Effects of acupuncture plus MOTOmed intelligent motor training in treating children with spastic cerebral palsy

Li Yong-liang (李永亮), Fang Li-ping (房丽萍), Xia Bao-zhi (夏保志), Wang Chang-zheng (王长征), Lu Rui-gen (芦瑞根),Liu Tao (刘涛), Wu Mi-ling (武密玲)

1 The Eighth Hospital of Shijiazhuang, Hebei Province, Shijiazhuang 050081, China

2 The First Hospital of Shijiazhuang, Hebei Province, Shijiazhuang 050011, China

Abstract

Keywords: Acupuncture Therapy; Exercise Therapy; Cerebral Palsy; Rehabilitation; Lymphocytes; Hemodynamics; Child,Preschool

Cerebral palsy (CP) is a common neurological disease in children, referring to the pediatric brain injury syndrome caused by various reasons from fetal period to one month after birth[1]. The main symptoms include abnormal posture, muscle tone change, and developmental retardation. Most CP children may also have secondary epilepsy, visual and auditory disorders,mental retardation, and motor retardation. The epidemiological survey results showed that the incidence of neonatal CP was about 2.0‰-2.5‰, of which about 60%-70% belonged to spastic CP[2]. The pathogenesis of spastic CP is still unclear, and its treatment is based on comprehensive rehabilitation.MOTOmed intelligent exercise training is one of the commonly used methods, showing reliable efficacy in the treatment of children with spastic CP. With the continuous development of traditional Chinese medicine (TCM) technology and theory, TCM treatment has gradually penetrated into various clinical fields and achieved certain results. Acupuncture therapy in TCM is helpful to establish synapse and neuromuscular junction, and improve the motor function of human limbs[3]. In this study, we observed the clinical efficacy of acupuncture plus MOTOmed intelligent motor training in treating spastic CP, and compared it with the effect of conventional rehabilitation plus MOTOmed intelligent motor training.

1 Clinical Materials

1.1 Diagnostic criteria

The Definition, Classification and Diagnostic Conditions of Infantile Cerebral Palsy was taken for referrence[4]. The symptoms occurred in infancy; the lesion that caused the motor dysfunction was in the brain, and the cause was non-progressive brain injury;exclusion of central dyskinesia caused by progressive diseases and temporary motor retardation.

1.2 Inclusion criteria

Those who met the above diagnostic criteria; aged>1 year; stopped taking other medications for CP 2 weeks before this trial; confirmed as cerebral palsy of spastic hemiplegia type by clinical diagnosis and imaging examination; parents of the children agreed to participate in this trial and signed informed consent.

1.3 Exclusion criteria

Those who had serious disease condition that could not be effectively controlled by drugs; with poor compliance; dropped out during the trial.

1.4 Statistical methods

All data were statistically analyzed by the SPSS version 21.0 statistical software. Counting data were expressed as composition ratio (%), and processed by Chi-square test. Rank sum test was used for the comparison of ranked data. Measurement data were expressed as mean ± standard deviation (±s). The pairedt-test was used for intra-group comparison before and after treatment. And the comparison between the groups was analyzed by independent samplet-test.P<0.05 was considered to indicate a statistically significant difference.

1.5 General data

This study was reviewed and approved by the Ethics Committee of the Eighth Hospital of Shijiazhuang, Hebei Province (Approval No. 201801224). Parents of the children all signed informed consent. A total of 42 children with spastic CP, treated with acupuncture method of benefiting intelligence and opening the orifices plus MOTOmed intelligent motor training, were selected from the Eighth Hospital of Shijiazhuang, Hebei Province, and enrolled into the observation group,between May 2017 and January 2019. Another 42 cases treated with conventional rehabilitation plus MOTOmed intelligent motor training in the same period were randomly selected as the control group. The general data of the two groups were statistically analyzed, and the differences between the two groups were not statistically significant, indicating that the two groups were comparable (Table 1).

