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World Journal ofAcupuncture-Moxibustion (WJAM) Vol. 24, No.3, 30th Sep. 2014
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Review
Meta-Analysis on scalp acupuncture based therapy in treating children cerebral palsy ~$t~±tit1J/J'\)LJlOO~EJ{]Meta*fJT LI Lan-ya (~~1~), LIU Zhen-huan (:*tl~~)l'8l, XIE Qiao-ling (1Mf;J:7"J.t)
1. Graduate Institution of Guangzhou University ofCM. Guangzhou 510000, Guangdong Province, China; 2. Nanhai Maternity and Child Healthcare Hospital, Guangzhou University of CM, Foshan 528200, Guangdong Province, China (1. jJm9='~~*~1iJfJl1:~, j*jj~1 510000; 2. jj~I9='~~*~~Jf-il1¥i 7ilJjS:9:)Lll~~, j*#liw 528200)
ARTICLE INFO
ABSTRACT
First Author: LI Lan-ya (1990-), female,
Objective To explore the effectiveness of applying scalp acupuncture in treating child cerebral palsy. Method Computer was adopt to retrieve relevant literature about scalp acupuncture based therapy in treating children cerebral palsy published during 1999-2014 in PubMed, China National Knowledge Infrastructure (CNKI), China Biology Medicine Disc (CBM), VIP database, Wanfang database, Longyuan Electronic Journal and People's University Copying Periodical Resources Full-Text Database. The quality of literature about scalp acupuncture based therapy in treating children cerebral palsy was systematically evaluated and Meta analysis was conducted for integrated data by adopting evidence-based medicine and bibliometrics and through RevMan 5.2 statistical software. Results Two hundred and thirty-four literature were retrieved in total, within which, 7 of them were included. There were 796 cases in included literature, which were divided into a treatment group (416 cases) and a control group (380 cases). The total effective cases in the treatment group was 378, with the total effective rate of 90.9%, and the total effective cases of the control group was 281, with the total effective rate of 73.9%, which could provide evidence for the fact that the treatment of scalp acupuncture has increased the effective rate of child cerebral palsy by 17%. It is shown by Meta analysis that: OR is 0.16, 95% CI is (0.11, 0.21) and combined effect test is Z=6.27, P
master degree candidate.
l'8l Corresponding author: L1U Zhen-huan (1958-), male, professor, chief physician. Research field: the treatment of pediatric disease by combined TCM and western medicine. Email:
[email protected] Accepted on June 10, 2014
KEY WORDS: acupuncture and moxibustion; cerebral palsy; randomized control trial (RCT); meta analysis
Child cerebral palsy (cerebral palsy for short) is a kind of syndrome caused by non-progressive cerebral injury and development defect from fertilization to
infancy stage, which mainly manifests as dyskinesia and postural dysfunction Pl. The international incidence of cerebral palsy is I %0-5%0, while in China, the
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Vol. 24, No.3, 30th Sep. 2014
incidence is 1.8%0-4.0%0, which gradually increases year by year [2]. In recent years, clinical research of adopting traditional acupuncture and moxibution to cure cerebral palsy at home and abroad is increasing and acupuncture and moxibution gradually shows its advantage in improving symptom of cerebral palsy children and prognosis, but still, corresponding evidence-based medicine proof is strongly needed in proving its effectiveness. In the following part of the essay, Meta analysis was conducted for literature about applying scalp acupuncture in treating cerebral palsy to get reliable and scientific evaluation and conclusion and provide reference for clinical practice.
DATAAND METHOD Retrieval strategy Computer was adopted to retrieve relevant literature about treating child cerebral palsy published since establishment in PubMed, China National Knowledge Infrastructure (CNKI), China Biology Medicine Disc (CBM), VIP database, Wangfang database, Longyuan Electronic Journal and People's University Copying Periodical Resources Full-Text Database. Different databases were retrieved crosswise to avoid missing retrieval. Chinese index words: tr fk., tr~tl, ~tr, IJ\)~Jllii~, Jllii~, ~;fJ1X1Jf~t English index words: CP; cerebral palsy; acupuncture, RCT. Computer retrieving combining with manual searching was adopted. The references of literature included were looked up to increase retrieval ratio of literature.
