Complementary and Alternative Medicine

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Complementary and alternative medicine (CAM) includes a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine. Complementary medicine is generally regarded as a complementary treatment that is used alongside conventional medicine, whereas alternative medicine is regarded as a treatment used in place of conventional medicine.[1]

There has been considerable interest in CAM, with a House of Lords Select Committee Report in November 2000 and a subcommittee of the Royal College of Physicians set up to examine certain aspects.[2] They reported in Clinical Medicine in 2003.[3]

The House of Lords Select Committee was very keen that there should be professional standards, registration and accountability in all aspects of CAM.[2] Statutory regulation of the acupuncture profession has failed to happen and it is now thought any regulation in the future will be voluntary.[4] Osteopathy is regulated by the General Osteopathic Council. Chiropractic is regulated by the General Chiropractic Council.

CAM does appeal to patients; many feel it is more natural; some feel the holistic approach benefits them; others may turn to it when they feel conventional medicine has let them down. We have a duty to help our patients make informed decisions about their healthcare. We should provide them with the evidence about CAM to aid their empowerment and decision-making process. High-quality evidence is often lacking and a UK study (looking at the impact of CAM on health outcomes) called for those evaluating impact, to use standardised tools to improve the overall quality of the studies.[5]

A report in the Lancet in 2007 stated that about 13,000 patients had been treated at four homeopathic hospitals (Bristol, Glasgow, Liverpool and London) in the UK each year.[6] 14.5% of the population say that they trust homeopathy and £38 million is spent on homeopathy each year in the UK.

Of the various forms of CAM, acupuncture is amongst the most popular. Approximately 3 million people undergo acupuncture treatment in the UK each year.[7]

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Homeopathic treatment is still available within the NHS; however, not all primary care trusts or GPs agree to fund referrals.[8]

The homeopathic approach is based on the concept that 'like cures like' - in other words, that "an illness can be treated with a substance, taken in small amounts, that produces similar symptoms in a healthy person".[9] For example, the homeopathic remedy allium cepa is made from an extract of onions. If a person chops onions, they make the eyes sting and water and the nose run. Using the homeopathic philosophy of 'like for like', this means that a disorder with these symptoms should be cured by a small dose of onion. Hence, allium cepa may be used to treat hay fever.

Homeopathic medicines are prepared by serial dilution in steps of 1:10 or 1:100, denoted by the Latin numbers x and c respectively. At each step there is succussion, or vigorous shaking. The dilution most frequently sold in pharmacies is 6c, which is a 10-12 dilution of the original mother tincture. Hence, it is likely that a 6c dilution will contain just a few molecules of the initial substance, but much higher dilutions, such as the 30c (10-60), will contain even fewer.

One of the leading proposals for how such 'ultramolecular' dilutions work is the 'information hypothesis'. This is the theory that water is capable of storing information relating to substances with which it has previously been in contact, and subsequently transmitting this information to biosystems.[10] There is some research from the field of materials science suggesting that this is plausible.[11] Succussion has been suggested as an important part of this process.

There have been many publications and much debate and controversy about the evidence for homeopathy. On the whole, meta-analyses of homeopathy are inconclusive and don't provide sufficient information for conclusions to be drawn about homeopathy in general. Certain randomised controlled trails and clinical outcome studies have, however, shown some benefit.[12][13] It has also been suggested that the benefits of homeopathy are due to the quality and holistic nature of the homeopathic consultation, rather than to the remedies themselves.[14] Cochrane reviews (various dates and conditions) state homeopathy provides no benefit above that of placebo.

The Faculty of Homeopathy regulates the training and practice of homeopathy by medically qualified doctors. There is a published list of doctors who are members of the faculty:[15][16]

  • The most experienced homeopaths have the qualifications FFHom or MFHom.
  • The qualification LFHom indicates a doctor who may use homeopathy in a limited way for minor ailments.

For homeopaths who are not doctors, there is no single registering body. The Society of Homeopaths is the largest professional organisation registering homeopaths in Britain. It has more than 2,300 members who must satisfy the Society's code of practice.

Acupuncture originated in China, probably more than 4,000 years ago. The profession has robust self-regulation by the British Acupuncture Council and this has been acknowledged by Parliament.[4] The house of Lords Select Committee on Science and Technology defined acupuncture as follows:[17]

'Acupuncture involves inserting small needles into various points in the body to stimulate nerve impulses. Traditional Chinese acupuncture is based on the idea of 'qi' (vital energy) which is said to travel around the body along 'meridians' which the acupuncture points affect. Western acupuncture uses the same needling technique but is based on affecting nerve impulses and the central nervous system; acupuncture may be used in the West as an anaesthetic agent and also as an analgesic.'

