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EUJIM 598 No. of Pages 8

European Journal of Integrative Medicine xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

European Journal of Integrative Medicine

journal homepage: www.elsevier.com/eujim

Review article

Acupuncture for Tourette syndrome: A systematic review and

meta-analysis
Sun-Yong Chung, KMD, PhDa , Byoung Jin Noh, KMD, PhDb , Chang-Won Lee, KMD, MSb ,
Man Ki Hwang, KMD, PhDb , Moonyeo Kang, KMD, PhDb , Sungeun Kwon, KMD, PhDb ,
Seung-Hun Cho, KMD, PhDa,*
a
Department of Neuropsychiatry, College of Korean Medicine, Kyung-Hee University, Seoul, Republic of Korea
b
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: Introduction: Tourette syndrome (TS) is a tic disorder with multiple motor and vocal or phonic tics. The
Received 29 July 2016 effect of acupuncture for TS has not been well established.
Received in revised form 1 September 2016 Methods: English, Japanese, Korean and Chinese databases, were explored systematically for randomized
Accepted 2 September 2016
controlled trials investigating the use of acupuncture for treating TS, up to August 2016, without language
Available online xxx
restrictions. All studies evaluating the effects of acupuncture were identified. Studies assessing the effect
of moxibustion were excluded. All ages were considered. Data were extracted independently using
Keywords:
predefined data fields, including study quality indicators. All pooled analyses were based on random-
Acupuncture
Tic disorders
effects models. The authors individually evaluated risk of bias with the Cochrane Collaboration’s tools.
Tics Results: Nineteen Studies (N = 1483) were systematically reviewed. A significant benefit was observed for
Tourette syndrome studies comparing acupuncture versus medication (pooled the risk ratio showed improvement by 1.17;
Randomized controlled trials 95% confidence interval: 1.10–1.25, p < 0.00001). Reporting of adverse events was poor with only one
Systematic review 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 efficacy and safety of acupuncture is
warranted.
ã 2016 Published by Elsevier GmbH.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.1. Information sources and search strategy . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2. Eligibility criteria and study selection . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2.1. Types of studies . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2.2. Types of participants . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2.3. Types of interventions . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.2.4. Types of outcome measures . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.3. Data collection . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.4. Assessment of risk of bias . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
2.5. Summary measures and synthesis of results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.1. Study characteristics . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3.2. Risk of bias in included studies . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

* 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/ã 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
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3.3. Synthesis of results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

1. Introduction pain reduction are promising [21]. However, no systematic reviews

for assessing acupuncture for TS have been published.
Tics are described as, non-rhythmic, repetitious involuntary, The purpose of this study was to analyze randomized controlled
vocalizations or unexpected movements [1]. Tic disorders are trials (RCTs) of acupuncture to determine its effectiveness in
divided by tic type and duration. Chronic tic disorders and Tourette reducing tic severity in TS.
syndrome (TS) are characterized by the presence of sudden
vocalizations or motor movements that persist for more than a 2. Methods
year [2]. TS affects the face, shoulders, neck and vocal apparatus
preferentially with involuntary motor and vocal tic behaviors [1,3]. 2.1. Information sources and search strategy
TS occurs worldwide and at all ages [4]. It affects around 2% of
school-age childrenand is the most common movement disorder For this systematic literature review, several healthcare
in the pediatric age group [5]. Individuals with TS frequently have databases including Medline, CINAHL, EMBASE, PsycINFO, a
complications especially attention-deficit hyperactivity disorder, Chinese database (CNKI), a Korean database(Oriental Medicine
obsessive compulsive disorder, anxiety disorders, impulse control Advanced Searching Integrated System) and a Japanese database
disorders and personality disorders [6]. Tics have also been (J-STAGE) were explored following the procedure suggested in
associated with functional impairment and diminished quality of PRISMA guidelines [22] (Fig. 1). Searches were conducted up to
life [3]. August 2016, using the following search terms (“Tourette” or “tic
A variety of treatment approaches have been used to manage disorder” or “tic” or “Tourette syndrome” and “acupuncture” or
tics in TS [7]. Traditionally, neuroleptics such as antipsychotics and “acupoint” or “pharmacopuncture” or “meridian” or “electro-
alpha-2 agonists have been considered the mainstay of treatment acupuncture”). There were no limitations on the language of
in TS, and haloperidol is deemed the first line of treatment [8]. publication. The results of the literature search were investigated
Psychotropic medications such as haloperidol have shown efficacy and any duplicates were excluded. The titles and abstracts of all
and usefulness [9]. Despite their effectiveness, antipsychotics may articles were reviewed and the irrelevant papers were excluded.
