Acupuncture for acute management and rehabilitation of traumatic brain injury

Exploring the biological basis of acupuncture treatment for traumatic brain injury: a review of evidence from animal models

Traumatic brain injury (TBI) occurs when external physical forces impact the brain, potentially causing long-term issues such as post-traumatic stress disorders and cognitive and physical dysfunctions. The diverse nature of TBI pathology and treatment has led to a rapid acceleration in research on its biological mechanisms over the past decade. This surge presents challenges in assessing, managing, and predicting outcomes for TBI cases. Despite the development and testing of various therapeutic strategies aimed at mitigating neurological decline after TBI, a definitive cure for these conditions remains elusive. Recently, a growing focus has been on preclinical research investigating acupuncture as a potential treatment method for TBI sequelae. Acupuncture, being a cost-effective non-pharmacological therapy, has demonstrated promise in improving functional outcomes after brain injury. However, the precise mechanisms underlying the anticipated improvements induced by acupuncture remain poorly understood. In this study, we examined current evidence from animal studies regarding acupuncture's efficacy in improving functional outcomes post-TBI. We also proposed potential biological mechanisms, such as glial cells (microglia astrocytes), autophagy, and apoptosis. This information will deepen our understanding of the underlying mechanisms through which acupuncture exerts its most beneficial effects post-TBI, assisting in forming new clinical strategies to maximize benefits for these patients.

Evidence-based rehabilitation medicine: definition, foundation, practice and development

To determine the definition, foundation, practice, and development of evidence-based rehabilitation medicine (EBRM) and point out the development direction for EBRM. Retrieve the database of PubMed, Cochrane Library, Embase, China national knowledge infrastructure (CNKI), Wanfang, and China science and technology journal database (CSTJ). The search was conducted from the establishment of the database to June 2023. The key words are "rehabilitation medicine and evidence based" in Chinese and English. After reading the abstract or full text of the literature, a summary analysis is conducted to determine the definition, foundation, practice, and development of EBRM. A total of 127 articles were included. The development of 14 sub majors in EBRM are not balanced, evidence-based musculoskeletal rehabilitation medicine (EBMRM) (31 articles, mainly focuses on osteoarthritis, osteoporosis and musculoskeletal pain), evidence-based neurorehabilitation medicine (EBNM) (34 articles, mainly concentrated in stroke, traumatic brain injury and spinal cord injury) and evidence-based education rehabilitation medicine (EBEDRM) (17 articles, mainly focuses on educational methodology), evidence-based nursing rehabilitation medicine (EBNRM) (2 articles), evidence-based engineering rehabilitation medicine (EBENRM) (7 articles), evidence-based traditional Chinese rehabilitation medicine (EBTCRM) (3 articles), evidence-based internal rehabilitation medicine (EBIRM) (11 articles), evidence-based intensive care rehabilitation medicine (EBICRM) (4 articles), evidence-based oncology rehabilitation medicine (EBORM) (6 articles), evidence-based physical therapy medicine (EBPTM) (3 articles), evidence-based cardiopulmonary rehabilitation medicine (EBCRM) (6 articles), evidence-based speech therapy medicine (EBSTM)/evidence-based occupation therapy medicine (EBOTM)/evidence-based geriatric rehabilitation medicine (EBGRM) (1 article). The EBMRM, EBNM and EBEDRM are relatively well developed. The development of EBNRM, EBENRM, EBTCRM, EBIRM, EBICRM, EBGRM, EBORM, EBCRM, EBPTM, EBSTM and EBOTM is relatively slow, indicating these eleven fields should be pay more attention in future.

Electroacupuncture regulates microglial polarization via inhibiting NF-κB/COX2 pathway following traumatic brain injury

BACKGROUND

Neuroinflammation and oxidative stress are important pathological mechanisms following traumatic brain injury (TBI). The NF-κB/COX2 pathway regulates neuroinflammation and oxidative damage, while microglia also play an important role in neuroinflammation. Since NF-κB is involved in microglial polarization, targeting this pathway and microglial polarization is a critical component of TBI treatment. Currently, electroacupuncture (EA) is widely used to treat various symptoms after TBI, but the mechanisms of EA remain poorly understood. Additionally, the optimal frequency of EA remains unclear, which affects its efficacy. This study focuses on exploring the optimal frequency parameters of EA on TBI and investigating the underlying mechanisms of EA through NF-κB/COX2 pathway and microglial polarization.

