Effect of scalp acupuncture combined with language rehabilitation training in tr

CHEN Zhi-xiu, MAO Zhong-nan, WU Yu-zhuang, LIN Xiao-zhen, LEI Qin

1.Gansu University of Traditional Chinese Medicine, Lanzhou 730000,China

2.Affiliated Hospital of Gansu University of Traditional Chinese Medicine, Lanzhou 730000,China

Keywords:

ABSTRACT Objective:To evaluate the efficacy of scalp acupuncture combined with language rehabilitation training in the treatment of motor aphasia.Methods:CNKI,VIP, Wan Fang Database, MEDLINE, Embase, Web of Science and Cochrane Library were searched for published researches up to March, 2021.Randomized controlled trials RCTs that focused on scalp acupuncture combined with language rehabilitation training in the treatment of motor aphasia were included.We managed the data analysis with RevMan 5.3 software.Results:A total of 16 RCTs with 1 323 patients were involved.The results of meta-analysis showed that:①The effective rate of scalp acupuncture combined with language rehabilitation training in the treatment of motor aphasia after stroke was significantly better than that of simple language rehabilitation training [OR=3.94, 95%CI (2.73,5.68), P＜0.000 01]; ②In the evaluation of language function, compared with the language rehabilitation training, the scalp acupuncture combined with language rehabilitation training can significantly improve the reading ability of the patients with motor aphasia after stroke [MD=7.22, 95% CI (3.55,10.89), P=0.000 1],writing ability [MD=6.51, 95%CI (3.61,9.41), P＜0.000 1], expressive ability [MD=4.13,95%CI(2.37,5.89), P＜0.000 1], retelling ability [MD=5.00, 95%CI (2.38,7.63), P=0.000 2], listening comprehension ability [MD=5.36, 95%CI (3.12,7.61), P＜0.000 01] and naming ability[MD=5.60, 95%CI (4.20,7.00), P＜0.000 01]; ③Compared with simple language rehabilitation training, scalp acupuncture combined with language rehabilitation can significantly improve the daily life language communication ability of patients with motor aphasia, and the difference was statistically significant [MD=30.01, 95%CI (11.30,48.72), P=0.002].Conclusion:Scalp acupuncture combined with language rehabilitation training has a significant effect on motor aphasia.However, due to the small sample size, more RCTs are needed to confirm that.

1.Introduction

Motor aphasia, also known as Broca aphasia or expressive aphasia, is a clinical syndrome characterized by the impairment of oral expression caused by lesions in the posterior part of inferior frontal gyrus (Broca area) and its adjacent areas.Its clinical features include difficulty in oral expression, decreased fluency, telegraphic language, and The repetition, naming, ability of reading and writing were damaged to varying degrees[1].Nearly 9% of the world′s deaths are caused by stroke, and 26% - 38% of stroke patients will have Broca aphasia[2].Thrombolysis, antiplatelet aggregation and other methods are mainly used in the treatment of acute stroke.However, Broca aphasia, as one of the main sequelae of stroke, is still lack of effective treatment methods, which is a great burden to patients′ family relationship, quality of life, psychology and economy[3].Therefore, how to treat motor aphasia more effectively is an urgent clinical problem.

Acupuncture and meridian theory of the motherland has unique understanding and opinions on stroke and Broca aphasia.Scalp acupuncture treatment not only has significant clinical effect on Broca aphasia, but also overcomes the disadvantages of Western medicine which only pays attention to its surface but not its origin.In addition, scalp acupuncture has the advantages of high safety,low price, high dependence and outstanding curative effect; At the same time, modern language rehabilitation training can promote the recovery of patients′ language function by repeatedly training patients′ visual, listening and speech functions to form stereotyped memory.Therefore, scalp acupuncture combined with language rehabilitation training has great potential and advantages in the treatment of Broca′s aphasia.This paper intends to systematically evaluate the clinical efficacy of scalp acupuncture combined with language rehabilitation training in the treatment of post-stroke motor aphasia by meta-analysis, so as to provide ideas and evidence-based medicine for clinical treatment.