be associated with adverse effects and limited admissibility [10]. Finally, the references of all eligible full-text articles were
Antipsychotic medication such as haloperidol can lead to examined for potentially relevant RCTs. References of classified
nervousness, cognitive dulling/feeling drugged, sedation, body studies and review papers were assessed for any additional
weight gain, low mood and extrapyramidal symptoms. Extrapyra- papers.
midal symptoms can take the form of fatigue, muscle rigidity,
posturing and tongue protrusion; parkinsonian symptoms such as 2.2. Eligibility criteria and study selection
tremors, rigidity, lack of facial expression, drooling and difficulty in
movement [8]. Pharmacological interventions remain the most Two reviewers evaluated the inclusion criteria independently.
common approach [7], but various nonpharmacological treatment Arguments between reviewers about inclusion and exclusion were
therapies have emerged in the past three decades, including such solved by discussion. Identified abstracts and citations were
as relaxation training, practice, habit reversal training, exposure evaluated for the following inclusion criteria.
and response prevention, and surgical therapies [11].
To avoid these adverse effects of medication, many patients 2.2.1. Types of studies
with tic disorders have explored the use of complementary and All randomised controlled trials and quasi-randomized studies
alternative medicine (CAM). The use of CAM in conventional were included. For randomized cross-over trials that were
medicine has grown dramatically in recent decades [12,13]. Nearly available only records up to the first phase of the cross-over were
40% of healthy children seen in pediatric clinics and more than 50% considered.
of children with chronic conditions, use CAM [13–15]. CAM has
been reported using CAM to control their tic disorders in some 2.2.2. Types of participants
people [16]. In a 2004 survey approximately 40% of patients Patients with a clinical diagnosis of TS were included. All ages
reported having used CAM in the previous year. Most users of CAM were considered.
reported improvements in their tic symptoms [17].
Acupuncture is one of the most popular CAM treatments [18]. It 2.2.3. Types of interventions
has been used to treat several diseases and alleviate symptoms and Studies that examined the efficacy of acupuncture in treating TS
is growing in importance in many parts of the world. Acupuncture were included. In the study selection criteria, acupuncture was
is used by a growing number of pediatric patients [19]. defined as the stimulation of specific acupuncture points along the
Acupuncture was used on more than 150,000 children (0.2%) in skin of the body by using needles with or without the application
2002. In current years, acupuncture has become integrated of heat, electrical current or laser light to these same points. RCTs
increasingly into pediatric clinics. The effectiveness of acupuncture that evaluated the effect of moxibustion or acupressure were
for some diseases is promising, with no reports of severe side excluded. When treatment effect information was not adequately
effects [19,20]. Acupuncture has been used widely for treatment of reported, study researchers were contacted to obtain data. If
asthma, cerebral palsy, autism spectrum disorder, and other treatment effect data were unavailable for separate conditions
conditions in children. Furthermore, the effectiveness of acupunc- and/or the authors did not respond to requests, the study was
ture for treating nocturnal enuresis, tic disorders, amblyopia, and excluded from analysis.

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
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Fig. 1. Flow diagram for the study selection on Tourette syndrome.
2.2.4. Types of outcome measures
The primary outcome measures were tic severity or response
rate, which included the number, intensity, complexity, and
interference. These outcomes were measured by the patients or
a clinician, using rating scales with Yale Global Tic Severity Rating
Scale (YGTSS), the Tic Symptom Self Report, a video protocol, or a
self-rating scale such as the TS Symptom List. The secondary
outcomes analyzed were any rated adverse effects.
2.3. Data collection
Data from the included studies in the review, data were
individually recorded by each reviewer and entered into an Excel
spreadsheet. Trials were coded by two raters for reliability, and
results were compared to confirm accuracy. Rater differences were
settled through discussion and agreement. Trials were coded for
the following characteristics (sample size, percent of sample on tic
medication, patients with TS, mean age of patients; number of
acupuncture sessions, mean difference(MD), treatment response,
inclusion of a comparison condition, and study methodology).
