Parkinson’s Disease: effectiveness of acupuncture

Maladie de Parkinson : évaluation de l'acupuncture

Articles connexes : - acupuncture expérimentale - évaluation du taiji-gigong-

1. Revues systématiques et méta-analyses

☆☆☆ Preuves en faveur d’une efficacité et d’un effet spécifique de l’acupuncture
☆☆ Preuves en faveur d’une efficacité de l’acupuncture
Preuves limitées en faveur d’une efficacité de l’acupuncture
Ø Absence de preuve ou preuves insuffisantes

1.1. Acupuncture générique

1.1.1. Liu 2018

Liu Yanhui, Chen Tao, Deng Yidong, Zhang Shan, Teng Si, Cai Benchi, Su Jiali. [A meta-analysis on clinical effect of acupuncture for Parkinson disease]. Journal of Chinese Physician. 2018;1:16-23,27. [201794].

Objective To evaluate the clinical effect of acupuncture on Parkinson disease (PD) with systematic review in view of evidence-based medicine (EBM).
Methods Articles on clinical effect of acupuncture on Parkinson disease published from the database-established year to May of 2017 we searched from China National Knowledge Internet (CNKI), Wanfang, VIP, Chinese Biomedical Literature Database (CBM), PubMed, and Cochrane Library databases without language limitation. Quality evaluation and data extraction were carried out according to the tool for assessing risk of bias provided by the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0).All statistical analyses were performed with Reviewer Manager Software (Version 5.3;Cochrane Collaboration, Oxford, UK). Assessments were performed with the total effective rate, the scores of each scale (the unified Parkinson disease rating scales-UPDRS and the Webster scale),and the improvement of different clinical manifestation.
Results In all,12 randomized controlled trials (RCTs) met our inclusion criterion, a total of 892 patients, including 468 cases in the experimental group (acupuncture with or without medicine) and 424 cases in the control group (medicine only).Meta-analysis showed favorable results for the experimental group compared to control group in the total effective rate, the total scales of UPDRS and the modified Webster scale [OR =2.16,95% CI (1.57,2.97),P<0.01;OR =7.20,95% CI(4.02,10.37),P<0.01;OR=3.33,95% CI(2.13,4.53),P <0.01].The experimental group was effective in relieving partial symptoms of PD such as rigidity, postural, gait, bradykinesia compared to the control group, while there was no significant difference in tremor at rest and sit-stand up movements (P > 0.05).
Conclusions Acupuncture had certain clinical effect on Parkinson disease, it can relieve the clinical symptoms of Parkinson disease to some extent, and postpone the progression of PD, which improves the quality of life of PD patients. Acupuncture can be recommended as a combination treatment for Parkinson disease.

1.1.2. Otayza 2018

Otayza J, Juri C. Is acupuncture an alternative for the treatment of Parkinson’s Disease?. Medwave. 2018;18(3). [158650].

Introduction It has been proposed that acupuncture has several benefits for patients with Parkinson’s disease. However, its real clinical effect is still under discussion.
Methods To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.
Results and conclusions We identified nine systematic reviews including 53 studies overall, of which 45 were randomized trials. We concluded acupuncture might have a small effect in improving motor symptoms and disability in Parkinson’s disease, but the certainty of the evidence is low.

1.1.3. Subramanian 2017 (nonmotor symptoms)

Subramanian I. Complementary and Alternative Medicine and Exercise in Nonmotor Symptoms of Parkinson's Disease. Int Rev Neurobiol. 2017:1163-1188. [160582]. The use of complementary and alternative medicine (CAM) therapy in nonmotor symptoms (NMS) for Parkinson disease (PD) is growing worldwide. Well-performed, systematic evidence-based research is largely lacking in this area and many studies include various forms of CAM with small patient numbers and a lack of standardization of the approaches studied. Taichi, Qigong, dance, yoga, mindfulness, acupuncture, and other CAM therapies are reviewed and there is some evidence for the following: Taichi in sleep and PDQ39; dance in cognition, apathy, and a mild trend to improved fatigue; yoga in PDQ39; and acupuncture in depression, PDQ39, and sleep. Exercise including occupational therapy (OT) and physical therapy (PT) has been studied in motor symptoms of PD and balance but only with small studies with a mounting evidence base for use of exercise in NMS of PD including PDQ39, sleep, fatigue, depression, and some subsets of cognition. Studies of OT and PT largely show some benefit to depression, apathy, and anxiety. Sustainability of an improvement has not been shown given short duration of follow up. Finding optimal control groups and blind for these interventions is also an issue. This is a very important area of study since patients want to be self-empowered and they want guidance on which form of exercise is the best. Additionally, evidence for PT and OT in NMS would give added weight to get these interventions covered through medical insurance.

1.1.4. Liu 2017 (association acupuncture + Modopar)

Liu H, Chen L, Zhang Z, Geng G, Chen W, Dong H, Chen L, Zhan S, Li T. Effectiveness and safety of acupuncture combined with Madopar for Parkinson's disease: a systematic review with meta-analysis. Acupunct Med. 2017;35(6):404-412. [99815].

