Scientific Evaluate Quantification of Social and Behavioral by Scalp Acupuncture on Children with Autism Spectrum Disorder

    


    


    Figure 20: Comparison of ABC score between control group and observation group after treatment.

    

The scores of ATEC social dimension in the control group after treatment were lower than those before treatment (P<0.01), suggesting that routine ASD rehabilitation training (guided education, speech training, music therapy) can improve the ability of common attention and social communication of ASD. (Cited from Jin BX et al, Chinese Acupuncture & Moxibustion 2020,40(02):162-166)

The scores of ATEC social dimension in the observation group after treatment were lower than those before treatment (P<0.01), suggesting that acupoint catgut embedding therapy can improve the common attention ability and social communication ability of ASD. (Cited from Jin BX et al, Chinese Acupuncture & Moxibustion 2020,40(02):162-166)

After treatment, the scores of ATEC social dimension in the observation group were lower than those in the control group (P<0.05), suggesting that acupoint catgut embedding therapy has a positive role in promoting common attention and social communication ability of ASD children. (Cited from Jin BX et al, Chinese Acupuncture & Moxibustion 2020,40(02):162-166)

The scores of each dimension of ABC in the control group after treatment were lower than those before treatment (P<0.01), suggesting that routine ASD rehabilitation training (guided education, speech training, music therapy) can improve the sense, communication, body movement, language and life ability of ASD. (Cited from Jin BX et al, Chinese Acupuncture & Moxibustion 2020,40(02):162-166)

The scores of each dimension of ABC in the observation group after treatment were lower than those before treatment (P<0.01), suggesting that acupoint catgut embedding therapy can improve the sense, communication, body movement, language and life ability of ASD. (Cited from Jin BX et al, Chinese Acupuncture & Moxibustion 2020,40(02):162-166)

After treatment, the scores of each dimension of ABC in the observation group were lower than those in the control group (P<0.05), suggesting that acupoint catgut embedding therapy has a positive role in promoting the sense, communication, body movement, language and life ability of ASD. (Cited from Jin BX et al, Chinese Acupuncture & Moxibustion 2020,40(02):162-166).

Methodological Weakness

The results indicated that acupuncture was effective in the treatment of ASD. Safety result indicates safety or no safety result is mentioned. However, the results should be explained cautiously due to methodological weakness.

Random sequence Only two trials [21,25] randomly assigned participants by using a random number table. Two trials [23,24] assigned participants according to the order of the outpatient or inpatient number. One trial [19,22] did not express detailed way of random sequence generation. One trial [20] did not mention random sequence generation.

Allocation concealment Only one trial [25] concealed allocation by adopting the sealed envelopes. Six trials [19-24] did not express detailed way of concealment.

Blinding It is difficult to implement blinding as sham acupuncture is rarely used. Therefore, it is deemed that all trials did not blind their experimenters and subjects. In regard to the blinding of outcome evaluation, four trials [19-22] indicated that the outcomes were evaluated by a third party. Three trials [23-25] did not describe the identity of the evaluator of the outcome.

Incomplete outcome data: Four trials [21,22,24,25] did not have subjects excluded, withdrawn, eventually included in the analysis. Another three trials [19,20,23] did not specify the cause of subjects excluded and withdrawn.

Selective reporting: With regard to the selective reporting, as all trials did not register the trial protocols, there were no selective reporting.

Other bias: There were no other bias in all of the trials.

In addition, Liu et al [18] did not set up a control group, so the interpretation of the research results needs to be more cautious.

In order to obtain powerful evidence of the effectiveness and safety of acupuncture in the treatment of ASD, it is worth designing a study with higher methodological quality. According to the guidelines for clinical trials of acupuncture, the perfect study of acupuncture treatment for ASD is a large-sample, multi-center, double-blind, rigorously randomized, and placebo-controlled study. Detailed recording of adverse events and correct selection of statistical methods should be considered.

Mechanistic Research

The mechanism of acupuncture treatment of ASD is still unclear. Although a large number of clinical trials have proved the efficacy and safety of acupuncture in the treatment of ASD, there are few studies to reveal the mechanism of acupuncture treatment for ASD. We have found some studies on the mechanism of acupuncture in the treatment of ASD. Due to the limited sample size, lack of representativeness and design defects, it is difficult to draw consistent conclusions from these studies. Due to these defects, the potential mechanism of acupuncture treatment of ASD should be further studied on the basis of existing research.

