat, India. 3Department ofBiotechnology, KIIT University, Bhubaneshwar, Odisha,
India. 4Sterling Hospital, Ahmedabad, Gujarat, India. 5Department ofNeurology, SVPIMSR, Director ofNeurosciences, Sterling Hospital,
Ahmedabad, Gujarat, India.
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globally, accounting for 143.23million disability-adjusted life years (DALYs) in 2019, which is 32% more than the year
1990 [1]. Although approximately 70% of stroke cases occur specifically in middle and low-income countries, India is
experiencing an astounding rise, with 1.8 million cases reported annually [5, 6]. According to a report, stroke is the
fifth leading contributor to DALYs in India [7]. This resulted in around 6.5 million prevalent stroke cases in 2016, 7.1%
of all deaths [8]. Although there are regional variations in the incidence of stroke, the Southern and Eastern regions
have the highest rates [9]. According to most of the studies, the incidence of stroke is more prevalent among men
than women in India [10–14]. According to American Heart Association, ischemic, hemorrhagic, transient ischemic
attack (TIA), cryptogenic, and stroke affecting the brainstem are the latest subsets of stroke [15]. Stroke caused due
to arterial occlusion, i.e., ischemic stroke, accounts for 87% of all stroke cases. Transient ischemic attack, on the other
hand, is caused due to an impermanent blood clot, also termed a mini-stroke. Hemorrhagic stroke causes vascular
rupture, whereas cryptogenic stroke is one for which the etiology still cannot be identified [15]. Based on recent
studies, high blood pressure, ambient particulate matter pollution, body mass index, high fasting blood glucose,
and smoking are major risk factors that can trigger stroke [1, 3, 8]. Apart from these, high BMI emerged as another
critical stroke risk factor between 1990 and 2019 [1].
Camilo R. Gomez once stated, "Time is brain," referring to how quickly and permanently neurons in the brain are
destroyed according to time following a stroke. A typical patient may lose 1.9million neurons, 13.8billion synapses,
and 12km of axonal fibers per minute when a large vessel ischemic stroke remains untreated [16]. If therapy is unsuc-
cessful, the brain loses as many neurons each hour as it does in approximately 3.6years of average aging [16]. Indeed,
the more prolonged treatment is put off, the lower the likelihood it will be effective. Therefore, early intervention
significantly limits the damage to the penumbral neurons [16–18].
It is well-known that stroke management is challenging and complex, with limited FDA-approved treatments such
as tissue plasminogen activators (tPAs) and mechanical thrombectomy (MT) [19]. Stroke impacts people’s health and
quality of life throughout the illness but necessitates significant healthcare resources, including medical expenditures
and long-term care costs [20]. As a result, complementary and alternative medicine gained popularity among stroke
patients and their families, predominantly in developing countries like India, Chile, and Africa [21]. Earlier reports
suggest that stroke patients will most likely observe considerable functional improvement during the first three to
six months of complementary and alternative medicine (CAM) treatment [22, 23]. Positive perception towards CAM,
mainly in Asians, may be attributed to the harmlessness of traditional medicine and their cultural connection with
society [24–26]. Some key variables driving the usage of CAM treatment include the higher expense of conventional
therapy, illiteracy in rural regions, discontent with modern medicine, and the perception of elderly people [24, 26,
27]. Some barriers to CAM usage may include lack of scientific evidence, disbelief in the safety and efficacy, and
unhygienic practices by CAM practitioners [24, 27]. According to World Health Organisation (WHO), complementary
or alternative medicines are a broad group of healthcare methods not included in a country’s conventional practices
and may be used interchangeably with traditional medicine [28, 29].
The use of CAM varies significantly by geography since various cultures and traditions approach healthcare dif-
ferently (Fig.1). Several CAM treatments originated in Asia and are still actively practiced there. Traditional Chinese
medicine (TCM), Ayurveda, and acupuncture are all standard CAM therapies throughout Asia. Herbal therapy, cupping,
and tai chi are other CAM therapies popular in Asia [30–33]. CAM is also popular in Europe. Homeopathy, osteopathy,
and naturopathy, acupuncture are a few of Europe’s most popular CAM techniques [34, 35]. In North America, CAM
utilization is more diverse, with various methods being implemented. Acupuncture, massage treatment, and chiro-
practic care are popular in the United States and Canada [36–40]. In North America, herbal medicine, aromatherapy,
and meditation are popular [41, 42]. Traditional healing practices coexist with modern medicine in many regions
of Africa. Traditional healers use a variety of CAM therapies, such as herbal medication, bone setting, and spiritual
healing [43, 44]. Traditional healers are acknowledged by the government in certain countries, such as South Africa,
and are incorporated into the public healthcare system [45]. Traditional Mexican healing, along with herbal medicine,
massage treatment, and acupuncture, is widespread across Latin America [40, 46–48]. It’s worth noting that CAM
procedures might differ considerably even within the same area or nation.
It was found that acupuncture, herbal therapy, cupping, and moxibustion are popular therapies in Asian countries,
particularly in East Asia [31–33, 49–51]. Whereas, in Southeast Asian nations such as Indonesia, Malaysia, and Thailand,
herbal medicine, massage, and energy healing therapies such as Reiki and Qi Gong are more popular [52–54]. Traditional
Chinese medicine, Ayurveda, and Persian medicine impact the CAM therapies practiced in Central Asia. Massage, cupping,
and herbal therapy are some of the most common treatments in this area [31, 55–57]. Ayurveda, which started in India
over 5000years ago, is South Asia’s leading traditional medicine practice [58, 59]. It is a holistic approach to healing that
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balances the body and mind via herbal medication, food, meditation, and other lifestyle practices. Yoga, homeopathy,
naturopathy, acupuncture, chiropractic, Unani, and Siddha medicines are some of India’s most extensively utilized com-
plementary treatments, along with Ayurveda [60–63]. Since March 1995, the Department AYUSH under the Ministry of
Health and Family Welfare has certied CAM practitioners in India [64].
In a study by Pandian JD etal., 314 stroke patients were interviewed, of which 230 (73.2%) were men. Among these
314 patients, 114 (36.3%) received the CAM treatment. Majority of subjects used were Ayurvedic massage, 67(59.3%)
followed by intravenous uids, 22(19.5%); herbal medicines, 17(15%); homeopathy, 15(13.3%); witchcraft, 3(2.7%); acu-
puncture, 3(2.7%); and other non-conventional treatment, 10(8.8%). Severe stroke (P < 0.0001), limb weakness (P < 0.0001),
dyslipidemia (P = 0.007), dysphagia (P = 0.02), hypertension (P = 0.03), and patients with poor outcome (P < 0.0001), all
predicted CAM usage. Among CAM users, 35.2% reported a considerable improvement, mostly in walking pattern (36.8%)
and lower limb (18.4%) and upper limb (15.8%) strength [64].
To strengthen traditional medicine’s role in public health, WHO launched the "WHO traditional medicine strategy
2014–2023" in 2013, with the goal of assisting member states in developing action plans and proactive policies to
strengthen the role of traditional medicine in public health[28]. This strategy is implemented to promote traditional
and complementary medicine use that is both safe and eective by appropriate regulation, research, and integration of
CAM practitioners, products, and practices in the health system [28].
