| Objectives This was a randomized research trial using three treating methods to determine the efficacy of acupuncture combined with chiropractic treatment for Attention Deficit Hyperactivity Disorder(ADHD)patients.The trial took place between June 2016 to April 2017.Under certain conditions for clinical research,90 ADHD patients aged between 6-17 years old were selected and treated with a combination of both acupuncture and chiropractic management,acupuncture treatment and chiropractic treatment respectively.The indications,scales and outcome measures used were SNAP IV Rating Scale,Conner’s Parent Short Form Questionnaire,Standard Progressive Matrices(SPM)and the Strengths and Difficulties Questionnaire(SDQ).Comprehensive curative effects,as well as the side effects and the role they play in reducing the core symptoms and other symptoms of ADHD were studied and recorded for the three types of treatments.After data collection and statistical analysis,the efficacy and safety of the three types of treatments were then evaluated objectively and scientifically in order to establish a set of standardized and effective treatments for treating ADHD.Methods Participants were chosen according to the clinical diagnostic and classification criteria of children ADHD enacted by DSM-V.This classification system defines ADHD as “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development”.According to the clinical research sample size estimation formula,90 cases were needed to be studied,then randomly divided into three groups,each group with 30 cases.Patients entered the cohort according to the inclusion criteria,being between the ages of 6 and 17 years old,having a diagnosis of ADHD combined type through clinical symptoms coinciding with the standard DSM-5 as well as coinciding with the traditional Chinese medicine differential diagnosis,course of disease was at least 6 months,having an informed verbal and written consent from parents/guardian for all participants as they are under 18 years old,and without mental retardation,pervasive development disorders,schizophrenia,manic episode,already diagnosed anxiety disorders,diphasic disorders,special learning skill maldevelopment and over-active symptoms caused by organic disorders and/or adverse drug reactions(ADRs).The inclusion of the traditional Chinese medicine differential diagnosis included internal disturbance of phlegm,kidney deficiency and liver excess,heartspleen deficiency,and heat in liver and heart.Exclusion criteria consisted of diagnosed developmental disorders,past history of epilepsy,presence of another neurotic disorder,pregnancy,and any changes in medications during the course of the study.Those who did not finish the whole course of treatment caused by reasons such as intolerance to acupuncture and chiropractic management,poor compliance,received other treatment other than acupuncture and chiropractic treatment during the study,or written consent not obtained were also excluded from the cohort.The informed consent form conveyed the following information: names of the chief investigator and supervisors/clinicians,name of the clinic conducting the research study,a brief description of the treatment groups involved in the study,the duration of the study,questionnaires used,ethics approval,the right to withdraw their child at any time,and the fact that the results of the study will be disseminated via conferences and publications while maintaining the child’s privacy.Once the participants met the inclusion criteria,passed the screening stage and provided written consent to participate,the eligible participants were enrolled into the trial and randomly allocated to 1 of 3 groups.Allocation was achieved using sequentially numbered,identical sealed opaque envelopes,each containing a 5 cm by 5 cm paper with a written code designating Group1,Group 2,or Group 3.These papers were placed in a folded sheet of aluminium foil fitted inside the envelope.There were no detectable differences in size or weight between the three groups. Group 1 received a combination of both acupuncture and chiropractic management.Group 2 received acupuncture only,and group 3 receied chiropractic treatment only.One acupuncture practitioner and one chiropractic practitioner participated in this study.The acupuncturist had a Bachelor’s degree on Traditional Chinese Medicine and the chiropractor had a Bachelor and Master’s degree on Chiropractic Science.Both practitioners are Australian licensed practitioners in New South Wales,Australia.Acupuncture Treatment: Acupuncture points were determined with a measure unit called ‘Personal Cun’ which is used in Traditional Chinese Medicine.A cun is the distance between the interphalangeal creases of the patient’s middle finger.For every treatment visit,participants were treated with basic mandatory acupuncture points for ADHD including Bai hui,Feng chi,Shen men,Tai xi,Tai chong.Other extra acupuncture points were chosen to be added to the basic acupoints if the patient showed extra signs and symptoms of traditional Chinese medicine syndrome differentiation and related clinical manifestations,according to their traditional Chinese medicine pulse and tongue diagnosis.Extra points include da ling and feng long for internal