PK Hui³⁹, HP So⁴⁰, Lin Lin⁴¹, Yang Zhimin⁴¹, MH Chan³⁹, Kelvin Poon⁴², Lu Yu Bo⁴¹, Lai Shilong⁴¹, V Wong⁴², WM Ko⁴² and WC Yip³⁹

³⁹ The TWGH-KWH-CUHK Chinese Medicine Research and Services Centre, Kwong Wah Hospital

⁴⁰ Wong Tai Sin Hospital

⁴¹ Guangzhou University of Traditional Chinese Medicine

⁴² The Hospital Authority, Hong Kong SAR

Abstract. It is unknown whether Traditional Chinese medicine (TCM) can affect the course of recovery of patients with severe acute respiratory syndrome (SARS). We studied 129 patients convalescing from SARS who chose for themselves whether to receive TCM or Western medical care. Ninety-one patients chose to receive TCM. The probabilities of normalizing laboratory test results over time were similar for patients who did and did not receive TCM treatment. Patients who participated in pulmonary rehabilitation programmes with or without TCM showed similar 6-minute-walk distance and hand-grip strength at start, interim and endpoint measurements. The Short-Form-36 (SF-36) health survey questionnaire scores were also similar at endpoints for patients who did or did not receive TCM treatment. A group of patients who experienced greater limitations on physical activities chose to receive TCM alone, but not to participate in a pulmonary rehabilitation programme. They showed improvements in 6-minute-walk distance and hand-grip strength equivalent to those seen in patients who did participate in pulmonary rehabilitation. These results suggest that TCM could provide an alternative treatment option for patients convalescing from SARS, particularly for those who experience limitations on physical activities.

Background

In May 2003, the Hospital Authority of Hong Kong SAR invited two Chinese medicine practitioners experienced in the treatment of SARS in Guangzhou to provide TCM services to SARS patients in Hong Kong SAR. In addition to caring for SARS patients during the acute phase of the disease, they also provided TCM services to patients convalescing from SARS.

This report aims to compare the effects of TCM with those of conventional treatment (Western medicine) on SARS patients who had been discharged from hospitals.

Methods

Design

This was a prospective non-randomized controlled trial.

Source of patients

The patients were from the Wong Tai Sin Hospital (WTSH), a regional convalescence hospital that serves several general hospitals. A few SARS patients had not been admitted to WTSH but had learned of the availability of TCM through the media and volunteered to join this programme. After a face-to-face explanation by nurses, patients chose their own treatment, i.e. with or without TCM care. Those who chose TCM were not required to pay additional fees.

Patient groups

Two groups of patients, namely inpatients and outpatients, participated in the study. Inpatients were admitted to WTSH immediately after they had been discharged from acute hospitals and they participated in a pulmonary rehabilitation programme. Outpatients were those study subjects who had already been discharged from WTSH, but were participating in outpatient follow-up pulmonary rehabilitation programmes that entailed a 7-day inpatient training period at the start. Patients who chose to receive TCM care but did not want to participate in a pulmonary rehabilitation programme were followed up as outpatients in the Chinese Medicine Research and Services Centre at Kwong Wah Hospital (Table 1).

Table 1. Patient groups

 

TCM, Traditional Chinese medicine.

Treatment with Traditional Chinese medicine

TCM physicians provided a 21-day course of individualized TCM treatment to patients who chose to receive it. Decoctions of Chinese medicine were prepared at a single TCM pharmacy located at Kwong Wah Hospital.

Parameters studied (1-4)

In this report, we present observations on normalization of abnormal laboratory results (probability), and 6-minute-walk distance, hand-grip strength and SF-36 questionnaire scores (5). Nurses (Western medicine) performed tests and observations independently of the TCM physicians. For laboratory results we compared the first set of results from patients on starting this programme with their second (8-14 days) and third (15-28 days) sets of laboratory results. For 6-minute-walk and hand-grips, measurement were done at start, interim (7 days; i.e. after training) and endpoints (1 month). For patients who did not participate in pulmonary rehabilitation, there was no training and no interim measurement. For SF-36 scores, measurements were made at start and endpoints (1 month).