Moreover, in March 2022, the Ministry of AYUSH (Government of India) signed an agreement with the WHO to set up
the WHO Global Centre for Traditional Medicine (GCTM) at Jamnagar, Gujrat. The center would be funded by a USD 250
million investment from the Indian government. The goal of this project is to strengthen the foundation of the public
health care system by utilizing the potential of complementary and alternative therapies through modern science and
technology [65]. The quality of life and speed of recovery of stroke survivors could be enhanced by ensuring that CAM is
used safely and eectively through regulation, research, and integration into the conventional health system. Patients
who choose CAM treatments often quit conventional medical care, so it’s essentialto keep in touch with the primary
care physician.
Fig. 1 Geographical distribution of dierent complementary and alternative medicines (CAM)- Asia has the highest varieties of CAM prac-
tices that include Traditional Chinese medicine (TCM), Ayurveda, acupuncture, herbal therapy, cupping, and tai chi. In the Europe, home-
opathy, osteopathy, naturopathy, and acupuncture are more in use. The North America reports maximum practice of acupuncture, massage
treatment, chiropractic care, herbal medicine, aromatherapy, and meditation. Traditional Mexican healing, herbal medicine, massage treat-
ment, and acupuncture are reported to be practiced more in South America. The Africa reports CAM practice using herbal medication, bone
setting, and spiritual healing
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2 Methods
A comprehensive literature search was conducted using standard online databases like PubMed, Google Scholar,
ResearchGate, and Scopus. We screened abstracts and titles of English-language studies using “complementary therapy”,
“alternative medicine”, “traditional medicine” “stroke”, and/or “adverse eects” as the primary keywords. This study mostly
comprised research and review publications with the most recent preclinical and clinical trials. Additionally, many stroke
treatment strategies that were referenced in ancient scriptures were taken into consideration.
3 Role ofAYUSH (Ayurveda, Yoga, Unani, Siddha, andHomeopathy) instroke management
3.1 Role ofAyurveda instroke management
Ayurveda is one of the ancient traditional medicine systems that believe the entire human physiological functions are
balanced by three basic senses of humor (dosha) [66]. These three humors are- Vata dosha, Pita dosha, and Kapha dosha,
collectively known as ‘Tridoshas.’ Vata is believed to control the catabolism of the body, whereas metabolism and anabo-
lism are governed by Pita and Kapha respectively [67]. It also considers neurological disorders are a result of Vata disorder
[67]. In Ayurveda, neurological treatment aims to maintain harmony between these Tridoshas (Fig.2). The treatment of
hemiplegia due to cerebral infarction includes therapies such as- snehan, swedana, virechana, and vasti, which involve
Ekangavir Rasa, Kaishore Guggulu, Sanjivani Vati, and Brihat Vatachintamoni Rasa as medication [68].
Hemiparesis (Pakshaghata) and its subdivisions are well classied in Ayurveda, along with their specic treatments
[68]. In the ‘Charak Samhita’ (Chikitsa sthana- chapter28), Acharya Charak has described hemiparesis as vata nanatmaj
vyadhi [67]. Whereas, in the Sushruta Samhita (Nidana sthana, chapter1), Acharya Sushrut has mentioned it as mahavat-
vyadhi [68]. Both the Acharyas recommended treatment protocols for hemiparesis that include- snehana, swedana,
Fig. 2 Pathophysiologi-
cal basis of dierent CAM
practices- Conventional
treatments of stroke are based
on cellular changes in ionic
gradient, excitotoxicity, and
changes in dierent intracel-
lular signaling pathways.
Whereas, Ayurveda believes in
imbalance between tridosha,
viz, vata, pitta and kapha can
result into post-stroke hemi-
plagia. On the other hand,
Unani believes on imbalances
between four humours of
body can result into stroke.
Chinese herbal medicine
believes on the alteration of
ve basic elements can result
in stroke and post-stroke
outcomes in a human body.
To maintain these balance
within the body, Aromather-
apy, music supported therapy,
acupuncture, moxibustion,
hirudotherapy and cupping
are practiced
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mridu virechana, basti karma, and murdhani. Chapter28 of Chikitsa sthana in Charak Samhita, hemiparesis is classied
as ‘paksha-vadha’, ‘ekanga-roga’ and ‘sarvanga roga’ [67]. According to Charak Samhita, paralysis of any one side of the
body by aggravated vayu causes immobility of that side and results in enormous pain and loss of speech, which is termed
‘paksha-vadha’ [67]. When the aggravated vayu aicts half of the body and may constrict vessels and ligaments, resulting
in contracture in one leg or hand with piercing pain, that is termed as ‘Ekanga-roga’. Finally, if any of these pervade the
entire body, it is termed as ‘Sarvanga-roga’ [67].
The eective line of treatment has been mentioned as ‘oleation therapy’ that includes the consumption of ghee, muscle
fat, oil, and bone marrow in the initiation of the treatment [67]. After a gap of few times, the treatment can be continued
with the help of milk, vegetable soup, and meat soup of domesticated/ aquatic/ small marshy-land inherited animals.
Following proper oleation, fomentation therapy should be started that includes ‘nadi-sveda’, ‘prastara-sveda’, ‘sankara-
sveda’ etc. The basis of these therapies believes that curved and sti limbs can be slowly brought back to their own
normal structure by oleation and fomentation therapies [67]. The softened body will immediately alleviate the tingling
sensation, pricking pain, ache, contracture and edema [67]. The oleation therapy is believed to provide instantaneous
nourishment to emaciate tissue elements and promotes strength to the Agni (enzymes of metabolism), plumpness and
elan vitae. Although inappropriate preparation of these formulation may lead to some adverse eects (Table1). The thera-
pies should be given repeatedly so that the viscera (kostha) remain soft and the tridoshas remain in harmony. However,
if inappropriate administration of the therapies happens, patient should undergo elimination therapy with the help of
mild drugs that includes medicated ghee prepared by boiling either with ‘tilvaka’ or ‘satala’. The therapy also includes
the consumption of castor oil with milk, which helps in rapid elimination of morbid materials for health benets. If the
patient is unsuitable for elimination or purgation therapy, a ‘niruha’ type enema can be prepared with ‘pacana’ (carmina-
tive) and dipana (stimulant of digestion). In addition, patients with vayu disorders should be continuously given a diet
containing sweet, sour, saline, and unctuous, along with inhalation and smoking therapies [67].
