Acupuncture for acute management and rehabilitation of traumatic brain injury: Cochrane systematic review

Abstract

Assessed as up to date: 2012/10/30

Background

Traumatic brain injury (TBI) can be life threatening depending on the severity of the insult to the brain. It can also cause a range of debilitating sequelae which require cognitive, motor, communication, emotional, or behavioral rehabilitation of varying intensity and duration. A number of studies conducted and published in China have suggested that acupuncture may be beneficial in the acute treatment and rehabilitation of TBI.

Objectives

To determine the efficacy and safety of acupuncture in the acute management or rehabilitation (or both) of patients with a TBI, including cognitive, neurological, motor, communication, emotional, or behavioral complications, or a combination of such complications.

Search methods

We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE, CINAHL, AMED, PsycINFO and others. We also searched the Chinese Acupuncture Studies Register, the Studies Register of the Cochrane Complementary Medicine Field, NCCAM, and NIH Clinical Studies Database. Three major Mainland Chinese academic literature databases (CNKI, VIP and Wang Fang Data) were also searched using keywords in simplified Chinese. We searched all databases through December 2009, and some searches have been updated to October 2012.

Selection criteria

Randomized controlled studies evaluating different variants of acupuncture and involving participants of any age who had suffered a TBI. Included trials compared acupuncture with placebo or sham treatment, or acupuncture plus other treatments compared with the same other treatments. We excluded trials that only compared different variants of acupuncture or compared acupuncture alone against other treatments alone, as they did not yield the net effect of acupuncture.

Data collection and analysis

Two review authors identified potential articles from the literature search and extracted data independently using a data extraction form. We performed methodological assessment of included studies using the Cochrane Collaboration's tool for assessing risk of bias. We were unable to perform quantitative data analysis due to insufficient included studies and available data.

Main results

Four RCTs, including 294 participants, reported outcomes specified by this review. Three investigated electro-acupuncture for TBI while one investigated acupuncture for acute TBI. The results seem to suggest that acupuncture is efficacious for these indications, however the low methodological quality of these studies renders the results questionable. No adverse effects of acupuncture were reported in any of the studies.

Authors' conclusions

The low methodological quality of the included studies does not allow us to make conclusive judgments on the efficacy and safety of acupuncture in either the acute treatment and/or rehabilitation of TBI. Its beneficial role for these indications remains uncertain. Further research with high quality trials is required.

Author(s)

Wong Virginia, Cheuk Daniel KL, Lee Simon, Chu Vanessa

Summary

Acupuncture for acute management and rehabilitation of traumatic brain injury

Acupuncture used for the acute treatment, rehabilitation (or both) of traumatic brain injury (TBI) has been studied in China. We conducted a systematic review to evaluate the efficacy and safety of acupuncture for these conditions. Four randomized controlled trials were eligible for inclusion in this review, involving 294 patients. Three investigated electro-acupuncture for TBI while one investigated acupuncture for acute TBI. The studies were of low methodological quality and were diverse in their objectives, participant characteristics, acupuncture modalities and strategies, and outcome measures. The small number of studies together with their low methodological quality means that they are inadequate to allow any conclusion to be drawn about the efficacy and safety of acupuncture in the treatment of TBI. Further methodologically robust studies are needed to generate evidence-based conclusions.

Reviewer's Conclusions

Implications for practice

There are no high quality randomized clinical studies supporting acupuncture for treatment of TBI. The current evidence in this review fails to provide solid grounds on which to base conclusions about the efficacy and safety of acupuncture in the acute treatment and rehabilitation of TBI. The current evidence is still far from sufficient to support recommendations for acupuncture as a standard procedure for TBI in clinical practice, although it may be used in experimental investigations. The potential side effects of acupuncture in the context of TBI treatment and rehabilitation remain unclear as these were not reported in any of the clinical trials reviewed. The sustainability of the effects of acupuncture in the long-term during and after TBI rehabilitation is also unclear as this was rarely investigated.

Implications for research

Future research may evaluate acupuncture for different TBI sequelae (e.g. headache, seizures, aphasia, facial paralysis, and hemiplegia). There are only a few RCTs investigating its application in each of these complications. Furthermore, the number of RCTs of good methodological quality is limited. Therefore, there is a need for more high quality RCTs to be conducted which investigate the potential effect of acupuncture when used for each of these complications, with the aim of generating evidence to either support or refute its application in these clinical contexts. In particular, more attention and effort should be dedicated to improving the methodological quality of trials to enhance internal validity. For example, there should be unified inclusion criteria, sample size determination to ensure the study is sufficiently powered, truly randomized methods of treatment allocation, adequate concealment of allocation, blinding of investigators, participants and outcome assessors to minimize performance and assessment bias, and use of widely recognized and commonly adopted standard validated outcome measures (e.g. Glasgow Coma Score, Glasgow Outcome Score, Barthel Index) to ensure validity, reliability and comparability, report any losses to follow up with reasons, conduct intention-to-treat analysis, and present results clearly in sufficient detail. Trials should include long-term follow up at specific time points, especially for rehabilitation studies, to determine long-term effects (e.g. survival, disability, and quality of life). Furthermore, it is unclear which treatment modalities and strategies (e.g. conventional needling, needling with electro-pulsation, site(s) of needling, the combination of acupoints to be stimulated, the frequency and duration of needling) are efficacious for each of the TBI complications. To reduce heterogeneity, trials may consider focusing on a more restricted and homogeneous subset of TBI patients and evaluating a single uniform acupuncture protocol. When reporting acupuncture studies, it is important to adhere to widely accepted standards, e.g., the STRICTA criteria, in order to facilitate interpretation of the trial report and comparison between acupuncture studies. The STRICTA criteria stipulated that acupuncture trials should adequately report the following: acupuncture rationale, details of needling, treatment regimen, other components of treatment, practitioner background, and control or comparator interventions.

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