Inclusive criteria for literature (1) Research design: CD The literature included must involve clinical randomized controlled trial (RCT) of applying scalp acupuncture in treating cerebral palsy; ® the scalp acupuncture therapy or scalp acupuncture combining other therapies was applied in the treatment group (combining with body acupuncture), and other therapies excluding scalp acupuncture were applied in the control group; ® proportionality of inter-group baseline characteristics was good, which was comparable, and method of random allocation was definite. (2) Object of study: gender and source of children patient, type of cerebral palsy and severity degree were not limited, specific diagnosis and inclusive criteria were established. (3) Application factors: acupoint, acupuncture manipulation, time for needle retention and interval and type of needling instrument in the treatment group
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were not limited; except acupuncture and moxibustion, other therapeutic methods applied in treatment group and control group shall be the same. (4) Outcome indicator: total effective rate (ineffective cases were excluded, means there was no significant change revealed by relevant evaluation result, that is, there was no improvement in myodynamia, muscular tension, large-scale motion, abnormal posture, primitive reflex and cognitive intelligence of children patients before and after treatment).
Exclusive criteria
CD Retrospective study (no real control group was set); ® secondary literature, review, case report, experience summary and so on; ® literature searched or published repeatedly. Literature selection and quality evaluation A valuator extracted data in accordance with the form, and another valuator adopted modified Jadad Rating Scale to conduct quality assessment, including: method of randomization, concealing, blinding method, withdraw and dropouts. Total points were 7; the literature with 1-3 point were regarded as lowquality literature, and 4-7 points were regarded as high-quality literature. Meta analysis was conducted for the literature being screened out and included in the research.
Statistical analysis RevMan 5.2 software was adopted to do statistical analysis. When the result of heterogeneity test was P>O.OI, then the homogeneity can be regarded as good. Fixed-effect model was adopted to make analysis, when P
RESULTS Retrieved result Two hundred and thirty-four papers were retrieved in total, and 7 papers were included according to inclusive criteria and Jadad rating result.
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Vol. 24, No.3, 30th Sep. 2014
Analysis of included literature
of them 3 points. (Table 1 and 2)
The 7 papers were all RCTs. In one[3] of them, odd-even of admission number was used as the random allocation method, in one[6] of them, completely random method was used, in one[4] of them, drawing lots was used to perform random allocation, in twO[5,8] of them, random number table was used and in one[7] of them, single-blind randomization was used; in twO[3,7] of them, the random method was hidden, and in one[9] of them, inclusion time was used as the random method'", with base line for all of them being balance; there was no exit and follow-up visit; the Jadad rating for three[3,5,7] of them were four points and four[4,6,8,9]
Curative effect evaluation
Table 1
RevMan 5.2.10 software was adopted to conduct heterogeneity test, the result shows that csr- 15.19, df=6 and P=0.02>0.01; homogeneity existed among studies, so fixed effect model was used for analysis. Given that the research data belonged to dichotomous, OR and its 95%CI were adopted to calculate, and the effect size of original data and combined effect size were brought in to analyze the results (Figure 1). OR=0.16, 95% confidence interval was (0.11, 021), the combined effect inspection was Z=6.27
Profile of included papers
Groups
Methods
HUANG Xin-fang!"