Acupuncture Affects Synaptic Plasticity

Synaptic plasticity plays an important role in the growth and development of the nervous system, damage repair, learning, memory and other important central nervous functions. The change of synaptic structure and function caused by mutation of candidate gene or abnormal signal pathway may be an important mechanism of autism.

Current studies have shown that electroacupuncture can achieve good effects in repairing synaptic morphology of damaged neurons in autistic rats. S. Hossein Fatemi et al [26] found that gap junctions composed of CX proteins are the structural basis of electrical synapses. The expression of CX protein was significantly abnormal in the cortex of autistic patients, which participated in the abnormal behavior process [27]. Hong Yuzhu et al [28] found that acupuncture can regulate the expression of CX protein, thus improving the learning and memory ability of children with autism. Postsynaptic density protein 95 (PSD-95) can interact with postsynaptic amino acid receptors and play a key role in the signal transduction and integration of glutamate receptors [29]. The decreased expression of PSD-95 affects the function of synapses, which in turn affects the learning and memory functions of children with autism. Zhang Xuejun et al [30] used electroacupuncture at Houhai acupoint to treat autism rat models and found that after acupuncture at Houhai acupoint, the expression of PSD-95 protein in the middle cortex and hippocampus of the model rats increased. By activating the BDNF-TrkB signaling pathway, it is the key to synaptic plasticity to promote the directional aggregation of PSD-95 protein from the cell body to the synapse. Neuroligin and neurexin [31,32] mainly act on nerve synapses, and the two interact and play an important role in the regulation of nerve synapses. It acts on the formation of synapse structures, or processes such as neurotransmitter release, synapse recognition, maturation and information transmission. Tero et al [33] found that NLGN1, NLGN3, and NLGN4X are significantly related to autism. Hong Lin et al [34] found that acupuncture at the Changqiang point of VPA autistic rats can up-regulate the expression level of NLGN3 and improve the abnormal behavior of rats.

Acupuncture can repair damaged neuron synapse morphology and structure in autistic rats, and affect synaptic transmission efficiency. Then directly participate in or improve synaptic plasticity, improve learning, memory, cognition and other functions, thereby treating autism.

Acupuncture Regulates the Release of Neurotransmitters

Acupuncture can regulate the synthesis and release of various neurotransmitters in the central nervous system. It has been found that endogenous opioid peptide system may also be involved in acupuncture induced LTP process, which may be related to the improvement of learning and cognitive impairment in autism by acupuncture [35,36]. Yang Jing et al [37] found that electroacupuncture can participate in the cerebral ischemic tolerance effect of rats by regulating endogenous opioid peptides. Modahl. C et al [38] found that the degree of social communication dysfunction in children with autism was significantly related to the decrease of oxytocin in plasma. Lei Xuefeng et al [39] found that electroacupuncture can regulate the release of OXT, thus playing an analgesic role.

As an important neurotransmitter and its receptor, 5-HT plays an important role in the regulation of emotion, cognition, memory and learning of central nervous system. 5-HTTLPR in the promoter region of SLC6A4 of 5-HT gene encodes gene polymorphism, which increases the probability of abnormal gene transcription, thus causing abnormal 5-HT, which may be related to mental state such as neuroticism or anxiety [40]. Yu Yutian et al [41] found that acupuncture can improve the activity of nervous system caused by abnormal 5-HT to a certain extent. Hawking et al [42] found that electroacupuncture can improve the activity of 5-HT in hippocampus of Alzheimer's disease model rats.

Studies have shown that there is a linkage disequilibrium relationship between glutamate gene and autism susceptibility. γ-aminobutyric acid is an amino acid transmitter that plays an important role in neurodevelopment, Warrier et al [43] found that there is an obvious linkage imbalance between gabarb3 gene and autism, which may also be related to autism with epilepsy. The abnormality of amino acid transmitters caused by gene mutation may be related to the occurrence of autism. Acupuncture can treat autism by regulating the abnormality of amino acid transmitters. Yan Liping et al [44] found that acupuncture prevention and treatment of epilepsy may be through g over regulating amino transmitters. Deng Yuanjiang et al [45] found that acupuncture can prevent and treat epilepsy by affecting amino acid transmitters in hippocampus.

In the above studies on autism, it is found that these neurotransmitters are involved in the occurrence and development of various human behaviors and are closely related to the pathogenesis of autism. Acupuncture can improve the symptoms of autism by regulating the release and occurrence of these neurotransmitters.