2.4. Assessment of risk of bias
The authors individually evaluated risk of bias in agreement
with the Cochrane Collaboration’s tools for evaluating quality and
risk of bias [23]. This tool considers ‘how the sequence was
generated, how allocation was concealed, the integrity of blinding,
the completeness of outcome data, selective reporting and other
biases’. The risk of bias in each domain were evaluated and
categorized into three groups: 1) ‘low risk of bias’, ‘plausible bias
unlikely to seriously alter the results’; 2) ‘high risk of bias’,
‘plausible risk of bias that seriously weakens confidence in the
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
3
results’; and 3) ‘unclear risk of bias’, ‘plausible bias that raises some
doubt about the results’. If the raters disagreed, the final 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 Mantel-
Haenszel 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% confidence 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 classified as “treat-
ment 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 significant
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 final 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
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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 identified 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). Consider-
ing the abstracts, 129 papers met the search inclusion criteria
detailed above. The majority of the papers using acupuncture did
not specifically 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
of acupuncture in the treatment for TS in all ages were included.
Seven studies were identified and excluded as acupuncture was
used in conjunction with another treatment option as an
intervention treatment. The remaining 19 studies [24–42] met
the inclusion criteria in our review. All included studies were
published in China.
In total, 9 of the 19 studies included in the review assessed
acupuncture versus haloperidol [24,25,27,29,30,32,38,39,41], two
studies [33,34] evaluated acupuncture versus risperidone, two
evaluated acupuncture versus tiapride [28,42], five evaluated
electro-acupuncture versus haloperidol [26,31,35–37] and one
study reported on pharmacopuncture versus haloperidol [40]. The
number of acupuncture sessions per patient ranged from 10 to 60
sessions. The length of each treatment time ranged from 3 weeks to
3 months. The most frequently used acupoints were GB20 and
GV20. Most of the trials were one arm-randomized studies. Two
trials [24,38] used a three-arm design. The number of patient

Table 1
Characteristics and the risk of bias assessment of included studies of acupuncture for Tourette syndrome.

Study Subjects (age range or mean age): Intervention type, Treatment sessions (treatment Control group Outcome Assessment
Duration of Tourette syndrome frequency); Treated acupoints measures risk of biasa
[24] 96 children(4–15y) and 9 subject (16– Acupuncture, 40 sessions (once everyday); MS1, MS5, a) Scalp acupuncture and herb Response U-U-U-U-L-
26y): 99 cases for 1–5y, 6 cases for 5–16y MS8 medicines: 40 days rate U-L
b) Haloperidol 0.5mg–8 mg/d
during 40 days
[25] 60 children (5–12 y): for 0.5-5y Acupuncture 40 sessions (once everyday); EX-HN3, Haloperidol Response U-U-U-U-L-
SP6,LR3, LI3, GB20, BL62, KI6 0.1 mg/d per body weight(kg) rate U-L
during 2 months
[26] 102 subjects (not reporting):for 1–8y Electro-acupuncture: 30 sessions (once everyday); Haloperidol 1.5mg–8 mg/d Response U-U-U-U-L-
PC6, LI4, GB20, GV20, Chorea-tremble control area rate U-L
[27] 49 children and adolescents (4–17y):for Acupuncture 20 sessions (once everyday); PC6, GB20, Haloperidol 1.5mg–6 mg/d Response U-U-U-U-L-
0.5-11y GV24, LR3, EX-HN1 rate U-L
[28] 140 children (4–15y):for 1–9y Acupuncture once in 2 days for 2 months: Motor area, Tiapride 100mg–500 mg/d for YGTSSb U-U-U-U-L-
Chorea-tremble control area 2 months L-L
