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Traditional Chinese medicine for chronic fatigue syndrome: A systematic review of randomized clinical trials
Complementary Therapies in Medicine, 4, 22, pages 826 - 833
- TCM therapies showed potential positive effect for alleviating fatigue symptoms.
- Whether TCM could improve the QOL of patients is still inconclusive.
- We could not draw a firm conclusion about the safety of TCM on CFS.
There is no curative treatment for chronic fatigue syndrome (CFS). Traditional Chinese medicine (TCM) is widely used in the treatment of CFS in China.
To evaluate the effectiveness and safety of TCM for CFS.
The protocol of this review is registered at PROSPERO. We searched six main databases for randomized clinical trials (RCTs) on TCM for CFS from their inception to September 2013. The Cochrane risk of bias tool was used to assess the methodological quality. We used RevMan 5.1 to synthesize the results.
23 RCTs involving 1776 participants were identified. The risk of bias of the included studies was high. The types of TCM interventions varied, including Chinese herbal medicine, acupuncture, qigong, moxibustion, and acupoint application. The results of meta-analyses and several individual studies showed that TCM alone or in combination with other interventions significantly alleviated fatigue symptoms as measured by Chalder's fatigue scale, fatigue severity scale, fatigue assessment instrument by Joseph E. Schwartz, Bell's fatigue scale, and guiding principle of clinical research on new drugs of TCM for fatigue symptom. There was no enough evidence that TCM could improve the quality of life for CFS patients. The included studies did not report serious adverse events.
TCM appears to be effective to alleviate the fatigue symptom for people with CFS. However, due to the high risk of bias of the included studies, larger, well-designed studies are needed to confirm the potential benefit in the future.
Keywords: Chronic fatigue syndrome, Traditional Chinese medicine, Systematic review, Randomized clinical trials.
Chronic fatigue syndrome (CFS) is a disorder characterized by unexplained and persistent fatigue, impaired memory or concentration, post exercise malaise/tiredness, sleep disturbances, musculoskeletal pain, and several other somatic complaints. 1 US Centers for Disease Control and Prevention (CDC) is offering a clinical definition (1994) of CFS, which was based on Holmes and Fukuda scoring and evaluating systems. 1 The pathogenesis of CFS is still not clear, but studies showed that multifactorial disease pathways might be contributing factors of its complex symptoms and mechanisms. 2 Studies reported that the prevalence rate of CFS in western countries ranged from 0.2% to 2.6%.3 and 4Similarly, the rates were 1.9% in Beijing and 3% in Hong Kong, China. 5
Currently, no curative treatments are available for CFS. There are some encouraging evidences showing that CFS patients might benefit from graded exercise therapy, 6 cognitive behavior therapy 7 and rehabilitation programs. 8 Patients with CFS in China can be referred to TCM therapies. A Cochrane systematic review in 2009 9 evaluated the effectiveness of traditional Chinese herbal medicine (CHM) in treating idiopathic chronic fatigue and chronic fatigue syndrome. However, this systematic review set strict inclusion criteria which required control groups applying placebo or conventional standard of care, and finally no studies fulfilled the criteria. Besides herbal medicine, TCM covers a broad range of medical therapies which are customized and tailored according to TCM theories, and related to the symptoms and signs of individual patient. 10 These therapies include CHM, acupuncture, moxibustion, massage (tuina), Qigong, cupping, Tai Chi.
The objective of this review is to evaluate the effectiveness and adverse events from available studies of TCM therapies on treating and managing patients with CFS.
Materials and methods
Standard protocol registrations
This systematic review was registered in PROSPERO, and the registration identifier of the protocol is CRD42013005965. 11
Search strategy and study selection
The following six online databases were searched for relevant studies from their inception to September 2013: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Infrastructure (CNKI), Chinese Scientific Journals Database (VIP), Chinese Biomedical Database (Sino-Med), and Wanfang Database. The following searching terms as abstract terms and MeSH terms were used individually or combined including “traditional Chinese medicine”, “’herbal medicine”, “acupuncture”, “tuina”, “qigong”, “tai chi”, “massage”, “chronic fatigue syndrome”, “CFS”, “randomly”, “trial”, “randomised” and “randomized”. The search strategy for PubMed can be found in Appendix S1, and other search strategies can be available through contacting corresponding author. No language restriction was applied.
