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Ovid: Oxford Handbook of General Practice

Editors: Simon, Chantal; Everitt, Hazel; Kendrick, Tony Title: Oxford Handbook of General Practice, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 4 – Complementary medicine Chapter 4 Complementary medicine Complementary medicine In the UK ~90% of the population have tried complementary or alternative medicine (CAM) at some time. But, although CAM undoubtedly helps many individuals, its use remains controversial. Reasons for caution

  • Lack of evidence of effectiveness: There are many anecdotal reports and small-scale observational studies of the positive effects of complementary therapies but large-scale, high-quality studies tend to be -ve.
  • Lack of regulation of practitioners: Anyone can call themselves a therapist and practice. It is always important to find a reputable practitioner with accredited training who is a member of a recognized professional body It is also important to ensure any practitioner used carries professional indemnity insurance.
  • Lack of regulation of products: Most complementary ‘medicines’ are sold as foods rather than medicines and do not hold a product licence. No licensing authority has assessed efficacy, safety, or quality and interactions with conventional medicines are unknown. Complementary medicines can, and do, cause adverse effects—just because they are natural does not mean they are safe.

Legal position of GPs Practising complementary medicine Conventionally trained doctors can administer any unconventional medical treatments they choose. The ‘Bolam test’ applies—in other words, if a doctor has undergone additional training in a complementary discipline and practises in a way that is reasonable and would be considered acceptable by a number of other medically qualified complementary practitioners, his or her actions are defensible. Referring to complementary medicine practitioners

  • Delegation to non-medically qualified practitioner: Ask yourself:
    • Is my decision to delegate to this complementary therapy appropriate? Evidence-based decisions are most persuasive; commonly accepted but unproven indications are also acceptable.
    • Have I taken reasonable steps to ensure that the practitioner is qualified and insured? Usually sufficient to ensure s/he is a member of the main professional regulatory body responsible for that discipline. Main bodies require members to be fully indemnified.
    • Has my medical follow-up been adequate? Continue following-up chronic conditions as usual. Don’t issue repeat prescriptions without having sufficient information to ensure safe prescribing.
  • Referral to medically qualified practitioner/state registered osteopath or chiropractor: Same legal situation as when referring to another conventional healthcare practitioner for any other service. As long as the decision to make the referral is appropriate (see above), all further responsibility is taken over by the practitioner providing the specialist service.

Further information Bandolier http://www.jr2.ox.ac.uk/bandolier/booth/booths/altmed.html P.143
Acupuncture Acupuncture means ‘piercing with a sharp instrument’. Needles are used to alleviate symptoms or cure disease. Mechanism of action remains unclear. Broadly, 2 forms exist—traditional/Chinese and modern/Western. There is no‘right way’ to practice as there is no scientific data comparing the two. Traditional acupuncture Based on Chinese medicine where health is a balance between ‘ying’ and ‘yang’, illness is imbalance, and treatment aims to restore balance. Needles are inserted into channels representing 12 organs recognized in Chinese medicine to stimulate or sedate the flow of chi, an energy force flowing in these channels (meridiens) and sustaining life in parallel to blood. In most cases, a number of needles are inserted and left for up to 20min. Modern acupuncture Uses modern anatomy and physiology and ignores the rules of traditional Chinese medicine. Traditional acupuncture points are still used for some illnesses but often the acupuncturist makes use of trigger points—areas, usually in muscle, which hurt when pressed and may cause pain to radiate to other places. Needling the trigger point relieves pain. Use and evidence Acupuncture has been used to treat all conditions but is commonly used in Europe and the USA to treat musculoskeletal problems and chronic disease. Although Table 4.1 reports the overall outcome of systematic reviews and good quality randomized controlled trials for various applications of acupuncture, it should be used with caution as there are very few large, good-quality trials in existence and almost all are–ve.

Table 4.1 Evidence for common uses of acupuncture
Largely +ve Inconclusive Largely -ve
Back painS Chronic painS Cocaine addictionR
Idiopathic headacheC Neck painS Smoking cessationC
Post-operative nausea and vomiting (adults)S FibromyalgiaS*
Rheumatoid arthritisC
Tennis elbowC
TMJ dysfunctionS
Weight reductionS
Labour painC
Carpal tunnel syndromeC
Hot flushesS
* Some evidence acupuncture causes exacerbation of symptoms for some patients.