Sushruta Samhita says that when aggravated vayu invades down, side, and upward ligaments or nerves (dhamanis),
it results in loosening of joints, destroying one half of the body, or commonly described as ‘pakshaghata’ [68]. If half of
the body gets destroyed (i.e. inactive) by vata/vayu alone, then it is dicult to cure [68]. However, if it is associated with
other doshas it is curable. In Chikitsa sthana, chapter4, Sushruta described therapies such as sneha (oleation), sveda
(sudation), abhyanga (oil bath and massage), basti (enema), sneha virechana (oily purgatives), sirobasti (enema to the
head), sirohsneha (oiling the head), snaihika dhuma (lubricating smoke inhalation), sneha gandusa (lubricating mouth
gargles), and snehika nasya (lubricating oily nasal drops) all should be comfortably warm [68]. In chapter15, nidanasthana
of Ashtanga Hridaya described hemiparesis as an imbalance of tridoshas similar to Charak Samhita. It says, when vata/
vayu seizes half of the body, it is called ‘ekangaroga’. Likewise, when whole body is invaded by vata, it is called ‘sarvanga-
roga’. In chapter21, chikitsa sthana, it is described as vata dosha alone can be treated by ghee, muscle fat, marrow or oil
consumption. Weak patients should be ensured by consuming milk, soup, meat, milk pudding, rice boiled with grams,
etc. by anuvasana (oil enema), navana (nasal medication), tarpana food with fats along with sudation therapy by sankara
sveda. However, even with these therapies the diseases do not subside, then sodhana or purication therapies should
be done with mild drugs mixed with milk [68].
A pilot study on a branch of Ayurveda similar to acupressure therapy named ‘adjunct marma’ therapy, reported a
benecial eect of massage therapy [69]. The response rate of the study was 91%; however, no signicant dierences
in the ecacies were noticed in the scores. The follow-up score as a secondary measure showed dierences of the
Motricity Index at 6 and 12weeks. The trunk control test at 6weeks reports improvement in the intervention group
(p < 0.05, p < 0.01) [69]. A randomized clinical trial (RCT) that compared 2 dierent Ayurvedic muscle-nourishing process
Navarakizhi and pinda sweda were applied in chronic stroke patients with hemiplegia [70]. In the study, 18 patients with
hemiplegia for 6months to 2years received treatment for 7days. Both groups received the same Ayurvedic oral medica-
tions for 14days. The intraquartile range showed better response in patients who received navarakizhi than those who
received pinda sweda [70].
Another study on Ayurveda-induced improvement in cardiac autonomic dysfunction following stroke as an adjunc-
tive treatment received standard allopathic medications as per neurologists [71]. In addition, randomized patients were
divided to two groups. First, to receive physiotherapy (Group I) and second, to receive Ayurveda treatment (Group II) for
14days. Patients in Group II reported statistically signicant improvement in dierent cardiac autonomic parameters.
There were signicant enhancements in the standard deviation of normal to normal intervals, and total and low frequency
powers (F = 8.16, P = 0.007, F = 9.73, P = 0.004, F = 13.51, and P = 0.001, respectively). The baroreex sensitivity increased
following the treatment period (F = 10.129, P = 0.004) [71]. It is the rst study that reported adjuvant Ayurveda treatment
in ischemic stroke can positively modulate cardiac autonomic activity [71].
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Table 1 Reported adverse events related to dierent CAM practices
Sl. no Therapy Expected adverse eect(s) References
1 Ayurveda Presence of heavy metals and alkaloids, can have adverse events like jaundice, abdominal discomfort, hepatic failure when prepared
inappropriately [183, 184]
2 Yoga Soreness and pain, muscle injuries and fatigue [185]
3 Unani Certain Unani formulations like Habb-e-Shifa that is used as anti-pyretic anti spasmodic agent, has found to cause dilation of pupil
leading to visual impairment and photophobia in patients [186]
4 Homeopathy Allergic reactions, atopic dermatitis, leucocytosis, gastrointestinal illness, hair loss, and cardiac, renal, pulmonary and hematological
adverse events [187, 188]
5 Tai Chi Increased risk of joint injury, falls and overexercise leads to musculoskeletal strain [189, 190]
6 Acupuncture Infection, blood vessel injury and bleeding, tissue and nerve damage, irritation around thestimulation site [191, 192]
7 Chinese Herbal Medicine (CHM) Presence of toxic ingredients and contaminants like heavy metals, dierent western drugs may cause cardiovascular, neurological,
gastrointestinal, hematological, and renal adverse events [193, 194]
8 Massage therapy Minor nerve injuries, bruises, and blood clot dislodgment [195]
9 Aromatherapy Allergic reactions, headache, respiratory issues, drug interactions, CNS overstimulation. [196]
10 Chiropractor Therapy Vertebral artery dissection, neck pain, and slipped disc [197]
11 Moxibustion Increased heat leads to skin irritation, burns andskin cracks leading to infection and inammation [50]
12 Hirudotherapy Hemorrhagic shock, anemia, pain and occasional infection [198]
13 Cupping Skin irritation, bruising, burns, headache, muscle tension and soreness [199, 200]
14 Reiki Muscle tightness, pain and pressure sensations [201]
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Another observational study prospectively compared outcomes in 2 cohorts of acute ischemic stroke (AIS) patients.
One treated with whole-system classical Ayurveda (n = 13) and another with conservative (nonthrombolytic, nonin-
terventional) Western biomedicine (n = 20). The outcomes were statistically non-signicant in mortality rates (15.38%
vs 15%, P = 1.00), nonfatal adverse event rates (15.38% vs 30%, P = 0.4), and functional disability measures. It is the rst
ever stand-alone report describing similar safety proles of classical Ayurveda and conservative Western biomedicine
following AIS [72].
3.2 Role ofYoga inStroke Management
According to Ministry of Ayush, Government of India, ‘Yoga’ means ‘to unite’. It implies the union of individual spirit with
the universal spirit of almighty. It is a combination of practices to engage with the world to create harmony [73]. As a
discipline, Yoga means- to engage, to participate, to get involved, and to connect [73]. Yoga involves several mind and
body practices that claim to use interactions among the mind, body, and behavior to promote optimal health over the
lifespan and improve dierent aspects of physical and mental health [74]. Modern Yoga has eight components: Yama or
moral disciplines, Niyama or positive observances, Asanas or postures, Pranayama or regulated breathing, Pratyahara or
sense withdrawal, Dharana or focussed concentration, Dhyana or meditation, and Samadhi or enlightenment [75]. Despite
of some reported adverse events (Table1), there are many positive correlations of Yoga have been reported that can be
considered stroke preventive measures. A meta-analysis of 6 trials demonstrated that yoga was associated with a reduc-
tion in systolic and diastolic blood pressure (− 5mmHg and − 4mmHg) respectively [76]. It is also reported to be eective
in smoking cessation, downregulating inammatory markers, and reducing stress and anxiety [77–80]. A study by Schimd
etal., reported benecial eects of yoga in male stroke survivors in a Veteran Hospital (NCT01109602- Registration dates:
First Submitted- 2010-04-02, First Submitted that Met QC Criteria- 2010-04-21, First Posted (Estimated)- 2010-04-23). The
patients were categorized into three groups viz, Group Yoga, Yoga plus i.e., group yoga with home training and control
patients. Following yoga training, the patients reported improvement in balance, quality of life, reduced fear of falling,
improvement in doing daily life activity independently [81].