2 Methods

Both groups received MOTOmed intelligent motor training, and the observation group was given additional acupuncture, and the control group was given additional conventional rehabilitation treatment.The pedal of viva1 Motomed intelligent motion system(RECK Company, Germany) was adjusted to the appropriate height. The physician gave the corresponding command to the child with the combination of the system prompt, including 3-4 min of passive training and 5-10 min of active training. Before the end of training, the child would receive another 3 min of passive relaxing training. The parameters of MOTOmed intelligent motion system should be adjusted according to the actual situation. The general resistance is 0-10 N, the speed is 15-30 r/min, and the training should be appropriate for the child tolerance.

Table 1. Comparison of general data between the two groups

2.1 Observation group

The observation group was treated with MOTOmed intelligent motor training plus acupuncture method of benefiting intelligence and opening the orifices.

Acupoints: For body part, Jinsuo (GV 8), Zhiyang(GV 9), Shenzhu (GV 12), Fengfu (GV 16), Baihui (GV 20),Shuigou (GV 26), Dazhui (GV 14), Mingmen (GV 4),Yaoyangguan (GV 3), Taixi (KI 3), Shenshu (BL 23), Pishu(BL 20) and Zusanli (ST 36) were selected. For upper limb part, Hegu (LI 4), Waiguan (TE 5), Zhongzhu (TE 3)and Quchi (LI 11) were selected. For lower limb part,Taichong (LR 3), Sanyinjiao (SP 6), Xuehai (SP 10), Futu(ST 32) and Fengshi (GB 31) were selected.

Methods:Disposable acupuncture needles of 0.30 mm in diameter and 20-40 mm in length were used in this study. After routine disinfection, Baihui(GV 20), Shuigou (GV 26), Zusanli (ST 36), Hegu (LI 4),Waiguan (TE 5), Zhongzhu (TE 3), Quchi (LI 11), Taichong(LR 3), Xuehai (SP 10), Futu (ST 32) and Fengshi (GB 31)were punctured with the child in a supine position. The needles were punctured by 20-30 mm in depth, and the specific depth was appropriate when the child felt obvious distension at the punctured part. After arrival of qi, the needles were retained for 30 min. Then, the child took a prone position, and Jinsuo (GV 8), Zhiyang(GV 9), Shenzhu (GV 12), Fengfu (GV 16), Dazhui (GV 14),Mingmen (GV 4), Yaoyangguan (GV 3), Taixi (KI 3),Shenshu (BL 23), Pishu (BL 20) and Sanyinjiao (SP 6)were punctured by 30 mm in depth. The reinforcing manipulation was applied as Taixi (KI 3), Shenshu(BL 23), Pishu (BL 20) and Zusanli (ST 36) were punctured. Jinsuo (GV 8), Zhiyang (GV 9), Shenzhu(GV 12), Fengfu (GV 16), Baihui (GV 20), Shuigou(GV 26), Dazhui (GV 14), Mingmen (GV 4) and Yaoyangguan (GV 3) were obliquely punctured with the needle tip downwards, at an angle of 45° between the needle and the spine. Even reinforcing-reducing manipulation was performed when acupoints on the limbs were punctured, and the needles were retained for 30 min after qi arrival. The treatment was performed once a day, 6 d a week. The treatment lasted for 1 month as one treatment course, and a total of 2 consecutive treatment courses were performed in both groups.

2.2 Control group

The control group was treated with MOTOmed intelligent motor training plus conventional rehabilitation treatment.

During the motion training period, the child was given hip flexion, knee flexion and ankle flexion training.During non-motion training period, the child took an anti-spasm position. When the child was in a standing position, it was necessary to extend the knee joint and abduct the hip joint, assisted with knees extension and bridging exercise, to prepare for the follow-up walking support. The overall treatment time of rehabilitation was controlled in 30 min.

3 Observation of Results

3.1 Observation items

3.1.1 Children’s Developmental Center of China (CDCC)scale[5]

CDCC scale was used to evaluate the intelligence development level of the child. This scale includes psychomotor development index (PDI) and mental development index (MDI). The higher the score, the better the level of child intelligence development. The score of 70-79 points is regarded as the borderline state,and less than 70 points represents mental retardation.

3.1.2 Gross motor function measure (GMFM) scale and modified Ashworth scale (MAS)[5]

GMFM scale and MAS were used to evaluate the motor function of lower limbs in both groups.

Area D in GMFM represents the standing function,with a total score of 39 points. Area E represents walking, running and jumping functions, with a total score of 72 points. The higher the score of the child, the better the gross motor function.

