THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 21, Number 1, 2015, pp. 40–45 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2014.0125
Treatment of Chronic Conditions with Traditional Chinese Medicine: Findings from Traditional Chinese Medicine Hospitals in Hubei, China Yi Cai, PhD,1 David L. Boyd, PhD,2 Remy R. Coeytaux, MD, PhD,3 Truls Østbye, MD, PhD, MPH,3 Bei Wu, PhD,4 and Zongfu Mao, PhD 5
Abstract
Objectives: This study aimed to document clinical use of Traditional Chinese Medicine (TCM) for chronic conditions in all TCM hospitals in a Chinese province and to recommend treatments most in need of evaluation for use in community health centers. Design: A cross-sectional survey was conducted in the summer of 2010. It included 119 of 132 TCM hospitals in Hubei Province, China. TCM physicians were asked to recommend specific TCM treatments for common chronic conditions. Nine types of chronic conditions recommended more than 3.7 times (mean of frequencies of chronic conditions) are included in this analysis. Frequency of each TCM treatment and the number of visits by type of chronic conditions were calculated. Results: The total number of recommendations by TCM physicians was 411. For seven types of treatments, six were recommended for musculoskeletal pain, five for soft tissue injuries, four for visceral pain and fractures, three for stroke and asthma, two for hemorrhoids, and one for hypertension. The most frequently recommended treatments for specific conditions include orally ingested herbs for visceral pain (n = 3), type 2 diabetes (n = 5), and hypertension (n = 7); herbs for external use for soft tissue injuries (n = 10), asthma (n = 6), and hemorrhoids (n = 8); acupuncture for musculoskeletal pains (n = 43) and for stroke (n = 10); and Chinese external fixation for fractures (n = 24). The number of visits for recommended treatments per year of was 671,759. The most frequently recommended treatments for specific chronic conditions have most visits, except for chronic conditions such as musculoskeletal pains, visceral pains, soft tissue injuries, and asthma. Conclusions: Patients with musculoskeletal pain have more treatment options than other patients. Herbal medicine is the option most commonly used for chronic conditions. These treatments for these conditions should be targeted for further evaluation of effectiveness and, only if found effective, considered for use in primary care settings.
adverse reactions to TCM injections.2,3 The effect of acupuncture treatment is not clear: Some trials have reported acupuncture to be superior to placebo, while others have found it superior to usual care but not to placebo.4 Most existing studies have been poorly designed, making it difficult to conclude the safety and effectiveness of TCM treatments.5 With sound evidence from well-designed clinical trials lacking, clinical experience from TCM use may be the first step toward helping patients choose appropriate TCM care.
Introduction
T
raditional Chinese medicine (TCM) is becoming increasingly popular for treating chronic conditions because of its accessibility and affordability in developing countries and because of its potential to complement biomedical healthcare in developed countries.1 However, TCM use still faces challenges, especially related to uncertain safety and effectiveness. Use of Chinese herbal medicine poses risks for herb-drug interaction, poisoning, and 1
Wuhan University HOPE School of Nursing, Wuhan, Hubei, China. Duke Global Health Institute, Duke University, Durham, NC. 3 Duke Clinical Research Institute, Duke University, Durham, NC. 4 School of Nursing, Duke University, Durham, NC. 5 Wuhan University School of Public Health, Wuhan, Hubei, China. 2
40
CHINESE MEDICINE FOR CHRONIC CONDITIONS
TCM hospitals in China accumulate extensive and varied clinical experience with TCM. The Chinese government has established a network of nonprofit TCM hospitals, including one provincial TCM hospital located in the capital city of each province, one municipal TCM hospital in each city, and one small-scale TCM hospital in each district/county, aiming to make TCM care accessible and equitable.6 In TCM hospitals, most doctors have better education and training, with different types of specializations, and they can therefore provide various types of TCM treatments, including those that are more limited in other institutional settings, and also provide a rich source of data on the use of such treatments. The TCM practice paradigm stresses individualized treatment based on TCM syndrome differentiation. However, such individualized diagnosis and treatment limit access to TCM care among patients with chronic disease in the community. The Chinese government therefore encourages TCM hospitals to explore ways to deliver TCM care for common chronic conditions and train TCM/non-TCM doctors in community health centers to provide the simplified treatments, with each treatment being specific to a specific chronic condition. TCM treatments are well known in China but less known in other countries. Introducing the TCM treatments to other countries may provide new perspectives on TCM use for health providers and patients with chronic conditions. Our study aims to document clinical use of TCM treatments for specific chronic conditions in TCM hospitals and to provide some recommendations about which TCM treatments for which diseases are most common in community health centers and therefore most in need of evaluation. Hubei Province is located in the middle of China. It consists of one large city (Wuhan city), 12 middle-size cities, and four small cities. There are 103 districts/counties within these cities. In 2010 the total population of Hubei Province was 57 million, with prevalence of most chronic conditions (e.g., stroke, hypertension, and type 2 diabetes) similar to the average of the state.7,8 Economic development and living standards vary widely within the province; thus, Hubei can provide a ‘‘typical’’ location for the clinical use of specific treatments for specific chronic conditions in China. Materials and Methods Sample size
In 2010, a cross-sectional survey was conducted among all 132 TCM hospitals in Hubei Province. A total of 119 TCM hospitals (90.15%) completed the questionnaire. The province has one provincial, 16 municipal, 67 county/ district, and 35 private TCM hospitals. Thirteen hospitals (one municipal, three county/district, and nine private hospitals) in Honghu city did not complete the survey because of a flood. Survey instrument and procedure
This survey was a part of a nationwide survey. After the first year of implementation of healthcare reform in 2009, the State Administration of TCM—the highest-level agency for TCM—completed the national survey to better under-
41
stand both TCM utilization and distribution of resources. The questionnaire was discussed and finalized by an expert panel consisting of health policy makers, TCM physicians, and epidemiologists and was then distributed to each Provincial Bureau of Health. The Hubei Bureau of Health helped conduct the survey across Hubei Province, including training staff from the information technology (IT) department in each of the TCM hospitals to complete an electronic questionnaire and to enter data into a database developed by the State Administration of TCM. The questionnaire included data on resources, health care use, revenue and expenditure, and academic activities as of the end of 2009. In addition, each TCM hospital was required, for each of a series of common chronic conditions, to recommend specific TCM treatments based on the clinical experience of their physicians and any available clinical trials data, and to report the number of visits per year for the specific treatments for each chronic condition. Each recommendation was made as ‘‘which type of TCM treatments is recommended to treat which type of chronic conditions.’’ The recommended treatments were limited to the seven modalities most commonly used in clinical practice: orally ingested herbs, herbs for external use, acupuncture, moxibustion, massage, cupping, and Chinese external fixation. The staff from each hospital’s IT department was responsible for collecting data and completing the electronic questionnaire online. This study was approved by all district Departments of Health and Wuhan University, and was deemed ethically sound by the Wuhan University College of Medicine Research Committee (reference number ZYJBXZDC2010). Types of TCM treatments Orally ingested herbs. This category consists of all herbal products for oral ingestion, including traditional herbal decoctions and Chinese patent medicine produced by pharmaceutical company and TCM hospitals. Herbs for external use. These externally applied herbs are applied in a bath or in the form of topical creams. Acupuncture. Filiform needles are inserted along specific ‘‘meridians’’ postulated to exist along longitudinal sectors of the body. Acupuncture is sometimes used in conjunction with electric stimulation and infrared radiation. Moxibustion. Heat from burning dried mugwort leaves (sometimes with other herbal additives) is dermally applied directly or indirectly, primarily at acupuncture points. Massage. This modality entails systematic manual manipulations of body tissues (including superficial and deeper layers of muscle and connective tissue but not joints) to affect the nervous and muscular systems along with general circulation. Cupping. Suction cups are applied dermally to produce hyperemia at acupoints. Chinese external fixation. Fractures are treated by using four splints in conjunction with three pressure pads and three or four slings after successful manipulative reduction.
