Complementary traditional Chinese medicine use in Children with cerebral palsy: a nationwide retrospective cohort study in Taiwan

This population-based study characterized complementary TCM usage among children with cerebral palsy in Taiwan. In this study, we found that the proportion of TCM users in children with CP (62.37%) was much higher than average (22.5%) [18]. Our study was in accordance with a previous study in which younger children with CP used complementary and alternative more frequently [24]. The lower the age of the child with CP, the higher the proportion of TCM utilization that was found. However, this finding was not in agreement with previous studies in which older children with allergic disorders were more likely to consult with TCM services [8‐10]. Furthermore, while both TCM users and non-TCM users exhibited high rates of annual outpatient visits, TCM users showed a higher proportion than non-TCM users. Patients with brain damage need early and comprehensive medical management. In line with some studies’ reports on the benefits of treating brain damage or neurological disorders with TCM methods [15, 25, 26], it was quite common in Taiwan to use Chinese medicine to treat children with CP. Compared to other diseases, the utilization of TCM in patients with CP was much higher [18, 27, 28]. Possible reasons for this difference included the following: (1) parents desired a variety of ways to help their ill children, (2) parents’ thought that natural products such as Chinese herbs generally had fewer side effects for developing children, and (3) the NHI program covered high-quality Chinese medical outpatient care for children with CP [29, 30], ensuring low medical costs for TCM on the part of the patients.

Children with CP often suffer from other disorders of cerebral function, such as intellectual disabilities, neurodevelopmental disorders, epilepsy, visual disorders, and speech and hearing impairments [5]. However, chronic pulmonary disease is a leading cause of death among children with severe CP [31]. The causes of pulmonary disease in these children are recurrent aspiration caused by gastroesophageal reflux and palatopharyngeal incoordination and restrictive disease due to scoliosis [31]. This may have explained why the three most common causes of clinical visits for children with CP in both TCM and non-TCM groups were related to the nervous, respiratory and digestive systems.

Therefore, children with CP did not only suffer from neurological and musculoskeletal disorders, but the therapy for CP was based on patients’ limitations in body structure and function. While medication and/or surgery may have helped to reduce spasticity, hyperreflexia, and clonus, they did not improve weakness and incoordination [32, 33]. Moreover, it was uncertain whether these interventions enhanced functional outcomes. Some reports showed that injections of botulinum toxin type A (BTX A) in combination with physical and occupational therapy improved some functional outcomes [34, 35], but this treatment did not affect associated disorders such as gastrointestinal and pulmonary dysfunction. Therefore, patients and parents needed to seek other ways to solve these problems. Previous studies also found that children with multiple disabilities chose a wide range of treatments to complement conventional therapies [24, 36]. This may have been another reason for high TCM usage in children with CP.

In Taiwan, the acceptance of acupuncture among children is lower than Chinese herbal medicine [18]. Among the children with CP, we found that many of the patients received acupuncture or Chinese orthopedic traumatology for symptoms related to injury, musculoskeletal system and connective tissue disorder, mental disorder, and nervous system. The NHI program also fully covered the integrative approaches, including tuina massage (a kind of Chinese orthopedic traumatology methods), ear acupuncture, scalp acupuncture, and somatic acupuncture together to aim to improve the quality of life in children with CP [29]. This provided an option for these children to receive the acupuncture and Chinese orthopedic traumatology.