3.3 Role ofUnani inStroke Management
Unani medicine (“Unani-Tibb”) is one of the old systems of healing, which originated in ancient Greece (Unan) and has its
presence in various civilizations such as the Arab, Rome, and Spain [82]. Buqrāṭ (Hippocrates, 460 BCE) introduced this
traditional Perso-Arabic system of medicine, while other scholars such as Galen, Ibn Betar, and Zakarya Razes inuenced
the advancement of the same [83]. Between the thirteenth and seventeenth centuries, Arabic physicians integrated it
with Indian medicinal plants, which helped it to spread throughout the Indian subcontinent [84]. It is based on the prin-
ciple of equilibrium of the proximal kaiyat (qualities) of which the body is made: the four arkān (elements), four akhlāṭ
(humours), and four mizāj (temperaments) of the human body [82]. The four elements (earth, air, water, and re) along
with the four humours, which are blood (dum), phlegm (balgham), yellow bile/ bilious (ṣafrā), and black bile/ melancholic
(saudā) controls the four temperaments (cold, dry, wet, and hot) (Fig.2) [82, 83]. The dierent temperaments are based
on the humour of the person while the umoor-e-tibiiya (forces of nature) and three arwah (forces) controls the simple
and compound a’dā’ (organs) of the body [82, 84]. Evaluation of the imbalance of the humours is done through nabz
(pulse), urine, and stool tests [83]. Following tashkhees (diagnosis), the treatment may be in the form of ilajbid-dawa
(pharmacotherapy), ilajbit-tadbeer (regimental therapy/lifestyle modication), ilajbil-ghiza (diet therapy), and jarahat [83].
The entire Unani treatment for stroke is based on the principle of Ta’deel (equalizing the temperament of the aected
organ) and Tanqiya (elimination of the main cause) [85, 86]. Regaining the humoral balance by the use of single or poly-
herbal remedies along with dietary control has been explored as eective management for stroke treatment (Fig.3) [87].
Preventive measures using pharmacotherapy which either includes either mufrad advia (single crude drugs) derived from
natural sources or murakkab advia (compound drugs) have been recorded in Unani treatment for stroke [88]. In unani
medicine garlic, (Allium sativum) Linn. is known as Seer in Persian and Saum in Arabic [89]. In the book Al Qanoon-l-Tib
(The Canon of Medicine) garlic has been recommended as antihyperlipidemic and antihypertensive [89]. The attributes
of this crude drug are to reduce the risk of ischemic stroke by reducing blood pressure and cholesterol levels. Garlic has
been reported as eective for post-stroke rehabilitation in the regimental approach of Unani medicine [84]. Post-stroke
hemiplegia (Fālij-i-Nisf) according to unani literature denotes istirkha (paralysis) of the longitudinal half of the body along
with loss of motor functions also with or without sensory functions [85]. The dalk (massage) therapy using the Unani
pharmacopoeial formulation of garlic oil (Roghan Seer) was documented to have signicant improvement in lower limb
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mobility in post-stroke hemiplegic patients [90]. Other formulations such as Roghan Qustand other medicated oils were
reported to improve the Fugl-Meyer upper limb score for hemiplegia caused by stroke and other musculoskeletal and
nervous system disorders [84]. In a rat model of permanent middle cerebral artery occlusion of stroke, Ginkgo biloba
extract has been reported as a potential therapeutic drug for the improvement of motor function [91]. The same has
been a part of the Unani formulations because of its pharmacological activity as an antagonist for platelet-activating
factor and it also increases cerebral blood ow, thus making this herb an integral part of the CAM for geriatric patients
[92]. Similarly, Ginger (Zingiber ocinale Roscoe) is another well-known CAM for stroke, whose fresh rhizome is known
as Saunth and Zanjabeel. In unani literature, it is recorded as an eective herb for platelet aggregation, improving
circulation, and reducing the fructose-induced elevation of lipid levels [93, 94]. The combination of these single drugs
has been formulated into compound drugs in the Unani system. Majun Khadar is such a Unani herbal formulation that
has shown protection against hippocampal neurochemical alterations and behavioral dysfunctions in rat model of
transient focal cerebral ischemia [87]. It is a preparation of 27 constituents, which has anti-inammatory, vasodilation,
nerve stimulant, and free radical scavenging (antioxidative) activities. Thus, this formulation exerts a synergistic eect
of these constituents on oxidative stress and inammatory condition in ischemic neuronal death. Other Unani herbal
compound formulations such as Khamira Abresham and Majun Baladar also have similar neuroprotective ecacy in
focal cerebral ischemia [95, 96].
The Unani treatment for stroke is based on the technique of ripening and expellingthe humoral substance with a
honey-based formulation (ma-ul-asal) and extract of eight to ten herbs. This technique is reported to treat the weakness
in the patient within 45–90days completely [83], although these claims aren’t supported with substantial proof. Various
clinical trials have been conducted using poly-herbal unani formulations to improve post-stroke conditions in patients.
Unani literature states that hemiplegia is mainly caused by the obstruction to the passage of nerve impulses (rūh-inafsāni)
[82]. Stroke is treated by the comprehensive package of Ta’deel (massage of the paralyzed limbs) and Tanqiya (poly-herbal
formulations) in Unani medication. In a single-arm clinical trial of 30 clinically diagnosed post-stroke hemiplegic patients,
the oral administration of Unani formulation of phlegmatic concoctive drugs (Joshanda Munzij-i-Balgham) for 15days
followed by dry cupping (Hijamah Bila Shart) of paralyzed limbs for 10min daily (16th to 30th day), reported improved
Fig. 3 A comparative
representation of conven-
tional stroke treatment with
dierent CAM practices- Con-
ventional stroke treatment is
based on reperfusion theory,
i.e., earliest removal of occlu-
sion to achieve neuropro-
tection. Whereas, various
CAM practices rely on their
traditional belief. Ayurveda
believes on the treatment
method that includes olea-
tion (Snehan), perspiration
(Swedan), metabolism (vire-
chan), and enema application
(vasti). It also relies upon Yoga,
that is helpful in post-stroke
rehabilitation. Homeopathy
believes in serial dilution
method that is directly
proportional to the potency
of the medication. Unani
applies dierent combination
of medications containing
common natural ingredients.
Chinese herbal medicine
has dierent classications
that deal with various other
treatment methods including
Tai-chi, massage therapy, aro-
matherapy, acupuncture, etc.
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motor recovery [82]. A similar result was reported by another single-blind, randomized, and standard-controlled clini-
cal trial of 40 patients and open observational clinical trial of 30 patients, based on both pre- and post-stroke Stroke
Rehabilitation Assessment of Movement (STREAM) criteria. In this study, the combination of oral poly-herbal decoction
(Nuskha munzije balgham, Nuskha Mushile Balgham, and Munzije Balgham) for Tanqiya and Ta’deel with massage of the
spinal column and paralyzed limbs with Roghan Malkangani [86, 97]. Through these clinical trials, the limitations of this
contemporary treatment were evaluated based on scientic parameters, which hinted towards a promising potential of
this therapy for the treatment of stroke.