42
CAI ET AL.
Statistical analysis
Excel 2010 was used for the descriptive analysis. Chronic conditions were sorted by name and then TCM treatments for each of the chronic conditions were sorted by type. The number of similar recommendations and the number of visits for treatments for all TCM hospitals were counted. The mean frequency of recommendation for specific chronic condition was seven; chronic conditions with a frequency below this mean are not presented here. Consequently, this analysis includes nine chronic conditions: musculoskeletal pain, visceral pain, fractures, soft tissue injuries, stroke, type 2 diabetes, asthma, hemorrhoids, and hypertension. Finally, the frequency of recommendation by TCM doctors and the number of visits over time were compared. Results
conditions, was 671,759 (Table 2). Within each type of chronic conditions, the most visits (n = 160,486) for musculoskeletal pain was for massage; the most visits (n = 4728) for visceral pain was for herbs for external use; the most visits (n = 19,800) for soft tissue injuries was for cupping; the most visits (n = 52,680) for stroke was for acupuncture; the most visits (n = 16,158) for type 2 diabetes was for orally ingested herbs; the most visits (n = 55,704) for asthma was for orally ingested herbs; the most visits (n = 11,149) for hemorrhoids was for herbs for external use; and the most visits (n = 2480) for hypertension was for orally ingested herbs. For specific chronic conditions, the most frequently recommended treatments have the most visits, except for musculoskeletal pains, visceral pains, soft tissue injuries, and asthma. Discussion
Frequency of specific TCM treatments for specific chronic conditions
For all chronic conditions, the number of recommendations for all types of TCM treatments was 411 (Table 1). Of all seven types of TCM treatments, six were recommended for musculoskeletal pain, five types for soft tissue injuries, four types for visceral pain and fractures, three types for stroke and asthma, two types for hemorrhoids, and one type for hypertension. The most frequent treatment recommendation for specific chronic conditions was for musculoskeletal pain (n = 126), followed by fractures (n = 36), soft tissue injuries (n = 26), stroke (n = 20), type 2 diabetes (n = 9), asthma (n = 9), hemorrhoids (n = 8), visceral pain (n = 7), and hypertension (n = 7). For each type of chronic conditions, the most commonly recommended treatments for specific chronic conditions included orally ingested herbs for visceral pain (n = 3), type 2 diabetes (n = 5), and hypertension (n = 7); herbs for external use for soft tissue injuries (n = 10), asthma (n = 6), and hemorrhoids (n = 8); acupuncture for musculoskeletal pain (n = 43) and for stroke (n = 10); and Chinese external fixation for fractures (n = 24). Number of visits related to the recommended treatments
The total number of visits per year, for all 119 hospitals, including the seven specific treatments for the nine chronic
Musculoskeletal pain, visceral pain, fractures, soft tissue injuries, stroke, type 2 diabetes, asthma, hemorrhoids, and hypertension are chronic conditions often recommended for TCM treatment. Patients with musculoskeletal pain have more treatment options and use more TCM treatments than other patients. Herbal medicine shows the widest utilization for chronic conditions. TCM hospitals show a wide use of externally applied herbs for several chronic conditions, a practice not widely employed outside China. For specific chronic conditions, the treatments most recommended are not always associated with the most use, such as for musculoskeletal pain, visceral pains, soft tissue injuries, and asthma. Recommendations of TCM treatments for chronic conditions by TCM physicians
These findings show that the recommendations for musculoskeletal pain are the most varied and frequent. Six types of TCM treatments were recommended to treat musculoskeletal pain. In contrast to this, only one type of TCM treatments is recommended for some chronic conditions, such as hypertension. This implies that patients with musculoskeletal pain may have far more treatment options than patients with hypertension. Considering frequency of
Table 1. Number of Recommendations for Traditional Chinese Medicine Treatments for Common Chronic Conditions from 119 Traditional Chinese Medicine Hospitals
Variable Musculoskeletal pain Visceral pain Fractures Soft tissue injuries Stroke Type 2 diabetes Asthma Hemorrhoid Hypertension Total
Orally ingested herbs
Cupping
Chinese external fixation
Total
31 (93.9)
8 (50.0)
–
126 (50.8)
– – 2 (6.1)
– – 8 (50.0)
– 24 (100.0) –
7 (2.8) 36 (14.5) 26 (10.5)
Externally used herbs Acupuncture Moxibustion Massage
15 (34.9)
25 (37.9)
43 (70.5)
4 (80.0)
3 (7.0) 2 (4.7) 1 (2.3)
2 (3.0) 9 (13.6) 10 (15.2)
1 (1.6) 1 (1.6) 5 (8.2)
1 (20.0) – –
8 (18.6) 5 (11.6) 2 (4.7) – 7 (16.3) 43 (100.0)
2 4 6 8
(3.0) (6.1) (9.1) (12.1) – 66 (100.0)
Values are expressed as number (percentage).