Treatment Control
Scalp acupuncture+medication Medication
35 35
32 22
91.4 62.9
JIAJie[4]
Group one Group two Group three
Scalp acupuncture Modem rehabilitation therapy Scalp acupuncture plus modem rehabilitation therapy
30 30
20 18
66.7 60.0
2 2
30
24
80.0
2
Treatment Control
Scalp acupuncture+functional training Functional training
124
120
96.8
36
76
66
86.8
36
Treatment Control
Body acupuncture+scalp acupuncture+functional training Functional training
135
130
96.3
3
121
106
87.6
3
ZHANG Xian[7]
Treatment Control
Scalp acupuncture+comprehensive treatment Comprehensive treatment
32
29
90.6
28
16
57.1
TAOXiaoling, et al [8]
Treatment Control
Scalp acupuncture+medication Medication
30 30
26 19
86.7 63.3
WANG Hong-jie [91
Treatment Control
Scalp acupuncture+ basic therapy Language training plus basic therapy
30
21
30
10
HANXue[SI
YU Ya-ping'"
Patients Effective Effective (Case) (Case) rate (%)
Course of Therapeutic treatment effect indices (Month) 3 Effective rate Effective rate 3
Included studies
Table 2 Included studies
Evaluation method Symptom, sign
Effective rate Effective rate ADL movement function Effective rate
Movement function Effective rate evaluation (MA Ruo-fei) Effective rate Movement function Effective rate evaluation (MA Ruo-fei) Effective rate Effective rate Effective rate
GMEMscale
2 2
Effective rate Effective rate
Postural reflex, movement function
70.0
3
33.3
3
Effective rate Effective rate
Dysarthria rating scale
Quality assessment for included papers Exit and Jadad Concealment BI' din Comparison follow-up of allocation In g of base line rating visit
Design
Randomization
Control
RCT
Odd-even of admission number
Yes
Yes
No
Balance
No
4
Modem rehabilitation
RCT
Draw lots
Yes
Unknown
No
Balance
No
3
Chinese Acupuncture and Moxibustion
RCT
Order of admission number
Yes
Unknown
No
Balance
No
4
Chinese Journal ofclinical rehabilitation
YU Ya-ping [6]
RCT
Completely random
Yes
Unknown
No
Balance
No
3
Modem Journal ofIntegrated Traditional Chinese and Western Medicine
ZHANG Xian[7]
RCT
Single blind random
Yes
Yes
No
Balance
No
4
Modem Preventive Medicine
Order of admission + random numeration table
Yes
Unknown
No
Balance
No
3
Shaanxi Journal ofTraditional Chinese Medicine
Inclusion time
Yes
Unknown
No
Balance
No
3
Chinese Pediatrics of Integrated Traditional Chinese and Western Medicine
HUANGXin-
fang!" JIAJie[4 I HANXue,
et al'"
TAO Xiao-ling, RCT et al[8] WANG Hongjie[9I
RCT
Published periodical
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Experimental Cont rol Risk Difference Events Total Events Total Weight lVI-II, Fixed, 95'Yo. CI
Study or Subgroup YU Va-ping 2005 ZHANG Xian 2011 WANG Hong-jie 2010 JIA Jie 2003 TAO Xiao-Iing 2012 HAN Xue 2002 HUANG Xin-fang 1999
130 29 21 20 26 120 32
135 32 30 30 30 124 35
Tot al (95% CI)
106 16 10 18 19 66
22
46
33.9% 7.9% 80% 8.0% 8.0% 25 .0% 9.3%
0.09 [0.02, 0.15] 0.33 [0.13, 0.54] 0.37 [0.13, 0.60] 0.07 [-0.18, 0.31] 0.23 [0.02, 0.44] 0.10 [0.02, 0.18] 0.29 [0.10, 0.47]
350 100.0%
0.1610.11,0.211
121 28 30 30 30 76 35
Total events 378 257 Heterogeneity: Chi'= 15.19, df = 6 (P = 0.02); 1'= 61% Test for overall effect: Z= 6.27 (P < 0.000 01)
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Risk Differen ce M-II , Fixed, 95'% CI
•
-1.0 -0.5 0.0 0.5 1.0 Favours [treatment] Favours [control]
Figure 1 Analysis result of original data effect size and combined effect size in each research
and P
Publication bias of the included clinical research The funnel plot of each research effect (Figure 2). showed that the points of each research effect were distributed in general symmetric funnel in reverse shape, which indicated that the research did not have obvious publication bias. 0.00
d ..
,/,0 \,\.
0.05
5'
:
~ 0. 10
,!
UJ
Vl
,... ,, ,,, ,
0. 15
,, ,,
,
,, ,,
a 0
0 \
0\, 0\
,, ,,
., .,, .,.