Objective To evaluate the effectiveness and safety of acupuncture combined with Madopar for the treatment of Parkinson's disease (PD), compared to the use of Madopar alone.
Methods A systematic search was carried out for randomised controlled trials (RCTs) of acupuncture and Madopar for the treatment of PD published between April 1995 and April 2015. The primary outcome was total effectiveness rate and secondary outcomes included Unified Parkinson's Disease Rating Scale (UPDRS) scores. Data were pooled and analysed with RevMan 5.3. Results were expressed as relative ratio (RR) with 95% confidence interval (Cis).
Results Finally, 11 RCTs with 831 subjects were included. Meta-analyses showed that acupuncture combined with Madopar for the treatment of PD can significantly improve the clinical effectiveness compared with Madopar alone (RR=1.28, 95% CI 1.18 to 1.38, P<0.001). It was also found that acupuncture combined with Madopar significantly improved the UPDRS II (SMD=-1.00, 95% CI -1.71 to -0.29, P=0.006) and UPDRS I-IV total summed scores (SMD=-1.15, 95% CI -1.63 to -0.67, P<0.001) but not UPDRS I (SMD=-0.37, 95% CI -0.77 to 0.02, P=0.06), UPDRS III (SMD=-0.93, 95% CI -2.28 to 0.41, P=0.17) or UPDRS IV (SMD=-0.78, 95% CI -2.24 to 0.68, P=0.30) scores. Accordingly, acupuncture combined with Madopar appeared to have a positive effect on activities of daily life and the general condition of patients with PD, but was not better than Madopar alone for the treatment of mental activity, behaviour, mood and motor disability. In the safety evaluation, it was found that acupuncture combined with Madopar was associated with significantly fewer adverse effects including gastrointestinal reactions (RR=0.38, 95% CI 0.23 to 0.65, P<0.001), on-off phenomena (RR=0.27, 95% CI 0.11 to 0.66, P=0.004) and mental disorders (RR=0.24, 95% CI 0.06 to 0.92, P=0.04) but did not significantly reduce dyskinesia (RR=0.64, 95% CI 0.35 to 1.16, P=0.14).
ConclusionAcupuncture combined with Madopar appears, to some extent, to improve clinical effectiveness and safety in the treatment of PD, compared with Madopar alone. This conclusion must be considered cautiously, given the quality of most of the studies included was low. Therefore, more high-quality, multicentre, prospective, RCTs with large sample sizes are needed to further clarify the effect of acupuncture combined with Madopar for PD.

1.1.5. Noh 2017 ☆

Noh H, Kwon S, Cho SY, Jung WS , Moon SK, Park JM, Ko CN, Park SU. Effectiveness and safety of acupuncture in the treatment of Parkinson's disease: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Med. 2017;34:86-103. [171620].

ObjectiveThis study aimed to examine the effectiveness and safety of acupuncture in the treatment of Parkinson's disease (PD).
MethodsEnglish, Chinese, and Korean electronic databases were searched up to June 2016. Randomized controlled trials (RCTs) were eligible. The methodological quality was assessed using Cochrane's risk of bias tool. Meta-analysis was performed using RevMan 5.3.
ResultsIn total, 42 studies involving 2625 participants were systematically reviewed. Participants treated using combined acupuncture and conventional medication (CM) showed significant improvements in total Unified PD Rating Scale (UPDRS), UPDRS I, UPDRS II, UPDRS III, and the Webster scale compared to those treated using CM alone. The combination of electroacupuncture and CM was significantly superior to CM alone in total UPDRS, UPDRS I, UPDRS II, and UPDRS IV. Similarly, the combination of scalp electroacupuncture, acupuncture, and CM was significantly more effective than CM alone in total UPDRS. However, our meta-analysis showed that the combination of electroacupuncture and CM was not significantly more effective than CM alone in UPDRS III, the Webster, and the Tension Assessment Scale. The results also failed to show that acupuncture was significantly more effective than placebo acupuncture in total UPDRS. Overall, the methodological quality of the RCTs was low. No serious adverse events were reported.
Conclusions We found that acupuncture might be a safe and useful adjunctive treatment for patients with PD. However, because of methodological flaws in the included studies, conclusive evidence is still lacking. More rigorous and well-designed placebo-controlled trials should be conducted.

1.1.6. Lee 2017 ☆☆

Lee SH, Lim S. Clinical effectiveness of acupuncture on Parkinson disease: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2017. [190954].