2.Data and methods

2.1 Literature search

The databases of CNKI, VIP, Wang Fang Database,Medline,Embase, Web of Science and Co-chrane Library were searched for all relevant literatures from the establishment of the database to February 2021.The Chinese key words included "scalp acupuncture", "language rehabilitation training", "stroke" and "motor aphasia", The English key words include "scale acupuncture","language rehabilitation training", "apoplexy" and "motor aphasia".The combination of subject words and free words is used for retrieval.

2.2 Inclusion criteria

①Research Type: RCT of scalp acupuncture combined with language rehabilitation training in the treatment of post-stroke motor aphasia; ②Participants: they met the diagnostic criteria of "stroke"in diagnostic essentials of various cerebrovascular diseases[4], and they were diagnosed as cerebral infarction or cerebral hemorrhage by CT / MRI examination and motor aphasia by Chinese aphasia test (ABC); The main symptoms of traditional Chinese medicine are sudden coma, unconsciousness, hemiplegia, mouth and eye deviation, speech difficulty and speech impediment; Side effects:dizziness, headache, dullness of consciousness, paresthesia of limbs;③Intervention Measures: the control group received language rehabilitation training, mainly including articulation training,pronunciation training, naming training, retelling training, reading ability training, writing training and communication ability training;The experimental group was treated with scalp acupuncture on the basis of the control group.The main points included the main points of language area 1 (2/5 below the anterior oblique line of parietal and temporal) and the front temporal line.The above points were treated with flat reinforcing and reducing manipulation, flat needling or Electroacupuncture.④Outcome Measures: at least one of the following items was included: total effective rate (based on BDAE score, CRRCAE and other evaluation methods), language function evaluation (CRRCAE score), daily life language communication ability (CFCP score), etc.

2.3 Exclusion criteria

Exclusion criteria: ①The intervention measures included Acupuncture of main points except scalp acupuncture; ②There were significant differences in baseline data between studies; ③ Repetitive publications; ④Aphasia except motor aphasia after stroke.

2.4 Data extraction and quality evaluation

Two researchers independently completed the data extraction and quality evaluation of the included literatures.If there were different opinions, they discussed and consulted or sought the opinions of the third researcher.Data extraction included the first author, publication time, patient age, sample size, intervention measures, course of treatment, outcome indicators, randomized method of study,allocation hiding method, etc.The bias risk assessment method recommended by Cochrane was used for quality evaluation.

2.5 Statistical methods

The effective rate was calculated by odds ratio (or); The mean difference (MD) was used in the evaluation of language function(CRRCAE) and daily life language communication ability (CFCP);The fixed effect model was used to analyze the studies with less heterogeneity (I2＜ 50%), otherwise, the random effect model was used; When P ＜ 0.05, the difference was statistically significant; The above statistical methods were completed with Review Manager 5.3 software.The sensitivity analysis was performed by stata12 software.Funnel plot and egger′s test were used to evaluate the publication bias.

3.Results

3.1 Search results, basic data of included literatures and quality evaluation

After screening, 16 randomized controlled trials[5-20] involving 1323 patients were included (see Figure 1 for details).The control group was treated with language rehabilitation training, and the experimental group was treated with scalp acupuncture combined with language rehabilitation training.The detailed data of the included studies are shown in Table 1.Seven studies[8,9,11,12,13,15,18]described the method of random allocation, six studies[6,10,14,16,17,19]only mentioned "random", the specific method is unknown, one study[5] allocated according to the lottery, two studies[7,20] allocation method is unknown.No blind method was mentioned in all studies.Two studies[15,19] used distributive concealment, and the rest did not mention distributive concealment.The quality evaluation of the included literatures is shown in Figure 2.