10 (16.4) – 1 (1.6) – – 61 (100.0)
– – – – – 5 (100.0) 33
– – – – – (100.0) 16
– – – – – (100.0)
– – – – – 24 (100.0)
20 9 9 8 7 248
(8.1) (3.6) (3.6) (3.2) (2.8) (100.0)
(53.8) (1.5) (8.0) (7.7) (14.3) (2.9) (9.7) (1.7) (0.4) (100.0) 36,1695 10,377 53,923 51,617 95,765 19,546 65,207 11,149 2480 671,759 – – 27,649 (100.0) – – – – – – 27,649 (100.0) 29,013 (59.3) – – 19,880 (40.7) – – – – – 48,893 (100.0) 160,486 (93.8) – – 10,672 (6.2) – – – – – 171,158 (100.0) 5974 (85.7) 1000 (14.3) – – – – – – – 6974 (100.0) 111,009 (62.9) 123 (0.1) 1565 (0.9) 9070 (5.1) 52,680 (29.8) – 2100 (1.2) – – 176,547 (100.0) (34.3) (5.0) (21.0) (10.7) (5.5) (3.6) (7.9) (11.9) – 93,792 (100.0) Values are expressed as number (percentage).
32,202 4728 19,722 10,072 5128 3388 7403 11,149
23,011 (15.7) 4526 (3.1) 4987 (3.4) 1923 (1.3) 37,957 (25.9) 16,158 (11.0) 55,704 (38.0) – 2480 (1.7) 146,746 (100.0) Musculoskeletal pain Visceral pain Fractures Soft tissue injuries Stroke Type 2 diabetes Asthma Hemorrhoid Hypertension Total
Chinese external fixation Cupping Massage Moxibustion Acupuncture Externally used herbs Orally ingested herbs Variable
Table 2. Number of Visits for Traditional Chinese Medicine Treatments for Common Chronic Conditions from 119 Traditional Chinese Medicine Hospitals
Total
CHINESE MEDICINE FOR CHRONIC CONDITIONS
43
recommendations, acupuncture for treating musculoskeletal pain also was the most frequently recommended. The number of recommendation for acupuncture for musculoskeletal pain was 43, followed by 31 recommendations for massage for musculoskeletal pain, 24 recommendations for Chinese external fixation for fractures, and no more than 10 recommendations for other conditions. This implies that TCM treatments for musculoskeletal are used more frequently than those for other chronic conditions. Further research is needed to conclude whether this frequency is due to better efficacy or safety compared with other TCM treatments. Although this study confirms the well-known and widely used TCM treatments, such as orally ingested herbs and acupuncture, for chronic conditions,9–14 it provides new insights by reporting the extent of use of other TCM treatments, such as herbs for external use and Chinese external fixation. In this study, herbs for oral ingestion and external use were commonly recommended for treatment of various chronic conditions. In general, orally ingested herbs increase risk of herb-drug interactions.15 TCM hospitals are becoming westernized, and nearly all patients in TCM hospitals now use herbs and conventional drugs together,16,17 so there is also a concern about herb-drug interactions. With both recommendations of herbs for oral ingestion and external use for specific chronic conditions, herbs for external use instead of oral ingestion for specific chronic conditions may reduce the risk of herb-drug interaction. Before herbs are recommended for external use instead of oral ingestion for specific chronic conditions, further studies should assess the safety and efficacy of, and patient preference for, the use of herbs as well as other TCM treatments. Chinese external fixation is potentially of great value for older people in poor areas and countries. Older people have a high occurrence of distal radius fracture from falls.18 The use of Chinese external fixation for stabilizing distal radial fractures as a functional method in Japan and Hong Kong was already reported in the 1980s.19,20 Chinese external fixation can be applied with four splints, three pressure pads, and four slings; thus, it is easy to practice, is convenient to adjust the splints, and is inexpensive. It was commonly used in the past but is now rarely used for treating distal radius fractures in TCM hospitals, primarily because it is not reimbursed well. In fact, because of China’s fee-for-service health care system, many potentially effective TCM treatments, such as moxibustion treatment,21 are rarely used in clinical practice. However, given the scarce clinical trial evidence, we can only highlight this practice and strongly recommend well-designed clinical trials evaluations comparing this approach to other commonly used non-TCM fracture treatments. Use of TCM treatments for chronic conditions by patients
With more recommendation by TCM physicians, Chinese herbal medicine does have wider use. In this analysis, both orally and externally used herbs are used for chronic conditions, with the exception of hemorrhoids (externally herb only) and hypertension (internally ingested herbs only). Additionally, acupuncture is a well-known treatment widely used for treating pain, poststroke rehabilitation, and sports-
44
related injuries.22–24 The current findings show more use of acupuncture than herbal medicine for musculoskeletal pain and stroke. Less commonly known TCM treatments, such as moxibustion and cupping, are used to treat one or two types of chronic conditions. In fact, these two types of TCM treatments are popular in China.25–28 Easily and safely practiced by nurses and patients, they may be frequently used by community health and for self-care by community residents themselves—potential use patterns that may explain why they are used less in TCM hospitals. Understanding uses of easily administered TCM treatments could help prevent and rehabilitate chronic conditions globally. Additional community-based studies should be performed identify utilization patterns and efficacy because the ease and costeffectiveness of these treatments might make them suitable candidates for global use. Differences between recommended and actual use of TCM treatment for chronic conditions
While a TCM physician may believe the most effective treatment choice is the one associated with the highest utilization patterns,29 the current findings show that the more commonly recommended treatments are not always associated with more actual clinical use. This analysis demonstrates differences between recommended use and actual clinical use for musculoskeletal pain, visceral pain, soft tissue injuries, and asthma. The Anderson model of health service utilization illustrates how such utilization is determined by population characteristics, health care system, and external environment.30 In China, few studies have focused on TCM use and attitudes of TCM providers and users; the current survey is the first to collect data from TCM facilities. However, this study did not have access to individual-level data that would have allowed further examination of determinants affecting TCM use. Finally, it is not possible to conclude which of these determinants are associated with the specific treatments discussed here. Therefore, the observed differences between recommended and actual utilization of specific TCM treatment for specific chronic condition should be the subject of further study. This study has several limitations. First, this crosssectional survey lacks follow-up information on adverse effects among patients who use these TCM treatments, so it is not possible to conclude whether the uses are safe and effective. Second, no quantitative or qualitative data are available to explain the observed differences between recommended and actual use of specific TCM treatment for specific chronic condition, or whether patients receive several different TCM treatments for one chronic conditions. Third, use of specific TCM treatments for specific chronic conditions in TCM hospitals cannot be generalized to guide use in community-based health care settings; in those locations, TCM care may be more commonly used by the chronically disabled, vulnerable, and elderly. In addition, TCM hospitals primarily serve patients with more complicated and serious conditions and do not target health promotion of the total population. Finally, because this survey was conducted in Hubei Province, the findings may not be representative of other provinces or areas outside of China.