Contraindications Unwilling or frightened patient, pregnancy (especially 1st trimester, as anecdotal evidence suggests ↑ risk of miscarriage), bleeding disorders and anticoagulant use (relative contraindication), skin infections or diseased skin, disorders of the immune system, valvular heart disease (only if indwelling needles are used). Side effects Rare (1:1000 treatments)

  • Infection (ONLY go to practitioners using disposable needles)
  • Bruising/haemorrhage
  • Anatomical damage (pneumothorax most common)
  • Needle fracture or needles left in situ
  • Fainting
  • Sweating
  • Convulsions
  • Miscarriage (anecdotal)

Variants of acupuncture Auriculotherapy Microsystem of acupuncture based on a ‘homunculus’ or map of the body on the ear. Stimulation of points on the ear representing an area in pain produces analgesia. Best known for treatment of addiction, especially smoking. No good-quality evidence of effectiveness. Often practised using semi-permanent needles in an attempt to prolong its effects at the risk of infection at the needle site. Should not be used for patients with artificial heart valves, valvular heart disease, or immune deficiency. Transcutaneous electrical nerve stimulation (TENS) Electrodes are placed on the skin over the painful area or at other locations e.g. over cutaneous nerves, trigger points, acupuncture sites. The TENS unit passes electrical current through the electrodes. The patient can control strength of current and pulse interval. Widely used by midwives, physiotherapists, and in hospitals. No good evidence of effectiveness. Reflexology A representation of the body is found on the foot. Diagnosis is through palpation of the sole of the foot for tender points. These correspond to the area of the body where there is pain. Treatment consists of massaging these points or applying acupressure to relieve symptoms. No good-quality evidence of effectiveness but unlikely to do any harm. Professional organizations British Medical Acupuncture Society Tel: 01925 730727; Fax: 01925 730492; http://www.medical-acupuncture.co.uk British Acupuncture Council Tel: 020 8735 0400 http://www.acupuncture.org.uk Acupuncture Association of Chartered Physiotherapists Tel: 01747 861151 Fax: 01747 861717 http://www.aacp.uk.com Association of Reflexologists Tel: 0870 5673320 http://www.aor.org.uk Further reading Effective health care (2001) Acupuncture 7(2) http://www.york.ac.uk/inst/crd/ehcb.htm P.146
Homeopathy From the Greek meaning ‘treatment by similars’ Theory of homeopathy Homeopathy works on the principle that like cures like. The majority of homeopathic remedies are derived from plants, although chemical and animal sources are also used. A remedy is chosen that mimics the symptoms displayed by the patient e.g. homeopathic ipecacuanha is used to treat nausea and vomiting. Most remedies are serially diluted in steps of 1:10 (decimal ×) or 1:100 (centesimal c). Some lay practitioners believe conventional drugs ↓ efficacy of homeopathy. It is important that users of homeopathic drugs do not stop taking conventional medicines unless advised to by the doctor who prescribed them. Use Often used to treat symptoms of acute self-limiting illness. Also used widely for chronic conditions e.g. eczema, stress, depression and chronic fatigue. Homoeopathic treatment is slow. The ‘rule of 12’ states 1mo. of treatment is required for each year the patient has the problem. Availability of drugs Manufacture of homeopathic medicine is controlled by the Medicines Act (1968). Homeopathic drugs can be purchased OTC at pharmacies and health food shops or prescribed on NHS prescription. Legal responsibility for prescribing lies with the person who signs the prescription form. Side effects/contraindications Homeopathic remedies of sufficient dilution (>30x or 12c) and obtained from a reputable manufacturer are unlikely to cause adverse effects or interact with conventional medicines. Homeopathy also appears to be safe in women who are pregnant/breastfeeding, but should not be used to treat serious conditions for which there is a proven conventional therapy. Evidence With higher dilutions (>12c), a theoretical problem arises as the solution may not contain any molecules of the mother substance. Nevertheless, homeopaths claim more dilute solutions are more effective. Meta-analysis1 published in 1997 pooled all studies comparing homeopathy against placebo and concluded that, overall, homeopathy works. However, there is insufficient information about use of homeopathy in most clinical situations to decide when, and if, homeopathy is a credible adjunct or alternative to conventional treatment.