MAS is mainly used to evaluate the improvement of lower limb gastrocnemius and femoral muscle spasm.The muscle tone is divided into 6 grades: 0, 1, 1+, 2, 3,and 4. Grade 0 indicates normal muscle tone; grade 4 indicates stiffness, that is, the affected part is not able to flex or extend.

3.1.3 T lymphocyte subsets

Peripheral venous blood was collected before and after treatment, and the levels of T lymphocyte subsets cells were detected by flow cytometry.

3.1.4 Cerebral hemodynamic indicator

Transcranial Doppler was used to detect the cerebral hemodynamic indicators of the two groups, including the peak systolic velocity (PSV) and mean flow velocity(MFV) of the anterior cerebral artery (ACA), middle cerebral artery (MCA) and posterior cerebral artery(PCA). The results were analyzed and compared.

3.2 Criteria of curative efficacy

According to the change of MAS grading, the curative efficacy was evaluated.

Markedly effective: Muscle tone decreased by at least 2 levels after treatment.

Effective: Muscle tone decreased by 1 level after treatment.

Invalid: Muscle tension increased or had no significant change.

3.3 Results

3.3.1 Comparison of GMFM scale

Before treatment, there were no statistical differences in the scores of area D and area E in GMFM scale between the two groups (allP>0.05). After treatment, the scores of areas D and E in both groups increased significantly (allP<0.05), and the scores of area D and area E in the observation group were significantly higher than those in the control group(bothP<0.05), (Table 2).

3.3.2 Comparison of the improvement of lower limb spasm

There was no case of MAS grading 4 in either group before and after treatment. After treatment, the condition of lower limb spasm in both groups improved.The total effective rate of the lower limb spasm improvements was 90.5% in the observation group, and 71.4% in the control group. The observation group had better efficacy than the control group, and the difference between the two groups was statistically significant (P<0.05), (Table 3 and Table 4).

3.3.3 Comparison of intelligence development level

Before treatment, there were no statistical differences in PDI and MDI scores of the CDCC scale between the two groups (allP>0.05). After treatment,scores of the CDCC items in both groups increased significantly (allP<0.05), and the PDI and MDI scores in the observation group were significantly higher than those in the control group (allP<0.05), (Table 5).

3.3.4 Comparison of T lymphocyte subsets

Before treatment, there were no statistical differences in T lymphocyte subset cell levels between the two groups (allP>0.05). After treatment, the levels of CD3+, CD4+, and CD4+/CD8+in both groups increased significantly (allP<0.05). The CD3+and CD4+levels in the observation group were significantly higher than those in the control group (bothP<0.05). There were no statistical differences in the CD8+level and CD4+/CD8+between the two groups (bothP>0.05), (Table 6 and Table 7).

3.3.5 Comparison of cerebral hemodynamic indicator

Before treatment, there were no statistical differences in PSV and MFV of ACA, MCA and PCA between the two groups (allP>0.05). After treatment,PSV and MFV of ACA, MCA and PCA in both groups increased significantly (allP<0.05), and PSV and MFV of ACA, MCA and PCA in the observation group were significantly higher than those in the control group (allP<0.05), (Table 8-Table 10).

Table 2. Comparison of gross motor function measure score between the two groups ( x ±s, point)

Table 3. Comparison of the changes of modified Ashworth scale grading between the two groups (case)

Table 4. Comparison of the improvement of the lower limb spasm between the two groups (case)

Table 5. Comparison of the intelligence development level between the two groups ( x ±s, point)

Table 6. Comparisons of the CD3+ and CD4+ levels between the two groups ( x ±s, %)

Table 7. Comparisons of CD8+ and CD4+/CD8+ ratio between the two groups ( x ±s)

Table 8. Comparisons of peak systolic velocity (PSV) and mean flow velocity (MFV) of the anterior cerebral artery between the two groups ( x ±s)

Table 9. Comparisons of peak systolic velocity (PSV) and mean flow velocity (MFV) of the middle cerebral artery between the two groups ( x ±s)

Table 10. Comparisons of peak systolic velocity (PSV) and mean flow velocity (MFV) of the posterior cerebral artery between the two groups (±s)

