Benefit of chuna for managing symptoms in chronic fatigue syndrome patients: A systematic review and meta-analysis

Article information

J Korean Med. 2020;41(3):205-220

Publication date (electronic) : 2020 September 01

doi : https://doi.org/10.13048/jkm.20036

Jeongyun Song

, Junyeol Kim

, Donghyun Nam

Department of Biofunctional Medicine and Diagnosis, College of Korean Medicine, Sangji University

Correspondence to: Donghyun Nam, Department of Biofunctional Medicine & Diagnostics, College of Korean Medicine, Sangji University 83 Sangjidae-gil Wonju-si Gangwon-do, Republic of Korean, #26339, Tel: +82-33-738-7504, Fax: +82-33-730-0653, E-mail: omdnam@sangji.ac.kr

Received 2020 June 16; Revised 2020 July 29; Accepted 2020 August 04.

Abstract

Objectives

The aim of this review is to assess the clinical benefit of chuna for managing symptoms in chronic fatigue syndrome (CFS)

Methods

We searched eligible studies from the following 11 databases with no language restriction: Pubmed, CENTRAL, Embase, CNKI, CQVIP, Wanfang, CiNii, OASIS, RISS and Koreamed. We selected randomized controlled trial (RCT), quasi-randomized controlled trial (Quasi-RCT) and controlled clinical trial (CCT) in which patients with chronic fatigue syndrome were treated with chuna. The results of the included studies were synthesized through meta-analysis, and their risk of bias were also assessed.

Results

We searched 914 potentially relevant studies, and only 20 studies were selected for this systematic review. Meta-analysis showed that chuna was more effective in improving general symptoms (n=291, RR 0.19 [95% CI 0.11 to 0.32], Z=6.08, p<0.00001, I2=0%), fatigue (n=487, SMD −0.95 [95% CI −1.19 to −0.71], Z=7.76, p<0.00001, I2=37%) and sleep disorder (n=139, SMD −0.58 [95% CI −0.92 to −0.24], Z=3.36, p=0.0008, I2=0%) compared to health supplements or usual care. When chuna was used as an added intervention, it was more effective in improving general symptoms(n=729, RR 0.25 [95% CI 0.15 to 0.42], Z=5.19, p<0.00001, I2=0%) and fatigue severity alone(n=217, SMD −1.21 [95% CI −1.53 to −0.89], Z=7.45, p<0.00001, I2=15%) compared to control.

Conclusion

We found that chuna was beneficial for improving severity of general symptoms and fatigue at post treatment in CFS patients.

Keywords: Tuina; Chuna; Chronic fatigue syndrome; Meta-analysis; Systematic review

Fig. 1

PRISMA chart

Fig. 2

(A) Risk of bias and (B) funnel plot for effectiveness. KM means Korea medicine.

Fig. 3

Forest plots of effectiveness. Chuna as (A) a single intervention and (B) an added intervention.

Fig. 4

Forest plots of fatigue severity. Chuna as (A) a single intervention and (B) an added intervention.

Table 1

Summary table of the included studies.

Table 2

The Quality of evidence.

Notes

이 연구는 보건복지부 한의약선도기술개발사업 한의표준임상진료지침개발사업(HB16C0055)의 지원에 의하여 이루어졌습니다. This work was supported by the Traditional Korean Medicine R&D Program, which was funded by the Ministry of Health and Welfare, Korea, through the National Development Institute of Korean Medicine (HB16C0055).

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Article information Continued

Fig. 1

PRISMA chart

Fig. 2

(A) Risk of bias and (B) funnel plot for effectiveness. KM means Korea medicine.

Fig. 3

Forest plots of effectiveness. Chuna as (A) a single intervention and (B) an added intervention.

Fig. 4

Forest plots of fatigue severity. Chuna as (A) a single intervention and (B) an added intervention.

Table 1

Summary table of the included studies.

Author	Year	Diagnostic criteria	No. of case (male : female) [experimental : control]	Intervention			Outcomes	Adverse event

				Experimental	control	Duration
E JS36)	2005	CDC 1988	64 (46:18) [33:31]	Chuna+acupuncture	Acupuncture	2 months	Effectiveness	N.R.
Zhao XD18)	2008	CDC 1988	60 (38:22) [30:30]	Chuna	Health supplements	4 weeks	Effectiveness	N.R.
Lei W20)	2011	CDC 1994	60(17:43) [30:30]	Chuna+cupping	Cupping	1 month	Effectiveness, Fatigue severity	N.A.E.
Wang Y21)	2011	CDC 1994	52 (20:32) [26:26]	Chuna+SGT	SGT	30 days	Effectiveness	N.R.
Chen YQ19)	2011	CDC 1994	129 (66:63) [65:64]	Chuna+SGT+SST	SGT+SST	2 months	Effectiveness	N.R.
Yao F22)	2012	CDC 1994	100 [50:50]	Chuna	Usual care	46 days	Fatigue severity	N.R.
Yao F28)	2013	CDC 1994	60 [30:30]	Chuna	Usual care	10 days	Sleep disorder	N.R.
Xiang H27)	2013	CDC 1988	82 [41:41]	Chuna+acupuncture	Acupuncture	2 months	Effectiveness	N.R.
Peng L26)	2013	N.R.	120 (49:71) [60:60]	Chuna+SYS	SYS	3 months	Effectiveness	N.R.
Fan YX23)	2013	CDC 1994	86 (34:52) [43:43]	Chuna+acupuncture	Acupuncture	22 days	Effectiveness	N.R.
Mao W25)	2013	CDC 1994	60 (25:35) [30:30]	Chuna+acupuncture	Acupuncture	6 weeks	Effectiveness, Fatigue severity	N.R.
Qi L30)	2014	CDC 1994	54 (22:32) [27:27]	Chuna+usual care	Usual care	10 days	Sleep disorder	N.R.
Chen H29)	2014	CDC 1994	51 (18:33) [27:24]	Chuna	Usual care	2 months	Effectiveness, Fatigue severity	N.R.
Qian LF37)	2016	CDC 2003	60 [30:30]	Chuna+usual care	Usual care	8weeks	Fatigue severity, Sleep disorder	N.R.
Wang HG31)	2016	CDC 1994	79 (40:39) [39:40]	Chuna	Usual care	10 days	Fatigue severity, Sleep disorder	N.A.E.
He CL24)	2013	CDC 1994	61 (23:38) [30:31]	Chuna+scraping	Scraping	2 weeks	Effectiveness	N.A.E.
Chen FT32)	2017	CDC 1994	60 (35:25) [31:29]	Chuna	Health supplements	4 weeks	Effectiveness, Fatigue severity	N.R.
Xu YX34)	2018	CDC 1994	73 (22:51) [37:36]	Chuna+usual care	Usual care	4 weeks	Fatigue severity, Sleep disorder	N.R.
Wang J33)	2018	CDC 1994	120 (70:50) [60:60]	Chuna	Usual care	15 days	Effectiveness	N.R.
Tang XN35)	2019	CDC 1994	40 (16:24) [20:20]	Chuna+moxibustion	moxibustion	3 weeks	Effectiveness, Fatigue severity	N.R.