disturbance of phlegm,san yin jiao and xia xi for kidney deficiency and liver excess,xin shu and pi shu for heartspleen deficiency,and zhao hai,shen ting for heat in liver and heart.The participants’ skin was first sterilised with alcohol and thin,disposable acupuncture tube needles were used.Needle method was a quick perpendicular insertion and after the insertion,the needle tube was pulled out and the needles were inserted to a depth of approximately 0.3-0.5 cun until a characteristic de qi was felt by the patient.De qi can be perceived as tingling,numbness,heaviness,and other different sensations that occur after an acupuncture needle has been properly placed in the acupoints.There was no manual stimulation and the acupuncture needles were maintained for 20 minutes.Size of needles 0.25×30mm.Needle brand Hanyi Disposable sterile acupuncture needles for single use.After the treatment,the needles were pulled out and the site was pressed for 5-10 seconds with cotton wool.This acupuncture treatment was conducted twice a week,for 12 weeks.There was a total of 24 treatments sessions.Safety and tolerability measures included vital signs and possible adverse effects including fainting,stuck needle, bent needle,broken needle,hematoma and unendurable pain.If any patient experienced worsening ADHD symptoms or adverse effects during the treatment,they were excluded from the study.Chiropractic Treatment: Chiropractic treatment included spinal manipulative therapy.Manipulations were targeted to spinal vertebral segments from the cervical to lumbar areas(C1-L5),clinically assessed by the registered chiropractor as showing evidence of joint dysfunction.The principal biomechanical ‘tool’ used by most chiropractors is palpation(136).In this study,static and motion palpation,along with joint feel were used to determine the fixated vertebrae along the participant’s spine from C1-L5.Spinal manipulation was applied to the cervical,thoracic and lumbar regions where needed.Chiropractic spinal manipulation was provided at the areas where the most consistent locations of facet joint irritation was found from cervical to lumbar.Diversified chiropractic technique was used and performed with patient in supine position for cervical adjustments,prone or seated position for thoracic adjustments and side lying position for lumbar adjustments,depending on the spinal area of motion restricted vertebral segment.The Scan(general spinal survey)was used to identify general areas in the spine which required more specific joint motion palpation.The procedure for the spinal scan included a wave of motion form the lumbar to cervical spine,to assess any areas of hypomobility,hypermobility and tenderness.Active range of motion was used to assess the areas of the spine from lumbar to cervical regions which have a decreased range compared with the normal ranges measured in degrees.Passive range of motion was used to assess the segmental end feel and any areas of restriction in specific directions of spinal movement.Range of motions in the cervical,thoracic and lumbar regions were all tested.These motions included flexion,extension,right lateral flexion,left lateral flexion,right rotation and left rotation.Orthopaedic testing was also used to determine restricted areas to be manipulated.Orthopaedic tests used were Kemp’s test for the cervical,thoracic and lumbar spine,as well as Compression/Decompression test for the spine.Maigne’s Test and De Kleyn’s Test were used for a screening test for Vertebrobasilar Insufficiency(VBI)to make sure it was safe for the patient to be adjusted in the cervical area.Cervical manipulation: The Bilateral Index.Tissue slack should be taken superior to inferior,and either lateral to medial(for lateral flexion adjustment)or medial to lateral(for rotation adjustments).Comfortable neck flexion is applied using the headpiece or by supporting the head with both the primary and secondary contact.Segmental lockup is created using localised lateral flexion about the primary enhanced by the action of the secondary contact.A sharp thrust is applied by using the primary contact in the line of correction.The secondary contact maintains the stabilisation role and head is not displaced.Thoracic manipulation: The Wing Lift.The segmental contact point is generally at the spinous process of the lower vertebra of motion segment to be adjusted.An average size bath towel should be used.It is folded in half,then in thirds,and finally rolled firmly.The practitioner’s chest or epigastric region is placed on the posterior aspect of the towel.Tissue slack is taken in an inferior to superior direction via extension of the practitioner’s legs.Pretension should be taken anteriorly via the practitioner’s chest and towel in order to create a fulcrum and localising the point for the trust.Pretension should also be taken superiorly with the secondary contact in a vector greater than the stabilising towel(P-A force),in order to create a traction effect at the point of localisation.A sharp thrust is applied via the secondary contact in the line of correction,balanced by the towel contact.At no stage is firm pressure exerted on the patient’s forearms to induce cervical or thoracic flexion.Lumbar manipulation: The Basic Lumbar Roll(BLR).Tissue