Commentary on the Pilot Study of Acupuncture Combined with Rehabilitation for Children with Spastic Hemiplegic Cerebral Palsy

Dear Editor

We read with great interest the article, “Body Acupuncture Conjunction with Rehabilitation for Upper Limb Improves Motor Functions in Children with Spastic Hemiplegic Cerebral Palsy: A Pilot Study,” published recently in the Journal of Evidence-Based Integrative Medicine. ¹ The authors are to be commended for advancing research in a challenging area of pediatric rehabilitation. Their randomized controlled trial brings attention to the potential synergistic effects of acupuncture combined with traditional rehabilitation for cerebral palsy (CP). We would like to offer several reflections that could enhance the interpretation and application of their findings.

First, Was the Randomization Robust Enough? The study reports random allocation to either acupuncture with rehabilitation or rehabilitation alone, but the process deserves further scrutiny. For instance, the use of a random number table for allocation while effective, raises concerns about allocation concealment. Without using tools like sealed envelopes or centralized assignment to ensure blinding of allocation, there might be risk of selection bias. ² Could the authors clarify how they mitigated potential bias when such allocation cannot blind parents or therapists due to the nature of the intervention?

Second, Are the Outcome Measures Optimal? The authors have employed muscle volume, Peabody Developmental Motor Scale (PDMS-FM), and root mean square (RMS) from surface electromyography as primary outcomes. While these are objective measurements, the use of muscle volume to infer functional improvement raises certain questions. Muscle hypertrophy does not necessarily translate into functional motor performance, especially in the pediatric population. Incorporating measures like the Quality of Upper Extremity Skills Test or the Pediatric Evaluation of Disability Inventory could provide a more holistic view of functional outcomes. ³

Third, the control group received standard rehabilitation but without acupuncture, which raises an interesting question: could additional placebo control for acupuncture (eg, sham acupuncture) be more illuminating? Although this would be challenging in pediatric populations, sham acupuncture protocols exist and can help clarify whether the results reflect a true acupuncture effect or placebo response. What was most striking was the authors’ report of significant RMS and PDMS-FM improvements in the affected limb only within the acupuncture group. This raises the question: Can such benefits result purely from placebo, or does acupuncture play a neuromodulatory role in enhancing rehabilitation gains? ⁴

In conclusion, this pilot study offers valuable insights into integrative approaches for spastic hemiplegic CP. We commend the authors for their efforts and hope for their continued exploration of innovative interventions for children with CP.