[29] 102 children (3–15y):for 1–9y Acupuncture 60 sessions (once everyday): LI4, LR3, Haloperidol 0.5 mg/d for Response U-U-U-U-L-
GV20, HT7, BL10, SI4 60 days rate, U-L
[30] 45 children and adolescents (5–16y):for Acupuncture 10 sessions (once everyday): LI4, LR3, Haloperidol 1.5mg–8 mg/d for Response L-U-U-U-L-
1–5y GB20, GV24, EX-HN1 10 days rate U-L
[31] 60 children (6–12 y):for 0.5-6y Electro-acupuncture 36 sessions (once everyday): Haloperidol 1.5mg–8 mg/d for Response U-U-U-U-L-
MS1, MS5, MS8 36 days rate U-L
[32] 58 children and adolescents (4–16y):for Acupuncture 30 sessions (once everyday): LI4, LR3, Haloperidol 4mg–8 mg/d for Response U-U-U-U-L-
1.5–12y GB20 30 days rate U-L
[33] 60 children and adolescents (6–18y):for 1– Acupuncture 3 sessions per week for 3 months: MS1, Risperidone Response U-U-U-U-L-
7y MS5, MS8 0.5mg–1 mg/d for 3 months rate, L-L
YGTSS
[34] 60 children and adolescents (5–16y):for Acupuncture 3 sessions per week for 3 months: GV24, Risperidone Response U-U-U-U-L-
1–8y GB13 0.5mg–1 mg/d for 3 months rate, L-L
YGTSS
[35] 60 children (10.2y): for 2.15y Electro-acupuncture everyday for 6 weeks: GV20, Haloperidol 1mg–4 mg/d for 6 Response L-U-U-U-L-
GV24, BL23, GV14 weeks rate, L-L
YGTSS
[36] 60 subjects (not reporting):for 1–5y Electro-acupuncture 20 sessions(once everyday): Haloperidol 1.5mg–8 mg/d for Response U-U-U-U-L-
GV20, GB20,LI4, Chorea-tremble control area 20 days rate U-L
[37] 60 children (8.6y):for 1–8y Electro-acupuncture 60 sessions(once everyday): Haloperidol 2mg–8 mg/d for 2 Response U-U-U-U-L-
GV20, GB20,LI4,GV24, LR3, Chorea-tremble control months rate, L-L
area YGTSS
[38] 150 children (8.5y):for 1–10y Acupuncture 45 sessions for 3 months: GV20, LI4, Medication group: Response U-U-U-U-L-
GB20, GV16, LR3, KI3 Haloperidol 1.5mg–4 mg/d for rate, U-L
3 months
Herbal group: Yi-gan-san for
3 months
[39] 62 children and adolescents (11.29y):for Acupuncture 5 sessions per week for 2 months; GV20, Haloperidol 2mg–6 mg/d for 2 Response U-U-U-U-L-
1–7y GV24, TE23, LI4, PC6 months rate U-L
[40] 90 children (6.7y): for not reporting Acupuncture and pharmacopuncture 6 sessions per Haloperidol 1mg–2 mg/d for 3 Response U-U-U-U-L-
week for 3 weeks: GV20, EX-HN3 weeks rate U-L
[41] 28 children (5–14 y): for 1–3y Acupuncture 36 sessions for 45 days: HT7, LI4, LR3, Haloperidol 1mg–8 mg/d for Response L-U-U-U-L-
LR2, ST41, BL62, KI6 45 days rate U-L
[42] 87 children (2–15 y): for 0.5-3.2y Acupuncture 60 sessions for 3 months: LI4, GB20, Tiapride 150mg–450 mg/d for Response L-U-U-U-L-
GV20, EX-HN5, EX-HN1 3 months rate U-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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sessions per patient ranged from 28 to 150 with a mean of 78.1
subjects per study. The diagnosis of TS was usually defined by
clinical criteria (CCMD-2-R or 3). A total of 1483 patients
participated in the included studies, with ages ranging from 4 to
26 years. Two of these trials [24,26] included adults while the
majority focused on the effect of acupuncture in children
(aged < 18 years). In general, most studies assessed the improve-
ment rate of symptoms. The YGTSS was used to assess the degree of
tic severity in five [28,33–35,37] of the included studies. Table 1
lists the 19 RCTs that met the inclusion criteria, which formed the
total sample of 1483 participants.
3.2. Risk of bias in included studies
Four [30,35,41,42] of the studies described their methods of
randomization (Table 1). None of the studies described allocation
concealment. All trials were conducted as open trials without
blinding of participants and outcome assessments. All trials
reported outcome measure data for all participants; however,
none of the authors mentioned if they used intention-to-treat
analysis. Five studies [28,33–35,37] used the examiner’s YGTSS
ratings; however, others did not report global tic severity scores.
There did not seem to be any other noticeable biases (e.g., baseline
imbalance, design-specific risk of bias and differential diagnostic
activity).
