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Review article
Department of Neuropsychiatry, College of Korean Medicine, Kyung-Hee University, Seoul, Republic of Korea
Inuri Medical Group, Seoul, Republic of Korea
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 29 July 2016
Received in revised form 1 September 2016
Accepted 2 September 2016
Available online xxx
Introduction: Tourette syndrome (TS) is a tic disorder with multiple motor and vocal or phonic tics. The
effect of acupuncture for TS has not been well established.
Methods: English, Japanese, Korean and Chinese databases, were explored systematically for randomized
controlled trials investigating the use of acupuncture for treating TS, up to August 2016, without language
restrictions. All studies evaluating the effects of acupuncture were identied. Studies assessing the effect
of moxibustion were excluded. All ages were considered. Data were extracted independently using
predened data elds, including study quality indicators. All pooled analyses were based on randomeffects models. The authors individually evaluated risk of bias with the Cochrane Collaborations tools.
Results: Nineteen Studies (N = 1483) were systematically reviewed. A signicant benet was observed for
studies comparing acupuncture versus medication (pooled the risk ratio showed improvement by 1.17;
95% condence interval: 1.101.25, p < 0.00001). Reporting of adverse events was poor with only one
study which reported that there were no adverse events in their acupuncture treatment group.
Conclusions: This analysis provided limited evidence from studies for the practice of acupuncture in
treating TS. However, the conclusions were limited by a high risk of bias. Future studies are needed to
verify the superior features of acupuncture. Further study into the efcacy and safety of acupuncture is
warranted.
2016 Published by Elsevier GmbH.
Keywords:
Acupuncture
Tic disorders
Tics
Tourette syndrome
Randomized controlled trials
Systematic review
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Information sources and search strategy . . .
2.1.
Eligibility criteria and study selection . . . . .
2.2.
Types of studies . . . . . . . . . . . . . . .
2.2.1.
Types of participants . . . . . . . . . . .
2.2.2.
Types of interventions . . . . . . . . . .
2.2.3.
Types of outcome measures . . . . .
2.2.4.
Data collection . . . . . . . . . . . . . . . . . . . . . . .
2.3.
Assessment of risk of bias . . . . . . . . . . . . . .
2.4.
Summary measures and synthesis of results
2.5.
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Study characteristics . . . . . . . . . . . . . . . . . . .
3.1.
Risk of bias in included studies . . . . . . . . . .
3.2.
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* Correspondence to: Hospital of Korean Medicine, Kyung Hee University Medical Center, Kyung Hee University, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447,
Repubic of Korea.
E-mail address: chosh@khmc.or.kr (S.-H. Cho).
http://dx.doi.org/10.1016/j.eujim.2016.09.001
1876-3820/ 2016 Published by Elsevier GmbH.
Please cite this article in press as: S.-Y. Chung, et al., Acupuncture for Tourette syndrome: A systematic review and meta-analysis, Eur. J. Integr.
Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.09.001
G Model
EUJIM 598 No. of Pages 8
S.-Y. Chung et al. / European Journal of Integrative Medicine xxx (2016) xxxxxx
4.
5.
3.3.
Synthesis of results
Discussion . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . .
Conicts of interest . . . . .
Acknowledgment . . . . . . .
References . . . . . . . . . . . .
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.
1. Introduction
Tics are described as, non-rhythmic, repetitious involuntary,
vocalizations or unexpected movements [1]. Tic disorders are
divided by tic type and duration. Chronic tic disorders and Tourette
syndrome (TS) are characterized by the presence of sudden
vocalizations or motor movements that persist for more than a
year [2]. TS affects the face, shoulders, neck and vocal apparatus
preferentially with involuntary motor and vocal tic behaviors [1,3].
TS occurs worldwide and at all ages [4]. It affects around 2% of
school-age childrenand is the most common movement disorder
in the pediatric age group [5]. Individuals with TS frequently have
complications especially attention-decit hyperactivity disorder,
obsessive compulsive disorder, anxiety disorders, impulse control
disorders and personality disorders [6]. Tics have also been
associated with functional impairment and diminished quality of
life [3].
A variety of treatment approaches have been used to manage
tics in TS [7]. Traditionally, neuroleptics such as antipsychotics and
alpha-2 agonists have been considered the mainstay of treatment
in TS, and haloperidol is deemed the rst line of treatment [8].
Psychotropic medications such as haloperidol have shown efcacy
and usefulness [9]. Despite their effectiveness, antipsychotics may
be associated with adverse effects and limited admissibility [10].
Antipsychotic medication such as haloperidol can lead to
nervousness, cognitive dulling/feeling drugged, sedation, body
weight gain, low mood and extrapyramidal symptoms. Extrapyramidal symptoms can take the form of fatigue, muscle rigidity,
posturing and tongue protrusion; parkinsonian symptoms such as
tremors, rigidity, lack of facial expression, drooling and difculty in
movement [8]. Pharmacological interventions remain the most
common approach [7], but various nonpharmacological treatment
therapies have emerged in the past three decades, including such
as relaxation training, practice, habit reversal training, exposure
and response prevention, and surgical therapies [11].
To avoid these adverse effects of medication, many patients
with tic disorders have explored the use of complementary and
alternative medicine (CAM). The use of CAM in conventional
medicine has grown dramatically in recent decades [12,13]. Nearly
40% of healthy children seen in pediatric clinics and more than 50%
of children with chronic conditions, use CAM [1315]. CAM has
been reported using CAM to control their tic disorders in some
people [16]. In a 2004 survey approximately 40% of patients
reported having used CAM in the previous year. Most users of CAM
reported improvements in their tic symptoms [17].
Acupuncture is one of the most popular CAM treatments [18]. It
has been used to treat several diseases and alleviate symptoms and
is growing in importance in many parts of the world. Acupuncture
is used by a growing number of pediatric patients [19].