Table 4.2 Evidence for common uses of homeopathy
Largely +ve Inconclusive Largely -ve
Post-operative ileusS Atopic eczemaS BruisingS
Dandruff and seborhhoeic dermatitisR Chronic asthmaC
Ocular symptoms of hayfeverS
Pre-menstrual syndromeR
Low back painR
Otitis mediaR
Acute sinusitisR
Labour painC
Rheumatoid arthritisS
Delayed-onset muscle sorenessS
Migraine prophylaxisS

Professional organizations British Homoeopathic Association Tel: 0870 444 3950 Fax: 0870 444 3960 http://www.trusthomeopathy.org Society of Homeopaths Tel: 01604 621400 Fax: 01604 622622 http://www.homeopathy-soh.org Footnote Linde et al. (1997) Lancet 350: 834-43. P.148
Herbal medicine Use of plants or plant parts for medicinal purposes. Conventional medicine uses many drugs derived from herbal substances e.g. digoxin, aspirin, and morphine. Herbal medicine uses plant extracts, not isolated constituents. Herbalists believe different compounds contained in a herbal preparation act synergistically. Availability of herbal medicine Widely available in the UK. Most products are unlicensed and sold as foods. Problems:

  • Quality assurance
  • Accidental contamination
  • Botanical quality
  • Unknown optimum dose/dosage range
  • Lack of data on drug interactions

Report all adverse herbal medicine reactions and drug interactions using the yellow card scheme (p.128). Keep a sample of the implicated herbal medicine. Uses and evidence Used for a wide range of conditions, often with little evidence of efficacy. See Table 4.3. Aromatherapy Use of aromatic plant oils (usually by inhalation or application to the skin) for benefit. No good evidence of effectiveness. Oils used are extremely concentrated. Uses:

  • Lavender oil
  • Tea tree oil
  • Geranium oil
  • Eucalyptus oil
  • Thyme oil
  • Rosemary oil
  • Peppermint oil
  • Valerian oil
  • Burns, blisters, insomnia
  • Headlice, athlete’s foot, wound infection
  • Calming, antidepressant
  • Clear blocked noses (Vicks Vaporub®)
  • Antiseptic—used for colds and flu
  • Antiseptic and soothing—good for sinus infections
  • Headache, indigestion
  • Anxiety and insomnia

Cautions, side-effects, and contraindications Volatile oils are readily absorbed through mucus membranes and may be as potent as any drug. Sold as unlicensed products—quality, safety, interactions, and efficacy have not been assessed. Can be poisonous if ingested. Professional organizations British Herbal Medical Association: Tel: 01202 433691 Fax: 01202 417079 http://www.ex.ac.uk/phytonet/bhma.html National Institute of Medical Herbalists: Tel: 01392 426022 Fax: 01392 498963 http://www.nimh.org.uk International Federation of Professional Aromatherapists Tel: 01455 637987 http://www.ifparoma.org Aromatherapy Organizations Council: Tel: 0870 7743477 http://www.aocuk.net

Table 4.3 Herbal products with evidence of efficacy
Herb Side-effects Evidence
Saw pallmetto Dizziness and mild Gl effects. Rare: pruritus, headache, ↑ BP. BPH. Improvement in symptoms when used for >1–2mo. Side-effects <finasteridec.
Echinacea Nausea, dizziness, SOB, dermatitis, pruritus, and hepatotoxicity. Prevention and treatment cold—majority of studies +veC.
image Advise patients NOT to take for >8wk. as can cause immune suppression Theoretically, may ↓ effects of immuno-suppressants and be harmful in autoimmune disease and HIV.
St. John’s Wort Dry mouth, Gl symptoms, fatigue, headache, dizziness, skin rash, and ↑ sensitivity to sunlight.
Drug interactions: ↓ effect of anti-convulsants, warfarin, ciclosporin, digoxin, theophylline, and COC pill.
Serotonergic effects (sweating, shivering, muscle contractions) with triptans and antidepressants.
image DO NOT use concurrently with prescription antidepressants.
Depression—effective treatmentS. Discontinue 2wk. prior to surgery as theoretical risk of interaction with anaesthetic agents.
Gingko biloba Spontaneous bleeding. Drug interactions: ↑ effect of warfarin and antiplatelet agents. Effective for improving cerebral blood flowS and intermittent claudicationS. May help tinnitusS.
Feverfew May cause breakthrough menstrual bleeding. Caution with anticoagulants. Migraine prophylaxis—probably effectiveC.
Chinese herbal medicine Serious blood dyscrasias and hepatotoxicity have been reported. Effective for childhood eczemaS and irritable bowel syndromeR.