3.3. Synthesis of results
As seen in Fig. 2, a random-effects analysis showed a significant
treatment effect for acupuncture compared to all control
medications (RR = 1.17, 95% CI: 1.10–1.25, p < 0.0001). Visual check
of the forest plot, Q statistic, and I2 statistic did not identify the
presence of heterogeneity among the studies (Chi2 = 28.39, p = 0.16,
I 2 = 25%).
There was a high RR in favor of group receiving acupuncture
experiencing a treatment response compared to the haloperidol
medication group (RR = 1.22, 95% CI: 1.09–1.37, z = 3.41, p = 0.0006).

Fig. 2. Forest plots showing comparisons of treatment response for acupuncture.

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Two studies [33,34] compared acupuncture treatment with
risperidone medication, and one study [42] compared acupuncture
with tiapride. In the two studies that used risperidone as the
comparison condition, the summary effect was calculated as a
significant treatment effect (RR = 1.31, 95% CI: 1.02, 1.67, z = 2.16,
p = 0.03), with less heterogeneity observed (I 2 = 0%). The study
using tiapride as the comparison condition described no significant
difference (RR = 1.09, 95% CI: 0.92–1.28). Five studies [26,31,35–37]
compared electro-acupuncture treatment with haloperidol medi-
cation. Merging these studies for assessment of improvement in tic
severity using a random-effects model presented an RR of
improving symptoms in favor of electro-acupuncture treatment
(RR = 1.14, 95% CI: 1.01, 1.28, z = 2.17, p = 0.03). Li [40] reported no
significance in the treatment group using pharmacopuncture
versus haloperidol (RR = 1.13, 95% CI: 0.98, 1.30). There was no
observable asymmetry in the funnel plots of these 19 RCTs (Fig. 3).
Mao [28] and Xu [34] exhibited that the decrease of YGTSS was
significantly better in an acupuncture group than in a medication
group (MD = 8.38, 95% CI = 2.63–14.13; MD = 4.31, 95% CI: 2.80–
5.82). Meanwhile Xu[33] described no significant difference
between the groups (MD =
0.31, 95% CI =
1.87–1.25). Combining
these results did not demonstrate a significant difference between
groups using a random-effects analysis model (pooled MD = 3.46,
95% CI =
0.67, 7.62, z = 1.63, p = 0.10, I2 = 91%).
Only one study observed and reported on adverse events. Liu
[38] reported that there were no adverse events in their
acupuncture treatment group.
4. Discussion
The purpose of this systematic review was to present evidence-
based information on the effectiveness of acupuncture for TS by
summarising the results of RCTs. The summary of RRs showed a
significant improvement of acupuncture groups (RR = 1.16, Fig. 2).
Our main result was that acupuncture meaningfully reduced tic
symptoms in patients with TS. While TS is usually managed with
pharmacotherapy, this statistical analysis suggests that acupunc-
ture could be an another treatment option with treatment effects
comparable to those of psychotropic medications. Approaches
used were diverse, including in terms of techniques and
acupuncture type, changing patients’ outlook on their condition,
Fig. 3. Funnel plot of comparisons: acupuncture versus medications.
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
and even modification of external factors. No serious adverse
events were described in the trials included in this review.
Fifteen studies compared acupuncture or electro-acupuncture
with haloperidol medication. Each of these RCTs discovered that
acupuncture was more effective at decreasing tic symptoms,
yielding RRs of 1.19,1.14. In addition, two studies by Xu [33,34]
showed an RR in tic severity of 1.31 in the acupuncture group
compared with risperidone. However, pharmacopuncture did not
appear to produce a significant difference versus haloperidol, in
contrast to the other 15 studies reviewed in the existing article.
Evidence for the effectiveness of pharmacopuncture treatments is
generally limited to small-sample studies. A greater percentage of
patients from the acupuncture group were found to be optimistic
responders compared with the medication group, causing in a
possible bias in follow-up evaluation of tic symptoms. The main
selected acupoints in the included studies were GB20, GV20, GV24,
MS1, MS5, MS8 and were located on the head. However, the
included studies were very heterogeneous in terms of chosen
acupoints and meridians. Additionally, the authors rated clinical
improvement rather than using the YGTSS. Although the summary
of RRs of for the improvement rate of the included acupuncture
trials showed favouring acupuncture, combining results in studies
using with YGTSS did not demonstrate a significant difference.
Thus, there were limitations on the exactness and generalizability
of the results.