Acupuncture Regulates Cell Apoptosis

Thompso CB et al. used autism model rats to conduct basic research and found that the ability of neuronal cells in the brain to inhibit apoptosis was up-regulated, which may be the mechanism that caused their abnormal behavior [46]. Studies have also shown that premature apoptosis of brain cells can cause encephalopathy such as Parkinson's disease, brain atrophy, and Alzheimer's, thereby affecting abnormal behavior [47]. Studies have shown that Bcl-2 is up-regulated, the expression of Bax and the ratio of Bax/Bcl-2 are decreased, causing abnormal hippocampal cell apoptosis, which may have an adverse effect on learning and memory [48]. Huang Qianru et al [49] found that acupuncture at DU-1 (Changqiang) can improve the abnormal behavior of rats with autism. The increase of Bax protein and Bax/Bcl-2 in the hippocampus of rats and the decrease of the expression of Bel protein weaken the abnormal apoptosis ability of the hippocampus of autistic rats and regulate the abnormal development of neurons. This may be related to improving its abnormal behavior mechanism.

Acupuncture Regulates Cerebral Blood Flow

Studies have shown that SPECT examination results for children with autism show that there are focal cerebral blood flow and brain function reduction areas [50,51]. Jia Shaowei et al [51] found that 34 children with autism had 114 different areas of cerebral blood perfusion and hypofunction through SPECT. Among them, 28 children were found to be consistent with low blood flow in the corresponding areas of children's learning, cognitive and language dysfunction. Electro-acupuncture at the points of LI-4 (Hegu), LI-11 (Quchi), ST-36 (Zusanli), SP-6 (Sanyinjiao) on both sides showed that the cerebral blood flow and brain function of the children were improved to varying degrees. The marked effect of electroacupuncture was 78.95%. It is preliminarily proved that acupuncture treatment of autism is related to improving cerebral blood flow and brain function. Whether through this mechanism or the secondary effects in the brain after acupuncture needs further study.

Acupuncture Affects Cytokines

Studies have found that changes in cytokines in autism play an important role in its pathogenesis, including pro-inflammatory and anti-inflammatory processes, leading to abnormal immune activation and response [52]. Among them, IL-6, IL-10, and TNF-a play an important role as cytokines, especially in the aspects of neuroplasticity, behavioral programming and differentiation. Hong Wei et al [53] confirmed that increased IL-6 levels reduced hippocampal excitement and then inhibited, and autistic rats with increased IL-6 levels showed autism-like behavior. IL-6 and TNF-a play an important role in regulating hippocampal synaptic plasticity on the one hand, and on the other hand are also involved in the toxicity of oligodendrocytes and axon growth [54,55]. Many studies have found that acupuncture has a good effect on anti-inflammatory and immune aspects. Acupuncture can inhibit and interfere with the occurrence and development of inflammation [56]. Acupuncture may protect the brain tissue by adjusting the concentration of cytokines [57].

Comments

In this part, we summarize the potential mechanism of acupuncture in the treatment of ASD. However, the mechanism of acupuncture treatment of ASD is still unclear. On the one hand, due to the complex etiology and biochemical changes of ASD, it is a neurodevelopmental disorder syndrome with a variety of biological factors. The mutation of candidate gene causes the change of transcription material, which leads to the change of neural structure, inflammatory immune response caused by cytokine imbalance, neuronal structural abnormality caused by abnormal signal pathway, apoptosis and other reasons. On the other hand, there are few basic researches on the mechanism of acupuncture in the treatment of ASD. As there is no unified evaluation standard for acupuncture treatment, it is more difficult to study it. The mechanism of acupuncture is complex, but it is certain that the treatment process of ASD must be multi-channel and multi-faceted. There is reason to believe that acupuncture can potentially affect different aspects of pathology of ASD. There is still a long way to go to reveal the secret of this mechanism.

Prospective Strategy: Xingnao Kaiqiao Scalp Acupuncture

Acupuncture has a short history in the treatment of autism, but the application of scalp points has achieved remarkable curative effect. Compared with the adverse reactions of Western medicine and complex behavior training, acupuncture and moxibustion with simple operation and no obvious adverse reactions are more easily accepted. "The head is the house of shrewdness". "The head is the meeting of all Yang" [58]. The application of acupoints on the head can adjust the meridians and Qi of viscera, dredge meridians and coordinate the balance of yin and Yang. And scalp acupuncture can act on the corresponding functional areas of cerebral cortex. Acupuncture enhanced the stimulation of the region by twisting manipulation or electroacupuncture. It improves the cerebral blood flow perfusion of relevant regions, activates dormant nerve cells, and repairs the damaged neural network, so as to improve the cognitive and social behavior abnormalities of patients [59].