METHODS

The study was divided into two parts. In Experiment 1, 42 Sprague Dawley (SD) rats were induced and randomly divided into seven groups (n = 6). Except for the sham group, all rats underwent controlled cortical impact (CCI) to establish TBI model. Four EA groups (with different frequencies) and manual acupuncture (without current stimulation) received stimulation on the acupoints of Shuigou (GV26), Fengchi (GB20) and Neiguan (PC6) once a day for 7 days. The neurological function was assessed by modified Neurological Severity Scores (mNSS), and the rats' memory and learning were examined by the Morris water maze (MWM). SOD, MDA, and GSH-Px were detected to evaluate the levels of oxidative stress. The levels of IL-1β, IL-6, and TNF-α were evaluated by Enzyme Linked Immunosorbent Assay (ELISA). Detection of the above indicators indicated a treatment group that exerted the strongest neuroprotection against TBI, we then conducted Experiment 2 using this screened acupuncture treatment to investigate the mechanism of acupuncture. 48 rats were randomly divided into four groups (n = 12): sham, TBI model, acupuncture and PDTC (NF-κB inhibitor). Evaluations of mNSS, MWM test, SOD, MDA, GSH-Px, IL-1β, IL-6, TNF-α, and IL-10 were the same as in Experiment 1. Western blot was applied for detecting the expression levels of NF-κB, p-NF-κB, COX2, and Arg-1. TUNEL was used to examine neuronal apoptosis. Brain structure was observed by H&E. Iba-1, COX2, and Arg-1 were investigated by immunofluorescence staining.

RESULTS

EA with frequency of 2/100 Hz markedly improved neuronal and cognitive function as compared to the other treatment groups. Moreover, it downregulated the expression of MDA, IL-6, IL-1β, and TNF-α and upregulated the levels of SOD and GSH-Px. In addition, Both EA with 2/100 Hz and PDTC reduced the levels of p-NF-κB, COX2 and M1 markers (COX2, IL-6, IL-1β, TNF-α) and increased the levels of M2 markers (Arg-1, IL-10). Moreover, they had similar effects on reducing inflammation, oxidative stress and apoptosis, and improving neuronal and cognitive function.

CONCLUSIONS

The collective findings strongly suggest that EA with 2/100 Hz can improve neurologic function by suppressing neuroinflammation, oxidative stress and apoptosis. Additionally, we confirm that EA promotes microglial polarization towards the M2 phenotype through the suppression of NF-κB/COX2 pathway, thus exerting neuroprotective effects after TBI.

The relationship of publication language, study population, risk of bias, and treatment effects in acupuncture related systematic reviews: a meta-epidemiologic study

BACKGROUND

There are debates in acupuncture related systematic reviews and meta-analyses on whether searching Chinese databases to get more Chinese-language studies may increase the risk of bias and overestimate the effect size, and whether the treatment effects of acupuncture differ between Chinese and non-Chinese populations.

METHODS

In this meta-epidemiological study, we searched the Cochrane library from its inception until December 2021, and identified systematic reviews and meta-analyses with acupuncture as one of the interventions. Paired reviewers independently screened the reviews and extracted the information. We repeated the meta-analysis of the selected outcomes to separately pool the results of Chinese- and non-Chinese-language acupuncture studies and presented the pooled estimates as odds ratios (OR) with 95% confidence interval (CI). We calculated the Ratio of ORs (ROR) by dividing the OR of the Chinese-language trials by the OR of the non-Chinese-language trials, and the ROR by dividing the OR of trials addressing Chinese population by the OR of trials addressing non-Chinese population. We explored whether the impact of a high risk of bias on the effect size differed between studies published in Chinese- and in non-Chinese-language, and whether the treatment effects of acupuncture differed between Chinese and non-Chinese population.

RESULTS

We identified 84 Cochrane acupuncture reviews involving 33 Cochrane groups, of which 31 reviews (37%) searched Chinese databases. Searching versus not searching Chinese databases significantly increased the contribution of Chinese-language literature both to the total number of included trials (54% vs. 15%) and the sample size (40% vs. 15%). When compared with non-Chinese-language trials, Chinese-language trials were associated with a larger effect size (pooled ROR 0.51, 95% CI 0.29 to 0.91). We also observed a higher risk of bias in Chinese-language trials in blinding of participants and personnel (97% vs. 51%) and blinding of outcome assessment (93% vs. 47%). The higher risk of bias was associated with a larger effect estimate in both Chinese-language (allocation concealment: high/unclear risk vs. low risk, ROR 0.43, 95% CI 0.21 to 0.87) and non-Chinese-language studies (blinding of participants and personnel: high/unclear risk vs. low risk, ROR 0.41, 95% CI 0.23 to 0.74). However, we found no evidence that the higher risk of bias would increase the effect size of acupuncture in Chinese-language studies more often than in non-Chinese-language studies (the confidence intervals of all ROR in the high-risk group included 1, Table 3). We further found acupuncture appeared to be more effective in Chinese than in non-Chinese population (Table 4).