Further problems with the observed studies relates to the
blinding process. The studies of acupuncture were not assessor-
blinded. In the study using YGTSS, the assessors who rated the
YGTSS were not blinded to the both groups of the patients. The
greatest inadequacy in the included studies was the disappoint-
ment in describing the randomization process or the method of
allocation concealment. Methodological heterogeneity inhibits
drawing firm conclusions.
Although antipsychotic treatments may have greater effective-
ness than acupuncture for TS, this advantage appears to be
counterbalanced by the presence of significantly greater side
effects, particularly extrapyramidal symptoms. In addition to side
effects, drugs carry the potential disadvantages of side effects, non-
compliance and unresponsiveness. It is worthwhile considering
the use of acupuncture treatments in patients with TS, instead of or
as well as pharmacotherapy, as have several advantages.
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There were several limitations intrinsic to our review. One
important limitation in the review was that administrations of the
same treatment tended to vary between studies. Although there
was no statistical heterogeneity, the most difficult challenge faced
in this review was clinical heterogeneity. The included studies
were heterogeneous in terms of the population included, control
groups, type of acupuncture, outcome measures, duration of
treatment, and presentation of data.
We used extensive searches and rigorous methods for this
review, but drawing meaningful conclusions from these results is
difficult because there was high risk of bias. Many RCTs had
methodological deficiencies such as insufficient blinding. Although
blinding of the therapist who applies acupuncture would be
complicated, blinding of patients and other care providers, as well
as outcome assessors should be attempted to minimize the
implementation and evaluation bias of trials. Due to lower
methodological quality, no clear recommendation could be made.
Although the reporting and methodological quality of the
studies have improved in recent years, in terms of detailed
reporting of acupuncture treatment, larger sample sizes, long-term
follow-up and blinding, there remains a lack of consensus
regarding adequate acupuncture treatment (e.g., number of
needles inserted, needle manipulation, treatment sessions, etc.).
Future studies are needed to evaluate the potentially superior
features of acupuncture. Many trials could not be involved in the
meta-analyses for the reason of the way the authors reported the
results. Therefore, we suggest that publications of coming trials
employ the YGTSS as a continuous measure. In illnesses like tics in
which individuals tend to have other co morbidities, selecting a
treatment approach should consider both subjective and objective
improvements. Likewise, quality of life should also be considered.
Replacing medication therapy with acupuncture may reduce
adverse effects and improve the quality of life. We noted
reductions in tic severity in patients given with pharmacopunc-
ture. The use of this pharmacopuncture therapy is sustained by
relatively little research in TS populations. To allow reliable
comparisons with acupuncture, future clinical studies should
explore the effect of pharmacopuncture in larger numbers of
patients with TS.
5. Conclusion
Our findings suggest that acupuncture is efficacious for
reducing tic severity in TS. The analysis suggests that acupuncture,
and electro-acupuncture, may have a slightly superior treatment
effect to that of haloperidol or risperidone, while there is no
significant difference in efficacy compared with tiapride.
However, the weak methodologies of the trials examined make
it difficult to draw firm decisions about whether the effect of
acupuncture is superior to medication therapy. Future studies are
needed that more accurately evaluate the effects of acupuncture.
To facilitate the interpretation of clinically important differences
between treatment groups, we suggest that publications of future
trials employ the YGTSS to assess the primary outcome of tic
severity among groups.
Conflicts of interest
None.
Acknowledgment
This work was supported by a grant from the National Research
Foundation of Korea (NRF), funded by the Korea government
[MEST] (No. 2012-0005755).
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
7
References
[1] J.F. McGuire, E. Nyirabahizi, K. Kircanski, J. Piacentini, A.L. Peterson, D.W.
Woods, et al., A cluster analysis of tic symptoms in children and adults with
Tourette syndrome: clinical correlates and treatment outcome, Psychiatry Res.
210 (2013) 1198–1204.
[2] C.A. Conelea, Exploring the impact of chronic tic disorders on youth: results
from the Tourette Syndrome Impact Survey, Child Psychiatry Hum. Dev. 42
(2011) 219–242.
[3] A.E. Cavanna, S. Servo, F. Monaco, M.M. Robertson, The behavioral spectrum of
Gilles de la Tourette syndrome, J. Neuropsychiatry Clin. Neurosci. 21 (2009)
13–23.
[4] R.D. Freeman, An international perspective on Tourette syndrome: selected
findings from 3,500 individuals in 22 countries, Dev. Med. Child Neurol. 42
(2000) 436–447.