Other products for which there is evidence of effectiveness

  • Aloe vera (psoriasisS and genital herpesS)
  • Oil of evening primrose (rheumatoid arthritisC)
  • Kava (anxietyS)
  • Valerian (insomniaS)
  • Peppermint oil (irritable bowel syndromeS)
  • Horse chestnut seed extract (chronic venous insufficiencyC)
  • Yohimbine (erectile dysfunctionS)

Further information Herbmeda http://www.herbmed.org P.150
Dietary manipulation and supplementation ‘Let your food be your medicine’ Hippocrates (460–377 BC) Healing foods Branch of herbal medicine. Common examples for which there is some evidence of effectiveness include:

  • Ghondroitin: ↓ pain and symptoms of OAS.
  • Cranberry juice: Trial evidence for effect in prevention or treatment of UTIR not supported by Cochrane reviewC.
  • Fish oil: Cardioprotective effectsR; ↓ pain and symptoms of RAS.
  • Garlic: ↓ cholesterolS; antithrombotic/fibrinolytic effectsS. May have a role in cancer prevention.
  • Ginger: ↓ nausea in a variety of situationsS.
  • Honey: Wound dressing—improves healingS.
  • Soya: ↓ menopausal symptomsS.
  • Yoghurt: No evidence for treatment of vaginal infection or prevention of recurrenceS. Mixed evidenceR and no systematic reviews for treating diarrhoea with yoghurt.
  • Xylitol: Some evidence in vitro and animal studies that ↓ bacterial infection. Currently under investigation for effects in minor illness e.g. sore throat.

Nutritional medicine Involves prescribing vitamins, minerals, amino acids, and essential fatty acids. Prescription is based on investigations into the individual’s nutritional state by history taking, nutritional diaries, and analysis of samples of blood, sweat, and hair. Evidence of effectiveness:

  • Calcium supplements ± vitamin D: ↓ incidence of osteoporosis and osteoporotic fractureCS. Calcium may ↓ BPS.
  • Folate supplements: Taken preconceptually ↓ incidence of neural tube defectR.
  • Glucosamine: ↓ pain and symptoms of OAC.
  • Selenium: Suggestion of protective effect against gastro-oesophageal cancer. No good-quality evidence and recent epidemiological data suggest supplements may be harmful.
  • Vitamin A: Cancer preventionS.
  • Vitamin B6: May be effective for premenstrual syndromS but excessive ingestion (>2000mg/d.) causes peripheral neuropathy. Possible effect on autismS.
  • Vitamin B12: No evidence of beneficial effect on cognitionC.
  • Vitamin C: ↓ duration of symptoms of common cold if used in high dosesC. May ↓ BPS.
  • Vitamin E: May have a role in prevention of cardiovascular diseaseS. Unclear whether helpful for dementiaC and intermittent claudicationC.
  • Zinc: Inconclusive evidence shortens duration of common coldC.