CONCLUSIONS

The findings of this study suggest the higher risk of bias may lead to an overestimation of the treatment effects of acupuncture but would not increase the treatment effects in Chinese-language studies more often than in other language studies. The difference in treatment effects of acupuncture was probably associated with differences in population characteristics.

TRIAL REGISTRATION

We registered our protocol on the Open Science Framework (OSF) ( https://doi.org/10.17605/OSF.IO/PZ6XR ).

Overview of Cochrane Systematic Reviews of Rehabilitation Interventions for Persons with Traumatic Brain Injury: A Mapping Synthesis

Background: The World Health Organization has identified an unmet global need for rehabilitation interventions concerning 20 non-communicable diseases, traumatic brain injury included. This overview compiles and synthesizes the quality and quantity of available evidence on the effectiveness of rehabilitation interventions for traumatic brain injury from Cochrane systematic reviews (CSRs). The results will be used to develop the Package of Interventions for Rehabilitation. Methods: All CSRs on TBI tagged in the Cochrane Rehabilitation database published between August 2009 and September 2021 were included. Evidence mapping was implemented to extract study characteristics and evidence from the CSRs. Results: Six CSRs (42 studies; n = 3983) examined the effectiveness of either non-pharmacological or pharmacological interventions after TBI. Among 19 comparisons, 3% were rated as high in quality of evidence, 9% moderate, 54% low, and 34% very low. Non-pharmacological interventions with moderate quality, hospital-based cognitive rehabilitation and cognitive didactic therapy, likely produced minimal to no changes in the return-to-work rate. Anti-epileptic drugs and neuroprotective agents resulted in a minimal difference to the frequency of late seizure episodes in post-traumatic epilepsy. Conclusions: No prominent advances in treatment options were reported in any of the CSRs. The high rate of low and very low quality of evidence makes it difficult to ascertain the effectiveness of several recommended non-pharmacological interventions.

The quality of Cochrane systematic reviews of acupuncture: an overview

BACKGROUND

Many systematic reviews of clinical trials on acupuncture were performed within the Cochrane Collaboration, the evidence-based medicine (EBM) most recognized organization. Objective of the article was to systematically collect and identify systematic reviews of acupuncture published in the Cochrane Library and assess their quality from a methodological perspective.

METHODS

A comprehensive literature search was performed in the Cochrane Database of Systematic Reviews to identify the reviews of acupuncture conducted until June 2019. The methodological quality of the included reviews was assessed using the AMSTAR 2 checklist, an evaluation tool for systematic reviews.

RESULTS

Out of a total of 126 eligible reviews, 50 systematic reviews were included. According to the AMSTAR 2, 52% of Cochrane Systematic Reviews (CSRs) were of low quality, due to the presence of one or more weaknesses in at least one of the domains defined as critical for the methodological quality assessment. The less satisfied critical domain was inadequate investigation and discussion of publication bias. Declaration of potential sources of conflict of interest, and funding of the authors of the review and of the included studies were other important weaknesses.

CONCLUSIONS

The main methodological flaws in the included CSRs were related to topics of relatively new concern in the conduction of systematic reviews of the literature. However, both, lack of attention about retrieval of negative studies, and statements about conflict of interests are crucial point for the evaluation of therapeutic interventions according to EBM methodology.

Early intervention combining Chinese and Western medicine in traumatic brain injury with diffuse axonal injury: A report of three cases

Background

Traumatic brain injury (TBI) is characterized by high prevalence, morbidity, and mortality. Diffuse axonal injury (DAI) is a specific type of TBI leading to prolonged consciousness impairment and disability. There is still no standard treatment for DAI, so we introduced traditional Chinese medicine into the treatment of these patients.