Source of data

Patients' laboratory data were obtained from a SARS-specific territory-wide database built by the Hospital Authority of Hong Kong SAR. Laboratory results had already been classified as normal, high or low in the corporate laboratory information system. Rehabilitation data were processed in a separate database in Kwong Wah Hospital using patients' unique Hong Kong identity numbers for indexing.

Statistical analysis

We first established benchmark values for patients who chose not to receive TCM care. For comparisons with benchmarks, we used a t-test for continuous data, the Wilcoxon rank-sum test for ranked data and the chi-squared test for probabilities. A statistically significant difference was defined by a p-value < 0.05. Unless specified, all p-values were two-sided.

Results

Normalization of laboratory results

Whether or not convalescent patients received TCM treatment, their abnormal laboratory test results gradually normalized. The probabilities of normalizing abnormal laboratory results (including levels of urea, creatinine, sodium, potassium, albumin, globulin and haemoglobin; white cell count, platelet count, absolute lymphocyte count, absolute neutrophil count; aspartate amino transferase; amino alanine transferase; and lactate dehydrogenase) during convalescence were similar for all patients whether or not they received TCM treatment (Fig. 1). The probabilities of normalization of the individual test results listed above were also similar for patients who did and did not receive TCM treatment.

Fig. 1. Probability of abnormal laboratory tests becoming normalized over time

IP, Inpatients; PR, pulmonary rehabilitation; OP, outpatient; TCM, Traditional Chinese medicine. ^aThe tests included: urea, creatinine, sodium, potassium, albumin, globulin, haemoglobin, white cell count, platelet count, absolute lymphocyte count, absolute neutrophil count, aspartate amino transferase, amino alanine transferase and lactate dehydrogenase.

Fig. 2. Six-minute-walk distance of various patient groups

IP, Inpatients; PR, pulmonary rehabilitation; OP, outpatient; TCM, Traditional Chinese medicine.

For inpatients, measurements in the TCM-treated group were comparable with benchmark values at start, interim and endpoint (Table 2).

Table 2. Six-minute-walk results (metres) for outpatients convalescing from SARS

 

TCM, Traditional Chinese medicine
No significant difference was found at the 5% level (t-test).

For outpatients, the TCM-treated groups were also comparable with benchmark values at start, interim and endpoint (Table 3). For the TCM patients who were also taking part in pulmonary rehabilitation programmes, most of the improvement had occurred by the time of the interim measurement.

Table 3. Six-minute-walk results (metres) of outpatients convalescing from SARS

 

TCM, Traditional Chinese medicine
No significant difference was found at the 5% level (t-test).

Of particular interest is that outpatients who were receiving TCM but were not taking part in the pulmonary rehabilitation programme also showed gradual improvement in the 6-minute-walk test. Performances were comparable with benchmark values at the start and endpoints (Table 4).

Table 4. Six-minute-walk results (metres) for outpatients receiving traditional Chinese medicine (TCM) compared with patients taking part in a pulmonary rehabilitation programme but not receiving TCM

 

No significant difference was found at the 5% level (t-test).

Fig. 3. Hand-grip strength in various patient groups

IP, inpatients; PR, pulmonary rehabilitation; OP, outpatient; TCM, Traditional Chinese medicine.

Tables 5-7 show that the hand-grip strengths of TCM patients were comparable with benchmark values in all patient groups. As for the results of the 6-minute walk, patients who were receiving TCM, but did not participate in the pulmonary rehabilitation programme, also showed gradual improvement, and their results were comparable with benchmark values at start and endpoints (Table 7). From Fig. 3, it is apparent that the improvement of hand-grip strength over time was more marked in inpatients.

Table 5. Hand-grip strength of convalescing SARS inpatients

 

TCM, Traditional Chinese medicine.
No significant difference was found at the 5% level (t-test).

