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Wrist–ankle acupuncture combined with pinching along the spine for children allergic rhinitis: A randomized controlled trial
World Journal of Acupuncture – Moxibustion 29 (2019) 259–263
Contents lists available at ScienceDirect
World Journal of Acupuncture – Moxibustion journal homepage: www.elsevier.com/locate/wjam
Clinical Research
Wrist–ankle acupuncture combined with pinching along the spine for children allergic rhinitis: A randomized controlled trial Yu Liu () a, Yi-Huang Gu () b,∗, Ying Xiong () b Affiliated Hospital of Nanjing University of Chinese Medicine/Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China ( /, 210029, ) b Second Clinical Medical College of Nanjing University of Chinese Medicine, Nanjing 210023, China (, 210023, ) a
a r t i c l e
i n f o
Article history: Available online 4 December 2019 Keywords: Wrist–ankle acupuncture Pinching along the spine Children Allergic rhinitis Randomized controlled trial (RCT)
a b s t r a c t Objective: To investigate the clinical effect of wrist–ankle acupuncture combined with pinching along the spine on allergic rhinitis (AR) in children. Methods: A total of 65 children with AR were collected from February 2017 through to December 2018 and they were randomly divided into a combined treatment group with wrist–ankle acupuncture, pinching along the spine and western medication (combined treatment group, 32 cases) and a western medication group (33 cases). In the western medication group, loratadine was prescribed for oral administration. In the combined treatment group, on the base of the medication as the western medication group, the wrist–ankle acupuncture was adopted in combination with pinching along the spine. Before and after treatment, the symptoms and physical signs were scored and the clinical effect was observed in the children of the two groups. Results: After the treatment and in the follow-up, the scores of the symptoms and physical signs in the combined treatment group were lower than those of the western medication group, indicating a statistical significance (all P < 0.05). The total effective rate was 93.7% in the combined treatment group, which was higher than 63.63% in the western medication group, indicating a statistical significance (P < 0.05). Conclusion: The combined treatment of wrist–ankle acupuncture combined with pinching along the spine and loratadine effectively relieves the clinical symptoms and the physical signs in AR children. The clinical effect of this combined treatment is better than the simple use of loratadine. © 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
Introduction Allergic rhinitis (AR) is a kind of allergic diseases, and the increased responsiveness of nasal mucosa is the pathological characteristics. The main clinical symptoms include sneezing, clear runny nose, nasal obstruction, itchy nose, etc. It may induce several of complications, e.g. nasal polyp, allergic asthma, secretory otitis media and allergic pharyngitis [1]. AR is a global epidemic disease and its incidence is listed on the top 5 in the world [2]. AR occurs in the childhood commonly and it has a severe impact on the memory, personality and sleep quality in children [3]. In modern medicine, AR is mainly treated with antihistamine, represented by loratadine and glucocorticoids and antileukotriens, represented by montelukast. In clinical practice, authors found that the combined treatment of wrist–ankle acupuncture combined with pinching along the spine could relieve the symptoms and the physical ∗
Corresponding author. E-mail addresses: [email protected] (Y. Liu), [email protected] (Y.-H. Gu).
signs in AR children, but the clinical effect of such therapy was unknown. Hence, this trial was designed to explore the clinical effect of the combined treatment of wrist–ankle acupuncture combined with pinching along the spine in AR children. The report is as follows. Clinical data General data From February 2017 through to December 2018, 65 AR children of the first or return visit were collected from Jiangsu Provincial Chinese Medicine Hospital. Using coin toss method, they were randomized into a group treated with wrist–ankle acupuncture combined with pinching along the spine and western medication (combined treatment group, 32 cases) and a western medication group (33 cases). In the combined treatment group, there were 18 males, 14 females, aged from 4 to 14 years old, averagely as (7.3 ± 1.1) years old, the duration of diseases ranged from 8 to
https://doi.org/10.1016/j.wjam.2019.12.002 1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
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Table 1 Comparison of the general data in AR children between the two groups. Groups
Combined treatment Western medication t value P value
Cases
32 33
Gender (cases)
Age (years)
Male
Female
Youngest
Oldest
Mean ± SD
Shortest
Longest
Mean ± SD
18 17 – > 0.999
14 16
4 5
14 14
7.3 ± 1.1 7.1 ± 1.4 0.642 0.524
8 7
32 34
13±9 15 ± 8 0.946 0.511
32 months, averagely as (13 ± 9) months. In the western medication group, there were 17 males, 16 females, aged from 5 to 14 years old, averagely as (7.1 ± 1.4) years old, the duration of disease ranged from 7 to 34 months, averagely as (15 ± 8) months. The differences in the general data were not significant statistically in the children between the two groups (all P > 0.05), indicating the comparability. See Table 1. Diagnosis criteria In reference to Guideline of the Diagnosis and Treatment of Allergic Rhinitis in Children [4], the diagnosis criteria were as followed. (1) Complied with one or more the following symptoms: sneezing, itchy nose and nasal discharge. (2) The exposure to exogenous allergen is the common inducement and the duration of attack is about 0.5 to 1.0 h per day. (3) Nasal examination: swelling, paleness, congestion or edema of nasal mucosa, etc. (4) At the attack stage, the conjunctival curettage and/or nasal secretion smears show Eosinophil (EOS) positive, or the allergen skin test indicates positive, of which, at least one result is (++) or more than it. (5) The specificity serum immunoglobulin E (IgE) test in serum is positive and the allergen nasal provocation test (NPT) is conducted if necessary. Inclusion criteria (1) Aged 4 to 14 years old. (2) In compliance with the diagnosis criteria in children mentioned above. (3) No administration of glucocorticoid 30 days before the clinical visit. (4) Agreement by the patient’s guardian and having signing informed consent form.