Based on this, the application of head acupoints as the main acupuncture site is more and more. There are different kinds of scalp acupuncture therapy in clinic. What we are going to introduce is "Xingnao Kaiqiao scalp acupuncture therapy". There are 13 needles in total, including frontal five needles, EX-HN-1 (Sishencong), emotional area and heart and liver area. The five acupuncture points on the forehead are DU-24 (Shenting), bilateral ST-8 (Touwei) and bilateral GB-15 (Toulinqi). Among them, DU-24 (Shenting) is the main acupoint, and this point is mainly used to treat diseases related to mind. EX-HN-1 (Sishencong), formerly known as shencong, opened 1 inch before, after, left and right of the DU-20 (Baihui).Because there are four acupoints, it is also known as four gods Cong. It can regulate the function of cerebral cortex and can be used to treat diseases caused by nervous and mental disorders. Except for EX-HN-1 (Sishencong), the other 9 needles wiere located in the forehead, corresponding to the prefrontal lobe of the brain. Acupuncture on the scalp corresponding to the prefrontal lobe can directly stimulate the area, adjust the EEG activity, improve the cerebral blood flow velocity, and promote the functional awakening and recovery of prefrontal lobe. So it can improve intelligence, improve affective disorder, attention disorder and abnormal behavior. We have a significant effect in clinical application. However, the mechanism of "Xingnao Kaiqiao scalp acupuncture" in the treatment of ASD is rare. Therefore, we should study the mechanism of "xingnaokaiqiao scalp acupuncture" in the treatment of ASD to verify its efficacy.

Selection of Duration

Study [60] have shown that electroacupuncture can improve the autonomic activity of autistic rats. Electroacupuncture for 20 seconds (15 times in total) can improve the abnormal behavior patterns of autistic rats, such as stereotyped repetition and decreased interest. Compared with normal rats, the expression of BDNF protein was down regulated and bcl-2 protein was up-regulated in hippocampus of autistic rats. The expression of BDNF protein was up-regulated and the expression of Bcl-2 protein was down-regulated after 20 s electroacupuncture (15 times in total). Electroacupuncture for 20 seconds (15 times in total) can activate the expression of p-CREB and CREB protein in hippocampus of autistic rats, and cause acupuncture response effect. Whether EA 20 s (15 times in total) or 20 s (240 s in total), the stimulation time in 20s was the shortest time to take effect. Therefore, the selection of electroacupuncture duration is 20s (15 times in total).

Animal Model Selection

ASD is a group of neurodevelopmental disorders which have a serious impact on children's physical and mental health. So far, its pathophysiological mechanism is not clear. With the continuous improvement of various research technologies, scientists have gradually reached a consensus that ASD is the result of interaction between genetic predisposing factors and environment. Environmental factors should not be ignored in the pathogenesis of ASD. Early embryonic development is very important for brain development. If pregnant women are infected with virus, malnutrition, contacting or taking some drugs such as sodium valproate, thalidomide or chemicals, the risk of autism in their offspring will be increased.

The 12-14 days of rat embryos are equivalent to 20-24 days of human embryos, which are the key periods of neural tube closure and motor nucleus development. The incidence rate of ASD is significantly increased when the pregnant woman takes the thalidomide (20-24d) when she is pregnant. Sodium valproate is a drug for the treatment of epilepsy and bipolar depression. Taking sodium valproate in the first three months of pregnancy will lead to autistic behavior of the offspring. The above studies on the toxicity of drugs provide the basis for the experimental study of ASD and the establishment of ASD model.

Studies have shown that in E9-12.5 exposure to sodium valproate, offspring represent ASD like behaviors such as decreased social activity and increased stereotyped behavior, as well as changes in brain morphology and biochemical indicators. A large number of literatures have shown that the method of intraperitoneal injection of sodium valproate at E12.5 has good reliability and validity. It has been widely used in ASD related research, and achieved ideal results. For example, in terms of behavior, the model can accurately simulate the core symptoms of ASD, such as social disorder, stereotyped repetition and so on. In terms of Neurology and molecular biology, the model is similar to autopsy reports of autistic patients. Based on the pilot study of our group and the reports of other researchers, Wistar rats were used in this study to establish the animal model of ASD by intraperitoneal injection of 600 mg / kg sodium valproate into pregnant rats at E12.5. According to roullet's method, typical indexes were selected to test the behavior of rats induced by sodium valproate to evaluate whether the animal model was successful or not, and lay a foundation for the follow-up test.