Two authors (YYW and XXL) identified studies which met the inclusion criteria. Any disagreements on studies to be included were resolved by discussion or a third author (JPL) was consulted.
Inclusion and exclusion criteria
Type of study
We included all relevant randomized controlled trials, irrespective of blinding, publication status or language. Quasi-randomized trials were excluded.
Type of participants
Participants met the diagnostic criteria of the US CDC definition (1994) 1 for CFS. There were no limitations on gender, age, the disease course and severity.
Type of intervention
We included any kind of TCM therapies used alone or in combination that was compared with placebo or no intervention, conventional medicine, or general non-specific treatments such as vitamins, adenosine triphosphate (ATP). Co-intervention was allowed if they were applied in both arms. We excluded studies that applied TCM in both intervention and control groups.
In this review, TCM is defined as a broad range of medical practice sharing common theoretical concepts and tradition in China, such as herbs, acupuncture and other acupoint stimulation, moxibustion, massage or qigong. 10
Type of outcomes
Fatigue was reported by a validated tool (e.g. Chalder's fatigue scale). The fatigue scores of post-treatment were compared between the intervention and control groups.
- (a) Quality of life measured by validated instruments;
- (b) Adverse events.
Data were extracted independently by two authors (XXL and HL) using a self-developed data extraction form. Disagreement was resolved by discussion. The following information was extracted: study population, participant demographics and baseline characteristics; details of the intervention and control; study methodology; outcome measures and main results.
Methodological quality assessment
The methodological quality of included studies was assessed independently by two authors (YYW and XXL) using the Cochrane risk of bias tool. 12 The tool included six items: random sequence generation (selection bias), allocation concealment (selection bias), blinding (performance bias and detection bias), incomplete outcome data (attrition bias), selective outcome reporting (reporting bias), and other bias.
The risk of bias was categorized as low/unclear/high risk of bias. Trials which met all criteria were judged as having a low risk of bias, trials which met none of the criteria were judged as having a high risk of bias, and trials with insufficient information to judge were classified as unclear risk of bias. Disagreements between the authors over the risk of bias in specific studies were resolved by discussion and consensus, with involvement of a third author when necessary.
Strategy for data synthesis
All data synthesis was performed by RevMan 5.1 software. Dichotomous data were presented as relative risk (RR) and continuous outcomes as mean difference (MD), both with 95% confidence intervals (CI). If necessary data could not be available, we contacted corresponding authors of the studies. Subgroup analyses were performed according to different outcome measures and different types of TCM interventions. We used fixed effects model unless there was evidence of heterogeneity (defined as heterogeneity testp < 0.1). Funnel plots were used to detect potential publication bias where sufficient numbers of studies were available.
Description of studies
The search process and study selection are presented by a flow chart (Fig. S1). Finally 23 RCTs13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, and 35involving 1776 participants with CFS were included.
The detailed characteristics of the included studies are listed in Table S1. All studies used CDC 1994 for CFS as their diagnostic criteria. Among the 23 RCTs, 18 studies13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 25, 28, and 24performed in mainland China, four studies18, 24, 26, and 35in Hong Kong, and one study 27 in Taiwan. 22 of 23 studies (included three unpublished dissertations)13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34published in Chinese, and only one 35 published in English. The number of participants randomized ranged from 60 to 240, but only one study 35 reported sample size calculation. The mean disease duration varied from 6 months to 32.68 months, and the duration of treatment ranged from 1.5 weeks to 16 weeks.
The types of comparisons were variable: herbal medicine versus non-specific treatment,13, 14, 15, 16, 17, 18, 19, 20, and 21acupuncture versus sham-acupuncture,24, 25, 26, 27, 28, and 30electroacupuncture versus sham-electroacupuncture, 29 moxibustion versus conventional medicine, 31 moxibustion versus non-specific treatment,32 and 33acupoint application versus placebo, 34 qigong versus no treatment. 35
Methodological quality assessment
The overall methodological quality of included trials was poor in terms of risk of bias (Figs. S2 and S3). Twelve of 23 studies13, 14, 15, 18, 19, 21, 23, 24, 29, 31, 32, and 33described “randomization” without reporting the specific method for random sequence generation. For allocation concealment, only two13 and 25used sealed, opaque envelops, and one 28 used a center controlled method. Blinding of participants and personnel were not mentioned in all studies, and five studies24, 25, 26, 28, and 30used blinding of the assessors. Sixteen studies13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 27, 31, 32, 33, and 34did not describe the information about dropouts. For selective outcome reporting, only one study 35 gave the clinical trial identifier number, and we were able to find the protocol for comparison and assessment. We could not conduct a funnel plot to detect publication bias due to significant clinical heterogeneity of the included trials.