CAI ET AL. Conclusion
Despite these limitations, the survey was successful, with an exceptional response rate of 90.2%; this was possible because of the health bureaus’ assistance. The collected data enable researchers and policy makers to better understand current use of various TCM treatments for specific chronic conditions in TCM hospitals by thousands of patients; this should provide useful reference information to better understand TCM use for chronic conditions. Additionally, the data set can serve as a useful guide for what treatments and chronic conditions are most commonly involved in TCM, thus implying which treatments and chronic conditions should likely be prioritized for future clinical trials of effectiveness and safety at the community level. Acknowledgments
This cross-sectional survey was financially supported by the Hubei Bureau of Health. The survey was conducted by the School of Public Health, Wuhan University, with help from the Hubei Bureau of Health. The authors thank all of the faculty and students at Wuhan University School of Public Health and staff at the Hubei Bureau of Health for collecting data. The named authors alone are responsible for the views expressed in this paper. Author Disclosure Statement
No competing financial interests exist. References
1. World Health Organization: WHO Traditional Medicine Strategy 2002–2005. [Homepage on the Internet]. Online document at: http://whqlibdoc.who.int/hq/2002/who_edm_ trm_2002.1.pdf. Accessed July 16, 2013 2. Efferth T, Kaina B. Toxicities by herbal medicines with emphasis to traditional Chinese medicine. Curr Drug Metab 2011;12:989–996. 3. Li T. Avoiding adverse drug reactions to Chinese medicine injections. J Evid Based Med 2010;3:44–49. 4. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture Trialists’ Collaboration. Individual patient data metaanalysis of acupuncture for chronic pain: protocol of the Acupuncture Trialists’ Collaboration. Trials 2010;11:90. 5. Luo H, Li Q, Flower A, Lewith G, Liu J. Comparison of effectiveness and safety between granules and decoction of Chinese herbal medicine: a systematic review of randomized clinical trials. J Ethnopharmacol 2012;140:555–567. 6. Hesketh T, Zhu WX. Health in China. Traditional Chinese medicine: one country, two systems. BMJ 1997;315:115– 117. 7. National Bureau of Statistics. [Homepage on the Internet]. Online at: http://www.stats.gov.cn Accessed July 16, 2013. 8. Kerkhoff AC, Moreira LB, Fuchs FD, Fuchs SC. Association between hypertension and musculoskeletal complaints: a population-based study. J Hypertens 2012;30: 2112–2117. 9. Lathia AT, Jung SM, Chen LX. Efficacy of acupuncture as a treatment for chronic shoulder pain. J Altern Complement Med 2009;15:613–618. 10. Wang J, He QY, Zhang YL. Effect of shenshao tablet on the quality of life for coronary heart disease patients with stable angina pectoris. Chin J Integr Med 2009;15:328–332.
CHINESE MEDICINE FOR CHRONIC CONDITIONS
11. Deng X, Liu ZW, Wu FS, Li LH, Liang J. A clinical study of weining granules in the treatment of gastric precancerous lesions. J Tradit Chin Med 2012;32:164–172. 12. Cabyoglu MT, Ergene N, Tan U. The mechanism of acupuncture and clinical applications. Int J Neurosci 2006;116: 115–125. 13. Luo H, Li Q, Flower A, Lewith G, Liu J. Comparison of effectiveness and safety between granules and decoction of Chinese herbal medicine: a systematic review of randomized clinical trials. J Ethnopharmacol 2012;140:555–567. 14. Chan K, Shaw D, Simmonds MS, et al. Good practice in reviewing and publishing studies on herbal medicine, with special emphasis on traditional Chinese medicine and Chinese materia medica. J Ethnopharmacol 2012;140:469–475. 15. Chan E, Tan M, Xin J, Sudarsanam S, Johnson DE. Interactions between traditional Chinese medicines and Western therapeutics. Curr Opin Drug Discov Devel 2010;13:50–65. 16. Qiu J. China plans to modernize traditional medicine. Nature 2007;446:590–591. 17. Shen JJ, Wang Y, Lin F, et al. Trends of increase in western medical services in traditional medicine hospitals in China. BMC Health Serv Res 2011;11:212. 18. Padegimas EM, Osei DA. Evaluation and treatment of osetoporotic distal radius fracture in the elderly patient. Curr Rev Musculoskelet Med 2013;6:41–46. 19. Leung KS, Shen WY, Leung PC, Kinninmonth AW, Chang JC, Chan GP. Ligamentotaxis and bone grafting for comminuted fractures of the distal radius. J Bone Joint Surg Br 1989;71:838–842. 20. Futami T, Yamamoto M. Chinese external fixation treatment for fractures of the distal end of the radius. J Hand Surg Am 1989;14:1028–1032. 21. Xu HQ, Zhang HR, Gu YH. Progress of researches on prevention and treatment of sports fatigue with moxibustion therapy. Zhen Ci Yan Jiu 2014;39:169–173. 22. Vickers AJ, Cronin AM, Maschino AC, et al; Acupuncture Trialists’ Collaboration. Acupuncture for chronic pain: in-
45
23.
24. 25.
26. 27. 28. 29. 30.
dividual patient data meta-analysis. Arch Intern Med 2012;172:1444–1453. Pulman J, Buckley E. Assessing the efficacy of different upper limb hemiparesis interventions on improving healthrelated quality of life in stroke patients: a systematic review. Top Stroke Rehabil 2013;20:171–188. Lin ZP, Lan LW, He TY, et al. Effects of acupuncture stimulation on recovery ability of male elite basketball athletes. Am J Chin Med 2009;37:471–481. Kuang YH, Wei JA. An introduction to the study of acupuncture and moxibustion in China. Part III. Review of clinical studies on acupuncture and moxibustion. J Trad Chin Med 1984;4:249–254. Wang T, Zhang Q, Xue X, Yeung A. A systematic review of acupuncture and moxibustion treatment for chronic fatigue syndrome in China. Am J Chin Med 2008;36:1–24. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PLoS One 2012;7:e31793. Cao H, Han M, Li X, et al. Clinical research evidence of cupping therapy in China: a systematic literature review. BMC Complement Altern Med 2010;10:70. Xing B, Yan QL. How to develop traditional Chinese medicine in the period time of evidence-based medicine. J Shandong Univ TCM 2003;27:87–89. Anderson RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995;36:1–10.