Objectives Parkinson's disease (PD) is the second-most-common chronic and progressive neurodegenerative disease. The long-term use of levodopa leads to a loss of efficacy and to complications. Therefore, many patients with PD have turned to complementary therapies to help relieve their symptoms. Acupuncture is most commonly used as a complementary therapy in patients with PD. This paper presents a systematic review and meta-analysis of the effects of acupuncture for patients with PD. This study was performed to summarize and evaluate evidence regarding the effectiveness of acupuncture in the relief of PD symptoms.
Methods Seven databases, namely, MEDLINE, EMBASE, the Cochrane Library, the China National Knowledge Infrastructure [CNKI], and three Korean medical databases, were searched from their inception through August 2015 without language restrictions. Randomized controlled trials (RCTs) were included if they contained reports of acupuncture compared with no treatment and conventional treatment alone or acupuncture plus conventional treatment compared with conventional treatment alone for PD symptoms. Assessments were performed with the unified PD rating scales (UPDRS) I, II, III, and IV and the total score, the Webster scale, and effectiveness rating. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale and the Cochrane risk of bias (ROB).
Results In all, 982 potentially relevant articles were identified; 25 RCTs met our inclusion criterion, 19 of 25 RCTs were high-quality studies (i.e., a score of 6 or higher). The included RCTs showed favorable results for acupuncture plus conventional treatment compared with conventional treatment alone in the UPDRS II, III, and IV and the total score. Acupuncture was effective in relieving PD symptoms compared with no treatment and conventional treatment alone, and acupuncture plus conventional treatment had a more significant effect than conventional treatment alone.
Conclusions We performed a systematic review and meta-analysis to evaluate the use of acupuncture for relief of PD symptoms and found that acupuncture has significant positive effects. Acupuncture can be considered as a combination treatment with conventional treatment for patients with PD. Further studies on this topic should be carried out according to rigorous methodological designs in both the East and the West.

1.1.7. Yin 2016 ☆

Yin Hong-na , Han Chao , Sun Zhong-ren , et al. [Randomized Controlled Trials of Acupuncture for Parkinson's Disease: A Systematic Review and Meta — analysis]. Journal of Clinical Acupuncture and Moxibustion. 2016;32(8):67. [189379].

ObjectiveTo summarize and evaluate the efficacy of acupuncture for Parkinson's disease(PD).
MethodsFour databases both in and abroad were searched electronically and relevant reviews were searched. Randomized controlled trials(RCTs) which compared acupuncture as the main intervention to medication, placebo or conventional therapy for treating PD were included for this meta-analysis.
Results9 RCTs were included in our review, involving 665 cases'PD. As a result, the total effective rate 'acupuncture for PD was significantly superior to those of the control group [OR =2. 60,95% CI(1. 78,3. 79), Z =4. 66, P < 0.000 01.
Conclusion Although acupuncture may be effective for treating PD, the methodological flaws in the included studies might affect the analysis. The rigorous higher-quality RCTs are needed.

1.1.8. Zhang 2015 ☆☆

Zhang G, Xiong N, Zhang Z, Liu L1, Huang J, Yang J, Wu J, Lin Z, Wang T. Effectiveness of traditional Chinese medicine as an adjunct therapy for Parkinson's disease: a systematic review and meta-analysis. PLoS One. 2015;10(3):.[176524].

Background Idiopathic Parkinson disease (PD) is a common neurodegenerative disease that seriously hinders limb activities and affects patients' lives. We performed a meta-analysis aiming to systematically review and quantitatively synthesize the efficacy and safety of traditional Chinese medicine (TCM) as an adjunct therapy for clinical PD patients.
Methods An electronic search was conducted in PubMed, Cochrane Controlled Trials Register, China National Knowledge Infrastructure, Chinese Scientific Journals Database and Wanfang data to identify randomized trials evaluating TCM adjuvant therapy versus conventional treatment. The change from baseline of the Unified Parkinson's Disease Rating Scale score (UPDRS) was used to estimate the effectiveness of the therapies.
Results Twenty-seven articles involving 2314 patients from 1999 to 2013 were included. Potentially marked improvements were shown in UPDRS I (SMD 0.68, 95%CI 0.38, 0.98), II (WMD 2.41, 95%CI 1.66, 2.62), III (WMD 2.45, 95%CI 2.03, 2.86), IV (WMD 0.32, 95%CI 0.15, 049) and I-IV total scores (WMD 6.18, 95%CI 5.06, 7.31) in patients with TCM plus dopamine replacement therapy (DRT) compared to DRT alone. Acupuncture add-on therapy was markedly beneficial for improving the UPDRS I-IV total score of PD patients (WMD 10.96, 95%CI 5.85, 16.07). However, TCM monotherapy did not improve the score. The effectiveness seemed to be more obvious in PD patients with longer adjunct durations. TCM adjuvant therapy was generally safe and well tolerated.
Conclusions Although the data were limited by methodological flaws in many studies, the evidence indicates the potential superiority of TCM as an alternative therapeutic for PD treatment and justifies further high-quality studies.