Case summaries

Three patients had TBI after traffic accidents. Their Glasgow Coma Scale (GCS) scores in the intensive care unit (ICU) were E₁V_EM₂-₃, E₁V_EM₂-₃, and E₁V_EM₂ respectively. All of them were diagnosed with DAI based on magnetic resonance imaging (MRI). Because of continuing consciousness disturbances, their families agreed to combine traditional Chinese medicine and modern medicine treatments through inpatient consultation in Taoyuan General hospital. Two patients took Buyang Huanwu Decoction, and one Tianma Gouteng Decoction twice a day. All of them received 20 min of acupuncture treatments 5 times per week. Acupuncture points included Baihui (GV20), Sishencong (EX-HN1), Shuigou (GV26), Hegu (LI4), and Taichong (LR3). All of them started Traditional Chinese medicine treatment within 2 weeks after TBI. The GCS of all three patients recovered to E₄M₅V₆.

Conclusions

The early addition of traditional Chinese medicine treatments to Western medical care can improve the prognosis of patients with diffuse axonal injury.

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Traumatic brain injury diagnosed with diffuse axonal injury, the lower GCS, the poorer outcome. This article points out that combining Chinese medicine and modern medicine can lead to better outcome(motor, speech function and GCS score).

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Chinese medicine has neuroprotective effect and it’s safe when combining with modern medicine in severe traumatic brain injury in this cases report.

Herbal Medicine for Traumatic Brain Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Limitations

Background: This systematic review aimed to evaluate the effectiveness (functional outcomes and clinical symptoms) and safety (incidence of adverse events) of herbal medicine (HM) as monotherapy or adjunctive therapy to conventional treatment (CT) for traumatic brain injury (TBI).

Methods: We comprehensively searched 14 databases from their inception until July 2019. Randomized controlled trials (RCTs) using HM as monotherapy or adjunctive therapy to treat TBI patients were included. The primary outcome was functional outcomes, consciousness state, morbidity, and mortality. Meta-analysis was performed to calculate a risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs), when appropriate data were available. Methodological quality of RCTs and the strength of evidence were also assessed.

Results: Thirty-seven RCTs with 3,374 participants were included. According to meta-analysis, HM as a monotherapy (RR 1.29, 95% CI: 1.21–1.37) or an adjunctive therapy to CT (RR 1.21, 95% CI: 1.16–1.27) showed significantly better total effective rate based on clinical symptoms, compared to CT alone. Subgroup analysis showed that HM had significantly improved post-concussion syndrome, dizziness, headache, epilepsy, and mild TBI, but not traumatic brain edema, compared to CT. Moreover, HM combined with CT had significantly improved post-concussion syndrome, mental disorder, headache, epilepsy, and mild TBI-like symptoms, but not cognitive dysfunction and posttraumatic hydrocephalus, compared to CT alone. When HM was combined with CT, functional outcomes such as activities of daily living and neurological function were significantly better than in patients treated using CT alone. In terms of the incidence of adverse events, HM did not differ from either CT (RR 0.88, 95% CI: 0.33–2.30) or placebo (RR 2.29, 95% CI: 0.83–6.32). However, HM combined with CT showed better safety profile than CT alone (RR 0.64, 95% CI: 0.44–0.93). Most studies had a high risk of performance bias, and the quality of evidence was mostly rated “very low” to “moderate,” mostly because the included studies had a high risk of bias and imprecise quantitative synthesis results.

Conclusion: The current evidence suggests that there is insufficient evidence for recommending HM for TBI in clinical practice. Therefore, further larger, high-quality, rigorous RCTs should be conducted.

Acupuncture to Promote Recovery of Disorder of Consciousness after Traumatic Brain Injury: A Systematic Review and Meta-Analysis

Traumatic brain injury (TBI) has become an economic and social burden for patients and their families. While acupuncture is an effective tool for promoting recovery of disorder of consciousness (DOC) following TBI, there have been no comprehensive meta-analyses and/or systematic reviews addressing this topic. The present systematic review and meta-analysis aimed to assess the therapeutic efficacy of acupuncture for DOC after TBI. All randomized controlled trials (RCTs) incorporating acupuncture, or acupuncture combined with other interventions for DOC after TBI, were included and assessed by two independent investigators. Six outcome indicators were assessed: Glasgow Coma Scale (GCS); Glasgow Outcome Scale (GOS); mortality; efficacy rate; activities of daily living (ADL); and functional comprehensive assessment. Direct comparisons were performed using RevMan 5.3.0 software, with results presented as mean difference (MD) for continuous outcomes and relative risk (RR) for binary outcomes. A total of 3511 patients from 49 trials were included. Pooled analyses indicated that acupuncture may have a superior effect on GCS score (MD=2.03, 95% CI :1.92 2.43, Z=16.54, and P<0.00001); GOS score (RR=1.23, 95%CI: 1.18 1.35, Z=6.65, and P<0.00001); efficacy rate (RR=1.48, 95%CI: 1.40 1.56, Z=13.49, and P<0.00001); ADL (MD=9.20, 95% CI:8.19 10.21, Z=17.84, and P<0.00001); and mortality (RR=0.50, 95% CI:0.38 0.67, Z=4.70, and P<0.00001). The results demonstrated that the acupuncture group fared better than the control group in the treatment of DOC after TBI. However, studies were generally of poor quality, and publication bias favoring positive studies was obvious. Therefore, rigorous evaluation standards and well-designed studies are necessary in future studies.