Effects of interventions
The effect estimates of TCM for CFS are shown in Table S2.
The severity of fatigue symptom was assessed by several different fatigue scales including Chalder's fatigue scale, fatigue assessment instrument by Joseph E. Schwartz (FAI), fatigue severity scale (FSS), guiding principle of clinical research on new drugs of TCM for fatigue symptom (GPFS), and Bell's fatigue scale (BFS). Chalder's fatigue scale is consisting of 14 items for evaluating two dimensions of chronic fatigue: physical fatigue (8 items) and mental fatigue (6 items). Generally, Chalder's fatigue scale was measured by a five-point Likert scale (none, better than usual, no more than usual, worse than usual, much worse than usual) scored from 0 to 4, however, several studies in China used a two-point scale (no or yes) scored from 0 to 1. In order to distinguish them, we marked them as CFS1 (0–1) and CFS2 (0–4). In addition, FAI consisted 29 items for evaluating four dimensions of fatigue: severity, situation-specificity, psychological consequence, and response to rest/sleep.
Chinese herbal medicine
Compared with non-specific treatment, a meta-analysis of five studies13, 14, 15, 16, and 17favored Chinese herbal medicine as measured by GPFS (MD −5.93 [−7.51, −4.34]). Two individual studies19 and 20both showed better effect of Chinese herbal medicine as measured by CFS1 total FS score (MD −1.51 [−2.40, −0.62], MD −3.90 [−5.05, −2.75] respectively), however due to high heterogeneity, a meta-analysis could not be conducted. One study 18 which was measured by CFS2 plus auxiliary symptom score also favored Chinese herbal medicine (MD −29.76 [−35.55, −23.97]); one study 21 favored Chinese herbal medicine on three dimensions of FAI (S, SS, PC), but not on the dimension of RTR/S (MD 0.52 [−0.25, 1.29]).
The results from two meta-analyses (four studies and two studies) and three individual studies all found significant better effects in acupuncture group. Only two individual studies24 and 25showed no significant difference between acupuncture group and sham-acupuncture group which were measured by CFS1-mental FS score and CFS2-physical FS score respectively. We conducted a summary of finding table to present these findings ( Table 1 ).
|Acupuncture compared to sham-acupuncture for CFS|
|Patient or population: patients with CFS|
|Outcomes||Illustrative comparative risks a (95% CI)||Relative effect (95% CI)||No of participants (studies)||Quality of the evidence (GRADE)||Comments|
|Assumed risk||Corresponding risk|
|CFS1-total FS score
CFS1. b Scale from: 0 to 14.
|The mean CFS1-total FS score ranged across control groups from 7.5 to 9.92 points||The mean CFS1-total FS score in the intervention groups was 2.61 lower (3.56–1.65 lower)||261
low c , d , e
|CFS1-physical FS score
CFS1. Scale from: 0 to 8.
|The mean CFS 1-physical FS score ranged across control groups from 5 to 5.61 points||The mean CFS 1-physical FS score in the intervention groups was 0.9 lower (2.44 lower to 0.65 higher)||141
|CFS1-mental FS score
CFS1. Scale from: 0 to 6.
|See comment||See comment||Not estimable||141
|Two studies could not synthesize into a meta-analysis due to statistical heterogeneity|
|CFS2-physical FS score
CFS2. g Scale from: 0 to 32.
|The mean CFS 2-physical FS score in the control groups was 23.7 points||The mean CFS 2-physical FS score in the intervention groups was 1.41 lower (3.97 lower to 1.15 higher)||99
low c , f
|CFS 2-mental FS score
CFS2. g Scale from: 0 to 24.