SJT means seogeun-tang (舒筋湯); SGT, Sagunja-tang (四君子湯); SST, Sihosogan-tang (柴胡疏肝湯); SYS, Soyo-san (逍遙散); N.A.E., no adverse event; N.R., not reported.

Table 2

The Quality of evidence.

Outcome	Certainty assessment						Summary of findings

	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Effect (95% CI)	Certainty
Effectiveness	Chuna versus health supplements or usual care: 4 studies
	RCT	Seriousa	Not seriousb	Not seriousc	Not seriousd	Nonee	RR 0.19 (0.11 ~ 0.32)	⊖⊖⊖○ MODERATE

	Chuna versus health supplements: 2 studies
	RCT	Seriousa	Not seriousb	Not seriousc	Seriousf	Nonee	RR 0.16 (0.05~ 0.52)	⊖⊖○○ LOW

	Chuna versus usual care: 2 studies
	RCT	Seriousa	Not seriousb	Not seriousc	Seriousf	Nonee	RR 0.19 (0.11 ~ 0.36)	⊖⊖○○ LOW

	Chuna added to KM interventions versus KM interventions: 10 studies
	RCT	Seriousa	Not seriousb	Not seriousc	Not seriousd	Nonee	RR 0.25 (0.15 ~ 0.42)	⊖⊖⊖○ MODERATE

Fatigue	Chuna versus health supplements or usual care: 4 studies
	RCT	Seriousa	Not seriousb	Not seriousc	Not seriousg	Nonee	SMD −0.73(−0.98 ~ −0.48)	⊖⊖⊖○ MODERATE

	Chuna versus health supplements: 1 study
	RCT	Seriousa	Serioush	Not seriousc	Seriousi	Nonee	SMD −0.85 (−1.38 ~ −0.32)	⊖○○○ VERY LOW

	Chuna versus usual care: 3 studies
	RCT	Not seriousj	Not seriousb	Not seriousc	Not seriousg	Nonee	SMD −0.69 (−0.97 ~ −0.41)	⊖⊖⊖⊖ HIGH

	Chuna added to KM interventions or usual care versus control: 4 studies
	RCT	Seriousa	Not seriousb	Not seriousc	Not seriousg	Nonee	SMD −1.21 (−1.53 ~ −0.89)	⊖⊖⊖○ MODERATE

	Chuna added to KM interventions versus KM interventions: 3 studies
	RCT	Seriousa	Not seriousb	Not seriousc	Seriousi	Nonee	SMD −1.29 (−1.70 ~ −0.87)	⊖⊖○○ LOW

	Chuna added to usual care versus usual care: 1 study
	RCT	Seriousa	Serioush	Not seriousc	Seriousi	Nonee	SMD −1.02 (−1.56 ~ −0.48)	⊖○○○ VERY LOW

Sleep disorder	Chuna versus usual care: 2 studies
	RCT	Not seriousj	Not seriousb	Not seriousc	Seriousi	Nonee	SMD −0.58 (−0.92 ~ −0.24)	⊖⊖⊖○ MODERATE

	Chuna added to usual care versus usual care: 3 studies
	RCT	Not seriousj	Very seriousk	Not seriousc	Seriousi	None	SMD −1.47 (−2.43 ~ −0.51)	⊖○○○ VERY LOW

RCT means randomized controlled trial; CI, confidence interval; RR, relative risk; SMD, standardized mean difference; KM, Korean medicine.

the proportion of studies assessed as low risk of bias was between 30% and 50%;

I2 was less than 50%;

directness was undoubted;

total sample size was more than 200, and 95% CI of RR did not cross 1;

publication bias was not assessed;

total sample size was less than 200, but 95% CI of RR did not cross 1;

total sample size was more than 200, and 95% CI of SMD did not cross zero;

only 1 study was included;

ⁱ

total sample size was less than 200, but 95% CI of SMD did not cross zero;

the proportion of studies assessed as low risk of bias was more than 50%;

I2 was more than 75%;

total sample size was less than 100, and 95% CI of SMD crossed zero.