Disease duration (months)
Wrist–ankle acupuncture: the child was in sitting position. The bilateral upper 1 were selected. The 0.25 mm × 25 mm filiform needle was inserted at the angle of 15°–30° formed by the needle body and the skin surface at the point. After penetrating the skin, the needle was inserted subcutaneously, along the longitudinal axis of the upper limb, toward the proximal part. No needling sensation was required, e.g., soreness, numbness, distention and pain and the limb movement would not induce the needle sensation. If the patient felt some needling sensation, the angle and depth of needle insertion should be adjusted till the sensation disappeared. The needles were removed after retained for 20 min. Pinching along the spine: (1) the child was in prone. With the hollow fist, the operator put the index fingers and the middle fingers on the back, pinched up the muscle by the coordination of the index fingers, the middle fingers and the thumbs, and by the alternative forward of the index fingers and the middle fingers as well as rolling backward of the thumbs, the two hands move forward simultaneously. Starting from the bilateral sides of the coccygeal vertebra, the manipulation was operated from Chángqiáng (GV1) to Dàzhu¯ı (GV14) and it was repeated for 5 times. In the 6th time of the manipulation, the “threepinching and one-lifting” technique was operated, in which, the skin was lifted with the index fingers, the middles fingers and thumbs once every 3 times of the pinching-rolling movement as described above. Such a 6- time manipulation was as 1 group of pinching along the spine and a total of 8 groups were required. (2) ¯ ( Finally, using pressing and rubbing technique, bilateral Fengchí ¯ (BL18) GB20), Fèishù (BL13), Píshù (BL 20), Ganshù and Shènshù (BL23) were stimulated, 1 min at each acupoint. The treatment was given once every two days, 3 treatments a weak, consecutively for 4 weeks.
Exclusion criteria
Therapeutic effect observation
(1) Combined with other serious diseases, e.g., the diseases in the heart, liver and kidney. (2) Mental disorders. (3) Skin trauma, e.g. burns and abrasions. (4) Allergic of all kinds of medications. (5) Poor compliance of the children or family members, failure to follow the treatment regimen.
Observation indexes
Therapeutic methods Western medication group Loratadine was prescribed for oral administration in children. Trade name: clarityne [Shanghai Schering-Plough Pharmaceutical, manufacture batch number H20120436, specification: 0.1% (60 mL, 60 mg)]. Oral administration: for body weight > 30 kg, 10 mL each time and for body weight ≤ 30 kg, 5 mL each time, once a day, consecutively for 4 weeks. Combined treatment group On the base of the treatment as the western medication group, the wrist–ankle acupuncture and pinching along the spine were given.
In reference to Guideline of the Diagnosis and Treatment of Allergic Rhinitis in Children [5], the scoring standard of the symptoms and physical signs of AR in children were drawn up. The symptoms and physical signs of children were scored and evaluated. The total score was the sum of the symptom score and the physical sign score. Symptoms: (1) sneezing (continuous counts of a sneeze): 0 point for less than 3 counts, 1 point for 3 to 9 counts, 2 points for 10 to 15 counts and 3 points for 15 counts or more. (2) Times of blowing the nose and runny nose (per day): 0 point for none, 1 point for 1–4 times, 2 points for 5–10 times and 3 points for 10 times or more. (3) Nasal congestion and obstructive nose when inhaling consciously: 0 point for none, 1 point for occasional attack, 2 points for moderate degree and 3 points for severe degree. (4) Itchy nose: 0 point for none, 1 point for intermittent attack, 2 points for tolerable formication and 3 points for intolerable formication. Physical signs: (1) turbinalia: 0 point: no swelling. 1 point: slightly swelling in the inferior turbinate, visible nasal septum and middle turbinate. 2 points: the inferior turbinate leaned closely against nasal septum (or nasal base), or slight space between the inferior turbinate and the nasal base (or nasal septum). 3 points:
Y. Liu, Y.-H. Gu and Y. Xiong / World Journal of Acupuncture – Moxibustion 29 (2019) 259–263 Table 2 Comparison of the symptom score in AR children between the two groups before and after treatment and in follow-up (point, Mean ± SD). Groups
Cases
Before treatment
After treatment
Combined treatment Western medication
32 33
7.48 ± 1.02 7.37 ± 0.88
2.73 ± 0.76a , b 4.20 ± 0.39a
In follow-up 3.55 ± 0.69a , b 5.17 ± 0.72 a
261
Table 3 Comparison of the score of physical signs in AR children between the two groups before and after treatment and in follow-up (point, Mean ± SD). Groups
Cases
Before treatment
After treatment
Combined treatment Western medication
32 33
2.83 ± 0.86 2.37 ± 0.68
0.87 ± 0.32a , b 1.20 ± 0.39a
In follow-up 1.00 ± 0.51a , b 1.93 ± 0.77a
Note: a Compared with the same group before treatment, P < 0. 05. b Compared with the western medication group at the same time, P < 0. 05.
Note: a Compared with the same group before treatment, P < 0. 05. b Compared with the western medication group at the same time point, P < 0. 05.
the inferior turbinate leaned closely against the nasal base and the nasal septum, the middle turbinate invisible or mucous polypoid in the middle turbinate, polyp formation. (2) Nasal mucosa: 0 point: no swelling. 1 point: mild swelling, no congestion. 2 points: light blue in color. 3 points: pale. The scores of the symptoms of physical signs were observed before and after treatment as well as in follow-up (6 months after treatment) and the statistical analysis were conducted.
Table 4 Comparison of clinical therapeutic effect in AR children between the two groups (cases). Groups
Cases
Combined treatment 32 Western medication 33
Remarkably Effective effective
No effect
22 15
3 12
7 6
Total effective rate (%) 93.75a 63.63
Note: a Compared with the western medication group, P < 0. 05.
Therapeutic effect evaluation According to Diagnosis and Treatment Principles and Recommendation Regimens of Allergic Rhinitis [6], the therapeutic effect evaluation was drawn up. The therapeutic effect was evaluated after the treatment. Score reduction rate = [(total score before treatment−the total score after treatment) ÷ total score before treatment] × 100%. Remarkable effect: score reduction rate > 50%, effect: 20% < score reduction rate ≤ 50%, no effect: score reduction rate ≤ 20%. Statistical analysis SPSS 22.0 software was adopted for data analysis. Measurement data were expressed by Mean ± SD. Two-independent sample ttest was adopted for the comparison between groups. The paired sample t-test was used for intra-group comparison. P < 0.05 indicates the statistical significance. Results (1) Comparison of the symptom score in children with AR between the two groups The difference was not significant in the symptom score between the two groups before treatment (P > 0.05). After treatment and in follow-up, the scores were lower as compared with those before treatment in the same group, indicating a statistical significance (both P < 0.05). After treatment and in follow-up, the symptom scores in the combined treatment group were lower than those of the western medication group, indicating a statistical significance (P < 0.05). See Table 2. (2) Comparison of the score of physical signs in children with AR between the two groups The difference was not significant in the score of physical signs between the two groups before treatment (P > 0.05). After treatment and in follow-up, the scores were lower as compared with those before treatment in the same group, indicating a statistical significance (both P < 0.05). After treatment and in follow-up, the physical signs scores in the combined treatment group were lower than those of the western medication group, indicating a statistical significance (P < 0.05). See Table 3. (3) Comparison of clinical therapeutic effect in AR children between the two groups The total effective rate was 93.75% in the combined treatment group and was 63.63% in the western medication group, indicating a statistical significance (P < 0.05). See Table 4.