|The mean CFS 2-mental FS score in the control groups was 14.92 points||The mean CFS 2-mental FS score in the intervention groups was 1.17 lower (3.03 lower to 0.69 higher)||99
low c , f
SF 12. h Scale from: 12 to 56
|The mean SF 12 score in the control groups was 38.72 points||The mean FS 12 score in the intervention groups was 2.64 higher (0.99 lower to 6.27 higher)||99
low c , f
|Three studies reported QOL using three different measurement tools showing inconsistent results.|
|Safety reporting||See comment||See comment||485
|Three of 23 studies reported safety, and no serious adverse events reported.|
a The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
b CFS1 was measured by a five-point Likert scale (none, better than usual, no more than usual, worse than usual, much worse than usual) scored from 0 to 4.
c The main problems were that insufficient information was given to assess.
d Statistical heterogeneity was substantial.
e All results were positive, which might have some publication bias.
f Only one study included. Total sample size was relatively small, and the 95% confidence interval was wide.
g CFS2 was measured by a two-point scale (no, yes) scored from 0 to 1.
h SF 12, the 12-item short form health survey.
CI: Confidence interval.
GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
One study 29 compared electroacupuncture to sham-electroacupuncture, and demonstrated a significant effect favoring electroacupuncture as measured by FSS (MD −12.87 [−15.86, −9.88]).
One study 34 compared Chinese medicinal ointment applying externally on acupoints with placebo, and the result favored treatment group as measured by GPFS (MD −14.87 [−16.78, −12.96]).
One study 35 compared Qigong with no treatment, and showed a significant effect favoring Qigong as measure by CFS2-total FS score (MD −10.50 [−15.01, −5.99]), CFS2-physical FS score (MD −7.40 [−10.17, −4.63]), and CFS2-mental FS score (MD −3.10 [−5.08, −1.12]).
One study 22 showed that a combination of Chinese herbal medicine and paroxetine was better than paroxetine alone as measured by CFS1-total FS score (MD −2.22 [−2.53, −1.91]), CFS1-physical FS score (MD −1.69 [−1.84, −1.54]) and CFS1-mental FS score (MD −1.65 [−1.81, −1.49]). Another study 23 also favored combined treatment (Modulated medium frequency electrotherapy plus Chinese herb Ciwujia injection) as measured by CFS1-total FS score (MD −5.84 [−7.08, −4.60]), CFS1-physical FS score (MD −3.31 [−3.99, −2.23]) and CFS1-mental FS score (MD −2.47 [−2.92, −2.02] when compared to non-specific treatment.
Quality of life
One study 33 found better improvement of moxibustion for QOL as measured by SF 36 (MD 163.60 [140.48, 186.72]) compared with non-specific treatment.
Among the 23 studies, 16 studies (69.6%)14, 15, 17, 18, 19, 21, 23, 26, 27, 29, 30, 31, 32, 33, 34, and 35did not report any information on adverse events. Of the seven studies13, 16, 20, 22, 24, 25, and 28that did mention safety outcomes, four studies13, 16, 24, and 25found no adverse events neither in the intervention nor in the control group. The remaining three studies20, 22, and 28reported detailed adverse events which were mild and transient, e.g. nausea, thirst or bleeding due to acupuncture.
In this review, various types of TCM interventions were identified and evaluated for the effectiveness and safety for CFS. Several TCM interventions used alone or in combinations showed potential positive effect for alleviating fatigue symptoms. However, we should be cautious about these positive findings which were based on the low quality of included studies. In addition, whether TCM could improve the QOL of patients is still inconclusive. Because four studies18, 26, 28, and 33that evaluated QOL outcomes showed inconsistent results, and we could not conduct a meta-analysis due to different intervention comparisons and measurements. Though no serious adverse events were reported, we could not draw a firm conclusion about the safety of TCM because 16 studies (70%) did not provide any information on safety.
A number of limitations were identified. Firstly, several studies were excluded because they did not meet inclusion criteria. Therefore, it was not possible to reach a global and complete summary of all evidence. For example, we excluded 80 studies due to TCM interventions in both intervention and control group. Since effectiveness of TCM was inconclusive and the purpose of this review was to evaluate the effectiveness of TCM, we thought it was inappropriate to include studies which applied one TCM intervention versus another TCM intervention. In addition, we also excluded 27 studies that did not report the outcomes of fatigue symptoms that we needed as primary outcome.
Secondly, the way of reporting and measuring outcomes varied, which prevented us conducting meta-analyses. For fatigue symptom, five different scales were used. Even for the same measurement, there were various methods to report. For example, Chalder's fatigue scale was an international scale measured on a five-point Likert scale (none, better than usual, no more than usual, much worse than usual), but some studies in China just measured on a two-point scale (no or yes). Hence, we could not synthesize data from these two kinds of outcomes into one meta-analysis.
