Chin J Integr Med 2013 Oct;19(10):723-729
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FEATURE ARTICLE Evidence-based Practice of Chinese Medicine in Physical Rehabilitation Science Arthur de Sá Ferreira1,2 ABSTRACT Chinese medicine is among other traditional medical systems practiced either as a coadjutant intervention to Greek medicine or as the unique therapeutic intervention for illness prevention, treatment or rehabilitation. The complete spectrum from that traditional system includes acupuncture and moxibustion, herbal and food therapy, massage therapy (tuina), physical exercises (taijiquan), and breathing exercises (qigong). In this article, it is presented several randomized controlled trials and systematic reviews on the application of all therapeutic modalities from Chinese medicine in the physical rehabilitation scenario. The discussed studies encompasses both "positive" and "negative" results of Chinese medicine intervention for disabilities due to illnesses of the nervous, musculoskeletal or cardiovascular systems. Additionally, the importance of the personalized approach for Chinese medicine and rehabilitation is emphasized together with the need for reproducible methods for pattern differentiation and intervention selection. Chinese medicine resources are recognized as promising methods for therapeutic rehabilitation and can be incorporated into the rehabilitation science. The wide variety of therapeutic resources explains why Chinese medicine is currently a multidisciplinary practice for health protection and promotion, early diagnosis and treatment as well as rehabilitation with roles in the public health care system. KEYWORDS rehabilitation, physical therapy, Chinese medicine
The use of traditional medicine among health providers and patients increased throughout the globe after the Alma-Ata Declaration. (1) It was estimated that between 70% and 95% of the population of developing countries use traditional medicine for illness prevention, treatment or rehabilitation. (2) Chinese medicine is among other traditional medical systems practiced either as a coadjutant intervention to Greek medicine or as the unique therapeutic intervention for management of health. (3) Chinese medicine is usually traced back to the Yellow Emperor era (Huangdi, 2695–2589 BCE), albeit the earliest systematic work preserved today is the Huangdi's Internal Classic (Huang Di Nei Jing) compiled during the Warring States period (481–221 BCE). The major focus of Chinese medicine is primary prevention as denoted by the famous quotation "to treat who is not yet ill".(4-6) However, an interesting connotation of such statement is that if a patient exhibits manifestations of an illness the intervention must enroll the appropriate internal systems to prevent pattern transmission and illness progression, disabilities or death. In this sense, Chinese medicine is applicable for secondary and tertiary prevention as well.
Rehabilitation belongs to the tertiary level of prevention with a view to minimize residual disability and complications to improve overall quality of life even if the illness itself cannot be cured.(7) Physicians, physical therapists, occupational therapists, and nurses are among the health professionals dealing with patients under rehabilitation, particularly physical rehabilitation. It is generally acknowledged that scientific advances in physical rehabilitation were mainly related to World War Ⅰ (WWⅠ, 1914–1918 CE) and Ⅱ (WWⅡ, 1939–1945 CE). (8) Warfare in China began much earlier, at least around 2193 BCE (first historical Chinese civil war) or 2146 BCE (first interstate war)(9) and several episodes occurred even after the compilation of Huangdi's Internal Classic
©The Chinese Journal of Integrated Traditional and Western Medicine Press and Springer-Verlag Berlin Heidelberg 2013 1. Laboratory of Computational Simulation and Modeling in Rehabilitation, Program of Rehabilitation Science, Centro Universitário Augusto Motta, Rio de Janeiro, RJ, Brazil (21041-021); 2. Department of Physical Therapy, Universidade Salgado de Oliveira, Niterói, RJ, Brazil (21041-021) Tel: 55-21-3868-5063, E-mail:
[email protected]/arthurde@ unisuamdoc.com.br DOI: 10.1007/s11655-013-1451-5
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(Huang Di Nei Jing).(10,11) Although not explicated by many ancient, leading Chinese medicine practitioners, it is possible they were also influenced by warfare to developed interventions for rehabilitation of soldiers returning from war. Additionally, epidemic infection-like episodes were observed in Chinese troops during war periods and probably contributed to development of therapeutic resources of Chinese medicine in primary and secondary levels as well.(10,11) The extrapolation of those interventions to health conditions not originally attributed to warfare would be straightforward.