Tab 1 Baseline data of included documents

Fig 1 Flowchart of document retrieval and screening

3.2 Meta analysis results

3.2.1 Efficiency

Thirteen studies[5-7,9-11,13,14,16-20] were included to compare the clinical effective rate.A total of 1142 patients were divided into BDAE score, CRRCAE score and other subgroups according to the different evaluation methods of the effective rate using fixed effect model (I2=0%).The results of the two subgroups showed that the effective rate of scalp acupuncture combined with language rehabilitation training in the treatment of motor aphasia after stroke was significantly better than that of simple language rehabilitation training, and the difference was statistically significant [OR=3.76,95%CI(2.67,5.31),P＜0.000 01].,as shown in Figure 3.

3.2.2 Language function assessment (CRRCAE score)

3.2.2.1 Reading ability

A total of 9 studies[5,8-11,16-19] were included in the comparison of reading ability, involving 734 patients.The results showed that there was statistical heterogeneity among the studies (P ＜ 0.000 01,I2=98%), so the random effect model was used for analysis.Theresults showed that: scalp acupuncture combined with language rehabilitation in improving the reading ability of patients with poststroke motor aphasia was significantly better than simple language rehabilitation training, and the difference was statistically significant[MD = 7.22, 95%CI(3.55,10.89), P = 0.000 1], as shown in Figure 4.Due to the large heterogeneity among the included studies,sensitivity analysis was conducted on the included reading ability studies.After removing individual studies one by one, MD values were between (3.55, 10.89), and the 95% confidence interval of each study did not cross the "0" invalid line, indicating that the results of meta-analysis were relatively stable, and no obvious source of heterogeneity was found, as shown in Figure 5.

Fig 2 Quality evaluation of included documents

Fig 3 Forest plot of comparative analysis of clinical efficiency

Fig 4 Forest plot of comparative analysis of reading ability

Fig 5 Sensitivity analysis of reading ability

3.2.2.2 Writing ability

A total of 6 studies[5,10,11,17-19] were included in the comparison of writing ability, involving 538 patients.The results showed that there was statistical heterogeneity among the studies (P ＜ 0.000 01,I2=93%), so the random effect model was used for analysis.The results showed that: scalp acupuncture combined with language rehabilitation in improving the writing ability of patients with poststroke motor aphasia was significantly better than simple language rehabilitation training, and the difference was statistically significant[MD = 6.51, 95%CI(3.61,9.41), P ＜ 0.000 1], as shown in Figure 6.

3.2.2.3 Language expression ability

A total of 6 studies [8-10, 16, 17, 19] involving 430 patients were included in the comparison of language expression ability.The results showed that there was statistical heterogeneity among the studies (P ＜ 0.000 01, I2=91%), so the random effect model was used for analysis.The results showed that: scalp acupuncture combined with language rehabilitation in improving the language expression ability of patients with post-stroke motor aphasia was significantly better than simple language rehabilitation training, and the difference was statistically significant [MD = 4.13, 95%CI(2.37,5.89), P ＜0.000 1], as shown in Figure 7.

Fig 6 Forest plot of comparative analysis of writing ability

Fig 7 Forest plot of comparative analysis of expressive ability

3.2.2.4 Retelling ability

A total of 8 studies[5,8-11,16,18,19] were included for the evaluation of retelling ability, involving 643 patients.The results showed that there was statistical heterogeneity among the studies (P ＜ 0.000 01,I2=97%), so the random effect model was used for analysis.The results showed that: scalp acupuncture combined with language rehabilitation in improving the retelling ability of patients with poststroke motor aphasia was significantly better than simple language rehabilitation training, and the difference was statistically significant[MD = 5.00, 95%CI(2.38,7.63), P = 0.000 2], as shown in Figure 8.