Thirdly, the methodological quality of included studies was not satisfactory. The main problem was that insufficient information was provided to assess risk of bias. More specifically, about half of included studies did not describe how they generate random sequence clearly, and allocation concealment was only mentioned in three studies.13, 25, and 28Therefore, we doubt that whether the randomization was conducted properly. In additional, only five studies24, 25, 26, 28, and 30reported the blinding of outcome assessment. We could not explain the reason why no studies claimed blinding to the participants and personnel. At least eight studies,24, 25, 26, 27, 28, 29, 30, and 34which used controls of sham-acupuncture or placebo, were available to apply double-blind. Moreover, of 23 studies, only one study 35 registered the protocol, which we could compare the protocol with the publication to assess selective outcome reporting bias, and other bias. We did not conduct funnel plot analysis due to insufficient number of studies included in the meta-analysis. However, almost all studies included reported positive findings, indicating existence of potential publication bias.
Though the strength of the results of the review may be weakened due to the above limitations, this systematic review is still meaningful since TCM interventions for treatment of CFS are increasing popular as well as lack of evidence. On the other hand, we can also achieve important implications from this review for future clinical trials in order to get high-qualified evidence. At least following aspects should be noticed for a rigorous trial on TCM interventions for CFS in the future.
Firstly, clinical trials should be prospectively registered in international trial registry. In this way, reviewers can recognize whether the trials have selective reporting and/or incomplete outcome reporting. And protocol registration is also a method to avoid publication bias that negative results were generally not published in the past.
Secondly, the appropriate control group and blinding are especially crucial for future trials. We recommend that it is better to use placebo or no treatment as control treatments when applicable since no curative treatments were available. Another reason to use placebo or no treatment is that CFS is a chronic disease, and generally it has no serious safety issue for using placebo. For Chinese herbal medicine, currently no placebo was used except one 34 for point application (pasting the medicinal ointment on the acupoints). The placebo ointment was made by flour, milk powder, ink and honey which was in according with the color and appearance of medicinal ointment. This placebo ointment can be used to blind participants because it was pasted on the acupoints. However, placebo of decoction of Chinese herbal medicine is still not easy to made, because Chinese patients are familiar with the smell and taste of real decoction of herbal medicine.
Thirdly, outcomes which are clearly defined, clinical relevant and internationally validated are required in the future trials. Currently, the outcomes on fatigue included Chalder's fatigue scale, fatigue severity scale, etc.
Finally, to ensure the quality of the future trials on TCM for CFS, other methodological items should also be clearly reported. The complete procedure of randomization, including random sequence generation and allocation concealment, is crucial, which can avoid potential performance bias and keep a balance between two groups on the baseline data. In addition ITT analysis is needed when there are noncompliance and missing outcomes.
In total, this review shows that TCM may have some beneficial effects on alleviating the fatigue symptom for people with CFS. However, the findings should be interpreted with cautions since most results were not concluded from the meta-analyses but individual studies, and the methodological quality of the included studies was poor. Therefore, large, well-designed studies are needed to confirm these findings in the future.
Source of funding
This research was supported by the Program for Innovative Research Team (2011-CXTD-09) of Beijing University of Chinese Medicine, the grant number 201207007 from the State Administration of Traditional Chinese Medicine in China, and the postgraduate program (532/0100604225) from Beijing University of Chinese Medicine. The study was also supported with a grant from the Norwegian Directorate of Health.
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a Center for Evidence-Based Medicine, Beijing University of Chinese Medicine, Beijing, China
b Department of Academic Exchange, World Federation of Chinese Medicine Societies, Beijing, China
c Institute for Tibetan Medicine, China Tibetology Research Center, Beijing, China
d School of Public Health, Hebei University, Baoding, Hebei, China
e The National Research Center in Complementary and Alternative Medicine, NAFKAM, Department of Community Medicine, Faculty of Health Science, UiT The Arctic University of Norway, 9037 Tromsø, Norway
Corresponding author at: Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, 11 Bei San Huan Dong Lu, Chaoyang District, Beijing 100029, China. Tel.: +86 1064286760; fax: +86 10 64286760.
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