slack is taken in the direction of the line of correction.The patient is placed in the lumbar roll position as the practitioner stands at the side of the couch at the level of the patient’s pelvis normally facing in the direction of the line of correction.The patient is rolled as a unit anteriorly to allow the practitioner’s centre of gravity to be over the patient.The chosen stabilisation method is applied.The practitioner flexes his/her knees slightly in a fencer’s stance with feet pointing in a place parallel to the line of drive.The primary and secondary contacts are applied and tension begins between these two points.A sharp thrust is applied by the primary contact in the line of correction,utilising body drop.Care must be taken to maintain the secondary contact as a stabilisation point and not actively thrust. This chiropractic procedure was performed twice a week,for 12 weeks.There was a total of 24 treatment sessions for the chiropractic protocol of this trial.Possible complications and adverse reactions to chiropractic care include minor reaction: musculoskeletal pain and tenderness for less than two days,exceeding reaction: musculoskeletal pain and tenderness for greater than two days,reversible complication: neurological deficit which completely resolves with time,and permanent complication: Neurological deficit which does not resolve If any patient experienced worsening ADHD symptoms during the treatment,they were excluded from the study.Outcome measures: The primary outcome for the study was change in ADHD symptoms from baseline to week 12 as measured by the Swanson,Nolam and Pelham-IV(SNAP IV)Rating Scale and Conner’s Parent Short Form Questionnaire.The SNAP IV Rating Scale is an ADHD specific 18 item assessment tool used to assess the core ADHD symptoms of inattention,hyperactivity and impulsiveness.Conner’s Parent Short Form Questionnaire is a 48 item assessment tool used to assess the ADHD symptoms.It is for assessing children ages 6-18 years old and is specially formatted to help determine if: the student qualifies for inclusion or exclusion in special education,the treatment or intervention is effective,ADHD is a concern,response to the treatment is positive and what treatment plans may work best.Secondary outcome measures include the Standard Progressive Matrices(SPM)and the Strengths and Difficulties Questionnaire(SDQ).The SPM is a test that nonverbally assesses intelligence in both children and adults through abstract reasoning tasks.For this trial,the SPM was used to assess the concentration span of participants,answering as many questions correctly as possible in 40 minutes.The SDQ is a 25-item behavioural screening questionnaire which assesses emotional symptoms,conduct problems,hyperactivity,peer problems and prosocial scale.All of the ratings scales and questionnaires were administered for all participants pre-intervention to establish baseline data,and were used as outcome assessments to measure intervention effects at the conclusion of the study trial at 12 weeks.Evaluation of efficacy: The symptom changes before and after the treatment was evaluated and was determined according to and national board associated with DSM-V.The definition of efficacy was as follows: cured-all major symptoms disappeared,markedly improved-at least ten symptoms were disappeared after treatment,effective-at least four symptoms were disappeared after treatment,and non-effective-no symptom was apparently disappeared.Any side effects such as fainting on acupuncture,stuck and bending of the needle,and hematoma during and after the treatments were recorded.Statistical Analysis: After data collection,statistical analysis was performed using a computer software SPSS version 19.0.The measurement data of normal distribution is recorded as mean±standard deviation,which was compared with t-test.The counting data was compared with the chi-square test and Fisher’s exact test.The non-normal distribution of quantitative data and hierarchical data is compared by non-parametric tests such as rank and sum test.The outcomes for each primary and secondary outcome measures were compared between the three groups used within the trial.A P value of P < 0.05 was considered statistically significant.Results There was no statistically significant difference from ratio of gender,average age,average course of symptoms and traditional Chinese medicine differential diagnosis,as well as the SNAP IV Rating Scale,Conner’s Parent Short Form Questionnaire,SPM and the SDQ before the treatment of the three groups(P > 0.05).Therefore,within this trial,all these for the three groups could be compared.After 12 weeks of treatment,the SNAP IV Rating Scale,Conner’s Parent Short Form Questionnaire,SPM and the SDQ of all three groups were compared with the pre-treatment,and the difference was statistically significant(P< 0.05).The results of group 1 compared with the two other groups was statistically significant(P < 0.05).There was no statistically significant difference between group 2 and group 3 in these results(P < 0.05).SNAP IV Rating Scale: Before treatment,the χ2 test showed that the average baseline scores among the three groups was not significant P = 0.396 >0.05,therefore the groups could be compared.After treatment,the