1.1.9. Sun 2013 (non-motor symptoms) ☆☆

Sun Miao-Xuan, Zhang Xiong. [Effect of acupuncture for non-motor symptoms of parkinson’s disease: a systematic review and meta-analysis]. Acta Universitatis Traditionis Medicalis Sinensis Pharmacologiaeque Shanghai. 2013;5:41-48; 6. [186902].

Objective To systematically evaluate the clinical efficacy of acupuncture for the non-motor symptoms (NMS)of Parkinson’s disease (PD).
Methods Randomized controlled trials (RCTs) of acupuncture in treatment of PD were identified from PubMed, Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database and VIP Database for Chinese Technical Periodicals, and some relevant journals were hand-searched. The quality of RCTs were evaluated based on Cochrane collaboration’s tool for assessing risk of bias, and the Review Manager (version 5. 0) software was used for meta-analysis.
Results A total of 18 RCTs involving 1 325 patients were included. The results of meta-analysis showed: ①Depression: The Hamilton Depression Scale (HAMD) and the Self-Rating Depression Scale (SDS) were used to evaluate depression. HAMD: There was statistical difference between two groups [SMD =- 5. 83, 95% CI (- 8. 61, - 3. 05), P < 0. 000 1]. SDS: There was statistical difference between two groups [SMD =- 4. 42, 95% CI (- 6. 44, - 2. 39), P < 0. 000 1]. ②Mental symptoms: There was statistical difference between two groups [OR = 0. 12, 95% CI (0. 02, 0. 65), P = 0. 01]. ③Sleep disorders: There was statistical difference between two groups [OR = 0. 04, 95% CI (0. 00, 0. 29), P = 0. 002]. ④Gastrointestinal symptoms: There was statistical difference between two groups [OR = 0. 15, 95% CI (0. 07, 0. 33), P < 0. 000 01]. ⑤ Activity of daily life: The Webster scale and the Unified Parkinson ’s Disease Rating Scale (UPDRS)-Ⅱwere used to evaluate the activity of daily life. Webster scale: There was statistical difference between two groups [OR =0. 45, 95%CI (0. 29, 0. 68), P =0. 000 1]. The total score of UPDRSⅡ: There was statistical difference between two groups [SMD =- 4. 24, 95% CI (- 5. 08, - 3. 39), P < 0. 000 01]. The different score of UPDRSⅡ: There was statistical difference between two groups [SMD = 3. 51, 95% CI (1. 64, 5. 38), P = 0. 000 2].
Conclusion Acupuncture therapy can improve some NMS of PD patients, however, the high-quality, large-sample and multi-center RCTs are needed to further certify; in addition, the evaluation standard of therapeutic effect of NMS is needed.

1.1.10. Fox 2011 (motor symptoms) ☆☆

Fox SH, Katzenschlager R, Lim SY, Ravina B, Seppi K, Coelho M, Poewe W, Rascol O, Goetz CG, Sampaio C. The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the motor symptoms of Parkinson's disease. Mov Disord. 2011;26 supp 3:s2-41.[162534] .

ObjectivesThe objective was to update previous evidence-based medicine reviews of treatments for motor symptoms of Parkinson's disease published between 2002 and 2005. Level I (randomized, controlled trial) reports of pharmacological, surgical, and nonpharmacological interventions for the motor symptoms of Parkinson's disease between January 2004 (2001 for nonpharmacological) and December 2010 were reviewed.
MethodsCriteria for inclusion, clinical indications, ranking, efficacy conclusions, safety, and implications for clinical practice followed the original program outline and adhered to evidence-based medicine methodology. Sixty-eight new studies qualified for review.
ResultsPiribedil, pramipexole, pramipexole extended release, ropinirole, rotigotine, cabergoline, and pergolide were all efficacious as symptomatic monotherapy; ropinirole prolonged release was likely efficacious. All were efficacious as a symptomatic adjunct except pramipexole extended release, for which there is insufficient evidence. For prevention/delay of motor fluctuations, pramipexole and cabergoline were efficacious, and for prevention/delay of dyskinesia, pramipexole, ropinirole, ropinirole prolonged release, and cabergoline were all efficacious, whereas pergolide was likely efficacious. Duodenal infusion of levodopa was likely efficacious in the treatment of motor complications, but the practice implication is investigational. Entacapone was nonefficacious as a symptomatic adjunct to levodopa in nonfluctuating patients and nonefficacious in the prevention/delay of motor complications. Rasagiline conclusions were revised to efficacious as a symptomatic adjunct, and as treatment for motor fluctuations. Clozapine was efficacious in dyskinesia, but because of safety issues, the practice implication is possibly useful. Bilateral subthalamic nucleus deep brain stimulation, bilateral globus pallidus stimulation, and unilateral pallidotomy were updated to efficacious for motor complications. Physical therapy was revised to likely efficacious as symptomatic adjunct therapy.
ConclusionsThis evidence-based medicine review updates the field and highlights gaps for research.