3.4 Role ofHomeopathy inStroke Management
Homeopathic medicine or homeopathy (Greek: “omeos” meaning similar and “pathos” meaning suering) was founded
by Samuel Hahnemann, a German physician in 1796 [98, 99]. Dr. John Martin Honigberger an Imperial Austrian physician
introduced it to India in 1839 [100]. This two-century-old system of healing is mainly based on the principle of similars,
“similia similibus curentur”, in simple words “like cures like”, which is very similar to the concept of immunization (used in
allopathic medicine)[98, 101]. This rst postulate of homeopathy states that if a substance causes symptoms of illness in
a healthy person, then that same substance can cure similar symptoms in another patient [99]. The preparation is done
by serial dilutions with strong strokes for potentization [101]. The second postulate, the principle of dilutions is contro-
versial since it states that higher dilution of a substance increases its potential [99]. This potentiation of biological action
is generally attended by dilution above Avogadro’s number [99]. The principle of the minimum dose is based on the
previous principle, where the undesirable eects are minimized by serial dilutions (called “potencies”) of the medicine.
This helps to determine the minimum dose that is optimal for treating the disease [102, 103]. The last postulate is of a
single remedy, in which one medicine that is tested (provings), should be able to overcome all the symptoms (physical,
emotional, and mental) of the illness [103]. The sources of homeopathic medicines are generally based on herbal, animal,
and their by-products, along with other mineral and energy origins[101]. Generally, homeopathic drugs are marketed
by their scientic names and diluted in a certain solvent for potentiation (Fig.3).
In preclinical models of stroke in rats, it has been reported that certain homeopathic drugs such as Arnica Montana
and Crotalus horridus improved the outcome of cerebral ischemia [104]. The drugs were tested in two dierent poten-
cies, 200C and 30C, pre- and post-stroke for 5days respectively [104]. Thus, the study stated that these medications may
have a potential prophylactic neuroprotective role. In an open-label pilot study the eectiveness of homeopathy for fty
stroke patients was explored as an adjuvant therapy to standard conventional care [105]. Out of the total fty patients
included, ten had suered from a stroke episode more than 1year ago and were suering from sequelae, while the
other twenty-seven patients had their episode between one month to one year and the thirteen patients had a recent
episode within 4weeks. The medications used were Causticum, Arnica Montana, Nux vomica, Lycopodium, and Lachesis,
while the assessment was done based on the National Institute of Health Stroke Scale (NIHSS) Score after six months
of treatment. Statistical seventy-six percent of the patients had a better recovery while none of the patients had any
worsening symptoms or manifestation of new infarcts [105]. In spite of few general adverse eects (Table1), the pres-
ence of positive reviews towards homeopathic medicines in both clinical and preclinical studies of stroke presents it as
a potential member of the CAM for the treatment of stroke.
4 Other complementary therapies
4.1 Tai Chi (TC)
Tai Chi Chuan is a mind–body relaxation exercise, consisting 108 forms taking 30min to perform altogether [106].
Studies reported that tai chi improves independent activities of daily living, especially when compared between with
conventional rehabilitation therapy [107]. Tai chi also increases the Fugl-Meyer Assessment score for the upper limb,
lower limb and overall score following stroke. The Berg Balance Scale revealed signicant improvements according to a
pooled estimation study of tai chi vs. conventional rehabilitation therapy [107].
In China, TC is extensively used for functional recovery following stroke [108]. TC possesses various dierent styles, such as
Sun, Yang and Chen. It has been reported to modulate neural function and biomechanics of balance by improving neuromus-
cular responses and increasing balance by various strategies. Studies reported that in TC trained individual, post-stroke bilat-
eral dorsolateral prefrontal cortex and hippocampus shows increased functional connectivity and low frequency uctuations
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in amplitude [108]. Although with some reported shortcomings (Table1), TC practitioners showed benecial eect on the
white matter of brain that are directly linked to the duration of TC practice and skills [109]. Post-stroke TC practice has also
been reported to attenuate anxiety and depression [110].
4.2 Acupuncture
In acupuncture method, metallic needles are inserted at specic locations in the body which are termed accupoints. Fol-
lowing insertion, manipulation of the needle is performed using heat or electric current. Acupuncture therapy with electric
current between two acupoints through needles is nowadays being used by various trained acupuncture therapists [111]. In
traditional Chinese medicine, acupuncture plays an important role. Studies reported that acupuncture improves neurologi-
cal decits of stroke patients [112]. Acupuncture is also reported to be benecial in acute pain [113]. Evidences show that
acupuncture activates adenosine triphosphate (ATP) and transient receptor potential vanilloid (TRPV) channels at acupoint
area. Analgesia by acupuncture is found due modulation neurotransmissions including serotonin, norepinephrine, opioids,
endocannabinoid and orexin in central nervous system (CNS) [113]. Out of several post-stroke disabilities, hemiplegia is one
of the common disabilities seen across patients, which occurs in the form of muscle weakness of the aected side along with
limb spasm. Acupuncture is found to be eective in rehabilitation therapy for post-stroke for improving the severe eects
of hemiplegia [4]. Evidences from clinical trial shows benecial eect of acupuncture in post-stroke balance impairment,
muscular spasticity and muscle strength [114]. Neurogenesis and cell proliferation are also possible by acupuncture in the
central nervous system. Increased cerebral blood ow and anti-apoptotic eect resulting into improved post-stroke awed
long-term potentiation (LTP) and memory are reported following acupuncture therapy [114]. Cellular proliferation is reported
in infarct region and some contiguous zones to the injury in a middle cerebral artery occlusion model, where neurogenesis
was hiked in subventricular zone of the lateral ventricle and the dentate gyrus of the hippocampus following acupuncture
[115]. Acupuncture is also reported to enhance stem cell proliferation following up-regulation of GSK-3β/PP2A expression,
neurotrophic factors (brain-derived neurotrophic factor or BDNF and vascular endothelial growth factor or VEGF) and retinoic
acid expression [115, 116]. It is crucial to maintain a proper practicing skill and setup/environment for this, since there are
reports of various adverse conditions such as infection and nerve damage (Table1). Electro-acupuncture (EA) has reported
to increase numbers of neuroblasts in the hippocampus and subventricular zone [116].
Some acupoints are majorly used for post-stroke treatment, which are Shuigou, Dazhui, Baihui, Zusanli, Hegu and
Quchi. On which acupuncture exerts its eect through various mechanisms [114]. Following cerebral ischemia, EA treat-
ment activates the Wnt/β-catenin pathway enhancing proliferation of neural progenitor cells [117]. EA can also upregulate
mRNA expression of stem cell factors and matrix metallopeptidase-9 (MMP-9) [118]. EA can activate ERK1/2 pathways
and cyclin expression [119, 120] and neuroprotection can be obtained by proliferation of glial brillary acidic protein
(GFAP)/vimentin/nestin-positive phenotypic astrocytes by enhancing BDNF expression in the peri-infarct cortex and
striatum [121].
EA at Hegu upregulates the expression of VEGF and angiogenin-1 that simultaneously inhibit endostatin which
downregulates angiogenesis [122]. At Dazhui, Shuigou and Baihui increases release of acetylcholine by which nitric
oxide is released that increases reperfusion on the ischemic portion [123]. Acupuncture is reported eective in stroke
rehabilitation and motor dysfunction based on assessments of neurological impairment, global neurological decit,
ADL functionality or water-swallowing ability [124]. Study shows that cognitive function is beneted signicantly and
depression along with anxiety are attenuated by Interactive Dynamic Scalp Acupuncture (IDSA) which increases self-
care ability of patient [125].