Address correspondence to: Zongfu Mao, PhD Wuhan University School of Public Health 115 Donghu Road Wuchang District Wuhan, Hubei 430071 China E-mail: [email protected]
Copyright of Journal of Alternative & Complementary Medicine is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Treatment of Chronic Conditions with Traditional Chinese Medicine: Findings from Traditional Chinese Medicine Hospitals in Hubei, China Yi Cai, PhD,1 David L. Boyd, PhD,2 Remy R. Coeytaux, MD, PhD,3 Truls Østbye, MD, PhD, MPH,3 Bei Wu, PhD,4 and Zongfu Mao, PhD 5
Abstract
Objectives: This study aimed to document clinical use of Traditional Chinese Medicine (TCM) for chronic conditions in all TCM hospitals in a Chinese province and to recommend treatments most in need of evaluation for use in community health centers. Design: A cross-sectional survey was conducted in the summer of 2010. It included 119 of 132 TCM hospitals in Hubei Province, China. TCM physicians were asked to recommend specific TCM treatments for common chronic conditions. Nine types of chronic conditions recommended more than 3.7 times (mean of frequencies of chronic conditions) are included in this analysis. Frequency of each TCM treatment and the number of visits by type of chronic conditions were calculated. Results: The total number of recommendations by TCM physicians was 411. For seven types of treatments, six were recommended for musculoskeletal pain, five for soft tissue injuries, four for visceral pain and fractures, three for stroke and asthma, two for hemorrhoids, and one for hypertension. The most frequently recommended treatments for specific conditions include orally ingested herbs for visceral pain (n = 3), type 2 diabetes (n = 5), and hypertension (n = 7); herbs for external use for soft tissue injuries (n = 10), asthma (n = 6), and hemorrhoids (n = 8); acupuncture for musculoskeletal pains (n = 43) and for stroke (n = 10); and Chinese external fixation for fractures (n = 24). The number of visits for recommended treatments per year of was 671,759. The most frequently recommended treatments for specific chronic conditions have most visits, except for chronic conditions such as musculoskeletal pains, visceral pains, soft tissue injuries, and asthma. Conclusions: Patients with musculoskeletal pain have more treatment options than other patients. Herbal medicine is the option most commonly used for chronic conditions. These treatments for these conditions should be targeted for further evaluation of effectiveness and, only if found effective, considered for use in primary care settings.
adverse reactions to TCM injections.2,3 The effect of acupuncture treatment is not clear: Some trials have reported acupuncture to be superior to placebo, while others have found it superior to usual care but not to placebo.4 Most existing studies have been poorly designed, making it difficult to conclude the safety and effectiveness of TCM treatments.5 With sound evidence from well-designed clinical trials lacking, clinical experience from TCM use may be the first step toward helping patients choose appropriate TCM care.
Introduction
T
raditional Chinese medicine (TCM) is becoming increasingly popular for treating chronic conditions because of its accessibility and affordability in developing countries and because of its potential to complement biomedical healthcare in developed countries.1 However, TCM use still faces challenges, especially related to uncertain safety and effectiveness. Use of Chinese herbal medicine poses risks for herb-drug interaction, poisoning, and 1
Wuhan University HOPE School of Nursing, Wuhan, Hubei, China. Duke Global Health Institute, Duke University, Durham, NC. 3 Duke Clinical Research Institute, Duke University, Durham, NC. 4 School of Nursing, Duke University, Durham, NC. 5 Wuhan University School of Public Health, Wuhan, Hubei, China. 2
40
CHINESE MEDICINE FOR CHRONIC CONDITIONS
TCM hospitals in China accumulate extensive and varied clinical experience with TCM. The Chinese government has established a network of nonprofit TCM hospitals, including one provincial TCM hospital located in the capital city of each province, one municipal TCM hospital in each city, and one small-scale TCM hospital in each district/county, aiming to make TCM care accessible and equitable.6 In TCM hospitals, most doctors have better education and training, with different types of specializations, and they can therefore provide various types of TCM treatments, including those that are more limited in other institutional settings, and also provide a rich source of data on the use of such treatments. The TCM practice paradigm stresses individualized treatment based on TCM syndrome differentiation. However, such individualized diagnosis and treatment limit access to TCM care among patients with chronic disease in the community. The Chinese government therefore encourages TCM hospitals to explore ways to deliver TCM care for common chronic conditions and train TCM/non-TCM doctors in community health centers to provide the simplified treatments, with each treatment being specific to a specific chronic condition. TCM treatments are well known in China but less known in other countries. Introducing the TCM treatments to other countries may provide new perspectives on TCM use for health providers and patients with chronic conditions. Our study aims to document clinical use of TCM treatments for specific chronic conditions in TCM hospitals and to provide some recommendations about which TCM treatments for which diseases are most common in community health centers and therefore most in need of evaluation. Hubei Province is located in the middle of China. It consists of one large city (Wuhan city), 12 middle-size cities, and four small cities. There are 103 districts/counties within these cities. In 2010 the total population of Hubei Province was 57 million, with prevalence of most chronic conditions (e.g., stroke, hypertension, and type 2 diabetes) similar to the average of the state.7,8 Economic development and living standards vary widely within the province; thus, Hubei can provide a ‘‘typical’’ location for the clinical use of specific treatments for specific chronic conditions in China. Materials and Methods Sample size
In 2010, a cross-sectional survey was conducted among all 132 TCM hospitals in Hubei Province. A total of 119 TCM hospitals (90.15%) completed the questionnaire. The province has one provincial, 16 municipal, 67 county/ district, and 35 private TCM hospitals. Thirteen hospitals (one municipal, three county/district, and nine private hospitals) in Honghu city did not complete the survey because of a flood. Survey instrument and procedure
This survey was a part of a nationwide survey. After the first year of implementation of healthcare reform in 2009, the State Administration of TCM—the highest-level agency for TCM—completed the national survey to better under-
41
stand both TCM utilization and distribution of resources. The questionnaire was discussed and finalized by an expert panel consisting of health policy makers, TCM physicians, and epidemiologists and was then distributed to each Provincial Bureau of Health. The Hubei Bureau of Health helped conduct the survey across Hubei Province, including training staff from the information technology (IT) department in each of the TCM hospitals to complete an electronic questionnaire and to enter data into a database developed by the State Administration of TCM. The questionnaire included data on resources, health care use, revenue and expenditure, and academic activities as of the end of 2009. In addition, each TCM hospital was required, for each of a series of common chronic conditions, to recommend specific TCM treatments based on the clinical experience of their physicians and any available clinical trials data, and to report the number of visits per year for the specific treatments for each chronic condition. Each recommendation was made as ‘‘which type of TCM treatments is recommended to treat which type of chronic conditions.’’ The recommended treatments were limited to the seven modalities most commonly used in clinical practice: orally ingested herbs, herbs for external use, acupuncture, moxibustion, massage, cupping, and Chinese external fixation. The staff from each hospital’s IT department was responsible for collecting data and completing the electronic questionnaire online. This study was approved by all district Departments of Health and Wuhan University, and was deemed ethically sound by the Wuhan University College of Medicine Research Committee (reference number ZYJBXZDC2010). Types of TCM treatments Orally ingested herbs. This category consists of all herbal products for oral ingestion, including traditional herbal decoctions and Chinese patent medicine produced by pharmaceutical company and TCM hospitals. Herbs for external use. These externally applied herbs are applied in a bath or in the form of topical creams. Acupuncture. Filiform needles are inserted along specific ‘‘meridians’’ postulated to exist along longitudinal sectors of the body. Acupuncture is sometimes used in conjunction with electric stimulation and infrared radiation. Moxibustion. Heat from burning dried mugwort leaves (sometimes with other herbal additives) is dermally applied directly or indirectly, primarily at acupuncture points. Massage. This modality entails systematic manual manipulations of body tissues (including superficial and deeper layers of muscle and connective tissue but not joints) to affect the nervous and muscular systems along with general circulation. Cupping. Suction cups are applied dermally to produce hyperemia at acupoints. Chinese external fixation. Fractures are treated by using four splints in conjunction with three pressure pads and three or four slings after successful manipulative reduction.