1.1.11. Yang 2010 ☆☆

Yang Li-Hong, Du Yuan-Hao, Xiong Jun, Liu Jia-Lin, Wang Yun-Na, Li Ying, Li Li-Na. [Acupuncture treatment for parkinson disease: a systematic review]. Chinese Journal of EBM. 2010;10(6):711-17.[166226].

Objective To assess the efficacy and safety of acupuncture versus western medicine in the treatment of parkinson disease.
Methods Randomized controlled trials (RCTs) involving acupuncture versus western medicines in the treatment of parkinson disease were identified from CBM (1978 to 2008), VIP (1989 to 2008), Wanfang Database (1998 to 2008), CNKI (1979 to 2008), PubMed (1966 to 2008), Embase (1980 to 2008), and The Cochrane Library (Issue 4, 2008). And some relevant journals were handsearched. Data were extracted and evaluated by two reviewers independently with a specially-designed extraction form. The Cochrane Collaboration’s RevMan 5.0.20 software was used for metaanalyses.
Results A total of 13 trials involving 832 patients were included. The result of meta-analyses showed that the total effective rates of the acupuncture group or of the group of acupuncture plus Madopar were similar when compared with Madopar alone in Webster score. (1) The total effective rate: The total effective rate in acupuncture plus Madopar was similar when compared with Madopar alone in UPDRS score at Day 30 (RR=1.33, 95%CI 0.95 to 1.88) and Day 66 (RR=1.38, 95%CI 0.84 to 2.24), but there were significant differences between acupuncture plus Madopar and Madopar alone (RR=1.61, 95%CI (1.19 to 2.17) at Day 84. The total effective rate in acupuncture plus benserazide-levodopa was higher than benserazide-levodopa alone (RR=1.70, 95%CI 1.08 to 2.68) at Day 66. (2)Webster score: There were no sig nificant differences between acupuncture and Madopar at Day 30 (WMD= – 2.51, 95%CI – 2.83 to – 2.19) and at Day 63 (WMD= – 2.48, 95%CI – 3.01 to – 1.95). There were significant differences between acupuncture plus Madopar and Madopar alone at Day 30 (WMD= – 13.48, 95%CI – 15.35 to – 11.61), but not at Day 42 (WMD= 0.50, 95%CI – 1.22 to 2.22). (3) UPDRS score: There were no significant differences between acupuncture and Madopar at Day 60 (WMD= – 7.19, 95%CI – 14.49 to 0.11). There were significant differences between acupuncture plus Madopar and Madopar alone at Day 30 (WMD= 7.07 and 95%CI 2.95 to 11.19) and at Day 84 (WMD= – 12.49,95%CI – 16.75 to – 8.23), but no significant differences were found at Day 66 and Day 33 (WMD= – 14.90, 95%CI – 31.89 to 2.09; WMD= – 8.60, 95%CI – 21.51 to 4.31).But there were statistical differences between acupuncture plus Madopar and Madopar alone at Day 30 (WMD= 7.07, 95%CI 2.95 to 11.19). There were no differences between acupuncture plus benserazide-levodopa and benserazidelevodopa alone at Day 66 (WMD=-10.80,95%CI-21.78 to 0.18) and at Day 33 (WMD=-15.60,95%CI-28.38 to -2.82). (4) Adverse reaction: Three trials reported adverse reactions including dizziness, heartbeat acceleration, slight mouth drying and nausea, but all of these were relieved or disappeared in the course of treatment.
Conclusion Acupuncture is safe and effective in the treatment of parkinson disease. Acupuncture plus western drugs may be superior to western drugs alone. Because of the defects in the methodological quality of the included trials, the conclusion is to be confirmed by more highquality RCTs.

1.1.12. Lam 2008 ☆

Lam YC, Kum WF, Durairajan SSK, Lu JH, Man SC, Xu M, Zhang XF, Huang XZ, Li M. Efficacy and safety of acupuncture for idiopathic parkinson's disease: a systematic review. Journal of Alternative and Complementary Medicine. 2008;14(6):663.[149982] .

Objectives To assess the efficacy and safety of acupuncture therapy (monotherapy or adjuvant therapy), compared with placebo, conventional interventions, or no treatment in treating patients with idiopathic Parkinson's disease (IPD).
Data sources International electronic database: (1) The Cochrane Controlled Trials Register, (2) Academic Search Premier, (3) ACP Medicine, Alternative Medicine, (4) CINAHL, (5) EBM Reviews, (6) EMBASE, (7) MEDLINE, (8) OLD MEDLINE, (9) ProQuest Medical Library. Chinese electronic databases searched included: (1) VIP, (2) CJN, (3) CBM disk, (4) China Medical Academic Conference. Hand searching was conducted on all appropriate journals. Reference lists of relevant trials and reviews were also searched to identify additional studies. Selection criteria: All randomized controlled trials (RCTs) of any duration comparing monotherapy and adjuvant acupuncture therapy with placebo or no intervention were included. Data collection and analysis: Data were abstracted independently by Y. C. Lam and S. C. Man onto standardized forms, and disagreements were resolved by discussion.
Main results Ten (10) trials were included, each using a different set of acupoints and manipulation of needles. None of them reported the concealment of allocation. Only two mentioned the number of dropouts. Two (2) used a nonblind method while others did not mention their blinding methods. Nine (9) studies claimed a statistically significant positive effect from acupuncture as compared with their control; only one indicated that there were no statistically significant differences for all variables measured. Only 2 studies described details about adverse events.
Conclusions There is evidence indicating the potential effectiveness of acupuncture for treating IPD. The results were limited by the methodological flaws, unknowns in concealment of allocation, number of dropouts, and blinding methods in the studies. Large, well-designed, placebo-controlled RCTs with rigorous methods of randomization and adequately concealed allocation, as well as intention-to-treat data analysis are needed.