Numerous Cochrane reviews have looked at the evidence for acupuncture in certain conditions. Many reviews conclude that further analysis is required, but the following have more positive conclusions:

  • Headache: acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic or chronic tension-type headaches.[18]
  • Migraine prophylaxis: acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.[19]
  • In vitro fertilisation (IVF) treatment: acupuncture does increase the live birth rate with IVF treatment when performed around the time of embryo transfer. Larger trials are needed.[20]
  • Neck pain: there is moderate evidence that acupuncture for chronic neck pain is more effective than placebo at the end of treatment and at short-term follow-up.[21]
  • Nausea and vomiting during chemotherapy: electro-acupuncture seems to be beneficial in treating acute vomiting induced by chemotherapy. However, it needs to be compared with the newer anti-emetics and its use in those with refractory symptoms needs investigating.[22]
  • Back pain: no firm conclusions can be drawn about the effectiveness of acupuncture for acute pain but it does achieve pain relief and functional improvement in chronic low back pain and is recommended by the National Institute for Health and Clinical Excellence (NICE).[23]
  • Postoperative nausea and vomiting: compared with anti-emetic prophylaxis, P6 acupoint stimulation seems to reduce the risk of nausea but not vomiting postoperatively.[24]

A large prospective UK trial of 34,000 consultations found no reports of serious adverse events (defined as events requiring hospital admission, leading to permanent disability, or resulting in death).[25] Practitioners did report 43 minor adverse events. The most common events were severe nausea and fainting. There were three avoidable events; two patients had needles left in and one patient had moxibustion burns to the skin, caused by practitioners' errors.

The House of Lords' Select Committee on Complementary and Alternative Medicine described reflexology as follows:[17] 'A system of massage of the feet based on the idea that there are invisible zones running vertically through the body, so that each organ has a corresponding location in the foot. It has also been claimed to stimulate blood supply and relieve tension.'

The concept behind reflexology is that reflex points on the feet and hands correspond to all of the organs, glands and parts of the body. For example, the toes represent the head and the ball of the foot represents the chest and lung region.[26] By applying pressure to these points, it is thought that blood circulation is improved, the body relaxes and organs and glands become balanced.[26] There is less research on the proposed mechanism of action of reflexology than on acupuncture or manipulation. It is thought that the areas activated by massage of the feet may have something in common with the lines of 'qi' in acupuncture.

The Database of Abstracts of Reviews of Effects (DARE) discussed a review in 2001 that looked at the existing literature on reflexology.[27] Seven trials were included in the review, five of which were randomised. However, there were only 214 participants in total and the authors of the review concluded that, of those trials that had been published on reflexology, 'all are methodologically flawed and their results are non-uniform. The effectiveness of reflexology is not supported by controlled clinical trials.' They suggested that more research was needed to establish specific effects.

The 'manipulative therapies' include osteopathy and chiropractic. The two therapies have some similarities. Their practitioners use their hands to work with joints, muscles and connective tissue and to diagnose and treat soft tissue imbalances and abnormalities in skeletal function. Manipulation techniques are commonly used for low back pain, neck pain, shoulder pain, headache and sports injuries.

Osteopathy is regulated by the General Osteopathic Council. Chiropractic is regulated by the General Chiropractic Council. The practices were first introduced into the UK in the late 19th century.[28][29]

Some common techniques used by both osteopaths and chiropractors include:[28]

  • High-velocity thrusts: a short, sharp controlled movement with low amplitude is applied to the spine to restore local articular range and quality of movement. This produces the classic 'cracking' sound.
  • Muscle energy technique: a soft tissue technique to increase a joint's range of movement.
  • Functional technique: taking a joint into continuous, different planes of movement that produce little tension and do not provoke pain. The idea is eventually to work back to the initial starting position - now, it is hoped, with less or no pain. This technique reduces the stimulation through the local neuromuscular tissues and can lead to a release in tension.

Much has been made of the potential dangers of spinal manipulation but (despite its widespread use) serious complications seldom occur. The risk of a serious complication due to manipulation is somewhere between 1 in 100,000[30] and 1 in 5.8 million.[29][31]

Where there have been problems from manipulation, they have more often been when manipulating the cervical spine.[29]

The following are contra-indications to manipulation at any level:

  • Any potential sinister cause of back pain, including a history of malignancy that may involve bone, such as breast cancer or a haematological malignancy.
  • A patient on anticoagulants or who has a clotting disorder.[32] Some suggest that this is a relative contra-indication and depends on the patient's age and where the practitioner is wanting to manipulate. Cervical spine manipulation carries a higher risk. Thoracic and lumbar spine manipulation carries a lower risk, especially in a younger patient.
  • A patient with neurological disease. Manipulation is contra-indicated if there are upper motor neurone signs. However, some practitioners would be happy to perform manipulation at adjacent joints in those with lower motor neurone signs, in order to unload the strain at the nerve root affected.
  • Presence of cauda equina syndrome.
  • Active inflammatory arthritis.

