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

A Modern Approach to the Treatment of Traumatic Brain Injury

Background: Traumatic brain injury manifests itself in various forms, ranging from mild impairment of consciousness to severe coma and death. Traumatic brain injury remains one of the leading causes of morbidity and mortality. Currently, there is no therapy to reverse the effects associated with traumatic brain injury. New neuroprotective treatments for severe traumatic brain injury have not achieved significant clinical success. Methods: A literature review was performed to summarize the recent interdisciplinary findings on management of traumatic brain injury from both clinical and experimental perspective. Results: In the present review, we discuss the concepts of traditional and new approaches to treatment of traumatic brain injury. The recent development of different drug delivery approaches to the central nervous system is also discussed. Conclusions: The management of traumatic brain injury could be aimed either at the pathological mechanisms initiating the secondary brain injury or alleviating the symptoms accompanying the injury. In many cases, however, the treatment should be complex and include a variety of medical interventions and combination therapy.

Traumatic Brain Injury: Acupuncture Treatment

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. It is estimated that half of the people in the world will experience at least 1 episode of TBI during their lifetimes. While the primary injury to the brain parenchyma is usually irreversible, the secondary effects, which involve cellular dysfunction, derangement of blood flow, and blood-brain barrier changes in ionic flux and elevated levels of free radicals are potentially amenable to treatment. At present, there are no neuroprotective agents in mainstream medicine to interrupt these secondary processes and improve the patient's neurologic outcome. Acupuncture holds promise to fill this gap and scientific evidence to that effect is presented. Sports-related brain injury is discussed in detail.

Effect of Acupuncture on Recovery of Consciousness in Patients with Acute Traumatic Brain Injury: A Multi-Institutional Cohort Study

Traumatic brain injury (TBI) causes cognitive dysfunction and long-term impairments. This study aims to examine the effectiveness of acupuncture on the recovery of consciousness in TBI patients. This is a retrospective, multi-institutional cohort study. We enrolled patients with newly diagnosed TBI from 1 January 2007 to 3 August 2021, aged 20 years and older, from the Chang Gung Research Database (CGRD). The outcome was defined based on the difference between the first and last Glasgow Coma Scale (GCS). A total of 2163 TBI patients were analyzed, and 237 (11%) received acupuncture in the treatment period. Generally, the initial GCS was lower in the acupuncture users (11 vs. 14). For the results of our study, a higher proportion of acupuncture patients achieved significant improvement (GCS differences ≥ 3) compared to non-acupuncture users (46.0% vs. 22.4%, p-value < 0.001). The acupuncture users had a 2.11 times higher chance of achieving a significant improvement when considering all assessable covariates (adjusted odds ratio (aOR) 2, 11, 95% confidence interval [CI]: 1.31-3.40; p-value = 0.002). Using 1:1 propensity score matching (PSM), the acupuncture users still had better outcomes than the non-acupuncture users (45.3% vs. 32.9%, p-value = 0.020). In conclusion, this study suggests that acupuncture treatment may be beneficial for TBI patients.

Acupuncture use for pain after traumatic brain injury: a NIDILRR Traumatic Brain Injury Model Systems cohort study

BACKGROUND

Pain after traumatic brain injury (TBI) is common and can become chronic. Acupuncture is an increasingly popular non-pharmacologic option in the United States and is commonly used for pain.

OBJECTIVE

We explored demographics, injury characteristics, and pain characteristics of individuals who reported using acupuncture for chronic pain after TBI.

METHODS

We analyzed a subset of data collected as part of the Pain After Traumatic Brain Injury collaborative study and identified individuals reporting a history of acupuncture as part of management for chronic pain after TBI. We characterized and compared basic demographic data, pain treatment engagements, pain severity, pain interference, functional independence, and pain locations using descriptive and inferential statistics.

RESULTS

Our sample included 1,064 individuals. Acupuncture use (n = 208) was lower proportionally among females, Blacks/African Americans, Asians, less educated, and nonmilitary service members. Insurance type varied between acupuncture and non-acupuncture users. Functional and pain outcomes were similar, but acupuncture users reported a higher number of pain sites.

DISCUSSION

Acupuncture is one treatment utilized by individuals with TBI and chronic pain. Further investigation would be helpful to understand the barriers and facilitators of acupuncture use to inform clinical trials to examine the potential benefit of acupuncture on pain outcomes after TBI.