. ,
0.20 '--------'-~'-----'-~-----'-'-------' -1.0 -0.5 0.0 0.5 1.0 RD
Figure 2
Funnel plot for combined effect data
DISCUSSION The acupuncture therapy possesses the functions of inducing resuscitation and benefiting intelligence, unblocking the governor vessel and nurishing yuan, and conditioning viscera and yin-yang. It is proved from the clinical research that applying acupuncture on the head acupoints has definite therapeutic effect in improving the intelligence level of children with cerebral palsy. Relevant literature sprang up in recent years about applying scalp acupuncture on child cerebral palsy vigorously verifies the unique advantage of acupuncture therapy. Two hundred and thirty-four
papers were retrieved in total and 7 of them were included in the study. There were 796 cases in the literature included, which were divided into treatment group (416 cases) and control group (380 cases), with the total effective cases of 378 and 281, and total effective rate of 90.9% and 73.9%, respectively. So we could believe that the effective rate of therapeutic effect of applying scalp acupuncture on child cerebral palsy increases by 17%. Meta analysis indicated that OR was 0.16, 95% confidence interval was (0.11, 0.21), the combined effect inspects Z=6.27, P
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Vol. 24, No.3, 30th Sep.2014
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they are not strictly controlled; the self-prepared rating index is mostly adopted for the criteria of therapeutic effect, which leads to that the universal adaptability of conclusion is decreased to some extent; the description of random method is not definite, the allocation concealing and blind method are not used, and the conditions of quit and loss to follow-up are not recorded in detail, there is scarcely any report on negative result; the evidence strength for safety evaluation of scalp acupuncture needs to be improved. In order to enhance the value of clinical research, the following improvements are suggested in future research: CD the quantity of subjects should be increased and randomized controlled trial with large sample and high quality should be carried out; ® the randomization should be carried out and described in detail strictly based on the requirement, allocation concealing should be used and blind method should be implemented correctly; @ standardization management should be implemented for the starting time, acupuncture frequency and manipulation of acupuncture in the interference therapy, and the therapy of control group should be objective and reasonable; @ as for the comprehensive evaluation of the therapeutic effect of acupuncture on child cerebral palsy, the research which would be published and is not still published should be fully collected, including the unpublished research on negative result, conference papers, academic thesis, etc., and the result of Meta analysis should be further improved and enriched. As long as we bear the scientific attitude, improve the implementation of clinical research, search the literature with high quality, we could make the research convincing and prompt the further application of scalp acupuncture on rehabilitation of
child neurologic diseases.
REFERENCES [1]
[2] [3]
[4]
[5]
[6]
[7]
[8]
[9]
Chinese Association of Rehabilitation Medicine, Professional Committee of Children Rehabilitation, China Association of Rehabilitation of Disabled Peaple, Professional Committee of Child Cerebral Palsy Rehabilitation. Definition, classification and diagnosis conditions of child cerebral palsy. Chin J Phys Med Rehabil (Chin) 2007; 29(5): 309-310. Li SC. Child Cerebral Palsy (Chin). Zhengzhou: Henan Science and Technology Press; 2000: 168-169. Huang XF, Rao LD. Observation of curative effect of treating 35 cases of child cerebral palsy through applying scalp acupuncture and acupoint injection. Modem Rehabil (Chin) 1999; 3 (7): 833. Jia J. Clinical research on treatment of child cerebral palsy by combining scalp acupuncture and modern rehabilitation. Chin Acup-Mox (Chin) 2003; 23(9): 513514. Han X, Shang Q. Rehabilitation therapeutic effect of treating child cerebral palsy by scalp acupuncture. Chin J Clin Rehabil (Chin) 2002; 6(5): 748. Yu YP, Zhou HL, Dong XL. Observation of curative effect of treating child cerebral palsy through combining acupuncture and functional training. Mod J Integr Tradit Chin West Med (Chin) 2005; 14(1): 66. Zhang X. Evaluation of therapeutic efficiency of treating gross motor function of child cerebral palsy through scalp acupuncture. Mod Prevent Med (Chin) 2011; 38 (16): 3208-3209. Tao XL, Ma LX. Treating 60 cases of child cerebral palsy through scalp acupuncture. Shaanxi J Tradit Chin Med (Chin) 2012; 33(1): 88-89. Wang HJ. Clinical observation of treating backward language functions of child cerebral palsy with scalp acupuncture. Chin Pediatr Integr Tradit West Med (Chin) 2010; 2(1): 32-33.
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