42
CAI ET AL.
Statistical analysis
Excel 2010 was used for the descriptive analysis. Chronic conditions were sorted by name and then TCM treatments for each of the chronic conditions were sorted by type. The number of similar recommendations and the number of visits for treatments for all TCM hospitals were counted. The mean frequency of recommendation for specific chronic condition was seven; chronic conditions with a frequency below this mean are not presented here. Consequently, this analysis includes nine chronic conditions: musculoskeletal pain, visceral pain, fractures, soft tissue injuries, stroke, type 2 diabetes, asthma, hemorrhoids, and hypertension. Finally, the frequency of recommendation by TCM doctors and the number of visits over time were compared. Results
conditions, was 671,759 (Table 2). Within each type of chronic conditions, the most visits (n = 160,486) for musculoskeletal pain was for massage; the most visits (n = 4728) for visceral pain was for herbs for external use; the most visits (n = 19,800) for soft tissue injuries was for cupping; the most visits (n = 52,680) for stroke was for acupuncture; the most visits (n = 16,158) for type 2 diabetes was for orally ingested herbs; the most visits (n = 55,704) for asthma was for orally ingested herbs; the most visits (n = 11,149) for hemorrhoids was for herbs for external use; and the most visits (n = 2480) for hypertension was for orally ingested herbs. For specific chronic conditions, the most frequently recommended treatments have the most visits, except for musculoskeletal pains, visceral pains, soft tissue injuries, and asthma. Discussion
Frequency of specific TCM treatments for specific chronic conditions
For all chronic conditions, the number of recommendations for all types of TCM treatments was 411 (Table 1). Of all seven types of TCM treatments, six were recommended for musculoskeletal pain, five types for soft tissue injuries, four types for visceral pain and fractures, three types for stroke and asthma, two types for hemorrhoids, and one type for hypertension. The most frequent treatment recommendation for specific chronic conditions was for musculoskeletal pain (n = 126), followed by fractures (n = 36), soft tissue injuries (n = 26), stroke (n = 20), type 2 diabetes (n = 9), asthma (n = 9), hemorrhoids (n = 8), visceral pain (n = 7), and hypertension (n = 7). For each type of chronic conditions, the most commonly recommended treatments for specific chronic conditions included orally ingested herbs for visceral pain (n = 3), type 2 diabetes (n = 5), and hypertension (n = 7); herbs for external use for soft tissue injuries (n = 10), asthma (n = 6), and hemorrhoids (n = 8); acupuncture for musculoskeletal pain (n = 43) and for stroke (n = 10); and Chinese external fixation for fractures (n = 24). Number of visits related to the recommended treatments
The total number of visits per year, for all 119 hospitals, including the seven specific treatments for the nine chronic
Musculoskeletal pain, visceral pain, fractures, soft tissue injuries, stroke, type 2 diabetes, asthma, hemorrhoids, and hypertension are chronic conditions often recommended for TCM treatment. Patients with musculoskeletal pain have more treatment options and use more TCM treatments than other patients. Herbal medicine shows the widest utilization for chronic conditions. TCM hospitals show a wide use of externally applied herbs for several chronic conditions, a practice not widely employed outside China. For specific chronic conditions, the treatments most recommended are not always associated with the most use, such as for musculoskeletal pain, visceral pains, soft tissue injuries, and asthma. Recommendations of TCM treatments for chronic conditions by TCM physicians
These findings show that the recommendations for musculoskeletal pain are the most varied and frequent. Six types of TCM treatments were recommended to treat musculoskeletal pain. In contrast to this, only one type of TCM treatments is recommended for some chronic conditions, such as hypertension. This implies that patients with musculoskeletal pain may have far more treatment options than patients with hypertension. Considering frequency of
Table 1. Number of Recommendations for Traditional Chinese Medicine Treatments for Common Chronic Conditions from 119 Traditional Chinese Medicine Hospitals
Variable Musculoskeletal pain Visceral pain Fractures Soft tissue injuries Stroke Type 2 diabetes Asthma Hemorrhoid Hypertension Total
Orally ingested herbs
Cupping
Chinese external fixation
Total
31 (93.9)
8 (50.0)
–
126 (50.8)
– – 2 (6.1)
– – 8 (50.0)
– 24 (100.0) –
7 (2.8) 36 (14.5) 26 (10.5)
Externally used herbs Acupuncture Moxibustion Massage
15 (34.9)
25 (37.9)
43 (70.5)
4 (80.0)
3 (7.0) 2 (4.7) 1 (2.3)
2 (3.0) 9 (13.6) 10 (15.2)
1 (1.6) 1 (1.6) 5 (8.2)
1 (20.0) – –
8 (18.6) 5 (11.6) 2 (4.7) – 7 (16.3) 43 (100.0)
2 4 6 8
(3.0) (6.1) (9.1) (12.1) – 66 (100.0)
Values are expressed as number (percentage).