Efficacy of acupuncture for cardiopulmonary cerebral resuscitation: A systematic review and meta-analysis

Background

Cerebral resuscitation is one of the main therapeutic aims in the treatment of cardiac arrest (CA) patients who experience a return of spontaneous circulation (ROSC). However, the therapeutic effects of current treatments are not ideal. The purpose of this study was to evaluate the efficacy of neurological function of acupuncture combined with conventional cardiopulmonary cerebral resuscitationthe (CPCR) for patients after ROSC.

Methods

Seven electronic databases and other related websites were searched to identify studies on acupuncture combined with conventional CPCR for patients after ROSC. R software was used to conduct a meta-analysis, and the outcomes that could not be pooled were analyzed using a descriptive analysis.

Results

Seven RCTs involving 411 participants who had experienced ROSC were eligible for inclusion. The main acupoints were Neiguan (PC6), Shuigou (DU26), Baihui (DU20), Yongquan (KI1), and Sanyinjiao (SP6). Compared to conventional CPCR, acupuncture combined with conventional CPCR led to significantly higher Glasgow Coma Scale (GCS) scores on day 3 (mean difference (MD)=0.89, 95% CI: 0.43, 1.35, I² = 0%), day 5 (MD = 1.21, 95% CI: 0.27, 2.15; I² = 0%), and day 7 (MD = 1.92, 95% CI: 1.35, 2.50; I² = 0%).

Conclusion

Acupuncture-assisted conventional CPCR may have a potential role in improving neurological function in CA patients after ROSC, but the certainty of evidence is very low and more high-quality studies are required.

Protocol registration

This review was registered at the International Prospective Registry of Systematic Reviews (PROSPERO): CRD42021262262.

Acupuncture Is Effective at Reducing the Risk of Stroke in Patients with Migraines: A Real-World, Large-Scale Cohort Study with 19-Years of Follow-Up

Migraines are common headache disorders and risk factors for subsequent strokes. Acupuncture has been widely used in the treatment of migraines; however, few studies have examined whether its use reduces the risk of strokes in migraineurs. This study explored the long-term effects of acupuncture treatment on stroke risk in migraineurs using national real-world data. We collected new migraine patients from the Taiwan National Health Insurance Research Database (NHIRD) from 1 January 2000 to 31 December 2017. Using 1:1 propensity-score matching, we assigned patients to either an acupuncture or non-acupuncture cohort and followed up until the end of 2018. The incidence of stroke in the two cohorts was compared using the Cox proportional hazards regression analysis. Each cohort was composed of 1354 newly diagnosed migraineurs with similar baseline characteristics. Compared with the non-acupuncture cohort, the acupuncture cohort had a significantly reduced risk of stroke (adjusted hazard ratio, 0.4; 95% confidence interval, 0.35-0.46). The Kaplan-Meier model showed a significantly lower cumulative incidence of stroke in migraine patients who received acupuncture during the 19-year follow-up (log-rank test, p < 0.001). Acupuncture confers protective benefits on migraineurs by reducing the risk of stroke. Our results provide new insights for clinicians and public health experts.

Effect of acupuncture for disorders of consciousness in patients with stroke: A systematic review and meta-analysis

Background

Disorder of consciousness (DOC) is frequent in patients with stroke, which is the second most common cause of death and a leading cause of disability. Acupuncture has been used as a curative method for DOC treatment in China. Nevertheless, no critical systematic review of acupuncture's effect on DOC has been published. This review aims to evaluate the present evidence regarding the efficacy of acupuncture for DOC after stroke.

Methods

Seven databases were searched from their inception to November 1, 2021, containing three English databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) and four Chinese databases (CNKI, CBM, VIP, and Wanfang Database). The primary outcomes comprise the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) before and after treatment. Secondary outcomes involve resuscitation rate, resuscitation time, and adverse events. Data synthesis was calculated by RevMan (V.5.4.1) software. According to the Cochrane Handbook, methodological quality was assessed with the risk of bias tool 2.0 (RoB2).

Results

Seventeen studies containing 1,208 patients were eventually included in our review. Overall, most trials were rated as high or had some concerns regarding the risk of bias. GCS was reported in 16 trials, and a meta-analysis showed that GCS improvement in the acupuncture group was greater than in the non-acupuncture group (MD 1.45, 95% CI 0.94–1.97, P &lt; 0.0001). One trial reported that GOS improvement in the acupuncture plus medication group was greater than in the medication group (MD 0.58, 95% CI 0.11–1.05, P = 0.01). Another study reported that acupuncture plus medication was statistically more effective in shortening resuscitation time than medication alone (MD−0.89, 95% CI −1.53 to −0.25, P = 0.006). Four trials reported that the resuscitation rate in the acupuncture group was higher than without acupuncture intervention (RR 1.68, 95% CI 1.30–2.18, I2 0%, P = 0.39). Adverse events were reported in two studies, with one case in the acupuncture group suffering from subcutaneous hematoma.