5 Chinese herbal medicine (CHM)
Chinese herbal medicinesin ischemic stroke were reported benecial in neurological decit on stroke scales. The improve-
ment has been measured in neurological decit score via dierent parameters such as Canadian Neurological Scale,
European Stroke Scale or Modied Edinburgh-Scandinavian Stroke Scale [110]. Studies shows that use of CHM as adjunc-
tive therapy in type 2 diabetes with stoke can increase overall survival rate [126].
Various CHM(s) are found to be benecial in post-stroke that includes Ginkgo biloba, Gastrodia elata, Rehmannia gluti-
nosa, Panax notoginseng. Dierent active ingredients extracted from CHMs are well studied for treatment of post-stroke
disabilities which has multiple mechanism of actions [127]. Some important CHM and their mechanism of actions are
as follows-
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Tanshinone IIA (TA) – TA is derived from dried roots and rhizomes ofSalvia miltiorrhiza called Danshen which is used
in China to treat cerebrovascular diseases [128]. Studies show that TA inhibits glial cell activation, reduces apoptosis,
and decreases oxidative stress. TA sulfonate attenuates MCAo-induced upregulation of autophagy-associated proteins
(Beclin-1, Sirt 6 and LC3-II) and exerts neuroprotection [129].
Baicalin (BA)—It is isolated from dried roots of Scutellaria baicalensis which is widely used CHM [130]. BA is a natural
avonoid and possesses anti-inammatory, antioxidant and anti-apoptotic ecacies. BA has the ability to penetrate blood
brain barrier and decreases activity of MMP-9 by downregulating its expression. BA reverses the haemorrhagic trans-
formation of ischemic stroke after treatment of tPA and decreases mortality rate signicantly. Studies show the ecacy
of BA in improving the learning and memory decits in global cerebral ischemia by diminishing the phosphorylation of
CaMKII that leads to hippocampal neuronal apoptosis prevention [131–134].
dl-3-n-butylphthalide (DLNBP)—It was earlier extracted from the seeds ofApium graveolensLinn. as l-3-n-butylphthal-
ide. Afterwards it was synthesized in lab as a racemic mixture dl-3-n-butylphthalide and it became the rst drug with
independent intellectual property rights for use in cerebrovascular disease treatment in China [135]. DLNBP increases
neurogenesis, axonal growth, ATP metabolism and enhances remyelination. It elevates expression of VGLUT1 and PSD95
and of sonic hedgehog expression [136–139].
Gastrodin (gas)—Gas is isolated from G. elataBlume, which is called tianma in Chinese [140]. Gas reduces ischemic
injury post-stroke by inhibiting apoptosis and it also inhibits Zinc (Zn+2)induced toxicity leading to death of cells, Gas is
found to be anti-inammatory and anti-oxidant improving oxidative damage, it promotes neurogenesis and angiogenesis
leading to its use as a promising rehabilitation therapy post-stroke [141–144].
Ginsenoside (GNS)—It is a saponin compound isolated from P. notoginseng and P. ginsengC, which have multiple actions
for treatment of stroke [145]. Studies found that they exert an angiogenic eect via activation of VEGF modulating the
PI3K/AKT/mTOR pathway. They also exert anti-inammatory activity and reduce serum levels of TNF-α, IL-1ß and IL-6. They
can also show anti-coagulant, anti-oxidant and anti-apoptotic activities. Studies reported that GNS can downregulate
protease-activated receptor (PAR-1) [146–150] and shows benecial role in neurological disorders.
Tetramethylpyrazine (TMP)—It is an alkaloid extracted from the rhizome of the Chinese herbRhizoma Chuanxionga
[151]. Evidences show that TMP decreases the infarct volume post stroke, modies behavioral functions and neurologi-
cal functions, improves neurogenesis and oligodendrogenesis and decreases blood brain barrier permeability. TMP is
reported to be benecial by decreasing free radicals, maintaining the mitochondrial Ca+2 overload, increasing the plas-
ticity of dendrites and decreasing the expression of MMP-9 and AQP4 [152–154].
5.1 Massage therapy
One of the earliest methods of rehabilitation, massage therapies work on the principle of mechanotransduction. Valdes
etal., in their systematic review, highlighted the wide practice of massage therapies in Asia for stroke rehabilitative
approaches [155]. A tenet of rehabilitation, mechanotransduction, is a process by which a cell converts mechanical
inputs into biochemical signals. In a study conducted to assess the eect of massage therapy on cellular functions post-
exercise-induced muscle damage, the researchers found that massage therapy results in clinical benets by reducing
inammation and promoting mitochondrial biogenesis [156]. Massage promotes muscular compliance and reduces
stiness by raising blood ow and temperature in the muscle mass, although few cases of minor nerve injuries, bruises
are reported (Table1) [157]. Several kinds of therapeutic massage have been reported, such as Swedish massage, Chinese
massage (Tuina), Indian massage (Dalk), and Thai massage. Research has found positive eects of therapeutic massage
on motor function, spasticity, behavioral symptoms, pain, stroke disability, and quality of life of stroke survivors. In a
meta-analysis of ndings of therapeutic massage for improving sequelae in stroke survivors, it was found that Tuina
massage is the most widely used form of massage used in treating stroke-related symptoms [155]. Tuina massage as an
adjunct to physiotherapy and electric acupuncture has been found to be eective in treating shoulder-hand pain [155,
158, 159]. When combined with Unani exercises, it was found that tuina massage improves upper limb functions, speed
of walking and the gait of stroke patients with unilateral hemiplegia or paralysis [155]. Esther Mok and Chin Pang Woo
(2004) in their study found that ten minutes of slow-stroke back massage (SSBM) for 7days signicantly reduced the pain
perception and anxiety of elderly stroke patients [160]. It is also reported that traditional tuina combined with current
rehabilitation therapy can successfully reduce or eliminate upper limb spasticity and improve daily living clinically [161].
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5.2 Aromatherapy
Aromatherapy is the application of essential oils as an additional form of treatment for a variety of physical and mental
illnesses [162]. Essential oils can be administered orally, topically, inhaled, intraperitoneally, or subcutaneously, following
which their individual elements can all pass through the blood–brain barrier and enter the central nervous system [163].
Its extensive usage as a therapeutic approach has been reported in several diseases of the nervous system—depres-
sion, migraine, chronic pain in multiple sclerosis and behavioral disturbances in dementia. Aromatherapy combined
with acupressure has been reported to be eective in reducing hemiplegic shoulder pain and improvement of motor
function post-stroke clinically [164].
A study evaluating the neuroprotective eects of Curcuma oil in a rat embolic stroke model found that a single-dose
intraperitoneal administration of the oil 30min before a stroke can reduce brain neutrophil inltration, expression of nitric
oxide synthase and neurodegeneration [165]. Vakili etal. found that lavender oil treatment (doses of 200 and 400mg/kg)
considerably improved functional outcomes following cerebral ischemia by reducing infarct size and brain edema [166].