1.1.13. Lee 2008 ∅

Lee MS, Shin BC, Kong JC, Ernst E. Effectiveness of acupuncture for Parkinson's disease: a systematic review. Mov Disord. 2008; 23(11):1505-15. [149866].

ObjectiveThe objective of this review is to assess the clinical evidence for or against acupuncture as a treatment for Parkinson's disease (PD).
MethodsWe searched the literature using 17 databases from their inception to September 2007 (searched again 3rd January 2008), without language restrictions. We included all randomized clinical trials (RCTs) regardless of their design. Methodological quality was assessed using the Jadad score.
ResultsEleven RCTs met all inclusion criteria. Three RCTs assessed the effectiveness of acupuncture on Unified Parkinson's Disease Rating Scale (UPDRS) compared with placebo acupuncture. A meta-analysis of these studies showed no significant effect (n = 96, WMD, 5.7; 95% CI -2.8 to 14.2, P = 0.19, heterogeneity: tau(2) = 0, chi(2) = 0.97, P = 0.62, I(2) = 0%). Another six RCTs compared acupuncture plus conventional drugs on improvement of symptoms of PD with drugs only. A meta-analysis of two of these studies suggested a positive effect of scalp acupuncture (n = 106, RR, 1.46, 95% CI = 1.15 to 1.87, P = 0.002; heterogeneity: tau(2) = 0.00, chi(2) = 1.14, P = 0.29, I(2) = 12%). Two further RCTs tested acupuncture versus no treatment. The meta-analysis of these studies also suggested beneficial effects of acupuncture. The results of the latter two types of RCTs fail to adequately control for nonspecific effects.
Conclusions The evidence for the effectiveness of acupuncture for treating PD is not convincing. The number and quality of trials as well as their total sample size are too low to draw any firm conclusion. Further rigorous trials are warranted.

1.2. Techniques particulières

1.2.1. Moxibustion

1.2.1.1. Cho 2017

Cho Ki-Ho, Kim Tae-Hun, Kwon Seungwon, Jung Woo-Sang et al. Moxibustion for idiopathic Parkinson’s disease: A systematic review and meta-analysis of randomized controlled trials. European Journal of Integrative Medicine. 2017;13:26-33. [206067].

Background Moxibustion is the burning of mugwort used to stimulate acupuncture points on the skin. In traditional East-Asian medicine, moxibustion is often used as a non-drug treatment for idiopathic Parkinson's disease (IPD).
AimThe aim of this systematic review was to evaluate the effectiveness and safety of moxibustion therapy to treat IPD.
Methods The following electronic databases were searched for studies published in or before December 2016: Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, OASIS (Korean database), and CNKI (Chinese database). Two researchers conducted the data extraction and risk of bias assessments.
Results From the results, a total of 10 studies (644 IPD patients) were included in this review. Overall methodological quality was not high and all studies included small numbers of participants which could not ensure the rigor of the synthesized evidence. There was a considerable clinical heterogeneity in terms of patient’s population, moxibustion types and control group interventions. Compared with control group, moxibustion did not show significant difference in the overall effectiveness ratio (RR 1.20, 95% CI [1.00, 1.44]). About the total unified Parkinson’s disease rating scale (UPDRS) score, however, there was significant difference between moxibustion and control interventions (MD −8.75, 95% CI [−12.54, −4.95]). Adverse events related to moxibustion treatment were not reported in most of the studies.
Conclusions Evidence on the benefit and harm of moxibustion therapy for IPD was not conclusive due to methodological problems and small sample sizes among the included studies. More rigorous clinical studies will be necessary in future.

1.2.2. Acupuncture crânienne☆

1.2.2.1. Qiang 2019 Ø

Qiang Tianyao, Cong Gai , Yuan Chai , Wandi Feng , Haojie Ma , Yi Zhang , Jing Feng , Zhenyu Guo , Ling Ma , Hongmei Sun. Combination therapy of scalp electro-acupuncture and medication for the treatment of Parkinson's disease: A systematic review and meta-analysis. Journal of Traditional Chinese Medical Sciences. 2019;6(1):26-34. [197195].