Discussion Allergic rhinitis (AR) is the common disease of nasal mucosa in children. The main pathological manifestation is nonspecific inflammation mediated by specific IgE, which belongs to type I allergic disease. A variety of allergen can cause AR, such as pollen, mites, dust and cold air. In recent years, the incidence of AR in children has been showed an upward trend. The medication achieves quick effect on the disease, but induces gastrointestinal side effects at the same time, such as nausea, vomiting and abdominal pain, and some medication may cause liver damage. Hence, a green treatment with simple operation and absence of side effect is demanded urgently in clinic to replace or partially replace medication. In this study, the comprehensive method of acupuncture, tuina (Chinese massage) and medication was adopted. It obtained the satisfactory clinical effect and reduced the utilization rate of the chemical medication. Traditional Chinese medicine (TCM) believes that this disease is in the category of bíqíu (). The causative factors of it include congenital abnormality, zangfu dysfunction, invasion of wind and cold, or contact unclean things, e.g., pollen and mites [7,8]. In pathogenesis, insufficiency of exterior yang, failure in defense, loose interstitial space and insufficiency of zangfu organs are the internal factors and invasion of wind and cold is the external one. The struggle between the two kinds of factors results in the conflict of the antipathogenic qi and the pathogens. The dysfunction of lung in dispersing and descending fails to promote water passage and distribute body fluids. As a result, the harmful fluid is accumulated in nasal cavity, thus, the disease occurs. This disease is located in the lung. In terms of the root cause of the disease, the lung, spleen and kidney are involved. Regarding the symptoms, the invasion of exogenous pathogens, wind, cold and unclean airs are considered. In 2015, acupuncture was listed, for the first time, as one of the regimens in American Guideline for Allergic Rhinitis [9], for the patients aged as young as 2 years old. Wrist–ankle acupuncture is a kind of micro acupuncture therapy, characterized as shallow needling, the subcutaneous insertion of needle body and no requirement of needling sensation, e.g., soreness, numbness, distention and pain. During needling insertion, it is required that the needle tip should be pointed to the affected area. The region division of wrist–ankle acupuncture is similar to the distribution of the cutaneous regions of twelve meridians. The sites of needle inserted are corresponded to the distribution of the cutaneous regions of the meridians on the wrist and
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the ankle. In this study, the upper 1 point was selected, indicating for frontal headache, eye disorders (conjunctivitis or bleeding, ametropia, visual disorder), nasal disorders (nasal obstruction, runny nose), oral and pharynx disorders (glossalgia, salivation, pharynx pain and tonsillitis) and common cold. This acupoint effectively relieves the symptoms of rhinitis, such as nasal obstruction, itchy nose, sneezing and runny nose, as well as its complications, such as frontal headache and lacrimation. As a kind of unique needling technology, wrist–ankle acupuncture is advantageous at its remarkable effect and persistent analgesia. Clinical trial has proved that wrist–ankle acupuncture is significantly effective on pain of muscle, joint and internal organ. However, there are few reports on the treatment for other diseases with this therapy and on its biological mechanism. Relevant research also shows that the effect mechanism of wrist–ankle acupuncture is roughly related to TCM theories on the twelve cutaneous regions of meridians and twelve meridians [10], but it is still unclear at present. Nowadays, the research of wrist–ankle acupuncture mostly focuses on the curative effect of pain, but there are very few researches on the other diseases, especially on AR. Some research indicates that wrist– ankle acupuncture reduces 5-HT level in the peripheral serum [11], which is one of the inflammatory mediators leading to AR. Besides, it regulates the release of neuropeptides, thus adjusting the release of peripheral neurotransmitters as well as neurogenic mediators. The research shows that the symptoms of AR are related to the regulation of nervous system to some extent [12]. Hence, wrist– ankle acupuncture improves serum inflammatory environment, reduces the concentration of inflammatory mediators in peripheral serum and regulates the release of neurogenic inflammatory mediators in AR patients, which may be the mechanism of this therapy on the improvements on local inflammation and the disease. TCM believes that pinching along the spine works on promoting meridian qi circulation, regulating qi and blood, especially stimulating qi of bladder meridian and governor vessel so as to bring the conductive role of corresponding meridians into play. The first line of bladder meridian on the back is the region, on which, the back-shu points are located. Back-shu points are the sites, into which, the five zang and six fu organs are opened. The governor vessel is regarded as the sea of yang meridians. Pinching along the spine exerted on this meridian is conductive to regulating yin and yang and balancing zangfu organs. The acupoints on the second line of bladder meridian on the back are corresponded to the mind dominated by five zang organs. Hence, by stimulating these acupoints on the back, pinching along the spine works on strengthening the spleen and benefiting the kidney, tonifying qi and nourishing blood, consolidating the root and cultivating the primary, as well as promoting the circulation of the governor vessel and regulating the mind. Ultimately, the immunity is improved and the purpose for both treatment and prevention is achieved [13]. Modern research [14] believes that pinching along the spine propels and activates immune system, improves the levels of serum IgG and CD4 and reduces the level of CD8 so that the immune function is improved. Additionally, pinching along the spine increases the content of trace elements and reduces the production of harmful substances in human body [15]. In this study, loratadine was used as oral medication. At present, the common medications for AR in children are cortisol (nasal use or oral administration) and antihistamine. The long-term use of cortisol has inhibitory effect on the function of hypothalamic-pituitary-adrenal (HPA) axis and affects the growth and development of human body to some extent. The first generation of antihistamine induces the significant central reactions, namely sedation and lethargy, thus, it is seldom used. The second generation of it, e.g., loratadine, has very less side effects and is recommended for adults and children as the critical therapeutic drug [16]. Clinically, loratadine is commonly used for rhinitis. It
was found that the effective rate was 70–80% in AR treated with the simple use of loratadine [17]. The effective rate was 60–86% in children and this medication effectively relieved the symptoms and physical signs. Besides, the statistical significance had been obtained for the influence on the relevant serum immune indexes [18,19]. It is considered that AR cannot be cured radically. The general goal of treatment is to achieve and maintain the control of clinical symptoms. Hence, the daily health management should be combined with clinical treatment. The health education should be focused on avoiding allergen contact, rational use of nasal hormones, and standardized operation of nasal spray and timely modification of the dose of oral medication [20]. Parents should understand the inducing factors and clinical symptoms of this disease, as well as their influences on the quality of life in children. For susceptible children, parents should give the special attention to daily preventive care, such as avoiding the contact with pets and plush toys. In season alternation or pollen season, the preventive treatment should be given with antihistamine and nasal glucocorticoids two weeks in advance. Moreover, wrist–ankle acupuncture, combined with pinching along the spine is applicable for preventive treatment and this combined therapy can alleviate allergic symptoms and reduce the use of anti-allergic medication. One study showed that, a survey of allergic diseases with 98 countries involved, in which, among children aged from 6 to 7 years old and 13 to 14 years old, the case rates were 8.5% and 14.6%, respectively [21]. In over 80% of AR patients, the symptoms were presented before the age of 20 years old [22]. In childhood, except the typical symptoms and signs of AR, the psychological and behavioral abnormality was presented as well [23]. Hence, AR seriously affects the health both physically and mentally as well as the quality of life in children. In treatment, the corresponding psychological and behavioral guidance should be provided at the same time in addition to the improvement in symptoms and signs. Specially, in treatment for AR in children, except traditional medication, the therapeutic methods with less side effects and easy compliance should be selected. Acupuncture should be manipulated gently and pinching along the spine be manipulated with average strength, softness, deep and thorough. The results of this study indicated that wrist–ankle acupuncture combined with pinching along the spine, achieved a satisfactory effects on AR in children in the aspects of the improvements in the symptoms and physical signs. In the future, the research should focus on the effect mechanism of this combined therapy, i.e., the effect on biochemical immunity, the effect during biochemical metabolism and the effect on cellular pathway.
