In Korea, many stroke patients receive oriental medical care, in which pattern-identification plays a major role. Pattern-identification is Oriental Medicine's unique diagnostic system. This study attempted to standardize oriental medical pattern-identification for stroke patients. This was a community-based multicenter study that enrolled stroke patients within 30 days after their ictus. We assessed the patients' general characteristics and symptoms related to pattern-identification. Each patient's pattern was determined when two doctors had the same opinion. To determine which variables affect the pattern-identification, binary logistic regression analysis was used with the backward method. A total of 806 stroke patients were enrolled. Among 480 patients who were identified as having a certain pattern, 100 patients exhibited the Fire Heat Pattern, 210 patients the Phlegm Dampness Pattern, nine patients the Blood Stasis Pattern, 110 patients the Qi Deficiency Pattern, and 51 patients the Yin Deficiency Pattern. After the regression analysis, the predictive logistic equations for the Fire Heat, Phlegm Dampness, Qi Deficiency, and Yin Deficiency patterns were determined. The Blood Stasis Pattern was omitted because the sample size was too small. Predictive logistic equations were suggested for four of the patterns. These criteria would be useful in determining each stroke patient's pattern in clinics. However, further studies with large samples are necessary to validate and confirm these criteria.
The prevalence rate of stroke has been rising recently, as the average life span has become longer. Since stroke can be fatal at acute stages and may leave irreversible neurological deficits, it has generated a great deal of social concern. In modern Western medicine, thrombolysis and anticoagulants are conventionally used. However, these are insufficient and are known to pose some adverse effects including a hemorrhagic tendency [
There has been little progress, however, in the standardization of oriental medical pattern-identification. In Japan, several standardized questionnaires have been suggested and used in the literature. All these questionnaires, except for the diagnostic criteria for
This study was a community-based multi-center trial. We enrolled stroke patients within 30 days after their ictus from the oriental medical university hospitals in the National Capital Region, including Seoul and Kyunggi-do. Kyung Hee Oriental Medical Center (Seoul), Kyung Hee East-West Neo Medical Center (Seoul), Dong Guk International Hospital (Kyunggi-do), and Kyung Won Oriental Medical Hospitals (Seoul and Incheon) were the involved hospitals. We excluded traumatic stroke such as subarachnoid, subdural, and epidural hemorrhage. Informed consent of all the study patients was obtained after a thorough explanation of the details. This study was approved by the Institutional Review Board (IRB) of Kyung Hee Oriental Medical Center (KOMC IRB 2007-07).
In this study, we used the Case Report Form (CRF) and the Standard Operation Procedures (SOPs) developed by the Experts Committee organized by the Korean Institute of Oriental Medicine [
Variables related to pattern-identification.
Body Mass Index | |
Inability to sleep or abnormal wakefulness | |
Lack of strength | |
A white complexion with a hint of blue or gray, oftern caused by yang collapse or exuberance of cold | |
Yellow discoloration of the face, generally suggesting accumulation of dampness | |
A complexion redder than normal, indicating the presence of heat | |
Dark discoloration of the face, often occurring in cold syndrome, water retention, or blood stasis | |
Localized flush in the cheeks, indicating yin deficiency | |
Pain in the head | |
Congestion in eyeballs indicating presence of heat | |
Subjective feeling of dryness in the eyeballs | |
An abnormal breathing sound by phlegm in the airways | |
A voice that is faint and low, scarcely audible | |
Ulceration in the oral cavity or tongue | |
Bad smell from the mouth | |
Feeling of dryness of the mouth with a desire to drink | |
A subjective bitter sensation in the mouth | |
Excessive sweating not related to a hot environment, physical exertion, or taking diaphoretics | |
Sweating during sleep that ceases on awakening | |
Unwell feeling of stuffiness and fullness in the chest | |
An unpleasant sensation with an urge to vomit | |
A rumbling sound made by the movement of gas in the intestines | |
Strong dislike of heat, also known as heat intolerance | |