Acupuncture was used on more than 150,000 children (0.2%) in
2002. In current years, acupuncture has become integrated
increasingly into pediatric clinics. The effectiveness of acupuncture
for some diseases is promising, with no reports of severe side
effects [19,20]. Acupuncture has been used widely for treatment of
asthma, cerebral palsy, autism spectrum disorder, and other
conditions in children. Furthermore, the effectiveness of acupuncture for treating nocturnal enuresis, tic disorders, amblyopia, and
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00
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Please cite this article in press as: S.-Y. Chung, et al., Acupuncture for Tourette syndrome: A systematic review and meta-analysis, Eur. J. Integr.
Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.09.001
G Model
EUJIM 598 No. of Pages 8
S.-Y. Chung et al. / European Journal of Integrative Medicine xxx (2016) xxxxxx
results; and 3) unclear risk of bias, plausible bias that raises some
doubt about the results. If the raters disagreed, the nal rating was
made by consensus.
2.5. Summary measures and synthesis of results
Study characteristics and quality ratings were assessed. A
random-effects model examined the risk ratio (RR) using Review
Manager (RevMan) (ver. 5.3. Copenhagen: The Nordic Cochrane
Centre, The Cochrane Collaboration, 2014).
Where possible we used a random-effects model using MantelHaenszel weights for synthesis of results because the true effect
sizes (ESs) were expected to vary across trials due to different study
characteristics. A random effects model calculated the RR and its
95% condence interval (CI) for treatment response between trials.
We recognize that the random-effects model is generally a more
plausible match. Heterogeneity of RR was assessed using the forest
plot, Q statistic, and I2 statistic. All groups with more improved or
improved of the improvement rating were classied as treatment responses The number of responders and non-responders
was calculated and the RR for each trial. For continuous outcomes
we assessed a MD using RevMan. MDs were considered on the
random-effects model because of no statistically signicant
heterogeneity. We also analyzed the standardized MD measures.
ESs were calculated using change means because doing so
increases the precision of ES estimators by controlling for
pretreatment group differences in tic severity. Publication bias
was assessed by graphic assessment of the funnel plot. Subgroup
analysis was undertaken, of types of acupuncture intervention.
However, the nal data assessed were from a meta-analysis. The
aim of the meta-analysis was to explore the effect of acupuncture
intervention for TS. Sensitivity analysis was not performed because
Please cite this article in press as: S.-Y. Chung, et al., Acupuncture for Tourette syndrome: A systematic review and meta-analysis, Eur. J. Integr.
Med. (2016), http://dx.doi.org/10.1016/j.eujim.2016.09.001
G Model
EUJIM 598 No. of Pages 8
S.-Y. Chung et al. / European Journal of Integrative Medicine xxx (2016) xxxxxx
there were not enough studies in the evaluation that examined the
change in robustness of the sensitivity.
3. Results
3.1. Study characteristics
Our initial search identied 860 studies, which were then
reviewed for suitability for inclusion in this review. After removing
duplicates, 681 studies remained and were evaluated carefully for
their eligibility for this review. Of the 681 potential abstracts/
citations, 129 were retained for detailed review (Fig. 1). Considering the abstracts, 129 papers met the search inclusion criteria
detailed above. The majority of the papers using acupuncture did
not specically focus on TS (n = 88) and were therefore excluded;
others were excluded because they reported case studies (n = 3), or
presented reviews (n = 10). Only RCTs examining the effectiveness
Table 1
Characteristics and the risk of bias assessment of included studies of acupuncture for Tourette syndrome.
Study
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
Control group
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
Medication group:
Haloperidol 1.5mg4 mg/d for
3 months
Herbal group: Yi-gan-san for
3 months
Acupuncture 5 sessions per week for 2 months; GV20, Haloperidol 2mg6 mg/d for 2
GV24, TE23, LI4, PC6
months
Acupuncture and pharmacopuncture 6 sessions per
Haloperidol 1mg2 mg/d for 3
week for 3 weeks: GV20, EX-HN3
weeks
Acupuncture 36 sessions for 45 days: HT7, LI4, LR3,
Haloperidol 1mg8 mg/d for
LR2, ST41, BL62, KI6
45 days
Acupuncture 60 sessions for 3 months: LI4, GB20,
Tiapride 150mg450 mg/d for
GV20, EX-HN5, EX-HN1
3 months
Outcome
measures
Assessment
risk of biasa
Response
rate
U-U-U-U-LU-L
Response
rate
U-U-U-U-LU-L
Response
rate
Response
rate
YGTSSb
U-U-U-U-LU-L
U-U-U-U-LU-L
U-U-U-U-LL-L
U-U-U-U-LU-L
L-U-U-U-LU-L
U-U-U-U-LU-L
U-U-U-U-LU-L
U-U-U-U-LL-L
Response
rate,
Response
rate
Response
rate
Response
rate
Response
rate,
YGTSS
Response
rate,
YGTSS
Response
rate,
YGTSS
Response
rate
Response
rate,
YGTSS
Response
rate,
Response
rate
Response
rate
Response
rate
Response
rate
U-U-U-U-LL-L
L-U-U-U-LL-L
U-U-U-U-LU-L
U-U-U-U-LL-L
U-U-U-U-LU-L
U-U-U-U-LU-L
U-U-U-U-LU-L
L-U-U-U-LU-L
L-U-U-U-LU-L
a
Assessment risk of bias: Random sequence generation, Allocation concealment, Blinding of participants, Incomplete outcome data, Selective reporting, Other bias: Low
risk of bias, categorised as L', High risk of bias as H, Unclear risk of bias as U.
b
YGTT = Yale Global Tic Severity Scale.
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