Huangdi's Internal Classic (Huang Di Nei Jing) was a recurrent reference for later well-known ancient Chinese medicine practitioners, whose contributions to the rehabilitation field cannot be disregarded. In preserved versions of their textbooks there are descriptions of interventions for health promotion and specific protection as easy as diagnostic methods for immediate treatment and rehabilitation. For instance, HUA Tuo (110–207 CE) provided great developments of medical gymnastics, massage, physical therapy(12) and breathing exercises.(13) He also discussed pattern differentiation (i.e. diagnosis) and manifestation profiles ( i . e . s i g n s a n d s y m p t o m s ) r e l a t e d t o modern neuromuscular disorders such as stroke, hypertonia, paresthesia, and hemiplegia.(5) ZHANG Zhong-jing (150–219 CE) largely discussed patterns currently interpreted as arthritis- and stroke-like disorders. (6) SUN Si-miao enumerated medicinals for several musculoskeletal and neurologic disturbances including arthritis, back pain and limited mobility, joint edema and hemiplegia.(14) WANG Qingren (1768–1831 CE) revised previous concepts on Chinese medicine based on his own knowledge of human anatomy.(15) Although many of his concepts were still erroneous, theories regarding the cardiovascular disease including stroke-like patterns were developed and are considered a revolutionary contribution to Chinese medicine at that time. (16) It is interesting to notice the empirical foundations of Chinese medicine remain largely uninvestigated and therefore criticized in the scientific field, just like physical rehabilitation practice was in its early epoch.(17)
Chinese Medicine Meets Evidence-Based Rehabilitation In the last decades, an increasing amount of research has been conducted towards the evidencebased practice of Chinese medicine, physical
Chin J Integr Med 2013 Oct;19(10):723-729
rehabilitation science, and their combination. From the timeline of records in scientific databases on these subjects it is possible to infer the spreading and acceptance of Chinese medicine in the rehabilitation science. For instance, the earliest records in PubMed database on either "rehabilitation", (18) and "physical therapy" or "physiotherapy",(19) are traced back to 1918—not surprisingly both in the context of recovering soldiers from WWⅠ physical injuries. Interestingly, the first record on "Chinese medicine"(20) is earlier and emphasized the "defects of the old system" in 1913. The earliest record combining the terms "rehabilitation" and "Chinese medicine" (21) was published much later in 1981 and discussed the same subject of this work, i.e. the role of Chinese medicine in rehabilitation practice. Altogether, these data suggest that researchers delayed to recognize Chinese medicine as a potential source for intervention with application to physical rehabilitation. Although acupuncture may be the most readily recognized therapeutic modality from Chinese medicine in the medical field, the complete spectrum (Figure 1) available for health practitioners from this traditional system includes acupuncture and moxibustion (and other practices such as cupping), herbal and food therapy, massage therapy (tuina), physical exercises (taijiquan), and breathing exercises (qigong). (22) Usually, those modalities are used in combination according to the holistic nature of Chinese medicine.(23) These modalities have being investigated in the rehabilitation field for several physical disabilities due to illnesses of the nervous, musculoskeletal and cardiovascular systems. For a representative description of the usefulness of therapeutic modalities from Chinese medicine into the rehabilitation context, some of those subjects are further discussed mostly based on randomized controlled trials (RCT) and systematic reviews.
Acupuncture, Moxibustion and Adjunct Resources Knee joint arthritis, low back pain, neck pain, temporomandibular disorder, shoulder arthritis, rheumatoid arthritis, and sciatica are among other disorders to what acupuncture has been proved to be effective by the World Health Organization. (24) Acupuncture was considered as a cost-effective intervention as compared to routine care for some chronic pain conditions including back pain,
Chin J Integr Med 2013 Oct;19(10):723-729
Taijiquan
Acupuncture Moxibustion
Tuina
Herbal and Food therapy
Qigong
Figure 1. The Interdependency and Complementarity of Chinese Medicine Therapeutic Modalities Distributed as a Plum Blossom: Acupuncture and Moxibustion, Taijiquan, Herbal and Food Therapy, Qigong, and Tuina
osteoarthritis pain, chronic neck pain,(25,26) and unilateral subacromial syndrome. (27) Electroacupuncture was found effective for myofascial pain (i.e. neck pain or headache) relief and quality-of-life increase (physical domain) in a study with 22 women.(28) Recent reviews focused on the efficacy of acupuncture for treating several musculoskeletal chronic pain and found it a safe, effective therapeutic resource not placeborelated.(25,26) Cupping was also found to be effective for reducing pain but such result was based on studies with poor methodological quality.(29) Another recent review on acupuncture-related techniques (ART) – acupuncture, electroacupuncture, and transcutaneous electrical acupoint stimulation – observed as consensus that: (a) pre-operative and post-operative ART can ameliorate post-operative pain and nausea/vomiting for the control of acute surgically-induced pain, (b) ART reduces pain as compared to untreated or wait-list controls in most chronic pain conditions, and (c) multiple sessions of ART (1 or 2 times per week for several weeks) are necessary for the treatment of chronic pain conditions in order to obtain a cumulative effect.(30) However, the use of personalized or group-defined acupoints and the need for a precise location of acupoints remain controversial and urge high-quality clinical trials. Sensory-motor impairments from stroke-like disturbances(6,15) such as one-sided (or hemilateral) withering, hemilateral impediment, or hypertonicity of the sinews have been described for at least 2000 years.(10) Currently, patterns may be used to describe the manifestation profile of post-stroke patients.(31) It
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was demonstrated that pre-modern (