Behavioral Assessments

Behavioral assessments have come to play increasingly important roles in designing experience ASD studies. Behavioral tasks are always used for verifying the success of establishing an animal model, or assessing the efficacy of a new therapy. As a behavioral test should have the following features: (1) objectivity and repeatability; (2) quantitative; (3) representativeness; (4) operability; and (5) sensitivity.

Three box experiment: Social intercourse refers to the communication between people in the society. It is a kind of social activities in which people transmit information and exchange ideas to achieve certain goals. The mechanism of social behavior is a complex process, which acts on a variety of sensory organs through the stimulation of internal and external environment, resulting in the corresponding behavior of individuals to the stimulation. Human beings can integrate themselves into this society through the interaction between human beings. For many animals, social interaction is equally important. Social disorder is a manifestation of depression and autism. In order to study the changes of social behavior in animal models, scientists have developed a series of social behavior experiments, among which the more mature is the "three box social test" for rats and mice. The principle is based on the natural gregarious nature of wild mice and the tendency to explore new things. Wild type mice are social animals, they have certain social attributes. When they contact with the same kind, they can form a certain social memory. This social memory can further influence their social decisions. Therefore, when faced with new and unfamiliar individuals, normal rats will recall the same kind of memory that they have contacted and are familiar with before. For them, the novelty of the same species is more alluring. Therefore, in the face of familiar and completely unfamiliar siblings, normal rats are willing to contact with strangers for a longer time, showing social desire and novelty preference. Early exposure to sodium valproate in rats leads to nervous system development disorders, decreased desire for novelty exploration, and loss of social desire and novelty preference.

Open field experiment: Rodents have the characteristics of pursuing advantages and avoiding harm. Animals will be very careful in an open new place. Animals like dark and avoid light, which makes them hide in the corner, and easily do not step into the central grid. However, they will also explore the open space (curiosity). It has certain novelty and certain fear at the same time. In open field experiments, they tend to stay in the corner or edge against the wall, and they also have the nature to explore new environment. They tend to stay in the center and have more distance to move. Open field experiments are often used to evaluate the depression and anxiety of animals. Depression animal models showed that they spent more time in the corner and edge. On the contrary, anxious animals run more, have more activities, spend more time in the center. The central grid residence time can also be used to evaluate the anxiety level of animals. Autistic children will generally show abnormal emotional problems, manifesting irritability, irritability, hyperactivity, rigid, do not like to change and new things. Autism rats often have the characteristics of abnormal mood, aggressive behavior, large amount of activity and hyperactivity, which are the manifestations of stress and anxiety.

Morris water maze: The camera system installed on the top of the maze mainly monitors the spatial learning and memory ability and memory maintenance time of animals, which can quantify learning and memory. In the positioning cruise experiment, the spatial learning and memory ability was evaluated by recording the time of escaping from lurking on the hidden platform. The prolongation of escape latency indicates the decline of learning and memory ability. In the space exploration experiment, the number of times that animals cross the original platform position in a specified time reflects their ability to maintain spatial memory.

Concluding Remarks (including perspectives)

In this chapter, we have summarized the clinical application of acupuncture in the treatment of ASD by reviewing current studies, and try to find the potential mechanism from the limited information available. A large number of studies have reported positive efficacy and fewer side effects of acupuncture in the treatment of ASD. Some studies focusing on the underlying mechanism of acupuncture are under way. If the effect of acupuncture is strictly verified, acupuncture will be introduced to the mainstream academic theory as an alternative therapy commonly used in the treatment of ASD.

Like other alternative therapies, the efficacy and safety of acupuncture have not been rigorously verified. Due to methodological defects, the observation and results thus obtained have overestimated the treatment efficacy and concealed the possible adverse events, which reduces the reliability of these studies. This is the main reason why some alternative therapies are not accepted.

What is worse is that not only is the therapy itself under doubt, but it has prejudiced the viewpoint of the involved researchers against the whole TCM theory system, including those from its motherland. It is for this reason that TCM today faces an awkward stand even in China. So we wish to raise these interests and bring forth the need for well-designed, rigorous clinical and experimental studies to provide formidable scientific evidence validating the efficacy and safety of acupuncture in the treatment of ASD.

At the end of this chapter, we put forward "Xingnao Kaiqiao scalp acupuncture therapy" We believe it will be accepted by most ASD researchers, including general medical surveys.

Author Statements

Acknowledgements

Thank Dr. Zhao Yong and Dr. Li Nuo for their outstanding contributions to this study, and all the medical staff of the children's rehabilitation department for their contributions to this study.

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