Cerebral palsy

Cerebral palsy (CP) is a group of permanent disorders of movement and posture caused by damage to the developing brain. A 2022 review from Harbin describes acupuncture as the main Chinese-medicine treatment for CP, with the emphasis on scalp acupuncture, in which fine needles are placed along lines and areas of the scalp. Almost every trial of it compares rehabilitation with acupuncture against the same rehabilitation without it, and almost every trial was run in China. Several meta-analyses since 2018 pool those trials and report better motor scores with acupuncture added. Of the reviews in the table below, the one that graded the certainty of its evidence rated it low or very low, and an overview of the reviews rated every one it appraised low or very low in quality.

The Cochrane protocol

Cochrane has no review of acupuncture for CP. A protocol by Mingming Zhang and Jing Li at the Chinese Cochrane Centre in Chengdu, first published in 2008, set out to test whether acupuncture improves movement, daily activities, cognition and quality of life in children with spastic, athetoid or ataxic CP, and what harms it carries. No review followed, and in January 2017 Cochrane’s Developmental, Psychosocial and Learning Problems editors withdrew the protocol because it had been published more than eight years earlier.

The reviews

Ling-Xin Li and colleagues at West China Hospital, Mingming Zhang of the withdrawn protocol among them, pooled 13 trials for the Gross Motor Function Measure (GMFM), the standard scale of what a child with CP can do with their body, such as sitting, crawling and walking. They report a standardised mean difference of 0.64 in favour of acupuncture plus rehabilitation (95% confidence interval 0.52 to 0.76), and pooled improvements in spasticity on the Modified Ashworth Scale (MAS), which grades how much a muscle resists being stretched, and in daily activities. Three trials reported adverse events: in one, children cried and felt minor pain in the first sessions, and two reported none. The authors asked that their result be read with caution because the trials were few and small.

Yuman Xue and colleagues at Heilongjiang University of Chinese Medicine in Harbin found that the scalp sites differed between trials but every trial needled GV20 (Baihui) at the crown, along with motor, sensory, balance and language areas of the scalp. They report better effective rates, development indices and GMFM scores with scalp acupuncture added, and one trial that recorded slight bleeding at needle sites. A letter from Qingbo Feng and colleagues at West China Hospital pointed out that the review had searched only PubMed for English-language trials, was not registered in advance, and ran no sensitivity analysis.

Yu-Yen Cheng and colleagues at Chang Gung Memorial Hospital in Taiwan report a mean difference in GMFM score of 5.93 in favour of acupuncture (95% CI 3.67 to 8.19), and better spasticity, balance and daily-activity scores. Two of their 20 trials had a sham acupuncture arm as a second control, one with minimal skin contact and one with a retractable placebo needle; the authors judged them too few and too different to analyse together. Four trials recorded adverse events and none reported a serious one. The authors mapped which points the trials used and found three recurring sets: XH01A (Sishencong), one of four points around the crown catalogued as XH01A to XH01D, with GV24 (Shenting) and GB13 (Benshen) on the forehead; GB06 (Xuanli), GB08 (Shuaigu) and GB09 (Tianchong) on the side of the head; and ST36 (Zusanli), LV03 (Taichong) and SP06 (Sanyinjiao) on the legs and feet.

The narrower reviews follow the same pattern. Yuanjie and colleagues at Hebei University of Chinese Medicine report a pooled MAS difference of −0.52 (95% CI −0.62 to −0.41) in favour of acupuncture. Xin Kang and colleagues report an odds ratio of 4.70 for the overall effective rate with Jingjin acupuncture, and call for better-designed trials. Shuzhen Liu and colleagues in Tianjin report better language comprehension and verbal scores when acupuncture was added to language training, and found that only one of their 56 trials reported on safety. Each of these reviews pooled an “effective rate”, the share of children a trial judged improved, alongside scale scores.

An overview by Lu and colleagues, published in Chinese in 2023, appraised 14 of these systematic reviews. On AMSTAR 2, a checklist for how well a review was conducted, it rated 4 low and 10 very low in quality. Of the 37 outcomes they reported, it graded 3 high, 7 moderate, 10 low and 17 very low in certainty under GRADE, the standard scale for how far a body of evidence can be trusted, downgraded mainly for the trials’ limitations, imprecision and publication bias.

The trials

The pooled trials compare rehabilitation with and without acupuncture, so children in the control group had fewer sessions, less contact and no needles, and neither the children, the parents nor usually the assessors were blinded. Sham acupuncture explains the designs that try to separate needling from everything around it, and Where the trials come from sets out why a literature drawn almost wholly from one country is read with care.

Two trials run with researchers outside mainland China tested the comparison differently. In a 2004 trial from the University of Hong Kong, Jun-Gang Sun and colleagues randomised 33 children with CP to tongue acupuncture (22) or sham acupuncture (11); the GMFM rose more in the tongue acupuncture group (p = 0.042). In a 2012 trial, Burris Duncan and colleagues randomised 75 children aged 12 to 72 months with spastic CP at a children’s hospital in Beijing to 12 weeks of intensive physical, occupational and hydrotherapy, five days a week, with or without acupuncture. Assessments were video-recorded and scored blind at a university in the United States. At 12 weeks the two groups did not differ significantly on the GMFM or the Pediatric Evaluation of Disability Inventory, a measure of self-care and mobility. Taken together, the children improved significantly over the 12 weeks, and the authors concluded that the contribution from acupuncture was unclear.

Guidelines

The State of the Evidence Traffic Lights 2019 by Iona Novak and colleagues, published in 2020, graded every intervention for children with CP with GRADE and a traffic-light system. It gave acupuncture for motor skills a yellow light, weak positive, the rating it defines as “probably do it”, citing the Li review and a 2012 review. It also notes a substantial rise in the number of systematic reviews of acupuncture for CP since its 2013 edition.

NICE’s guideline on cerebral palsy in under 25s (NG62), published in January 2017, does not mention acupuncture. For movement and posture it refers to NICE’s guideline on spasticity in under 19s (CG145), published in 2012 and last updated in November 2016, whose recommendations do not mention it either.

Safety in children

The trials report few adverse events, but most did not report on harms at all: three of the 21 trials in the Li review and one of the 56 in the Liu review did. Acupuncture for children covers what the wider paediatric literature records of harms, and Scalp acupuncture describes the lines and areas the trials needled.

What the reviews could not settle

The reviews could not separate acupuncture from the extra attention and treatment time that came with it, because few trials used a sham arm and the Duncan trial, whose outcomes were scored blind in the United States, found no significant difference at 12 weeks. They could not say which form of acupuncture, which points or how many sessions matter, since protocols differed from trial to trial. The Li review found one trial that followed children for 12 months. With the trials drawn almost wholly from China, the reviews could not say whether the results carry to rehabilitation services elsewhere. The AcuiQ pages for cerebral palsy and spasticity list the protocols published trials prescribed, each with its source, and Stroke recovery covers the adult literature on scalp acupuncture after brain injury.