References [1] Huang XZ, editor. Otorhinolaryngology. Beijing: The People’s Medical Publishing House; 1996. p. 38–40. [2] Han DM. Clinical diagnosis and treatment of head and neck surgical diseases of otorhinolaryngology, 89. Beijing: The People’s Medical Publishing House; 2009. [3] Wang M, Tan GL, Zhao SJ. Epidemiological investigation and related risk factors analysis of allergic rhinitis in primary and middle school students in Changsha. J Clinic Otorhinolaryngol Head Neck Surg 2014;4(28):97. [4] Rhinology group of journal of clinical otorhinolaryngology head and neck surgery, rhinology group and pediatrics group of the branch of otorhinolaryngology head and neck surgery, chinese medical association. Guideline of the diagnosis and treatment of allergic rhinitis in children (2010, Chongqing). Chin J Otorhinolaryngol Head Neck Surg 2011;46(1):7–8. [5] Rhinology group of journal of clinical otorhinolaryngology head and neck surgery, rhinology group of the branch of otorhinolaryngology head and neck surgery, Chinese medical association. Guideline of the diagnosis and treatment of allergic rhinitis in children (2015, Tianjin). Chin J Otorhinolaryngol Head Neck Surg 2016;51(1):5–24. [6] Journal of clinical otorhinolaryngology head and neck surgery, branch of otorhinolaryngology head and neck surgery. Diagnosis and treatment principles and recommendation regimens of allergic rhinitis. Chin J Otorhinolaryngol Head Neck Surg 2005;40(3):166.
Y. Liu, Y.-H. Gu and Y. Xiong / World Journal of Acupuncture – Moxibustion 29 (2019) 259–263 [7] Inuo C, Kondo Y, Tanaka K, et al. Japanese cedar pollen-based subcutaneous immunotherapy decreases tomato fruit-specific basophil activation. Int Arch Allergy Immunol 2015;167(2):137–45. [8] Kang HR, Liu Y, Li XR. Traditional Chinese theory of moxibustion on governor vessel of allergic rhinitis about lung qi deficiency cold type. Liaoning J Trad Chin Med 2016;11(8):1735–7. [9] Meng X. Acupuncture is listed in the American guideline for allergic rhinitis. Chin Acup Moxi 2015;35(5):482. [10] Lu FF, Qian XL. Advances in studies on wrist-ankle acupuncture in treating non-pain diseases. J Liaoning Univ Trad Chin Med 2018;20(01):117–19. [11] Zhang CP, Zhou QH. Study on the mechanisms of wrist-ankle acupuncture analgesia. J Liaoning Univ Trad Chin Med 2018;20(02):74–6. [12] Zhang C, Sha JC, Zhu DD. Effect of neurogenic inflammatory mediators on the pathogenesis of allergic rhinitis. Chin J Lab Diagn 2017;21(07):1272–4. [13] Zhang YH. Research progress on the mechanism of pinching along the spine therapy of infantile anorexia. J Liaoning Univ Trad Chin Med 2016;18(6):222–3. [14] Li XC, Liu YC, Li MY, Wang H. Influence of pinching along the spine therapy on contents of ghrelin and vasoactive intestinal peptide in rabbit with bradygastria. China J Trad Chin Med Pharm 2016;31(2):637–9. [15] Li JX, Li MY, Wang H. Application status and manipulation analysis of simply spinal pinching therapy in the treatment of pediatric diseases. China J Tradit Chin Med Pharm 2018;33(1):325–8.
263
[16] Tao CY, Sun X, Xu LM. Visualization analysis on current status of clinical treatment for children with allergic rhinitis in China. China Med 2019(10):1566–70. [17] Zhang SH. Progress in the treatment of allergic rhinitis. Tianjin Pharma 2019;31(04):72–5. [18] Zhang FR, Jin RJ, Liu L, Lu QW, Zhou C. Observations on the efficacy of thumb– tack needle therapy plus medication for allergic rhinitis in children. Shanghai J Acup Moxi 2018;37(05):552–6. [19] Sun XL, Liu HJ, Fu L, Wang L, Gan XR. Efficacy of compound xinyidibiye combined with loratadine in the treatment of children with allergic rhinitis and its influence on the immune function. Progr Mod Biomed 2019;19(03):482–5. [20] Collaborative Group of Chinese Allergic Rhinitis Research Expert consensus on subcutaneous immunotherapy for allergic rhinitis 2015. Chin Arch Otolaryng Head Neck Surg 2015;22(8):384. [21] Fernandez F, Porras G, Mormède P, et al. The international study of asthma and allergies in childhood (ISAAC) phase three: a global synthesis. Allergol Immuno pathol 2013;41(2):73–85. [22] Skoner DP. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol 2001;108(1 S):2–8. [23] Feng BH, Shi YB, Chen BP. Allergic rhinitis and psychological and behavioral problems. Chin J Otorhinolaryngol Integr Med 2017;25(03):170–3.