Among the most common Chinese herbal medicine prescribed for children with CP, majority of them were indicated to treat condition related to the digestive system. Children with CP often have growth failure, which is mainly associated with poor nutrition [37] due to inadequate intake and gastrointestinal abnormalities [37‐41]. More than 90 percent of children with CP have clinically significant gastrointestinal symptoms such as swallowing disorders, chronic constipation, regurgitation and/or vomiting, chronic aspiration, and abdominal pain [41]. Furthermore, poor digestive function could lead to chronic pulmonary disease, the main cause of death in these patients [31]. The most commonly prescribed herbal formula in TCM to relieve constipation due to deficient fluid in the colon was Ma-zi-ren-wan, also known as Hemp Seed Pill. In a previous randomized double-blind study, Ma-zi-ren-wan was shown to be safe and effective at alleviating functional constipation [42]. One of the commonly prescribed single herb, Radix et Rhizoma Rhei, was also a commonly used laxative [43]. Other herbal formulas such as Liu-wei-di-huang-wan was used for improving osteoporosis [44] and Shao-yao-gan-cao-tang for relieving muscle spasm [45]. Since neurodevelopmental disorders [46], growth failure [37], orthopedic disorders [47, 48] and osteopenia [49‐52] were commonly associated disorders in children with CP, it was reasonable that some of the TCM prescriptions were used for treating these illness. Another category of TCM prescriptions, such as Chai-hu-jia-long-gu-mu-li-tang [21], Rhizoma Acori Graminei [53], Rhizoma Gastrodiae [54] and Radix Polygalae [55], were used for alleviating spasms and regulate the central nervous system. These three herbs were included in the core patterns of Chinese herb medicine for the treatment of patients with CP. Children with CP were also commonly found to have spastic syndromes [56], dyskinetic syndromes [57], epilepsy [5] and emotional disorders [46]. Various Chinese herbs, such as Xin-Yi-Qing-Fei-Tang, Ma-Xing-Shi-Gan-Tang, Bulbus Fritillariae Thunbergii and Semen Armeniacae, were used for treating respiratory symptoms. Finally, Radix Astragali was used traditionally to raise Qi and has been found to modulate immunity [58]. Taken together, some of the commonly prescribed Chinese herbs were used to complement one another to improve the main symptoms of CP. Others could help treat associated disorders that were not improved by BTX A injection, physical or occupational therapy, such as gastrointestinal and pulmonary dysfunction.

With regard to the rate of TCM and non-TCM use among the four common diseases that we previously found to be prevalent in pediatric TCM users [18], musculoskeletal system and connective tissue diseases had the highest ratio in both groups. The main concerns of patients and parents were likely related to limitations of the body’s structure and function. In all four diseases, the proportion of TCM use was significantly higher (p < 0.0001) than non-TCM use. This was consistent with our previous study that showed that the rate of TCM use for these four common diseases was higher in children in Taiwan [18].

Interestingly, although the medical expenditure for visiting outpatient clinics within one year of diagnosis of CP of complementary TCM user were higher than the non-TCM users, the medical costs for utilizing ER service and hospitalization were significantly lower. Many parents and policy-makers concerned about the costs of complementary and alternative medicine for patients with CP [59, 60]. This study provided some substantial economic evaluation for the integration of TCM treatment into the clinical healthcare of CP.

Overall, our study provided useful information regarding healthcare and epidemiological patterns of TCM use to treat children with CP. The importance of this study was based on the following aspects: First, based on the literature review and our knowledge, this study was the first large-scale investigation of complementary TCM to patients with CP. Second, this study included all patients below age 18 in the NHIRD with catastrophic illness certificates of CP. The potential for selection bias was eliminated. Third, the NHI system provides low-cost and convenient medical insurance to nearly all residents in Taiwan. Under the NHI program, both Western- and Chinese-based medical resources are very accessible. In 2012, there were approximately 59,017 Western medical doctors and 5,556 licensed TCM doctors serving 23 million people in Taiwan. Moreover, 93.7% of Taiwan’s medical institutions, including hospitals and clinics, take part in the NHI program [61].

The present study had several limitations. First, the NHI system did not reimburse purchases of healthy foods containing herbal ingredients. Second, we were unable to estimate treatment efficacy and disease severity in this study due to the lack of disease severity data in the NHIRD. Lastly, the neuroscience evidence of acupuncture and pharmacological mechanism of Chinese herbal medicine remained unclear. Therefore, we expected future studies and clinical trials to investigate the mechanism and clinical efficacy based on this study.