Fever more marked in the afternoon | |
Subjective feverish feeling in the palms and soles | |
Uncomfortable heat sensation in the extremities | |
Pronounced cold in the extremities up to the knees and elbows, also the same as cold extremities | |
Increased frequency of urination | |
Dark yellow or even reddish urine, indicating heat | |
Hardened feces difficult to evacuate | |
A tongue less red than normal, indicating Qi and blood deficiency | |
A tongue of normal color | |
A tongue redder than normal, indicating the presence of heat | |
A cyanotic tongue, indicating blood stasis or heat | |
A tongue coating white in color | |
A tongue coating yellow in color | |
A tongue coating where the underlying tongue surface is not visible | |
A tongue coating that looks dry and feels dry to the touch | |
A tongue with dental indentations on its margin | |
A tongue that is larger than normal, pale in color and delicate | |
A tongue with red, white or black spots | |
A completely smooth tongue free of coating, like a mirror | |
A superficially located pulse which can be felt by light touch and grows faint on hard pressure | |
A deeply located pulse which can only be felt when pressing hard | |
Bradycardia | |
Tachycardia | |
A general term for strongly beating pulse | |
A general term for a feeble and void pulse | |
A pulse as thin as a silk thread, straight and soft, feeble yet always perceptible upon hard pressure | |
A pulse coming and going smoothly like beads rolling on a plate | |
A pulse coming and going unsmoothly with small, fine, slow joggling tempo like scraping bamboo with a knife | |
A pulse beating like dashing waves with forceful rising and gradual decline |
Two oriental internal medical doctors from each hospital and who had at least more than three years of clinical experience with stroke identified the pattern of each patient as follows the Fire Heat Pattern, the Phlegm Dampness Pattern, the Blood Stasis Pattern, the Qi Deficiency Pattern, and the Yin Deficiency Pattern, as suggested by the Korean Institute of Oriental Medicine [
To determine which variables affect the pattern-identification, binary logistic regression was used. We removed the variables without statistical significance step by step using the backward method until a combination composed of purely significant variables was reached and considered each retained variable as an independent factor for the predictive model. The derived logistic equation was
A total of 806 stroke patients were recruited. Of these, 326 could not be classified as having a certain pattern because the diagnoses of the two doctors differed. These patients were excluded from the analyses. The diagnostic differences may be explained by the subjectivity of pattern-identification and the absence of objective standard criteria, that is, precisely why this study is necessary. Among the remaining 480 patients, 100 patients had the Fire Heat Pattern, 210 patients the Phlegm Dampness Pattern, 9 patients the Blood Stasis Pattern, 110 patients the Qi Deficiency Pattern, and 51 patients the Yin Deficiency Pattern. There were more male patients with the Fire Heat Pattern, and there were more patients who exhibited more variables related with the metabolic syndrome such as hypertension, diabetic mellitus, and hyperlipidemia under the Phlegm Dampness Pattern. As for TOAST classification [
Demographic data of each pattern-identification.
Fire heat | Phlegm dampness | Blood stasis | Qi deficiency | Yin deficiency | |
---|---|---|---|---|---|
Total number | 100 | 210 | 9 | 110 | 51 |
Age, yr | |||||
Gender, male | 77 (77.0) | 105 (50.) | 5 (55.6) | 46 (41.8) | 21 (41.2) |
BMI (kg/m2) | |||||
W/H ratio | |||||
Ischemic stroke | 82 (82.0) | 190 (90.5) | 8 (88.9) | 91 (82.7) | 42 (82.4) |
TOAST* | |||||
LAA | 13 (13.0) | 37 (17.6) | 1 (11.1) | 13 (11.8) | 6 (11.8) |
CE | 5 (5.0) | 16 (7.6) | 0 | 9 (8.2) | 6 (11.8) |
SVO | 64 (64.0) | 135 (64.3) | 5 (55.6) | 66 (60.0) | 29 (56.9) |
SOE | 0 | 2 (1.0) | 1 (11.1) | 1 (0.9) | 1 (2.0) |
SUE | 0 | 0 | 1 (11.1) | 2 (1.8) | 0 |
Medical history | |||||
Hypertension | 55 (55.0) | 150 (71.4) | 5 (55.6) | 64 (58.2) | 24 (47.1) |
Diabetic mellitus | 24 (24.0) | 73 (34.8) | 3 (33.3) | 23 (20.9) | 11 (21.6) |
Hyperlipidemia | 7 (7.0) | 45 (21.4) | 0 | 17 (15.5) | 3 (5.9) |
Ischemic heart | 7 (7.0) | 18 (8.6) | 1 (11.1) | 11 (10.0) | 8 (15.7) |
Atrial fibrillation | 10 (10.0) | 13 (6.2) | 1 (11.1) | 7 (6.4) | 6 (11.8) |
Smoking | 38 (38.0) | 39 (18.6) | 0 | 20 (18.2) | 13 (25.5) |
Values in parenthesis refer to %.