Contents lists available at ScienceDirect
World Journal of Acupuncture – Moxibustion journal homepage: www.elsevier.com/locate/wjam
Clinical Research
Wrist–ankle acupuncture combined with pinching along the spine for children allergic rhinitis: A randomized controlled trial Yu Liu () a, Yi-Huang Gu () b,∗, Ying Xiong () b Affiliated Hospital of Nanjing University of Chinese Medicine/Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029, China ( /, 210029, ) b Second Clinical Medical College of Nanjing University of Chinese Medicine, Nanjing 210023, China (, 210023, ) a
a r t i c l e
i n f o
Article history: Available online 4 December 2019 Keywords: Wrist–ankle acupuncture Pinching along the spine Children Allergic rhinitis Randomized controlled trial (RCT)
a b s t r a c t Objective: To investigate the clinical effect of wrist–ankle acupuncture combined with pinching along the spine on allergic rhinitis (AR) in children. Methods: A total of 65 children with AR were collected from February 2017 through to December 2018 and they were randomly divided into a combined treatment group with wrist–ankle acupuncture, pinching along the spine and western medication (combined treatment group, 32 cases) and a western medication group (33 cases). In the western medication group, loratadine was prescribed for oral administration. In the combined treatment group, on the base of the medication as the western medication group, the wrist–ankle acupuncture was adopted in combination with pinching along the spine. Before and after treatment, the symptoms and physical signs were scored and the clinical effect was observed in the children of the two groups. Results: After the treatment and in the follow-up, the scores of the symptoms and physical signs in the combined treatment group were lower than those of the western medication group, indicating a statistical significance (all P < 0.05). The total effective rate was 93.7% in the combined treatment group, which was higher than 63.63% in the western medication group, indicating a statistical significance (P < 0.05). Conclusion: The combined treatment of wrist–ankle acupuncture combined with pinching along the spine and loratadine effectively relieves the clinical symptoms and the physical signs in AR children. The clinical effect of this combined treatment is better than the simple use of loratadine. © 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
Introduction Allergic rhinitis (AR) is a kind of allergic diseases, and the increased responsiveness of nasal mucosa is the pathological characteristics. The main clinical symptoms include sneezing, clear runny nose, nasal obstruction, itchy nose, etc. It may induce several of complications, e.g. nasal polyp, allergic asthma, secretory otitis media and allergic pharyngitis [1]. AR is a global epidemic disease and its incidence is listed on the top 5 in the world [2]. AR occurs in the childhood commonly and it has a severe impact on the memory, personality and sleep quality in children [3]. In modern medicine, AR is mainly treated with antihistamine, represented by loratadine and glucocorticoids and antileukotriens, represented by montelukast. In clinical practice, authors found that the combined treatment of wrist–ankle acupuncture combined with pinching along the spine could relieve the symptoms and the physical ∗
Corresponding author. E-mail addresses: [email protected] (Y. Liu), [email protected] (Y.-H. Gu).
signs in AR children, but the clinical effect of such therapy was unknown. Hence, this trial was designed to explore the clinical effect of the combined treatment of wrist–ankle acupuncture combined with pinching along the spine in AR children. The report is as follows. Clinical data General data From February 2017 through to December 2018, 65 AR children of the first or return visit were collected from Jiangsu Provincial Chinese Medicine Hospital. Using coin toss method, they were randomized into a group treated with wrist–ankle acupuncture combined with pinching along the spine and western medication (combined treatment group, 32 cases) and a western medication group (33 cases). In the combined treatment group, there were 18 males, 14 females, aged from 4 to 14 years old, averagely as (7.3 ± 1.1) years old, the duration of diseases ranged from 8 to
https://doi.org/10.1016/j.wjam.2019.12.002 1003-5257/© 2019 Published by Elsevier B.V. on behalf of World Journal of Acupuncture Moxibustion House.
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Table 1 Comparison of the general data in AR children between the two groups. Groups
Combined treatment Western medication t value P value
Cases
32 33
Gender (cases)
Age (years)
Male
Female
Youngest
Oldest
Mean ± SD
Shortest
Longest
Mean ± SD
18 17 – > 0.999
14 16
4 5
14 14
7.3 ± 1.1 7.1 ± 1.4 0.642 0.524
8 7
32 34
13±9 15 ± 8 0.946 0.511
32 months, averagely as (13 ± 9) months. In the western medication group, there were 17 males, 16 females, aged from 5 to 14 years old, averagely as (7.1 ± 1.4) years old, the duration of disease ranged from 7 to 34 months, averagely as (15 ± 8) months. The differences in the general data were not significant statistically in the children between the two groups (all P > 0.05), indicating the comparability. See Table 1. Diagnosis criteria In reference to Guideline of the Diagnosis and Treatment of Allergic Rhinitis in Children [4], the diagnosis criteria were as followed. (1) Complied with one or more the following symptoms: sneezing, itchy nose and nasal discharge. (2) The exposure to exogenous allergen is the common inducement and the duration of attack is about 0.5 to 1.0 h per day. (3) Nasal examination: swelling, paleness, congestion or edema of nasal mucosa, etc. (4) At the attack stage, the conjunctival curettage and/or nasal secretion smears show Eosinophil (EOS) positive, or the allergen skin test indicates positive, of which, at least one result is (++) or more than it. (5) The specificity serum immunoglobulin E (IgE) test in serum is positive and the allergen nasal provocation test (NPT) is conducted if necessary. Inclusion criteria (1) Aged 4 to 14 years old. (2) In compliance with the diagnosis criteria in children mentioned above. (3) No administration of glucocorticoid 30 days before the clinical visit. (4) Agreement by the patient’s guardian and having signing informed consent form.