Table 10. Comparisons of peak systolic velocity (PSV) and mean flow velocity (MFV) of the posterior cerebral artery between the two groups (±s)

Group n PSV t-value P-value MFV t-value P-value Before treatment After treatment Before treatment After treatment Observation 42 71.3±10.2 95.1±10.2 10.693 0.000 46.3±5.2 67.8±8.0 14.603 0.000 Control 42 72.4±11.6 85.3±11.8 5.052 0.000 45.4±5.3 56.3±7.8 7.491 0.000 t-value 0.462 4.072 0.786 6.670 P-value 0.646 0.000 0.434 0.000

4 Discussion

Spastic type is the most common type of CP. The superior neurons cannot control the subordinate neurons, resulting in the incoordination of muscle movement, showing a series of symptoms such as abnormal walking ability, motor dysfunction, and imbalance of the body[6]. Results of present study suggested that injury of the pyramidal tract system is the main cause of the high disability rate in spastic CP[7].Pyramidal tract injury breaks the contraction-diastolic loop of skeletal muscles which is in an originally balanced state, resulting in excessive stretch reflex and muscle spasm in children[8]. If the pathological state of the child is not corrected in time, spasm symptoms will further aggravate[9]. Limb spasm will lead to abnormal posture and joint movement disorder, forming a vicious circle, and resulting in severe limitation of the gross motor function of the child. At present, the main treatment of spastic CP is physical therapy, generally intervening various motor disorders of the patients one by one through various rehabilitation training.MOTOmed intelligent motor training system is a set of rehabilitation equipment developed for children with CP,which can help children to train limb function. The specific operation mechanism is to drive the limbs through the motor, making the limbs exercise passively,while relaxing the muscles of the limbs and reducing muscle tone. Passive exercise can also make the body produce a normal sense of motion, thereby improving the movement ability of the limbs, strengthening muscle strength, and improving coordination. The system is highly sensitive, and once the child has spasm symptoms during training, the system can actively identify and stop the motion instructions. After the child's symptoms are relieved, the exercise training will restart, and the intensity will gradually increase[10]. The gradual rehabilitation training can effectively promote the repair of nerve cells in children, thereby improving the limb motor function of children.

Acupuncture has certain effect in improving physical dysfunction[11]. Modern medical study suggests that most children with CP have extensive intracranial cerebral hemodynamic changes, indicating that spastic CP may be related to cerebral blood perfusion in children[12].Blood supply disorders of ACA, MCA and PCA lead to brain dysplasia, which has adverse effects on intelligence development of children. Acupuncture treatment can effectively improve the blood perfusion of local brain tissue in children, which plays an important role in promoting intellectual development and improving motor function. CP in children belongs to the category of ‘five stiffness’, ‘five infantile flaccidity’and ‘five retardations’ in TCM[13]. The pathogenesis is that the mother who is in frail health during pregnancy invaded by the exogenous pathogen, coupled with genetic factors and improper delivery, finally leading to the disease in children. The key pathogenesis is congenital insufficiency and acquired weakness of spleen and stomach[14]. Therefore, promoting qi and blood circulation, relaxing tendons and unblocking collaterals, and improving the immune function of the children are keys to the improvement of the efficacy for CP. Study proved that acupuncture method of benefiting intelligence and opening the orifices could improve the cerebral blood circulation in CP children,increase the blood oxygen supply for brain, and promote the recovery of injured neurons, thereby improving the intelligence and behavior expression of the children[15]. Acupoints of Governor Vessel are mainly selected for the acupuncture method of benefiting intelligence and opening the orifices,because the Governor Vessel is the sea of yang meridians, and acupuncture at those points can benefit the brain essence, regulate Zang-fu organs, and unblock meridians and collaterals[16]. In this study, acupuncture method of benefiting intelligence and opening the orifices was applied in the observation group. Among them, selecting Zusanli (ST 36) was to invigorate spleen for generating blood, Shenshu (BL 23) was to generate yang qi, Pishu (BL 20) was to nourish the tendons and bones, Taixi (KI 3) was to nourish and generate the essence of kidney, Jinsuo (GV 8) was to disperse liver and regulate qi, Zhiyang (GV 9) was to strengthen yang for benefiting qi, Shenzhu (GV 12) was to ventilate lung for clearing heat, and Fengfu (GV 16) was to dispel and stop the wind. Baihui (GV 20) and Shuigou (GV 26) were used for resuscitating and opening the orifices, Dazhui(GV 14) was for clearing heat and benefiting qi, and Mingmen (GV 4) was for cultivating primordial qi and consolidating the basis. Hegu (LI 4), Waiguan (TE 5),Zhongzhu (TE 3) and Quchi (LI 11) were used to harmonize qi and blood, and unblock the meridians and collaterals. Taichong (LR 3) was used for calming the liver to stop the wind, Sanyinjiao (SP 6) was for regulating liver to invigorate kidney, Xuehai (SP 10) was for invigorating the spleen to generate blood, Futu(ST 32) was for unblocking collaterals and relieving pain,and Fengshi (GB 31) for transportation and transformation of fluid-dampness. Reinforcing manipulation was applied at some acupoints to promote the flow of meridian qi, which was conducive to limb joint activities of the children. And acupuncture method of penetrating needling in the direction of reversing the meridian course was performed at some acupoints to regulate the meridian qi of the Governor Vessel (GV) and promote the ascending of yang qi, so as to open the orifices and resuscitate brain, and harmonize Zang-fu organs. In addition, acupuncture can enhance the non-specific and specific immunity of the body, and enhance the immune function. It was pointed out that about 1/3 of children with CP had the problem of weakened immunity, who could not effectively take advantage of the nutrients from breast milk. And their immune system were imperfect, which leaded to a weakened immune function and was easy to be stimulated by external adverse factors[17].