Some products are derived from marine sources—patients allergic to shellfish should ensure product is synthetically manufactured. Patients should NOT take supplements in pregnancy. P.151
Probiotics Probiotics are orally administered microbial cell preparations or components of microbial cells that may have a beneficial effect on the health and well-being of the host. There is some evidence of efficacy in treating a variety of medical problems including infectious diarrhoeaC, other gastrointestinal conditions (including inflammatory bowel disease and irritable bowel syndrome), and atopyS. There is increasing interest in the use of probiotics in mainstream medicine and the evidence base for or against the use of these preparations is likely to increase over the next few years. Environmental medicine Based on the premise that individuals develop adverse responses to environmental substances, most commonly foods, which manifest as disease. Adverse reactions are termed ‘allergies’ or intolerance. This is a different use of the term allergy than that used in conventional medicine. In environmental medicine it means a reaction with insidious onset that is not predictable and does not trigger the immune pathways responsible for allergy. Investigations involve diagnostic use of elimination diets or substance avoidance; challenge testing by exposure to the substance, and the coca pulse test (speeding or slowing of the pulse by >10bpm after exposure). Allergy testing machines based on electrical skin resistance are in common use, though they produce inconsistent results and there is no evidence they are predictive of intolerance. Food intolerances are generally multiple with 1 or 2 ‘major’ foods and several more ‘minor’ foods responsible for triggering effects. Common examples are: caffeine, milk, gluten, citrus fruit. Beware that patients on multiple exclusion diets do not become malnourished. There is very little evidence of effect—Cochrane review of use for recurrent childhood abdominal pain and systematic review of use for childhood eczema were both inconclusive. Professional organizations British Herbal Medical Association: Tel: 01202 433691 http://www.ex.ac.uk/phytonet/bhma.html Society for Environmental Therapy (SET) Tel: 01473 723552 P.152
Physical therapies Osteopathy and chiropractic Physical treatments aimed at restoring alignment of the joints and improving functioning of the body. In the UK, both are distinguished from other complementary therapies by being under statutory regulation. All osteopaths and chiropractors have to undergo training lasting 4–5y.. After that time, they are registered with their governing body which enforces a code of standards and discipline. They must have professional indemnity insurance. Osteopathy From Greek meaning ‘bone disease’. Operates on the theory that if structure is improved, improvement in function follows. Chiropractic Diagnosis, treatment, and management of conditions due to mechanical dysfunction of the joints and their effects on the nervous system. Chiropractors aim to restore normal alignment of joints. McTimoney chiropractic Branch of chiropractic that uses slightly different, gentler techniques than conventional chiropractic treatment. Method Osteopaths and chiropractors use standard orthopaedic techniques and may perform investigations including X-rays. They like to work closely alongside conventional physicians, referring back to them any problems they detect outside their field of expertise. Treatment is usually physical, using massage and joint manipulation. Both treat the whole patient, giving advice on posture, lifestyle, and prevention of musculoskeletal and other problems. Evidence Some good evidence of effectiveness especially for back painR. Massage If we hurt ourselves, we rub it better. There are many different variants of massage, but the most common seen in the UK are ‘Swedish massage’ and ‘Shiatsu’ (or Japanese massage). Shiatsu uses a variant of acupressure (allied to acupuncture but using pressure on key points rather than needles) to enhance its effect. Evidence ↑ mobilityR, ↑ blood flowR, ↑ expiratory volumeR, ↓ musculoskeletal and phantom limb painR, ↓ lymphoedemaR. No convincing systematic review evidence of effect. Yoga Ancient art involving a sequence of physical stretches involving the whole body over a session. It is done slowly and in silence. Whilst performing the moves, participants breath slowly and deeply, fixing their minds on the activity they are doing. Yoga should be taught by an experienced instructor. Evidence ↓ seizure frequency for epilepticsC. Tai chi chuan Variously translated as ‘supreme boxing’ and the ‘root of all motion’. It is considered a martial art but is not combative. It is based on fluidity and circular movements. Evidence ↓ falls and fear of falls in the elderlyR. P.153
Physiotherapy Physiotherapy is a healthcare profession concerned with maximizing potential, enhancing bodily function, and preventing future problems. It uses mainly physical approaches to achieve this including:

  • Manipulation
  • Exercise
  • Posture
  • Massage
  • Relaxation
  • Ultrasound