Disease duration (months)
Wrist–ankle acupuncture: the child was in sitting position. The bilateral upper 1 were selected. The 0.25 mm × 25 mm filiform needle was inserted at the angle of 15°–30° formed by the needle body and the skin surface at the point. After penetrating the skin, the needle was inserted subcutaneously, along the longitudinal axis of the upper limb, toward the proximal part. No needling sensation was required, e.g., soreness, numbness, distention and pain and the limb movement would not induce the needle sensation. If the patient felt some needling sensation, the angle and depth of needle insertion should be adjusted till the sensation disappeared. The needles were removed after retained for 20 min. Pinching along the spine: (1) the child was in prone. With the hollow fist, the operator put the index fingers and the middle fingers on the back, pinched up the muscle by the coordination of the index fingers, the middle fingers and the thumbs, and by the alternative forward of the index fingers and the middle fingers as well as rolling backward of the thumbs, the two hands move forward simultaneously. Starting from the bilateral sides of the coccygeal vertebra, the manipulation was operated from Chángqiáng (GV1) to Dàzhu¯ı (GV14) and it was repeated for 5 times. In the 6th time of the manipulation, the “threepinching and one-lifting” technique was operated, in which, the skin was lifted with the index fingers, the middles fingers and thumbs once every 3 times of the pinching-rolling movement as described above. Such a 6- time manipulation was as 1 group of pinching along the spine and a total of 8 groups were required. (2) ¯ ( Finally, using pressing and rubbing technique, bilateral Fengchí ¯ (BL18) GB20), Fèishù (BL13), Píshù (BL 20), Ganshù and Shènshù (BL23) were stimulated, 1 min at each acupoint. The treatment was given once every two days, 3 treatments a weak, consecutively for 4 weeks.
Exclusion criteria
Therapeutic effect observation
(1) Combined with other serious diseases, e.g., the diseases in the heart, liver and kidney. (2) Mental disorders. (3) Skin trauma, e.g. burns and abrasions. (4) Allergic of all kinds of medications. (5) Poor compliance of the children or family members, failure to follow the treatment regimen.
Observation indexes
Therapeutic methods Western medication group Loratadine was prescribed for oral administration in children. Trade name: clarityne [Shanghai Schering-Plough Pharmaceutical, manufacture batch number H20120436, specification: 0.1% (60 mL, 60 mg)]. Oral administration: for body weight > 30 kg, 10 mL each time and for body weight ≤ 30 kg, 5 mL each time, once a day, consecutively for 4 weeks. Combined treatment group On the base of the treatment as the western medication group, the wrist–ankle acupuncture and pinching along the spine were given.
In reference to Guideline of the Diagnosis and Treatment of Allergic Rhinitis in Children [5], the scoring standard of the symptoms and physical signs of AR in children were drawn up. The symptoms and physical signs of children were scored and evaluated. The total score was the sum of the symptom score and the physical sign score. Symptoms: (1) sneezing (continuous counts of a sneeze): 0 point for less than 3 counts, 1 point for 3 to 9 counts, 2 points for 10 to 15 counts and 3 points for 15 counts or more. (2) Times of blowing the nose and runny nose (per day): 0 point for none, 1 point for 1–4 times, 2 points for 5–10 times and 3 points for 10 times or more. (3) Nasal congestion and obstructive nose when inhaling consciously: 0 point for none, 1 point for occasional attack, 2 points for moderate degree and 3 points for severe degree. (4) Itchy nose: 0 point for none, 1 point for intermittent attack, 2 points for tolerable formication and 3 points for intolerable formication. Physical signs: (1) turbinalia: 0 point: no swelling. 1 point: slightly swelling in the inferior turbinate, visible nasal septum and middle turbinate. 2 points: the inferior turbinate leaned closely against nasal septum (or nasal base), or slight space between the inferior turbinate and the nasal base (or nasal septum). 3 points:
Y. Liu, Y.-H. Gu and Y. Xiong / World Journal of Acupuncture – Moxibustion 29 (2019) 259–263 Table 2 Comparison of the symptom score in AR children between the two groups before and after treatment and in follow-up (point, Mean ± SD). Groups
Cases
Before treatment
After treatment
Combined treatment Western medication
32 33
7.48 ± 1.02 7.37 ± 0.88
2.73 ± 0.76a , b 4.20 ± 0.39a
In follow-up 3.55 ± 0.69a , b 5.17 ± 0.72 a
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Table 3 Comparison of the score of physical signs in AR children between the two groups before and after treatment and in follow-up (point, Mean ± SD). Groups
Cases
Before treatment
After treatment
Combined treatment Western medication
32 33
2.83 ± 0.86 2.37 ± 0.68
0.87 ± 0.32a , b 1.20 ± 0.39a
In follow-up 1.00 ± 0.51a , b 1.93 ± 0.77a
Note: a Compared with the same group before treatment, P < 0. 05. b Compared with the western medication group at the same time, P < 0. 05.
Note: a Compared with the same group before treatment, P < 0. 05. b Compared with the western medication group at the same time point, P < 0. 05.
the inferior turbinate leaned closely against the nasal base and the nasal septum, the middle turbinate invisible or mucous polypoid in the middle turbinate, polyp formation. (2) Nasal mucosa: 0 point: no swelling. 1 point: mild swelling, no congestion. 2 points: light blue in color. 3 points: pale. The scores of the symptoms of physical signs were observed before and after treatment as well as in follow-up (6 months after treatment) and the statistical analysis were conducted.
Table 4 Comparison of clinical therapeutic effect in AR children between the two groups (cases). Groups
Cases
Combined treatment 32 Western medication 33
Remarkably Effective effective
No effect
22 15
3 12
7 6
Total effective rate (%) 93.75a 63.63
Note: a Compared with the western medication group, P < 0. 05.
Therapeutic effect evaluation According to Diagnosis and Treatment Principles and Recommendation Regimens of Allergic Rhinitis [6], the therapeutic effect evaluation was drawn up. The therapeutic effect was evaluated after the treatment. Score reduction rate = [(total score before treatment−the total score after treatment) ÷ total score before treatment] × 100%. Remarkable effect: score reduction rate > 50%, effect: 20% < score reduction rate ≤ 50%, no effect: score reduction rate ≤ 20%. Statistical analysis SPSS 22.0 software was adopted for data analysis. Measurement data were expressed by Mean ± SD. Two-independent sample ttest was adopted for the comparison between groups. The paired sample t-test was used for intra-group comparison. P < 0.05 indicates the statistical significance. Results (1) Comparison of the symptom score in children with AR between the two groups The difference was not significant in the symptom score between the two groups before treatment (P > 0.05). After treatment and in follow-up, the scores were lower as compared with those before treatment in the same group, indicating a statistical significance (both P < 0.05). After treatment and in follow-up, the symptom scores in the combined treatment group were lower than those of the western medication group, indicating a statistical significance (P < 0.05). See Table 2. (2) Comparison of the score of physical signs in children with AR between the two groups The difference was not significant in the score of physical signs between the two groups before treatment (P > 0.05). After treatment and in follow-up, the scores were lower as compared with those before treatment in the same group, indicating a statistical significance (both P < 0.05). After treatment and in follow-up, the physical signs scores in the combined treatment group were lower than those of the western medication group, indicating a statistical significance (P < 0.05). See Table 3. (3) Comparison of clinical therapeutic effect in AR children between the two groups The total effective rate was 93.75% in the combined treatment group and was 63.63% in the western medication group, indicating a statistical significance (P < 0.05). See Table 4.