For instance, 200mg/kg of lavender oil reduced the amount of malondialdehyde (MDA) while simultaneously increasing
the activities of glutathione peroxidase, superoxide dismutase, and total antioxidant capacity [166].
Treatment with curcumin has also been found to greatly enhance neurological functions and aid in reducing brain
damage by attenuating Blood–brain Barrier disruption [167]. Amantea etal. (2009) have demonstrated the neuroprotec-
tive mechanisms of intraperitoneal administration of bergamot essential oil (BEO) [168]. BEO can prevent excitatory amino
acid export and ROS generation, which can revert the functioning of glutamate transporters in ischemia situations [168].
Though only preliminary work has been conducted to assess the eect of aromatherapy in humans, its benets have
been reported for pain-related symptoms, behavioral symptoms (stress, quality of sleep, delirium) as well as clinical
symptoms (motor and language) [169]. A study conducted by Shin and Lee (2007) evaluated the benets of aromatherapy
with essential oils of lavender, rosemary and peppermint diluted in jojoba oil, as an additive therapeutic approach to
acupressure, in stroke patients with hemiplegic shoulder pain (HSP) where they found a signicant reduction in HSP fol-
lowing acupressure-aromatherapy with respect to acupressure is the only therapeutic approach [164]. Lee etal. (2017)
in their study, evaluated the eect of aromatherapy massage which included a combination of juniper, lavender, orange,
patchouli, and rosemary, on behavioral symptoms [170]. These researchers noted signicant reductions in body tempera-
ture along with improvements in psychological stress, mood status, and sleep quality [170]. Despite consistent positive
ndings of aromatherapy in stroke rehabilitation in human studies, it has been linked to occasional adverse events, such
as allergic reactions, respiratory issues in some other medical conditions (Table1). So, further research work needs to be
conducted to standardize the appropriate dosage or procedure of this therapeutic approach. The eect of aromatherapy
reaches beyond the pain domain and exerts positive eects on behavioral symptoms as well and has the potential to be
used in conjunction with other therapies to treat motor, behavioral and emotional problems in stroke patients.
5.3 Chiropractor therapy
Chiropractic therapy involves treating the subluxated spinal segments using a variety of manual procedures, including
high-velocity, low-amplitude adjustments which are often referred to as spinal manipulation. The main focus of this
therapeutic approach is the relationship between the spinal cord and the nervous system [171]. In this method, vertebral
subluxations are identied using pathophysiological indicators of spinal dysfunction and corrected with the help of sev-
eral manual techniques [172]. Emerging evidence has brought to light the eect of chiropractic care on somatosensory
processing, sensory integration, and motor control following just a single session [173].
Single-session chiropractic benets- A research study aimed at investigating the eects of a single session of chiropractic
care in stroke patients found that following at least one chiropractic adjustment to their cervical, thoracic and lumbopel-
vic spinal regions, plantarexion muscle strength rose by 64.2% on average [173]. The same study also attempted to
investigate the underlying mechanisms that modulate the potential changes in strength and found that the observed
changes in strength were more heavily inuenced by an increased cortical drive than spinal excitability [173]. A rand-
omized cross-over study of 17 male stroke patients found that a single chiropractic spinal adjustment session raised the
amplitude of the N30 somatosensory evoked potential (SEP) peak indicating changes in early sensorimotor integration
[174]. However, the functionalsignicance or longevity of any of these changes is not known yet.
Long-term chiropractic sessions- A randomized controlled trial involving 63 stroke patients investigated the eects
of longer-term chiropractic care on motor functions of the participants [175]. The study found that the combination
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of chiropractic spinal adjustments and physical therapy signicantlyimproved lower limb motor functions of stroke
patients though these eects were no longer persistent at the 8-week follow-up. Chiropractic has also been found to
bring about an improvement in the health-related quality of life of stroke survivors though further investigation would
help determine the robustness of this application.
Chiropractic care may be crucial for a range of clinical groups if it improves spinal functions and has a central neuronal
plastic inuence since it is thought that brain plasticity holds the key to encouraging motor-function recovery in stroke
patients.
5.4 Moxibustion
Moxibustion is the practice of applying heat to certain body parts—skin and subdermal tissues called acupoints by
burning moxa (mugwort), shaped in the form of a cone, placed on those acupoints. [176]. Current research reports
moxibustion to be benecial as an adjunct to standard approaches for stroke rehabilitation, on motor function [177]. The
usage of dierent types of moxibustion techniques such as, suspended moxibustion, warm-needle moxibustion, and
indirect moxibustion have been reported in the treatment of stroke-related symptoms [178]. Research has found that
warm needle moxibustion helps in alleviating muscle spasticity by accelerating metabolism, dilating blood vessels, and
decreasing nerve excitability [179]. Few studies reported adverse events like allergy, infection, burns associated with the
moxibustion in dierent medical condition (Table1). A novel device called “plum blossom needle with mild moxibus-
tion is currently undergoing clinical trials for assessing its feasibility in widespread clinical practice for upper limb pain
disorder and motor symptoms of post-stroke patients with shoulder-hand syndrome (PS-SHS) [180]. It has been found
that moxibustion, when used as an adjunct therapy for PH-SHS, exerts favorable eects on the improvement of regional
skin congestion, activation of blood and lymphcirculation, capillary expansion, sedation, and analgesic nature [180].
A systematic review and meta-analysis of RCTs conducted to assess the eect of moxibustion on cognition and activi-
ties of daily living (ADL) post-stroke found that it signicantly enhanced cognitive function and ADL in stroke patients,
who received moxibustion treatment as compared to the control group [181]. Another review conducted to assess the
ecacy of moxibustion for the treatment of post-stroke depression (PSD) found that current literature supports the pos-
sibility of moxibustion as an eective intervention for PSD [182]. However, the reliability of the ndings from randomized
clinical trial on moxibustion therapyis limited and the extent of eectiveness of this therapy is yet to be explored.
5.5 Music‑supported therapy (MST)
Music-supported therapy(MST) involves providing appropriate stimulation to improve physical, cognitive, and emotional
impairments resulting from stroke [202]. Using real-time auditory feedback, MST has been used to improve the upper limb
motor function [203]. Music-supported therapy (MST) is one of the most frequently used treatment for hand function
related problems. A growing body of literature has highlighted the benets of MST in treating stroke-related symptoms
[202, 204]. The observed benets can be attributed to the combination of auditory sensory input along with movement
training. Besides, this sensory stimulation brought on by music can induce functional recovery in injured hemispheres.
Studies reported that a 4-week MST program, can improve hand mobility, uency, and speed of work in stroke patients. In
order to train both ne and gross motor abilities, music-supported therapy utilizes playing a keyboard and/or electronic
drum utilizing motor sequences of escalating diculty [204]. Clinical research has found 30min of active playing over
a period of 4weeks in addition to conventional is benecial in improving paretic upper body movement parameters,
such as speed, precision and smoothness [202]. Though consistent positive ndings exist on MST in stroke rehabilita-
tion, recent intervention protocols have suggested an increase in intensity and duration may be required to promote
eective motor recovery for chronic stroke patients [202]. Current research has indicated that music-based intervention
has great potential for supporting or recovering motor function and could be a powerful tool in stroke rehabilitation.