[5] B. Tijero-Merino, J.C. Gomez-Esteban, J.J. Zarranz, Tics and Gilles de la Tourette
syndrome, Rev. Neurol. 48 (Suppl. 1) (2009) S17–S20.
[6] N. Hassan, A.E. Cavanna, The prognosis of Tourette syndrome: implications for
clinical practice, Funct. Neurol. 27 (2012) 23–27.
[7] J. Stern, S. Burza, M. Robertson, Gilles de la Tourette's syndrome and its impact
in the UK, Postgraduate Med. J. 81 (2005) 12 1–9.
[8] R.R. Silva, D.M. Muñoz, W. Daniel, J. Barickman, A.J. Friedhoff, Causes of
haloperidol discontinuation in patients with Tourette's disorder: management
and alternatives, J. Clin. Psychiatry 57 (1996) 129–135.
[9] S.A. Franklin, M.R. Walther, D.W. Woods, Behavioral interventions for tic
disorders, Psychiatr. Clin. North Am. 33 (2010) 641–655.
[10] H. Weisman, I.A. Qureshi, J.F. Leckman, L. Scahill, M.H. Bloch, Systematic
review: pharmacological treatment of tic disorders – efficacy of antipsychotic
and alpha-2 adrenergic agonist agents, Database Abstr. Rev. Eff. (2013) 1162–
1171.
[11] T. Deckersbach, S. Rauch, U. Buhlmann, S. Wilhelm, Habit reversal versus
supportive psychotherapy in Tourette's disorder: a randomized controlled trial
and predictors of treatment response, Behav. Res. Ther. 44 (2006) 1079 10–90.
[12] K.J. Kemper, S. Vohra, R. Walls, Complementary tTFo, medicine A, the
provisional section on complementary H, et al: the use of complementary and
alternative medicine in pediatrics, Pediatrics 122 (2008) 1374–1386.
[13] S. Gottschling, B. Gronwald, S. Schmitt, C. Schmitt, A. Längler, E. Leidig, et al.,
Use of complementary and alternative medicine in healthy children and
children with chronic medical conditions in Germany, Complementary Ther.
Med. 21 (Supp. l) (2013) S61–S69.
[14] L.J. McCann, S.J. Newell, Survey of paediatric complementary and alternative
medicine use in health and chronic illness, Arch. Dis. Child. 91 (2006) 173–174.
[15] S.K. Aburahma, Y.S. Khader, K. Alzoubi, N. Sawalha, Complementary and
alternative medicine use in a pediatric neurology clinic, Complementary Ther.
Clin. Pract. 16 (2010) 117–120.
[16] K. Kompoliti, W. Fan, S. Leurgans, Complementary and alternative medicine
use in Gilles de la Tourette syndrome, Mov. Disord. 24 (2009) 2015–2019.
[17] B.J. Mantel, A. Meyers, Q.Y. Tran, S. Rogers, J.S. Jacobson, Nutritional
supplements and complementary/alternative medicine in tourette
syndrome, J. Child Adolesc. Psychopharmacol. 14 (2004) 582–589.
[18] H.A. Tindle, R.B. Davis, R.S. Phillips, D.M. Eisenberg, Trends in use of
complementary and alternative medicine by US adults: 1997–2002, Altern.
Ther. Health Med. 11 (2005) 42–49.
[19] C.A. Braun, L.H. Bearinger, L.L. Halcón, S.L. Pettingell, Adolescent use of
complementary therapies, J. Adolesc. Health 37 (2005) 76.
[20] A.J. Vickers, R.W. Rees, C.E. Zollman, R. McCarney, C.M. Smith, N. Ellis, et al.,
Acupuncture for chronic headache in primary care: large, pragmatic,
randomised trial, BMJ 328 (2004) 744.
[21] C. Yang, Z. Hao, L. Zhang, Q. Guo, Efficacy and safety of acupuncture in children:
an overview of systematic reviews, Pediatr. Res. (2015).
[22] D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, P.G. The, Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement, PLoS Med. 6
(2009) e1000097.
[23] The Cochrane Collaborationo, Julian Higgins, Sally Green, Handbook for
Systematic Reviews of Interventions Version 5.1.0, The Cochrane
Collaboration, 2011 (updated March 2011).