The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map

OBJECTIVE

To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI).

METHODS

We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality).

FINDINGS

We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs.

CONCLUSION

A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.

Effect of acupuncture on the TLR2/4-NF-κB signalling pathway in a rat model of traumatic brain injury

Objective

To study the effect of acupuncture on the TLR2/4-NF-κB signalling pathway in the cortex of Sprague-Dawley rats following traumatic brain injury (TBI), and investigate the possible mechanism underlying the effects of acupuncture on scar repair.

Methods

TBI was established using Feeney’s free-falling epidural percussion model. In total, 108 rats were randomly divided into a normal group (n=18), untreated TBI model group (TBI group, n=36) and manual acupuncture-treated TBI group (TBI+MA, n=36). Each group of rats was subdivided into three time groups: 3-day (3d), 7-day (7d) and 14-day (14d). No treatment was given to rats in the normal and TBI groups. The TBI+MA group received manual acupuncture at GV20, GV26, GV16 through GV15, and bilateral LI4. mRNA expression of TLR2, TLR4, NF-κB and protein in the rat cortices was quantified using real-time fluorescence quantitative polymerase chain reaction (qPCR) and Western blot analyses.

Results

The modified neurological severity score (mNSS) scores of the TBI+MA group were improved compared with baseline scores 12 hours after modelling, and improved at 7d and 14d compared with the TBI group (P<0.05), while the score of the TBI group did not improve until 14d compared to baseline. mRNA and protein expression of TLR2, TLR4 and NF-κB in the TBI group were higher than the normal group at 3d (P<0.05), reached a peak at 7d, then began to decrease at 14d. mRNA and protein expression of TLR2, TLR4 and NF-κB were higher in the TBI+MA group compared with the TBI group at 3d (P<0.05), were significantly down-regulated at 7d (P<0.01), and decreased to normal levels at 14d.

Conclusions

Acupuncture has a bidirectional regulatory effect on the TLR2/4-NF-κB signalling pathway-related genes TLR2, TLR4 and NF-κB in the TBI rat cortex, promoting their expression in the early stage and inhibiting it in the later stage.

Supplements, nutrition, and alternative therapies for the treatment of traumatic brain injury

Studies using traditional treatment strategies for mild traumatic brain injury (TBI) have produced limited clinical success. Interest in treatment for mild TBI is at an all time high due to its association with the development of chronic traumatic encephalopathy and other neurodegenerative diseases, yet therapeutic options remain limited. Traditional pharmaceutical interventions have failed to transition to the clinic for the treatment of mild TBI. As such, many pre-clinical studies are now implementing non-pharmaceutical therapies for TBI. These studies have demonstrated promise, particularly those that modulate secondary injury cascades activated after injury. Because no TBI therapy has been discovered for mild injury, researchers now look to pharmaceutical supplementation in an attempt to foster success in human clinical trials. Non-traditional therapies, such as acupuncture and even music therapy are being considered to combat the neuropsychiatric symptoms of TBI. In this review, we highlight alternative approaches that have been studied in clinical and pre-clinical studies of TBI, and other related forms of neural injury. The purpose of this review is to stimulate further investigation into novel and innovative approaches that can be used to treat the mechanisms and symptoms of mild TBI.