Li GY’s study[18]found that rehabilitation training plus acupuncture method of invigorating spleen, tonifying kidney and regulating GV could significantly improve the lower limb function for children with spastic CP, and effectively improve the symptom of lower limb spasm.In this study, GMFM and MAS were used to evaluate the lower limb function of the children with spastic CP.And we found that after treatment, the scores of areas D and E of the GMFM scale in the observation group were significantly higher than those in the control group(bothP<0.05), and the improvement of the lower limb spasm in the observation group was significantly better than those in the control group (allP<0.05), which were the same as the Li GY’s study results, indicating that acupuncture plus rehabilitation training can effectively promote the recovery of the lower limb function for children with spastic CP, improve the gross motor function and the symptoms of lower limb spasm. Xu S,et al[19]found that the method of invigorating spleen,tonifying kidney, unblocking GV and opening the orifices could promote the establishment of synapses and neuromuscular junctions, and repair the damaged neurological function, thereby improving the physical condition and intelligence development level of the children. In this study, it was found that PDI and MDI scores in the observation group after treatment were significantly higher than those in the control group(bothP<0.05), indicating that children’s intelligence development level had been improved to a certain extent. Although the children's current intelligence level was still at borderline state, considering the short treatment time, whether acupuncture combined with rehabilitation training could restore the intelligence of children with spastic CP to the normal level, or how long it would take to reach the normal level remains to be studied.

Tan JX,et al[20]pointed out in their study that acupuncture plus MOTOmed intelligent motor training could effectively restore the blood perfusion of local brain tissue in children with spastic CP, thereby improving clinical symptoms. In this study, it was found out that the improvements of cerebral hemodynamic indicators in the observation group after treatment were superior to those in the control group (allP<0.05),indicating that acupuncture can improve local blood circulation, and therefore improve brain function. The levels of CD3+and CD4+in the observation group after treatment were significantly higher than those in the control group (bothP<0.05), while the differences in the CD8+level and CD4+/CD8+between the two groups were not statistically significant (bothP>0.05), which might be related to the short study period. This result showed that acupuncture treatment could improve the immune function of patients to a certain extent.

In summary, acupuncture method of benefiting intelligence and opening the orifices plus MOTOmed intelligent motor training can produce significant efficacy for children with spastic CP. It can effectively improve the lower limb motor function and promote the intelligence development.

Conflict of Interest

The authors declare that there is no potential conflict of interest in this article.

Acknowledgments

There was no project-fund supporting for this study.

Statement of Informed Consent

Informed consent was obtained from the guardians of the recruited children in this study.

Received: 16 May 2020/Accepted: 20 October 2020