Conclusion

Acupuncture may improve consciousness level, increase the resuscitation rate, and shorten resuscitation time for post-stroke patients with DOC. Adverse events from acupuncture were rare, tolerable, and recoverable. However, the results should be interpreted cautiously, and more rigorous RCTs with better methodology are warranted.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=289802, identifier 289802.

Early complementary acupuncture improves the clinical prognosis of traumatic brain edema: A randomized controlled trial

BACKGROUND

Traumatic brain edema occurs commonly brain injury, and most manifests as pericontusional edema of brain contusions. On the basis of evidence-based medicine, apart from recommending craniotomy and mannitol, there are few particularly effective measures to prevent and treat traumatic brain edema. It is uncertain whether an early complementary acupuncture treatment would improve long-term outcomes of patients with traumatic brain edema. The aim of this study is to assess the efficacy and the safety of early complementary acupuncture for patients with traumatic brain edema.

METHODS

This study is an actively accruing, single-center, single-blinded, 2-arm, randomized controlled trial. Patients with traumatic brain injury, a Glasgow Coma Scale score of 6∼12, and brain edema on computed tomography scan will be divided into 2 groups on the basis of stratified block randomization. All patients will receive conventional treatment, and the study group will undergo additional acupuncture therapy (start within 72 hours after the injury) once a day for 28 days. The primary outcome is the dichotomized Glasgow Outcome Score at 6 months and 12 months after injury, and the secondary outcomes are the Glasgow Coma Scale, the volume of traumatic brain edema, the serum levels of C-reactive protein and interleukin-6, and the Modified Barthel Index.

DISCUSSION

This study will provide data regarding the efficacy of early complementary acupuncture for traumatic brain edema. If the study yields positive results, its findings may offer insights into a valuable complementary option of acupuncture for traumatic brain edema that could provide pilot evidence for large, randomized, controlled trials.Trial registration: This trial has been published in the Chinese Clinical Trial Register, http://www.chictr.org.cn/edit.aspx?pid=141208&htm=4 (Identifier: ChiCTR2100053794, registered on December 3, 2021).

Arousing Effects of Electroacupuncture on the "Shuigou Point" in Rats with Disorder of Consciousness after Traumatic Brain Injury

Orexin is an important neuropeptide that stimulates cortical activation and arousal and is involved in the regulation of wakefulness and arousal. Our previous meta-analysis showed that acupuncture fared well in the treatment of TBI-induced DOC in which “shuigou (DU 26)” was the most important and frequent point targeted. In the present study, we investigated whether electroacupuncture (EA) promotes TBI-induced unconsciousness wakefulness via orexin pathway. A TBI rat model was established using a control cortical impact (CCI) model. In the stimulated group, TBI rats received EA (15 Hz, 1.0 mA, 15 min). In the antagonist group, TBI rats were intraperitoneally injected with the orexin receptor 1 (OX1R) antagonist SB334867 and received EA. Unconsciousness time was observed in each group after TBI, and electrocorticography (ECoG) was applied to detect rats' EEG activity. Immunohistochemistry, enzyme-linked immunosorbent assay, and western blot were used to assess the levels of orexin-1(OX1) and OX1R expression in the mPFC. We show that duration of unconsciousness and the ratio of delta power in ECoG in the EA group were significantly reduced compared with those in the TBI group. EA could increase OX1 and OX1R expression in the mPFC and reduced the loss of orexin-producing neurons in LHA. However, all the efficacy of EA was blocked by the OX1R antagonist SB334867. Our findings suggest that EA promotes the recovery of consciousness of TBI-induced unconscious rats via upregulation of OX1and OX1R expression in mPFC.

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.

Traditional Chinese Medicine in Emergency Treatment Mechanism and Application

Traditional Chinese medicine has usually been recognized to be efficacious to treat chronic diseases from the western point-of-view. However, there is a long history in China of applying traditional Chinese medicine in many acute and urgent medical conditions. In this review, selected methods documented in traditional Chinese medicine including blowing air to ear, nose insufflating therapy, acupuncture and moxibustion were presented as the common practices to promote consciousness recovery from coma. We aimed to explore the mechanism of these four methods with current scientific evidence, further discuss the potential of traditional Chinese medicine to be applied in emergency medicine and provide a path forward to more rigorously validate these procedures. The development of the integrated traditional Chinese medicine and western medicines provides a new therapeutic direction for the new first-aid treatment.