10 (16.4) – 1 (1.6) – – 61 (100.0)
– – – – – 5 (100.0) 33
– – – – – (100.0) 16
– – – – – (100.0)
– – – – – 24 (100.0)
20 9 9 8 7 248
(8.1) (3.6) (3.6) (3.2) (2.8) (100.0)
(53.8) (1.5) (8.0) (7.7) (14.3) (2.9) (9.7) (1.7) (0.4) (100.0) 36,1695 10,377 53,923 51,617 95,765 19,546 65,207 11,149 2480 671,759 – – 27,649 (100.0) – – – – – – 27,649 (100.0) 29,013 (59.3) – – 19,880 (40.7) – – – – – 48,893 (100.0) 160,486 (93.8) – – 10,672 (6.2) – – – – – 171,158 (100.0) 5974 (85.7) 1000 (14.3) – – – – – – – 6974 (100.0) 111,009 (62.9) 123 (0.1) 1565 (0.9) 9070 (5.1) 52,680 (29.8) – 2100 (1.2) – – 176,547 (100.0) (34.3) (5.0) (21.0) (10.7) (5.5) (3.6) (7.9) (11.9) – 93,792 (100.0) Values are expressed as number (percentage).
32,202 4728 19,722 10,072 5128 3388 7403 11,149
23,011 (15.7) 4526 (3.1) 4987 (3.4) 1923 (1.3) 37,957 (25.9) 16,158 (11.0) 55,704 (38.0) – 2480 (1.7) 146,746 (100.0) Musculoskeletal pain Visceral pain Fractures Soft tissue injuries Stroke Type 2 diabetes Asthma Hemorrhoid Hypertension Total
Chinese external fixation Cupping Massage Moxibustion Acupuncture Externally used herbs Orally ingested herbs Variable
Table 2. Number of Visits for Traditional Chinese Medicine Treatments for Common Chronic Conditions from 119 Traditional Chinese Medicine Hospitals
Total
CHINESE MEDICINE FOR CHRONIC CONDITIONS
43
recommendations, acupuncture for treating musculoskeletal pain also was the most frequently recommended. The number of recommendation for acupuncture for musculoskeletal pain was 43, followed by 31 recommendations for massage for musculoskeletal pain, 24 recommendations for Chinese external fixation for fractures, and no more than 10 recommendations for other conditions. This implies that TCM treatments for musculoskeletal are used more frequently than those for other chronic conditions. Further research is needed to conclude whether this frequency is due to better efficacy or safety compared with other TCM treatments. Although this study confirms the well-known and widely used TCM treatments, such as orally ingested herbs and acupuncture, for chronic conditions,9–14 it provides new insights by reporting the extent of use of other TCM treatments, such as herbs for external use and Chinese external fixation. In this study, herbs for oral ingestion and external use were commonly recommended for treatment of various chronic conditions. In general, orally ingested herbs increase risk of herb-drug interactions.15 TCM hospitals are becoming westernized, and nearly all patients in TCM hospitals now use herbs and conventional drugs together,16,17 so there is also a concern about herb-drug interactions. With both recommendations of herbs for oral ingestion and external use for specific chronic conditions, herbs for external use instead of oral ingestion for specific chronic conditions may reduce the risk of herb-drug interaction. Before herbs are recommended for external use instead of oral ingestion for specific chronic conditions, further studies should assess the safety and efficacy of, and patient preference for, the use of herbs as well as other TCM treatments. Chinese external fixation is potentially of great value for older people in poor areas and countries. Older people have a high occurrence of distal radius fracture from falls.18 The use of Chinese external fixation for stabilizing distal radial fractures as a functional method in Japan and Hong Kong was already reported in the 1980s.19,20 Chinese external fixation can be applied with four splints, three pressure pads, and four slings; thus, it is easy to practice, is convenient to adjust the splints, and is inexpensive. It was commonly used in the past but is now rarely used for treating distal radius fractures in TCM hospitals, primarily because it is not reimbursed well. In fact, because of China’s fee-for-service health care system, many potentially effective TCM treatments, such as moxibustion treatment,21 are rarely used in clinical practice. However, given the scarce clinical trial evidence, we can only highlight this practice and strongly recommend well-designed clinical trials evaluations comparing this approach to other commonly used non-TCM fracture treatments. Use of TCM treatments for chronic conditions by patients
With more recommendation by TCM physicians, Chinese herbal medicine does have wider use. In this analysis, both orally and externally used herbs are used for chronic conditions, with the exception of hemorrhoids (externally herb only) and hypertension (internally ingested herbs only). Additionally, acupuncture is a well-known treatment widely used for treating pain, poststroke rehabilitation, and sports-
44
related injuries.22–24 The current findings show more use of acupuncture than herbal medicine for musculoskeletal pain and stroke. Less commonly known TCM treatments, such as moxibustion and cupping, are used to treat one or two types of chronic conditions. In fact, these two types of TCM treatments are popular in China.25–28 Easily and safely practiced by nurses and patients, they may be frequently used by community health and for self-care by community residents themselves—potential use patterns that may explain why they are used less in TCM hospitals. Understanding uses of easily administered TCM treatments could help prevent and rehabilitate chronic conditions globally. Additional community-based studies should be performed identify utilization patterns and efficacy because the ease and costeffectiveness of these treatments might make them suitable candidates for global use. Differences between recommended and actual use of TCM treatment for chronic conditions
While a TCM physician may believe the most effective treatment choice is the one associated with the highest utilization patterns,29 the current findings show that the more commonly recommended treatments are not always associated with more actual clinical use. This analysis demonstrates differences between recommended use and actual clinical use for musculoskeletal pain, visceral pain, soft tissue injuries, and asthma. The Anderson model of health service utilization illustrates how such utilization is determined by population characteristics, health care system, and external environment.30 In China, few studies have focused on TCM use and attitudes of TCM providers and users; the current survey is the first to collect data from TCM facilities. However, this study did not have access to individual-level data that would have allowed further examination of determinants affecting TCM use. Finally, it is not possible to conclude which of these determinants are associated with the specific treatments discussed here. Therefore, the observed differences between recommended and actual utilization of specific TCM treatment for specific chronic condition should be the subject of further study. This study has several limitations. First, this crosssectional survey lacks follow-up information on adverse effects among patients who use these TCM treatments, so it is not possible to conclude whether the uses are safe and effective. Second, no quantitative or qualitative data are available to explain the observed differences between recommended and actual use of specific TCM treatment for specific chronic condition, or whether patients receive several different TCM treatments for one chronic conditions. Third, use of specific TCM treatments for specific chronic conditions in TCM hospitals cannot be generalized to guide use in community-based health care settings; in those locations, TCM care may be more commonly used by the chronically disabled, vulnerable, and elderly. In addition, TCM hospitals primarily serve patients with more complicated and serious conditions and do not target health promotion of the total population. Finally, because this survey was conducted in Hubei Province, the findings may not be representative of other provinces or areas outside of China.