Table 6. Hand-grip strength of outpatients convalescing from SARS

 

TCM, Traditional Chinese Medicine

Table 7. Hand-grip strength of outpatients on traditional Chinese medicine (TCM) only, compared with patients taking part in a pulmonary rehabilitation programme but not receiving TCM

 

No significant difference was found at the 5% level (t-test).

Short-Form-36 scores

For inpatients, the SF-36 scores of patients treated with TCM were comparable with benchmark values at the endpoint despite weaker scores in vitality, social functioning and emotional orientation at the start (Table 8). (Higher scores indicated a more satisfactory quality of life than did lower scores.)

Table 8. SF-36 scores for inpatients convalescing from SARS

 

SF-36, Short-from-36 health survey questionnaire; TCM, Traditional Chinese medicine; NS, not significant.

For outpatients, the SF-36 scores of patients receiving TCM were comparable with benchmark values for all patient groups (Tables 9 and 10).

Table 9. SF-36 scores for convalescing SARS outpatients

 

SF-36, Short-from-36 health survey questionnaire; TCM, Traditional Chinese medicine; NS, not significant.

Table 10. SF-36 scores for outpatients receiving traditional Chinese medicine (TCM) but not pulmonary rehabilitation (PR), compared with patients undergoing PR but not receiving TCM

 

SF-36, Short-from-36 health survey questionnaire; NS, not significant.

To analyse why some patients preferred not to undergo pulmonary rehabilitation, we looked at the scores for question 3 of the SF-36 questionnaires and found that those who chose not to participate in a pulmonary rehabilitation programme had significantly lower scores (p < 0.05) for strenuous and moderate physical activities, carrying weights, walking up flights of stairs and for bathing and dressing.

Discussion

Because patients chose their own programmes, it was difficult to balance the numbers of patients in the different treatment groups. It was noted that the TCM programme was less popular among inpatients than in outpatients, probably because the treatment in the former group was started earlier and time was needed for TCM to gain acceptance.

It is unknown whether TCM can influence the course of recovery in SARS patients. From our results, TCM did not appear to have any additional benefits over a period of one month. One explanation for this observation is that when patients gradually recover, their physical performance will level off at their best intrinsic ability, and additional TCM cannot lead to any additional improvement.

However, we did observe that in the outpatient group, those who received TCM showed most of the improvements in their 6-minute-walk distance between the baseline and interim measurements, although at the endpoint the distances were comparable with those measured in the non-TCM-treated comparison group. In the future, studies on whether TCM can hasten the recovery of physical strength in SARS patients, by means of more frequent tests near the start of TCM care would be useful.

During the follow-up period, we noted that a few patients complained of hip pains while performing the 6-minute-walk tests. We referred these patients for further investigations and follow-up for any avascular necrosis of the femoral head, a known complication of steroid treatment.

It was interesting to note that there were some patients who chose to receive TCM, but did not want to participate in pulmonary rehabilitation. There is evidence that their avoidance of pulmonary rehabilitation may have been related to their greater limitations in physical activities. Because patients on TCM showed only gradual improvement over time and their progress was essentially similar to that of patients on the pulmonary rehabilitation programme, we propose that TCM could be an alternative option for patients convalescing from SARS, particularly for those whose ability to perform physical activities is limited.

Conclusion

During convalescence from SARS, patients who chose to receive TCM treatment alone showed improvements in the 6-minute-walk distance and hand-grip strength comparable to those measured in patients who participated in a pulmonary rehabilitation programme. TCM could provide an effective alternative treatment for convalescing SARS patients, particularly for those whose ability to perform physical exercise is limited.

Acknowledgements

We thank the Statistics Team at the Hospital Authority Head Office for their expert advice. We are also grateful to the TCM team at the Tung Wah Group of Hospitals who organized the ward rounds and prepared Chinese medicine decoctions of the highest quality.

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