Objective To summarize the current clinical evidence related to the therapeutic effects and safety of adjuvant scalp electro-acupuncture (SEA) treatment for Parkinson's disease in China.
Methods Following the PRISMA statement, seven electronic databases were searched to retrieve randomized controlled clinical trials that used SEA combined with medication as the treatment intervention, and medication as the control. RevMan 5.3 was used to analyze outcomes, including the Unified Parkinson's Disease Rating Scale (UPDRS), Webster scale, effectiveness rate, and UPDRS III.
Results Nine randomized controlled trials, with certain methodological flaws and risks of bias, were included that involved 474 participants. SEA combined with medication was more effective than medication alone in overall therapeutic effects, as evidenced by total UPDRS scores (mean difference (MD): 7.15, 95% confidence interval [CI] 0.24 to 14.07, P = .04), Webster scores (MD: 1.60, 95% CI 0.20 to 2.99, P = .03), and effectiveness rate (risk ratio: 1.35, 95% CI 1.19 to 1.54, P < .001). In addition, there was significant improvement in pooled motor function results after adjuvant SEA treatment compared with medication alone (MD: 5.75, 95% CI 4.18 to 7.32, P < .001).
Conclusion The combination of SEA and medication may be a promising intervention for patients with Parkinson's disease, especially to improve motor function. However, results were inconclusive, and additional studies with rigorous experimental design and larger sample sizes are needed to verify these results.
1.2.2.2. Lee 2013

Lee HS, Park HL, Lee SJ, Shin BC, Choi JY, and Soo Lee MS. Scalp Acupuncture for Parkinson's Disease: A Systematic Review of Randomized Controlled Trials. Chin J Integr Med. 2013;19(4):297-306. [165812].

Objective To evaluate the effectiveness of scalp acupuncture (SA), a modern acupuncture technique specialized to neurological disorders, in managing motor function and symptoms for Parkinson's disease (PD) patients.
Methods Two independent reviewers extracted data from all of the randomized clinical trials (RCTs) that assessed the efficacy of SA for PD compared with conventional therapies (CTs). Sixteen electronic databases were searched. The risk of bias was appraised with the Cochrane Collaboration tool, and the reporting of the included studies was evaluated by the Consolidated Standards of Reporting Trials (CONSORT) 2010 checklist and the revised Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) guidelines.
Results In total, 4 RCTs met the inclusion criteria. As assessed by the Unified PD Rating Scale (UPDRS), 2 RCTs showed that SA combined with CTs proved superior to CTs alone [60 cases; weighted mean difference, —3.94; 95% confidence interval (CI), —6.05 to —1.84, P=0.01; 12=O%]. Based on the Webster scale, however, 3 RCTs showed no superior effect of SA when combined with CTs with high heterogeneity (154 cases; risk ratio, 1.29; 95% CI, 0.79 to 2.12, P=0.30; 12=84%). The Cochrane risk of bias, adherence to the CONSORT and the STRICTA checklist showed that the quality of all the included RCTs was generally low.
Conclusions The result of our systematic review and meta-analysis suggested that the effectiveness of SA for PD is promising, however, the evidence is not convincing. A sham-controlled RCT design that adheres to the CONSORT and STRICTA guidelines to overcome methodological weakness and that includes a large sample size is strongly recommended to confirm the precise effect of SA on PD.

1.2.3. Pharmaco-acupuncture

1.2.3.1. Cho 2018

Cho KH, Kim TH, Jung WS, Moon SK, Ko CN, Cho SY, Jeon CY, Choi TY, Lee MS, Lee SH, Chung EK, Kwon S. Pharmacoacupuncture for Idiopathic Parkinson's Disease: A Systematic Review of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2018. [170448].

Introduction Pharmacoacupuncture is a new acupuncture treatment that stimulates acupuncture points by injecting herbal medicine into them. Recently, pharmacoacupuncture has been widely used in the treatment of idiopathic Parkinson's disease in traditional East Asian medicine. The purpose of this systematic review is to evaluate the efficacy and safety of pharmacoacupuncture in the treatment of idiopathic Parkinson's disease.
Methods The following electronic databases were searched for studies published in or before December 2016: Medline, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, OASIS, and CNKI, without language restriction. The main outcome assessed was the total Unified Parkinson's Disease Rating Scale (UPDRS) score. The details of the pharmacoacupuncture intervention, such as the herbal medicine and acupuncture points used, were also investigated.
Results From 138 studies, 3 randomized controlled trials were included; the number of patients analyzed was 134. Most of the studies showed considerable methodological flaws. There was heterogeneity of the intervention type and treatment duration in the included studies. Therefore, we could not conduct a meta-analysis. In one study, adjunctive bee venom pharmacoacupuncture therapy significantly improved total UPDRS scores compared with conventional therapy alone. Another study, which used adjunctive Kakkonein pharmacoacupuncture, did not reveal significant improvement compared with conventional therapy alone. A third study reported that Mailuoning pharmacoacupuncture was able to significantly improve the modified Webster Symptom Score when compared with no treatment. Adverse events related to the pharmacoacupuncture were reported in only one case, itching caused by the bee venom.
Conclusions Our findings regarding the efficacy of pharmacoacupuncture as a therapy for idiopathic Parkinson's disease are currently inconclusive. Further large and rigorous clinical trials are needed.