Fig 8 Forest plot of comparative analysis of retelling ability

3.2.2.5 Listening comprehension

A total of 8 studies[5,8,9,11,16-19] were included to evaluate the ability of listening comprehension, involving 658 patients.The results showed that there was statistical heterogeneity among the studies (P ＜ 0.000 01, I2=96%), so the random effect model was used for analysis.The results showed that: scalp acupuncture combined with language rehabilitation in improving the listening comprehension ability of patients with post-stroke motor aphasia was significantly better than simple language rehabilitation training, and the difference was statistically significant [MD = 5.36,95%CI(3.12,7.61), P ＜ 0.000 01], as shown in Figure 9.

Fig 9 Forest plot of comparative analysis of listening comprehension

3.2.2.6 Naming ability

Three studies[8,10,11] were included to evaluate the naming ability,involving 176 patients, using fixed effect model (I2=0%).The results showed that: scalp acupuncture combined with language rehabilitation in improving the naming ability of patients with poststroke motor aphasia was significantly better than simple language rehabilitation training, and the difference was statistically significant[MD = 5.60, 95%CI(4.20,7.00), P ＜ 0.000 01], as shown in Figure 10.

Fig 10 Forest plot of comparative analysis of naming ability

3.2.3 Daily life language communication ability (CFCP score)

A total of 4 studies[6,7,12,15] were included in the comparison of daily life language communication ability, involving 3332 patients.The results showed that there was statistical heterogeneity among the studies (P ＜ 0.000 1, I2=87%), so the random effect model was used for analysis.The results showed that: scalp acupuncture combined with language rehabilitation in improving the daily life language communication ability of patients with post-stroke motor aphasia was significantly better than simple language rehabilitation training, and the difference was statistically significant [MD = 30.01,95%CI(11.30,48.72), P = 0.002], as shown in Figure 11.

Fig 11 Forest plot of comparative analysis of the daily life language communication ability

3.3 publication bias

Funnel plot and egger′s plot were drawn according to the outcome index of clinical effective rate, as shown in Figure 12.The distribution of each research point in funnel plot was symmetrical,and egger′s test P = 0.108 ＞ 0.05, indicating that no significant publication bias was detected.

Fig12 Funnel plot and Egger′s plot

4.Discussion

The results of this meta-analysis show that scalp acupuncture combined with language rehabilitation training can significantly improve the clinical efficiency of patients with post-stroke motor aphasia.At the same time, in the evaluation of language function,compared with simple language rehabilitation training, scalp acupuncture combined with language rehabilitation training can significantly improve the reading ability, writing ability, language expression ability, retelling ability, listening comprehension ability,naming ability and daily life language communication ability of patients with motor aphasia after stroke.In the reading ability group,the heterogeneity among the included studies is large, and the included studies are excluded one by one, and no obvious source of heterogeneity is found.For the heterogeneity, the following reasons may be considered: 1) the different scalp acupuncture points and the effects of getting Qi and getting Qi to disease caused by different acupuncture methods have great differences in the results;② The patients included in the study had different brain lesions and lesions, and the curative effect was different; ③ In some studies,electroacupuncture intervention was given on the basis of scalp acupuncture.The above reasons easily lead to large deviation in the analysis results.

Motor aphasia after stroke belongs to the category of "Fengyi","Yinfei", "Yujian" in traditional Chinese medicine, such as "Fengyi is choked in the pharynx, the tongue is strong and unable to speak,and the classic name is Yinluo".The brain is the place of the original spirit.After stroke, the blood stasis of the brain collaterals, the obstruction of Qi and blood, or the hyperactivity of liver Yang and the reversal of Qi and blood lead to the evil effects of wind, fire,phlegm and blood stasis, which hinder the brain, clear the orifices and blind the brain.The brain gods are closed and can not control the language function.Zhang jiebin said: "the meridians and Qi of the five zang organs and six Fu organs are all injected into the face and go through the empty orifices".The head is the meeting of all Yang, the governor vessels enter the collaterals in the brain, and the circulation of the six yang meridians of hand and foot all go up to the head and face, indicating that the head and face and the five zang organs and six Fu organs of the human body are closely related in physiology and pathology with the help of meridians and collaterals.Scalp acupoints have been used to treat diseases for a long time.The innovative development of scalp acupuncture is not only based on the meridian theory of traditional Chinese medicine,but also combined with the functional orientation of cerebral cortex in modern medicine.Acupuncture in the corresponding area of the head can not only awaken the brain and open up the orifices, regulate Yin and Yang, improve the blood circulation of the brain, but also activate Qi and blood, dredge meridians, and restore its language function, It has significant effect on motor aphasia after stroke.