Discussion Allergic rhinitis (AR) is the common disease of nasal mucosa in children. The main pathological manifestation is nonspecific inflammation mediated by specific IgE, which belongs to type I allergic disease. A variety of allergen can cause AR, such as pollen, mites, dust and cold air. In recent years, the incidence of AR in children has been showed an upward trend. The medication achieves quick effect on the disease, but induces gastrointestinal side effects at the same time, such as nausea, vomiting and abdominal pain, and some medication may cause liver damage. Hence, a green treatment with simple operation and absence of side effect is demanded urgently in clinic to replace or partially replace medication. In this study, the comprehensive method of acupuncture, tuina (Chinese massage) and medication was adopted. It obtained the satisfactory clinical effect and reduced the utilization rate of the chemical medication. Traditional Chinese medicine (TCM) believes that this disease is in the category of bíqíu (). The causative factors of it include congenital abnormality, zangfu dysfunction, invasion of wind and cold, or contact unclean things, e.g., pollen and mites [7,8]. In pathogenesis, insufficiency of exterior yang, failure in defense, loose interstitial space and insufficiency of zangfu organs are the internal factors and invasion of wind and cold is the external one. The struggle between the two kinds of factors results in the conflict of the antipathogenic qi and the pathogens. The dysfunction of lung in dispersing and descending fails to promote water passage and distribute body fluids. As a result, the harmful fluid is accumulated in nasal cavity, thus, the disease occurs. This disease is located in the lung. In terms of the root cause of the disease, the lung, spleen and kidney are involved. Regarding the symptoms, the invasion of exogenous pathogens, wind, cold and unclean airs are considered. In 2015, acupuncture was listed, for the first time, as one of the regimens in American Guideline for Allergic Rhinitis [9], for the patients aged as young as 2 years old. Wrist–ankle acupuncture is a kind of micro acupuncture therapy, characterized as shallow needling, the subcutaneous insertion of needle body and no requirement of needling sensation, e.g., soreness, numbness, distention and pain. During needling insertion, it is required that the needle tip should be pointed to the affected area. The region division of wrist–ankle acupuncture is similar to the distribution of the cutaneous regions of twelve meridians. The sites of needle inserted are corresponded to the distribution of the cutaneous regions of the meridians on the wrist and
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the ankle. In this study, the upper 1 point was selected, indicating for frontal headache, eye disorders (conjunctivitis or bleeding, ametropia, visual disorder), nasal disorders (nasal obstruction, runny nose), oral and pharynx disorders (glossalgia, salivation, pharynx pain and tonsillitis) and common cold. This acupoint effectively relieves the symptoms of rhinitis, such as nasal obstruction, itchy nose, sneezing and runny nose, as well as its complications, such as frontal headache and lacrimation. As a kind of unique needling technology, wrist–ankle acupuncture is advantageous at its remarkable effect and persistent analgesia. Clinical trial has proved that wrist–ankle acupuncture is significantly effective on pain of muscle, joint and internal organ. However, there are few reports on the treatment for other diseases with this therapy and on its biological mechanism. Relevant research also shows that the effect mechanism of wrist–ankle acupuncture is roughly related to TCM theories on the twelve cutaneous regions of meridians and twelve meridians [10], but it is still unclear at present. Nowadays, the research of wrist–ankle acupuncture mostly focuses on the curative effect of pain, but there are very few researches on the other diseases, especially on AR. Some research indicates that wrist– ankle acupuncture reduces 5-HT level in the peripheral serum [11], which is one of the inflammatory mediators leading to AR. Besides, it regulates the release of neuropeptides, thus adjusting the release of peripheral neurotransmitters as well as neurogenic mediators. The research shows that the symptoms of AR are related to the regulation of nervous system to some extent [12]. Hence, wrist– ankle acupuncture improves serum inflammatory environment, reduces the concentration of inflammatory mediators in peripheral serum and regulates the release of neurogenic inflammatory mediators in AR patients, which may be the mechanism of this therapy on the improvements on local inflammation and the disease. TCM believes that pinching along the spine works on promoting meridian qi circulation, regulating qi and blood, especially stimulating qi of bladder meridian and governor vessel so as to bring the conductive role of corresponding meridians into play. The first line of bladder meridian on the back is the region, on which, the back-shu points are located. Back-shu points are the sites, into which, the five zang and six fu organs are opened. The governor vessel is regarded as the sea of yang meridians. Pinching along the spine exerted on this meridian is conductive to regulating yin and yang and balancing zangfu organs. The acupoints on the second line of bladder meridian on the back are corresponded to the mind dominated by five zang organs. Hence, by stimulating these acupoints on the back, pinching along the spine works on strengthening the spleen and benefiting the kidney, tonifying qi and nourishing blood, consolidating the root and cultivating the primary, as well as promoting the circulation of the governor vessel and regulating the mind. Ultimately, the immunity is improved and the purpose for both treatment and prevention is achieved [13]. Modern research [14] believes that pinching along the spine propels and activates immune system, improves the levels of serum IgG and CD4 and reduces the level of CD8 so that the immune function is improved. Additionally, pinching along the spine increases the content of trace elements and reduces the production of harmful substances in human body [15]. In this study, loratadine was used as oral medication. At present, the common medications for AR in children are cortisol (nasal use or oral administration) and antihistamine. The long-term use of cortisol has inhibitory effect on the function of hypothalamic-pituitary-adrenal (HPA) axis and affects the growth and development of human body to some extent. The first generation of antihistamine induces the significant central reactions, namely sedation and lethargy, thus, it is seldom used. The second generation of it, e.g., loratadine, has very less side effects and is recommended for adults and children as the critical therapeutic drug [16]. Clinically, loratadine is commonly used for rhinitis. It
was found that the effective rate was 70–80% in AR treated with the simple use of loratadine [17]. The effective rate was 60–86% in children and this medication effectively relieved the symptoms and physical signs. Besides, the statistical significance had been obtained for the influence on the relevant serum immune indexes [18,19]. It is considered that AR cannot be cured radically. The general goal of treatment is to achieve and maintain the control of clinical symptoms. Hence, the daily health management should be combined with clinical treatment. The health education should be focused on avoiding allergen contact, rational use of nasal hormones, and standardized operation of nasal spray and timely modification of the dose of oral medication [20]. Parents should understand the inducing factors and clinical symptoms of this disease, as well as their influences on the quality of life in children. For susceptible children, parents should give the special attention to daily preventive care, such as avoiding the contact with pets and plush toys. In season alternation or pollen season, the preventive treatment should be given with antihistamine and nasal glucocorticoids two weeks in advance. Moreover, wrist–ankle acupuncture, combined with pinching along the spine is applicable for preventive treatment and this combined therapy can alleviate allergic symptoms and reduce the use of anti-allergic medication. One study showed that, a survey of allergic diseases with 98 countries involved, in which, among children aged from 6 to 7 years old and 13 to 14 years old, the case rates were 8.5% and 14.6%, respectively [21]. In over 80% of AR patients, the symptoms were presented before the age of 20 years old [22]. In childhood, except the typical symptoms and signs of AR, the psychological and behavioral abnormality was presented as well [23]. Hence, AR seriously affects the health both physically and mentally as well as the quality of life in children. In treatment, the corresponding psychological and behavioral guidance should be provided at the same time in addition to the improvement in symptoms and signs. Specially, in treatment for AR in children, except traditional medication, the therapeutic methods with less side effects and easy compliance should be selected. Acupuncture should be manipulated gently and pinching along the spine be manipulated with average strength, softness, deep and thorough. The results of this study indicated that wrist–ankle acupuncture combined with pinching along the spine, achieved a satisfactory effects on AR in children in the aspects of the improvements in the symptoms and physical signs. In the future, the research should focus on the effect mechanism of this combined therapy, i.e., the effect on biochemical immunity, the effect during biochemical metabolism and the effect on cellular pathway.