[24] Y. Shan, W. Yao, Clinical observation on treatment of mu ltiple tourette0 s
syndrome with scalp acupuncture, Chin. Acuponcture Moxibustion (2001)
331–332.
[25] Y. Zhang, Treatment of gilles de la tourette's syndrome by Dongjing
acupuncture, Chin. Acuponcture Moxibustion (2002).
[26] W. Guo, X. Chi, Y. Sun, Clinical observation on 102 cases of child gilles de la
tourette's syndrome by electroacupuncture on the head, Chin. J. Tradit. Med.
Sci. Technol. 11 (2004) 304.
[27] D.-w. Sun, Treatment of 25 cases of child gilles de la tourette’s syndrome by
combined scalp and body acupuncture, Shanghai J. Acupuncture Moxibustion
24 (2005) 15–16.
[28] H.-r. Mao, T.-f. Zhang, Control Study of Scal Acupunctyure and Tiapride for
Gilles De La Tourette's Syndrome, Hubei College of Traditional Chinese
Medicine, 2005.
[29] S. Ma, X.-y. Liu, R.-l. Yu, L.-j. Chen, Clinical observation on acupuncture for
treatment of Tourette’s syndrome, Chin. Acupuncture Moxibustion (2006)
392–394.
[30] G.-s. Du, Observations on the curative effect of acupuncture on child tourette’s
syndrome, Shanghai J. Acupuncture Moxibustion (2007) 5–6.
G Model
EUJIM 598 No. of Pages 8
8 S.-Y. Chung et al. / European Journal of Integrative Medicine xxx (2016) xxx–xxx
[31] Q.-y. Ge, H. Yang, Treatment of child tourette’s syndrome by scalp acupuncture,
J. Sichuan Tradit. Chin. Med. (2008) 114–115.
[32] Z.-r. Zhang, Clinical efficacy of acupuncture with plum needle acupuncture in
treating Tourette’s syndrome, Chin. J. Gen. Pract. (2009) 1331–1332.
[33] S.-f. Xu, B.-c. Zhu, Observations on the curative effect on 30 cases of Dong-liu
acupuncture on Tourette’s syndrome guiding, J. Tradit. Chin. Med. Pharm.
(2009) 58–59.
[34] S.-f. Xu, Treatment of 30 Cases of Gilles de la Tourette’s Syndrome by Jin three
needle therapy, Shansi J. Tradit. Chin. Med. 12 (2009) 1648–1649.
[35] J. Mu, J. Cheng, J. Ao, L. Zho, J. Wang, W. Fang, Clinical study on 60 cases of gilles
de la Tourette's syndrome by electroacupuncture and psychotherapy jiangsu, J.
Tradit. Chin. Med. 41 (2009) 49–51.
[36] L. Lui, X.-p. Yu, Y.-l. Li, Y.-f. Xu, B. Qu, Clinical observation of effects on the
Treatment of GTS by Using Electroacupuncture on the Head, J. Clin.
Acupuncture Moxibustion 26 (2010) 21–22.
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
[37] L. Liu, X-l. Li, F. Wang, Y-f. Xu, X. Guan, Clinical effects and influences of
neurotransmitters on the treatment of GTS by using electroacupuncture on the
head, Acta Chin. Med. Pharmacol. (2010) 128–131.
[38] H.-m. Liu, X.-d. Han, S. Dai, J. Lu, Comparation of therapeutic effects of YGS and
acupuncture on child tourette’s syndrome, Chin. Gen. Pract. 240 (2010) 1–2.
[39] Y.-a. Jin, Treatment of Tourette's syndrome with the ‘Head-hand-foot triple
acupuncture kinesitherapy Liaoning, J. Tradit. Chin. Med. 37 (2007) 272–273.
[40] Q. Li, Observation on therapeutic effect of 45 casse of tic disorders treated with
pharmacoacupuncture, Seek Med. Ask Med. (2012) 818.
[41] Y. Sun, X.-l. Nie, Treatment of Tourrete's syndrome with Bai-hui and distal end
of four limbs acupuncture, J. Clin. Acupuncture Moxibustion 30 (2014) 29–30.
[42] X-j. Zhang, X.-l. Wang, Y. Wei, Y.-z. Wu, Clinical study of treatment of Tourette's
sydrome by Dongliu acupuncture Shandong, J. Tradit. Chin. Med. 34 (2015)
266–267.