According to modern medical research, the occurrence of motor aphasia after stroke is closely related to hypoperfusion and hypometabolism of speech function area[21].After stroke, cerebral ischemia and hypoxia lead to neuron damage.When the brain tissue damage affects the corresponding language center, it affects the fiber conduction pathway in the language functional area, resulting in local tissue hypoperfusion and low metabolism, leading to the expression disorder of language ability.Brain has certain plasticity and functional reorganization.Some areas of human head are the projection of cerebral cortex function on the body surface.After local scalp acupuncture stimulation, the brain hemorheology changes, promote the absorption of hematoma, reduce the degree of brain edema, further regulate the cortical thalamic cortical conduction pathway, activate language neurons, and promote the recovery of speech function in patients with motor aphasia after stroke[22, 23].According to research, acupuncture can improve blood viscosity and adjust lipid metabolism in patients with cerebral infarction and hyperlipidemia[24].Scalp acupuncture also has a certain effect on EEG activity.Acupuncture at scalp acupoints can improve the inhibition state of cerebral cortex, induce the EEG activity of cortical cells, regulate the nerve conduction pathway, and reduce the damage degree of brain function[25].Scalp acupuncture combined with language rehabilitation training can fundamentally promote the rehabilitation of brain nerve function, regulate brain microcirculation, maintain the integrity of cerebrovascular function,and promote the recovery of cerebral cortex function.At the same time, speech rehabilitation training can ensure that patients′ local muscles do not lose their use through repeated stimulation of voice to local muscles.Repeated functional training can transmit sensory impulses to the brain, Continuous negative feedback can induce normal movement, promote the recovery of motor and language nerves, improve the aphasia state of patients, and improve the therapeutic effect of patients with motor aphasia.It can also be found from this study that scalp acupuncture combined with language rehabilitation training can not only improve the patients′ reading ability, language expression ability, retelling ability, daily life and language communication ability, but also significantly improve their writing ability and listening comprehension ability.Through multitarget and comprehensive improvement of stroke sequelae.

5.Deficiencies and Prospects

The limitations of this study are as follows: ①most of the literatures included in this study were not blinded and distributed, and the quality of the literatures was low; ②The included literatures are all domestic studies, and lack of large sample randomized controlled trials, so the research results are not convincing; ③The differences in the selection of scalp acupuncture points and the operators in each study are likely to affect the results, which is also one of the sources of heterogeneity of research indicators.In the future research,we should optimize the selection of scalp acupuncture points and acupuncture methods, carry out standardized, standard and unified large sample experimental research with the selected points, improve the blind method and feasible allocation hiding method in the experiment, avoid the experimental deviation, so as to better verify the efficacy and safety of scalp acupuncture combined with speech rehabilitation training in the treatment of post-stroke motor aphasia,To provide relevant ideas for clinical treatment.

To sum up, scalp acupuncture combined with speech rehabilitation therapy can significantly improve the speech function of patients with motor aphasia after stroke, reduce the severity of aphasia,especially in the aspects of retelling, language expression and reading ability, significantly improve the language communication ability of patients in daily life, with significant curative effect and high safety, which has great potential and advantages.However,more high-quality and large sample RCTs are needed to verify.