*TOAST classification includes LAA (large artery atherosclerosis), CE (cardiogenic embolism), SVO (small vessel occlusion), SOE (stroke of other determined etiology), and SUE (stroke of undetermined etiology).
To come up with a predictive model for pattern-identification, binary logistic regression analysis was applied using the backward method on the assessed pattern-related variables. Fire Heat, Phlegm Dampness, Qi Deficiency, and Yin Deficiency were studied. The Blood Stasis Pattern was omitted because the sample size was too small.
A total of 100 patients (20.8% of all the patients) were identified as having the Fire Heat Pattern. All of the assessed variables were included in the first logistic regression analysis. Among the statistically significant variables (
Phlegm Dampness Pattern was identified in 210 patients (43.8% of all the patients). Thick fur and slow pulse had lower significance and were removed earlier from among the significant variables (
A total of 110 patients (22.9% of all the patients) were identified as having the Qi Deficiency Pattern. Among the statistically significant variables (
There were 51 patients, or 10.6% of all the patients, with the Yin Deficiency Pattern. Among the statistically significant variables (
This is the first study to standardize oriental medical diagnostic pattern-identification of stroke patients in Korea. The following predictive logistic equation was set
The Fire Heat Pattern is by pathogenic Fire characterized by intense heat that is apt to injure fluid, consume Qi, engender wind, induce bleeding, and disturb mental activities [
In the Phlegm Dampness Pattern, which is characterized by its impediment to Qi movement and its turbidity, heaviness, stickiness, and downward flowing properties [
Qi is the basic element that constitutes the cosmos and, through its movement, changes and transformations. In the field of medicine, Qi refers both to the refined nutritive substance that flows within the human body as well as to its functional activities. Qi Deficiency generally leads to decreased visceral functions and lowered body resistance [
Yin Deficiency indicates a pathologic change marked by deficiency of Yin with diminished moistening, calming, downbearing, and Yang-inhibiting function, leading to relative hyperactivity of Yang Qi [
The finding that Korean OM doctors take tongue and pulse diagnosis seriously into their consideration is notable because all the patterns in this study basically included tongue and pulse diagnosis in their final equations. The Fire Heat Pattern and the Yin Deficiency Pattern have more positively quantified variables than negatively quantified variables. Thus, if some symptoms or signs reflect heat, the pattern could be determined easily. The Phlegm Dampness Pattern has two simple criteria overweight and slippery pulse. The Qi Deficiency Pattern is an exclusive pattern composed of many negatively quantified variables. This pattern could be identified merely on the condition that the other patterns were excluded.
Recently, Kim et al. suggested a questionnaire for the Heat Pattern [
With the results of this study, predictive logistic equations were suggested for four patterns the Fire Heat Pattern, the Phlegm Dampness Pattern, the Qi Deficiency Pattern, and the Yin Deficiency Pattern. These criteria would be helpful in determining the pattern of each stroke patient in clinics. However, further studies using large samples are necessary to validate and confirm these criteria.
This work was supported by a Grant from the Korean Institute of Oriental Medicine (K09200).