2. Overviews of systematic reviews / Revues de revue systématiques

2.1. Cao 2020

Cao L, Li X, Li M, Yao, Hou L, Zhang W, Wang Y, Niu J, Yang K. The effectiveness of acupuncture for Parkinson's disease: An overview of systematic reviews. Complement Ther Med. 2020. [209268]. doi

Objectives Acupuncture is an alternative therapy for Parkinson's disease (PD), but its efficacy and safety are controversial. This overview aimed to summarize the existing evidence from systematic reviews (SRs) and meta-analyses (MAs) in order to assess the effectiveness of acupuncture as a treatment for PD.
Methods Seven electronic databases were searched from their inception until July 2019. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklists were used to assess evidence quality and methodological quality, respectively. The outcomes of study were calculated using mean differences (MDs) and risk ratios (RRs) with 95 % confidence intervals (CIs). A meta-analysis was performed using RevMan 5.3 software.
Results A total of 12 SRs/MAs were included. All 12 SRs/MAs had more than one critical weakness in AMSTAR 2 and were considered of critically low methodological quality. The quality of evidence was unsatisfactory according to the GRADE checklist. Meta-analyses showed that acupuncture combined with drug for the treatment of PD can significantly improve the total effectiveness rate compared with drug alone (RR = 1.25, 95 % CI 1.16-1.34, P < 0.001). It was also found that acupuncture combined with drug significantly improved the UPDRS I-IV total summed scores (WMD=-6.18, 95 % CI -10.32 to -2.04, P < 0.001) and Webster scores (WMD=-4.20, 95 % CI -7.59 to -0.81, P < 0.001).
Conclusion Acupuncture might improve the UPDRS score, Webster score, and total effective rate in treatment of PD. It might be a safe and useful adjunctive treatment for patients with PD. However, we should interpret the findings of these reviews with caution, considering the overall limited methodological and reporting quality.

3. Recommandation pour la pratique clinique

⊕ recommandation positive (quel que soit le niveau de preuve annoncé)
Ø recommandation négative, ou absence de preuve ou non conclusif

3.1. Parkinson Canada 2019 Ø

2e édition du guide canadien pour la maladie de parkinson, Parkinson Canada. 2019:60P. [115066].

Même si beaucoup de malades souhaitent recourir aux thérapies non conventionnelles comme l’acupuncture, les données appuyant ces méthodes sont insuffisantes. De plus en plus de patients s’ouvrent et s’intéressent à ce type de traitement, et la profession médicale devra fournir des données scientiques valides pour les guider. L’effet placebo est un phénomène bien connu, en particulier chez les patients atteints de la maladie de Parkinson, et il pourrait être médié par la dopamine. Par conséquent, toute méthode appelée à traiter la maladie de Parkinson doit faire l’objet d’une évaluation scientiquement rigoureuse de son efficacité, pour faire en sorte que les patients en aient le plus possible pour leur argent, leur temps et leurs efforts.

3.2. Haute Autorité de Santé (HAS, France) 2016 Ø

HAS. Maladie de Parkinson et syndromes apparentés : techniques et modalités de la prise en charge non médicamenteuse des troubles moteurs. Paris: Haute Autorité de Santé (HAS). 2016;:54P. [167786].

Nous n’avons pas trouvé de preuve suffisante et consistante pour affirmer, au-delà des effets qu’elles peuvent engendrer transversalement (dus à l’intensité, la diversité, etc.), que les thérapeutiques suivantes sont bénéfiques ou pas (preuve insuffisante pour supporter ou réfuter leur utilisation) : thérapie manuelle ; balnéothérapie ; acupuncture ; biofeedback ; réalité virtuelle ; serious games ; technique Alexander.

3.3. Parkinson Society Canada ( PSC, Canada) 2012 Ø

Grimes D, Gordon J, Snelgrove B, Lim-Carter I, Fon E , Martin W et al. Canadian Guidelines on Parkinson’s Disease. Canadian Journal of Neurological Sciences. 2012;39(4) sup 1:s1-30. [197040].

C57 There is insufficient evidence to support or refute the use of acupuncture, manual therapy, biofeedback or the Alexander technique in the treatment of PD. AAN Level U

3.4. American Academy of Neurology (AAN, USA) 2006 Ø

Suchowersky O, Gronseth G, Perlmutter J, Reich S, Zesiewicz T, Weiner WJ; Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: neuroprotective strategies and alternative therapies for Parkinson disease(an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2006;66(7):976-82. [198765].

There is insufficient evidence to support or refute the use of acupuncture in PD (Level U).