paired T-test method showed that there was a difference in average scores among the three groups P = 0.00 < 0.01 which was statistically significant.After treatment,the combined acupuncture and chiropractic group average scores was better than acupuncture group alone,and chiropractic group alone,and had statistical meaning P = 0.00 < 0.05.Though,when comparing the average scores of the acupuncture group alone with the chiropractic group alone,there was no statistical significance P = 0.927 > 0.05.Conners Parent Short Form Questionnaire: Before treatment,the χ2 test showed that the average baseline scores among the three groups was not significant P = 0.682 > 0.05,therefore the groups could be compared.After treatment,the paired T-test method showed that there was a difference in average scores among the three groups P = 0.00 < 0.01 which was statistically significant.After treatment,the combined acupuncture and chiropractic group average scores was better than Acupuncture group alone,or Chiropractic group alone and had statistical meaning P = 0.00 < 0.05.Though,when comparing the average scores of the Acupuncture group alone with the Chiropractic group alone,there was no statistical significance P = 0.296 > 0.05.Standard Progressive Matrices: Before treatment,the χ2 test showed that the average baseline number of correct answers answered by the participants among the three groups was not significant P = 0.848 > 0.05,therefore the groups could be compared.After treatment,the paired T-test method showed that there was a difference in average number of correct answers answered by the participants among the three groups P = 0.00 < 0.01 which was statistically significant.After treatment,the combined acupuncture and chiropractic group average number of correct answers answered by the participants was better than that of the acupuncture group alone,and the chiropractic group alone,and had statistical meaning P = 0.00 < 0.05.Though,when comparing the average number of correct answers answered by the participants of the acupuncture group alone with the chiropractic group alone,there was no statistical significance P = 0.864 > 0.05.Strengths and difficulties Questionnaire: Before treatment,the χ2 test showed that the average baseline scores among the three groups was not significant P = 0.822 > 0.05,therefore the groups could be compared.After treatment,the paired T-test method showed that there was a difference in average scores among the three groups P = 0.00 <0.01 which was statistically significant.After treatment,the combined acupuncture and chiropractic group average scores was better than acupuncture group alone,and chiropractic group alone,and had statistical meaning P = 0.00 < 0.05.Though,when comparing the average scores of the acupuncture group alone with the chiropractic group alone,there was no statistical significance P = 0.814 > 0.05.In the combined acupuncture and chiropractic group,8 participants were cured,9 participants markedly improved,11 participants were effective and 2participants were non-effective.The total effective rate for the combined acupuncture and chiropractic group was 93.33 %.In the acupuncture group only,3 participants were cured,5 participants markedly improved,14 participants were effective and 8 participants were non-effective.The total effective rate for the acupuncture group only was 73.33 %.In the chiropractic group only,4 participants were cured,5 participants markedly improved,9 participants were effective and 12 participants were non-effective.The total effective rate for the chiropractic group only was 60.00%.When the three groups were compared together as a whole,the efficacy of the combined acupuncture with chiropractic group was significantly better than that of the acupuncture group alone,and the chiropractic group alone(P < 0.05).Conclusions In conclusion,a 12 week course of acupuncture combined with chiropractic treatment changed the results of various ADHD rating scales with effectiveness in diminishing or lessening core symptoms of ADHD.The indexes such as age,gender and course of symptoms,as well as the SNAP IV Rating Scale,Conner’s Parent Short Form Questionnaire,SPM and the SDQ before the treatment of the three groups could be compared.The reduction of the core symptoms of ADHD in group 1 were greater than the two other groups.The curative effect was best and the total effective rate was highest in group 1.In this study trial,the results showed that the combined acupuncture with chiropractic management could significantly elevate the therapeutic effect of ADHD.It can ameliorate the core symptoms,and improve the symptoms and signs of ADHD combined type.Acupuncture combined with Chiropractic Spinal Manipulation more effective in treating core symptoms of ADHD compared to each group alone.Both acupuncture and chiropractic could obtain curative effects,but a combination of both acupuncture and chiropractic management was better than acupuncture treatment alone and chiropractic treatment alone.In summary,a combination of both acupuncture and chiropractic treatment is an effective method for the treatment of ADHD.The combination of treatment is easily administered,and with minor side effects,it is worth popularizing in clinical practice. |