References [1] Huang XZ, editor. Otorhinolaryngology. Beijing: The People’s Medical Publishing House; 1996. p. 38–40. [2] Han DM. Clinical diagnosis and treatment of head and neck surgical diseases of otorhinolaryngology, 89. Beijing: The People’s Medical Publishing House; 2009. [3] Wang M, Tan GL, Zhao SJ. Epidemiological investigation and related risk factors analysis of allergic rhinitis in primary and middle school students in Changsha. J Clinic Otorhinolaryngol Head Neck Surg 2014;4(28):97. [4] Rhinology group of journal of clinical otorhinolaryngology head and neck surgery, rhinology group and pediatrics group of the branch of otorhinolaryngology head and neck surgery, chinese medical association. Guideline of the diagnosis and treatment of allergic rhinitis in children (2010, Chongqing). Chin J Otorhinolaryngol Head Neck Surg 2011;46(1):7–8. [5] Rhinology group of journal of clinical otorhinolaryngology head and neck surgery, rhinology group of the branch of otorhinolaryngology head and neck surgery, Chinese medical association. Guideline of the diagnosis and treatment of allergic rhinitis in children (2015, Tianjin). Chin J Otorhinolaryngol Head Neck Surg 2016;51(1):5–24. [6] Journal of clinical otorhinolaryngology head and neck surgery, branch of otorhinolaryngology head and neck surgery. Diagnosis and treatment principles and recommendation regimens of allergic rhinitis. Chin J Otorhinolaryngol Head Neck Surg 2005;40(3):166.
Y. Liu, Y.-H. Gu and Y. Xiong / World Journal of Acupuncture – Moxibustion 29 (2019) 259–263 [7] Inuo C, Kondo Y, Tanaka K, et al. Japanese cedar pollen-based subcutaneous immunotherapy decreases tomato fruit-specific basophil activation. Int Arch Allergy Immunol 2015;167(2):137–45. [8] Kang HR, Liu Y, Li XR. Traditional Chinese theory of moxibustion on governor vessel of allergic rhinitis about lung qi deficiency cold type. Liaoning J Trad Chin Med 2016;11(8):1735–7. [9] Meng X. Acupuncture is listed in the American guideline for allergic rhinitis. Chin Acup Moxi 2015;35(5):482. [10] Lu FF, Qian XL. Advances in studies on wrist-ankle acupuncture in treating non-pain diseases. J Liaoning Univ Trad Chin Med 2018;20(01):117–19. [11] Zhang CP, Zhou QH. Study on the mechanisms of wrist-ankle acupuncture analgesia. J Liaoning Univ Trad Chin Med 2018;20(02):74–6. [12] Zhang C, Sha JC, Zhu DD. Effect of neurogenic inflammatory mediators on the pathogenesis of allergic rhinitis. Chin J Lab Diagn 2017;21(07):1272–4. [13] Zhang YH. Research progress on the mechanism of pinching along the spine therapy of infantile anorexia. J Liaoning Univ Trad Chin Med 2016;18(6):222–3. [14] Li XC, Liu YC, Li MY, Wang H. Influence of pinching along the spine therapy on contents of ghrelin and vasoactive intestinal peptide in rabbit with bradygastria. China J Trad Chin Med Pharm 2016;31(2):637–9. [15] Li JX, Li MY, Wang H. Application status and manipulation analysis of simply spinal pinching therapy in the treatment of pediatric diseases. China J Tradit Chin Med Pharm 2018;33(1):325–8.
263
[16] Tao CY, Sun X, Xu LM. Visualization analysis on current status of clinical treatment for children with allergic rhinitis in China. China Med 2019(10):1566–70. [17] Zhang SH. Progress in the treatment of allergic rhinitis. Tianjin Pharma 2019;31(04):72–5. [18] Zhang FR, Jin RJ, Liu L, Lu QW, Zhou C. Observations on the efficacy of thumb– tack needle therapy plus medication for allergic rhinitis in children. Shanghai J Acup Moxi 2018;37(05):552–6. [19] Sun XL, Liu HJ, Fu L, Wang L, Gan XR. Efficacy of compound xinyidibiye combined with loratadine in the treatment of children with allergic rhinitis and its influence on the immune function. Progr Mod Biomed 2019;19(03):482–5. [20] Collaborative Group of Chinese Allergic Rhinitis Research Expert consensus on subcutaneous immunotherapy for allergic rhinitis 2015. Chin Arch Otolaryng Head Neck Surg 2015;22(8):384. [21] Fernandez F, Porras G, Mormède P, et al. The international study of asthma and allergies in childhood (ISAAC) phase three: a global synthesis. Allergol Immuno pathol 2013;41(2):73–85. [22] Skoner DP. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol 2001;108(1 S):2–8. [23] Feng BH, Shi YB, Chen BP. Allergic rhinitis and psychological and behavioral problems. Chin J Otorhinolaryngol Integr Med 2017;25(03):170–3.