Often physiotherapists also use other complementary therapies during the course of their work e.g. acupuncture, aromatherapy, TENS. Physiotherapists work in many health settings and are widely used and appreciated by patients in the community for conditions ranging from stress incontinence, and chest disease to musculoskeletal problems. They are an integrated part of the healthcare team and work closely with other members of the team. Evidence There is an extensive evidence base for the effectiveness of physiotherapy in a wide variety of conditions. Pilates Method of exercise involving physical movement designed to stretch, strengthen, and balance the body, together with focused breathing patterns. Evidence No specific evidence, though probably has the same benefits as general exercise—p.232. Professional organizations General Osteopathic Council Tel: 020 7357 6655 http://www.osteopathy.org.uk British Chiropractic Association Tel: 0118 950 5950 http://www.chiropractic-uk.co.uk The Shiatsu Society Tel: 0845 130 4560 http://www.shiatsu.org The British Wheel of Yoga Tel: 01529 306 851 http://www.bwy.org.uk Tai Chi Union Tel: 0141 810 3482 http://www.taichiunion.com Chartered Society of Physiotherapy Tel: 020 7306 6666 http://www.csp.org.uk UK Pilates Foundation Tel: 07071 781 859 http://www.pilatesfoundation.com Pilates Institute Tel: 020 7253 3177 http://www.pilates-institute.com P.154
Other complementary therapies Alexander Technique Practical method for improving the way we ‘use’ ourselves in the activities of everyday life. No evidence of effectiveness but unlikely to be harmful. Art therapy Use of art as a therapeutic activity. Review of role in treatment of schizophrenia inconclusiveC. Autogenic training A kind of relaxation technique which involves passive concentration and psychophysiological stimuli. There are 6 standard exercises to aid relaxation, ↑ warmth in the abdominal region, and cool the cranial region. The technique takes ~ 8wk. to learn effectively and sessions 3x/d. are encouraged. It is used for a variety of conditions, including the treatment of hypertension. No evidence of effectiveness. Ayurveda Practised primarily in the Indian subcontinent for 5000y. Ayurveda includes diet and herbal remedies and emphasizes the use of body, mind, and spirit in disease prevention and treatment. No good evidence of effectiveness. Cognitive behaviour therapy p.958 Counselling p.958 Faith healing Healing is an ancient art, practised by most civilizations, and given much prominence by the ancient Greeks. During the healing process, the healer transmits an ‘energy’ which produces a harmonizing and healing effect. This energy is transmitted in different ways according to the type of healer consulted. No good-quality evidence of effect, though one study did show prayer ↓ mortality in a cardiac unitR. Hypnotherapy Hypnosis can be defined as a state of heightened suggestibility or altered state of consciousness where the subject feels very relaxed. In medical hypnotherapy, the patient is not controlled or manipulated and can normally remember what has taken place after the session has ended. Hypnotherapy consists of training the patient to relax very deeply—often with a focus, a scene, smell, touch sensation, or colour to aid this process. Evidence: No evidence of effectiveness for smoking cessatioC or weight lossC. May be helpful for pain relief in labourC and to ↓ symptoms of IBSS. Meditation The instructor gives each individual a phrase or word—the mantra—which must not be divulged. The process involves siting quietly with eyes closed repeating the mantra for 20min. at a time 1 or 2x/d. The mantra focuses the mind on a single idea. If distractions occur, they are observed and put out of mind. No good evidence of effectiveness. P.155
Reiki Japanese word representing universal life energy. Reiki is based on the belief that when spiritual energy is channelled through a Reiki practitioner, the patient’ spirit is healed, which in turn heals the physical body. No evidence of effectiveness. Relaxation Can either be done with a therapist or alone. A number of good relaxation tapes exist. It must be done in a quiet environment.

  • The patient starts in a comfortable position.
  • S/he is asked to close his/her eyes and then focus on each part of the body in turn, from toes upwards, for a period of about 10sec. at each location.
  • Often the patient is asked to feel the part of the body being focused on becoming heavy.
  • After this has been done, the patient is asked to visualize an idyllic scene—to breath the smells, hear the sounds, and feel the textures.
  • An image can be provided such as a perfect evening on a warm, deserted beach.

Relaxation training is widely used throughout medicine. No convincing evidence of effect but unlikely to be harmful. Professional organizations Society of Teachers of the Alexander Technique Tel: 020 7284 3338 http://www.stat.org.uk British Autogenic Society Tel: 020 7383 5108 http://www.autogenic-therapy.org.uk National Federation of Spiritual Healers Tel: 0845 1232777 http://www.nfsh.org.uk The Hypnotherapy Association Tel: 01257 262124 http://www.thehypnotherapyassociation.co.uk UK Reiki Federation Tel: 01264 773774 http://www.reikifed.co.uk

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