Effects of freshwater clam extract on fracture induced inflammation at early stage

The inflammatory process after traumatic fracture and soft tissue injury includes release of inflammatory cytokines and activated polymorph nuclear cells (PMN) that can cause subsequent affected limbs delayed healing and vital organ complications. Analgesics have good effect on relief of the symptom but may cause further burden for hepatic and renal metabolism. Freshwater clam extract (FCE) has been demonstrated to suppress the release of the pro-inflammatory cytokine tumor necrosis factor-α production after hemorrhagic shock, and decrease the level of liver injury marker in rats. The aim of the present study was to determine whether FCE is able to affect the inflammation induced by unilateral tibial fracture in a rat model. The rats were randomly divided into control, fracture, FCE and fracture with FCE groups. The fracture group received left tibia and fibula shaft fractures using a consistent three point bending method. For the fracture with FCE group, FCE (40 mg/kg) was administered orally after fracture. Their physiological changes were continuously monitored for 48 h. Blood samples were extracted from the femoral arterial catheter at 1, 3, 6, 9, 12, 18, 24 and 48 h after fracture. In comparison with fracture group, those whom were fed with FCE had more stable heart rate frequency, lower central temperature at the initial h, and lower serum level of the proinflammatory cytokines and muscle damage markers induced by fracture. FCE was also associated with decreased recruitment of inflammatory cells in the adjacent soft tissue. Thus, the present results suggest that FCE could decrease fracture induced inflammation reaction and have beneficial regulatory effect on post inflammatory response.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.

Electroacupuncture Improved Hippocampal Neurogenesis following Traumatic Brain Injury in Mice through Inhibition of TLR4 Signaling Pathway

The protective role of electroacupuncture (EA) treatment in diverse neurological diseases such as ischemic stroke is well acknowledged. However, whether and how EA act on hippocampal neurogenesis following traumatic brain injury (TBI) remains poorly understood. This study aims to investigate the effect of EA on hippocampal neurogenesis and neurological functions, as well as its underlying association with toll-like receptor 4 (TLR4) signaling in TBI mice. BrdU/NeuN immunofluorescence was performed to label newborn neurons in the hippocampus after EA treatment. Water maze test and neurological severity score were used to evaluate neurological function posttrauma. The hippocampal level of TLR4 and downstream molecules and inflammatory cytokines were, respectively, detected by Western blot and enzyme-linked immunosorbent assay. EA enhanced hippocampal neurogenesis and inhibited TLR4 expression at 21, 28, and 35 days after TBI, but the beneficial effects of EA on posttraumatic neurogenesis and neurological functions were attenuated by lipopolysaccharide-induced TLR4 activation. In addition, EA exerted an inhibitory effect on both TLR4/Myd88/NF-κB and TLR4/TRIF/NF-κB pathways, as well as the inflammatory cytokine expression in the hippocampus following TBI. In conclusion, EA promoted hippocampal neurogenesis and neurological recovery through inhibition of TLR4 signaling pathway posttrauma, which may be a potential approach to improve the outcome of TBI.

Restoration of Function With Acupuncture Following Severe Traumatic Brain Injury: A Case Report

This case report illustrates the improvement of an acupuncture-treated patient who incurred a severe traumatic brain injury (TBI) from a snowboarding accident. Over 4 years, the patient progressed from initially not being able to walk, having difficulty with speech, and suffering from poor eyesight to where he has now regained significant motor function, speech, and vision and has returned to snowboarding. A core acupuncture protocol plus specific points added to address the patient's ongoing concerns was used. This case adds to the medical literature by demonstrating the potential role of acupuncture in TBI treatment.

Decreased risk of stroke in patients with traumatic brain injury receiving acupuncture treatment: a population-based retrospective cohort study

BACKGROUND

Patients with traumatic brain injury (TBI) face increased risk of stroke. Whether acupuncture can help to protect TBI patients from stroke has not previously been studied.

METHODS

Taiwan's National Health Insurance Research Database was used to conduct a retrospective cohort study of 7409 TBI patients receiving acupuncture treatment and 29,636 propensity-score-matched TBI patients without acupuncture treatment in 2000-2008 as controls. Both TBI cohorts were followed until the end of 2010 and adjusted for immortal time to measure the incidence and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of new-onset stroke in the multivariable Cox proportional hazard models.

RESULTS

TBI patients with acupuncture treatment (4.9 per 1000 person-years) had a lower incidence of stroke compared with those without acupuncture treatment (7.5 per 1000 person-years), with a HR of 0.59 (95% CI = 0.50-0.69) after adjustment for sociodemographics, coexisting medical conditions and medications. The association between acupuncture treatment and stroke risk was investigated by sex and age group (20-44, 45-64, and ≥65 years). The probability curve with log-rank test showed that TBI patients receiving acupuncture treatment had a lower probability of stroke than those without acupuncture treatment during the follow-up period (p<0.0001).

CONCLUSION

Patients with TBI receiving acupuncture treatment show decreased risk of stroke compared with those without acupuncture treatment. However, this study was limited by lack of information regarding lifestyles, biochemical profiles, TBI severity, and acupuncture points used in treatments.