CAI ET AL. Conclusion
Despite these limitations, the survey was successful, with an exceptional response rate of 90.2%; this was possible because of the health bureaus’ assistance. The collected data enable researchers and policy makers to better understand current use of various TCM treatments for specific chronic conditions in TCM hospitals by thousands of patients; this should provide useful reference information to better understand TCM use for chronic conditions. Additionally, the data set can serve as a useful guide for what treatments and chronic conditions are most commonly involved in TCM, thus implying which treatments and chronic conditions should likely be prioritized for future clinical trials of effectiveness and safety at the community level. Acknowledgments
This cross-sectional survey was financially supported by the Hubei Bureau of Health. The survey was conducted by the School of Public Health, Wuhan University, with help from the Hubei Bureau of Health. The authors thank all of the faculty and students at Wuhan University School of Public Health and staff at the Hubei Bureau of Health for collecting data. The named authors alone are responsible for the views expressed in this paper. Author Disclosure Statement
No competing financial interests exist. References
1. World Health Organization: WHO Traditional Medicine Strategy 2002–2005. [Homepage on the Internet]. Online document at: http://whqlibdoc.who.int/hq/2002/who_edm_ trm_2002.1.pdf. Accessed July 16, 2013 2. Efferth T, Kaina B. Toxicities by herbal medicines with emphasis to traditional Chinese medicine. Curr Drug Metab 2011;12:989–996. 3. Li T. Avoiding adverse drug reactions to Chinese medicine injections. J Evid Based Med 2010;3:44–49. 4. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture Trialists’ Collaboration. Individual patient data metaanalysis of acupuncture for chronic pain: protocol of the Acupuncture Trialists’ Collaboration. Trials 2010;11:90. 5. Luo H, Li Q, Flower A, Lewith G, Liu J. Comparison of effectiveness and safety between granules and decoction of Chinese herbal medicine: a systematic review of randomized clinical trials. J Ethnopharmacol 2012;140:555–567. 6. Hesketh T, Zhu WX. Health in China. Traditional Chinese medicine: one country, two systems. BMJ 1997;315:115– 117. 7. National Bureau of Statistics. [Homepage on the Internet]. Online at: http://www.stats.gov.cn Accessed July 16, 2013. 8. Kerkhoff AC, Moreira LB, Fuchs FD, Fuchs SC. Association between hypertension and musculoskeletal complaints: a population-based study. J Hypertens 2012;30: 2112–2117. 9. Lathia AT, Jung SM, Chen LX. Efficacy of acupuncture as a treatment for chronic shoulder pain. J Altern Complement Med 2009;15:613–618. 10. Wang J, He QY, Zhang YL. Effect of shenshao tablet on the quality of life for coronary heart disease patients with stable angina pectoris. Chin J Integr Med 2009;15:328–332.
CHINESE MEDICINE FOR CHRONIC CONDITIONS
11. Deng X, Liu ZW, Wu FS, Li LH, Liang J. A clinical study of weining granules in the treatment of gastric precancerous lesions. J Tradit Chin Med 2012;32:164–172. 12. Cabyoglu MT, Ergene N, Tan U. The mechanism of acupuncture and clinical applications. Int J Neurosci 2006;116: 115–125. 13. Luo H, Li Q, Flower A, Lewith G, Liu J. Comparison of effectiveness and safety between granules and decoction of Chinese herbal medicine: a systematic review of randomized clinical trials. J Ethnopharmacol 2012;140:555–567. 14. Chan K, Shaw D, Simmonds MS, et al. Good practice in reviewing and publishing studies on herbal medicine, with special emphasis on traditional Chinese medicine and Chinese materia medica. J Ethnopharmacol 2012;140:469–475. 15. Chan E, Tan M, Xin J, Sudarsanam S, Johnson DE. Interactions between traditional Chinese medicines and Western therapeutics. Curr Opin Drug Discov Devel 2010;13:50–65. 16. Qiu J. China plans to modernize traditional medicine. Nature 2007;446:590–591. 17. Shen JJ, Wang Y, Lin F, et al. Trends of increase in western medical services in traditional medicine hospitals in China. BMC Health Serv Res 2011;11:212. 18. Padegimas EM, Osei DA. Evaluation and treatment of osetoporotic distal radius fracture in the elderly patient. Curr Rev Musculoskelet Med 2013;6:41–46. 19. Leung KS, Shen WY, Leung PC, Kinninmonth AW, Chang JC, Chan GP. Ligamentotaxis and bone grafting for comminuted fractures of the distal radius. J Bone Joint Surg Br 1989;71:838–842. 20. Futami T, Yamamoto M. Chinese external fixation treatment for fractures of the distal end of the radius. J Hand Surg Am 1989;14:1028–1032. 21. Xu HQ, Zhang HR, Gu YH. Progress of researches on prevention and treatment of sports fatigue with moxibustion therapy. Zhen Ci Yan Jiu 2014;39:169–173. 22. Vickers AJ, Cronin AM, Maschino AC, et al; Acupuncture Trialists’ Collaboration. Acupuncture for chronic pain: in-
45
23.
24. 25.
26. 27. 28. 29. 30.
dividual patient data meta-analysis. Arch Intern Med 2012;172:1444–1453. Pulman J, Buckley E. Assessing the efficacy of different upper limb hemiparesis interventions on improving healthrelated quality of life in stroke patients: a systematic review. Top Stroke Rehabil 2013;20:171–188. Lin ZP, Lan LW, He TY, et al. Effects of acupuncture stimulation on recovery ability of male elite basketball athletes. Am J Chin Med 2009;37:471–481. Kuang YH, Wei JA. An introduction to the study of acupuncture and moxibustion in China. Part III. Review of clinical studies on acupuncture and moxibustion. J Trad Chin Med 1984;4:249–254. Wang T, Zhang Q, Xue X, Yeung A. A systematic review of acupuncture and moxibustion treatment for chronic fatigue syndrome in China. Am J Chin Med 2008;36:1–24. Cao H, Li X, Liu J. An updated review of the efficacy of cupping therapy. PLoS One 2012;7:e31793. Cao H, Han M, Li X, et al. Clinical research evidence of cupping therapy in China: a systematic literature review. BMC Complement Altern Med 2010;10:70. Xing B, Yan QL. How to develop traditional Chinese medicine in the period time of evidence-based medicine. J Shandong Univ TCM 2003;27:87–89. Anderson RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995;36:1–10.
Address correspondence to: Zongfu Mao, PhD Wuhan University School of Public Health 115 Donghu Road Wuchang District Wuhan, Hubei 430071 China E-mail: [email protected]
Copyright of Journal of Alternative & Complementary Medicine is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