5.6 Hirudotherapy
Hirudotherapy, is the use of medicinal leeches for therapeutic purposes, and has been used in traditional medicine from
centuries to treat various ailments, including stroke [205]. Hirudo medicinalis is one of the best species used in hirudother-
apy. The leeches are believed to contain hundreds of bioactive compounds that have anticoagulant, anti-inammatory,
and analgesic properties, which can help improve blood ow and reduce swelling in the aected area [206, 207].
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Leech saliva contains nerve growth factor, which is known to promote the growth and survival of neurons and promote
neuroplasticity [208]. Although there is limited research performed to establish the exact mechanisms by which hirudo-
therapy promotes neural plasticity. However, some studies suggest that hirudotherapy may help to stimulate the growth
of new neurons and synapses, and promote the rewiring of neural circuits in the brain [209]. One potential mechanism by
which hirudotherapy may promote neural plasticity is through the secretion of growth factors by the medicinal leeches.
Hirudotherapy may also promote neural plasticity by increasing blood ow to the aected area. Improved blood ow
can help to provide oxygen and nutrients to the brain, which can support the growth and survival of new neurons and
synapses [210]. The results suggested that hirudotherapy may promote neural plasticity by improving the recruitment of
neurons in the aected area and promoting the growth of new neurons. Furthermore, hirudotherapy may promote neu-
ral plasticity by reducing inammation and oxidative stress in the brain. Inammation and oxidative stress can damage
brain tissue and hinder the growth of new neurons and synapses, so reducing these factors can help to promote neural
plasticity and recovery [211]. Nonetheless, leech saliva contains hirudin which is one of the most potent anti- coagulants;
that supress the process of blood clotting. Apart from this leech saliva contains many other substances having in anti-
inammatory, analgesic, vasodilation, and bacteriostatic action. All this action contributes to the elimination of damaged
vascular tissues, elimination of hypoxia, reduction of blood pressure and increase in immunity [212, 213].
5.7 Cupping
Cupping therapy is the physical treatment reported about 1550 BC by Ebers papyrus, it is one of the part oldest healing
system and used in many ailments [214]. Initially cupping was classied into two types by Hippocrates i.e., dry, and wet,
but later in 2013 it was developed and categorised into 5 types later in 2016 it was updated and further categorised into
6 types [215, 216]. Although cupping categorized into many types dry and wet cupping are most famous. Dry cupping
is the non-invasive method where skin is pulled in the cups by suction, without drawing the blood and in wet cupping
skin is pulled in the cups where stagnant ow of blood is maintained. The cups used for cupping are made with dierent
materials such as glass, bamboo, or plastics [217–220].
Cupping therapy is being used for myriad of diseases from ancient times, and it was the most frequently used remedy
in modern east Asian traditional medicine till date [221]. There are several literatures have been reported about cupping
therapy but evidence of using for stroke is lacking behind. However wet cupping have shown the favourable eect for
stroke rehabilitation in 2 RCT [222]. 3 RCTs and 2 systematic reviews have reported that cupping is ineective therapy
for stroke. However, Huang etal. studied the eect of pricking and cupping on the abdominal center for biceps after
stroke and showed that combined therapy of pricking and cupping along with conventional stroke rehabilitation could
contribute signicantly to the improvement in hand function and reducing spasticity in stroke patients [223]. However,
a meta-analysis done by Kim etal., compared wet cupping with the active control drug baclofen for controlling muscle
tone in dierent post-stroke patients reported that the patients receiving wet cupping therapy oers signicantly more
improvement in muscle tone than patients with baclofen [221]. There are other studies in which cupping has shown
superior eect as compared to acupuncture in hemiplegic shoulder pain and upper limb myodynia after stroke [222].
The possible mechanism of cupping to improve the outcome is due to letting out excess of uid and toxins from blood,
bringing blood to the stagnant skin and muscles or giving negative pressure to promote stroke rehabilitation [219, 224].
There are limited scientic studies have been done so far although cupping therapy is using from ancient times in stroke.
Due of lack of clear evidences on cupping therapy, it is controversial to use in stroke as an alternative therapy. However
well designed and more robust scientic studies are needed to establish the cupping therapy for stroke [224].
5.8 Reiki
Reiki is the Buddhist healing therapy which was originated thousands of years ago in Tibetan Sutras and then re-estab-
lished by Buddhist monk in mid-nineteenth century in Japan. The word reiki is composed of two Japanese words one is
‘rei’ that means supreme being, and other is ‘ki’ that means universal life energy [225]. Reiki is a spiritual practice where
practitioner believes that the energy is transferred from healer to the patient and promote self-healing, maintains har-
mony and balance to the body and mind. The practitioner who performs the reiki therapy should have at least three years
of practice. The goal of reiki therapy is to direct the way of healing energy from practitioner to the patient [226]. It is used
in number of ailments and diseases including cancer, edema, dyspnoea, pain, stress, and anxiety [227] [228]. However
the use of reiki in stroke is lacking; One study done on patients with subacute stroke undergoing standard rehabilitation
therapy for 3weeks and reported that reiki is not signicantly eective in those patients [229]. In systematic review they
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analysed 12 studies relevant to the reiki as CAM therapy for stroke patients but nally reported about 31 outcome stat-
ing that the reiki therapy is still on the exploratory mode [226]. Although there are very few studies has been conducted
so far, they are poor in quality, suggesting that to establish the reiki therapy as CAM for stroke more robust and quality
scientic studies are needed.
6 Conclusion andfuture prospects
Post-stroke impairment depends on the severity of brain injury and accessibility of initial interventions. Various pre-
clinical and clinical studies have reported benecial eects of CAM in dierent neurological disorders as well as in stroke.
CAM along with conventional stroke management strategies may improve post-stroke rehabilitation. Owing to reported
adverse events (Table1), proper treatment regime of CAM may further be explored. A robust pre-clinical and clinical
studies are necessitated to decipher the molecular mechanisms required for establishing CAM as one of the rehabilita-
tion therapies for stroke.
Acknowledgements Department of Pharmaceuticals, Ministry of Chemical and Fertilizers, Govt. of India and National Institute of Pharma-
ceutical Education and Research (NIPER) Ahmedabad, Gandhinagar, India. Authors acknowledge www. biore nder. c om for image preparation.
Author contributions Bibliographic analysis: AB, CS, GK, JM, TM, BG, NR, AD, HS, SS and PB.; writing original draft preparation: AB, GK, JM, TM,
BG, NR, AD, and PB and; intellectual inputs and editing by all authors; Proof reading: CS, HS, SS and PB.; All authors have read and agreed to
the nal version of the manuscript.
Data availability Not applicable.
Declarations
Ethics approval and consent to participate Not applicable.
Patient consent Not applicable.
Competing interests The authors declare no competing interest.
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which
permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to
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do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party
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the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco
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