The evidence for manipulation for back pain:

  • The UK 'back pain, exercise and manipulation' (BEAM) trial was a randomised trial based on 181 general practices.[33] It concluded that spinal manipulation is a cost-effective addition to 'best care' for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.
  • A Cochrane review in 2004 concluded that there was no evidence that spinal manipulative therapy was superior to other standard treatments for patients with acute or chronic low back pain.[34]
  • The European Back Pain Guidelines have recommended the use of manipulation for acute nonspecific low back pain[35] and chronic nonspecific low back pain.[36]

Aromatherapy is a complementary therapy that uses plant extract essential oils that are either inhaled, used as a massage oil, or occasionally ingested. It can be used to alleviate specific symptoms or as a relaxant.[17] It is based on the healing properties of essential oils, of which there are over 400, extracted from plants all over the world. Popular oils used include chamomile, lavender, rosemary and tea tree.[37] Aromatherapy carrier oils are used for mixing blends of essential oils in order to make bath oils or massage oils. They are mainly extracted from nuts and seeds. Examples are sweet almond oil, evening primrose oil and black seed oil.

Aromatherapy can help to promote relaxation.[38] It is currently widely used in the management of chronic pain, depression, anxiety and stress, insomnia and some cognitive disorders.[39]

Side-effects can include allergic reactions (including rash for patient or therapist[40]), headache and nausea. It should also be noted that:[41]

  • Patients with diabetes should avoid angelica.
  • Patients with epilepsy should avoid fennel, rosemary and sage (because of the risk of over-stimulating the nervous system).
  • Patients with hypertension should avoid hyssop, rosemary, sage and thyme.
  • Pregnant ladies should avoid basil, laurel, angelica, thyme, cumin, aniseed, citronella and juniper. An aromatherapist should always be alerted if the patient is pregnant because of potential teratogenic and uterine effects of the oils.
  • Those with sensitive skins should avoid basil, laurel, coriander, tea tree, neroli, geranium, mint, yarrow, Roman and German chamomile, lemon balm, citronella, ginger, hops, jasmine, lemon, lemon grass (unless greatly diluted with a carrier oil), turmeric and valerian. Skin patch testing can be carried out beforehand if there are concerns. Care should be taken in those with a history of allergy or atopic conditions such as asthma, eczema or hayfever.
  • Oestrogen-dependent tumours such as breast cancer or ovarian cancer, are a contra-indication to the use of oils with oestrogen-like compounds, such as fennel, aniseed, sage, and clary sage.
  • There may be possible interactions of essential oils, with antibiotics, antihistamines and sedatives.
  • Cinnamon, turmeric, valerian, laurel, juniper, aniseed, coriander and eucalyptus should not be used for longer than two weeks at a time because of concerns about toxicity.
  • Bitter almond, red thyme, common sage, rue, wormwood, tansy, savory, wintergreen and sassafras oils should be avoided at all times by everyone as they can be poisonous.

A review in the British Journal of General Practice in 2000 found 12 trials of aromatherapy.[42] It concluded that:

  • The studies suggested that aromatherapy massage has a mild, transient anxiolytic effect.
  • The effects of aromatherapy are probably not strong enough for it to be considered for the treatment of anxiety.
  • The hypothesis that it is effective for any other indication is not supported by the findings of rigorous clinical trials.

The medicinal properties of herbs have been exploited for many centuries. The druids and the Ancient Egyptians are amongst the best known exponents of herbal medicine. The concern is that many herbal remedies that are for sale have not been thoroughly tested for efficacy, toxicity, drug interactions and teratogenicity. In addition, there are often problems of variation in potency between batches and correct doses are not carefully established.

The Medicines and Healthcare products Regulatory Agency (MHRA) is the government agency which is responsible for ensuring that medicines and medical devices work, and are acceptably safe.[43] The MHRA website also provides a list of herbal ingredients which are prohibited or restricted in medicines.

See separate article St John's Wort - of all the various herbal remedies, one of the best-researched.

Hypnosis may be practised by medically qualified people, clinical psychologists or those without healthcare qualifications. Hypnosis must be used with skill and care, as adverse events, including the implantation of false memories, may occur. The British Society of Clinical Hypnosis can help in finding a registered practitioner.[44] Both competence and ethics are essential.

Examples of conditions amenable to treatment include:

  • Smoking cessation.
  • Weight control.
  • Irrational fears and phobias.
  • Stress management.
  • Compulsive behaviour.
  • Anxiety and panic attacks.

There have been a number of systematic reviews, including Cochrane reviews of the various topics.

The aim of the macrobiotic diet is to avoid foods containing toxins. It is a completely vegan diet and no dairy products or meats are allowed. Macrobiotic diets have become popular with people who have cancer who believe that it can help them fight their cancer and lead to a cure. However, as yet there is no scientific evidence supporting a macrobiotic diet treating or curing cancer or any other disease.[45]

Chelation therapy is the use of chelating agents - usually the man-made amino acid ethylene diamine tetra-acetic acid (EDTA) - to remove heavy metals from the body. It is of proven value in Wilson's disease, haemochromatosis and heavy metal poisoning (including lead and mercury). However, it has also been promoted by some for the treatment of other disorders, including arterial disease, Alzheimer's disease and autism.

Faith healing is not new. It is well documented in both the Old Testament (Second Book of Kings, chapter 5) and New Testament (Gospel of Luke, chapter 8, verses 26 to 56) of the Bible, along with the observation that it is only effective where there is absolute faith. There are still charismatic preachers who carry out 'faith' healing in which people come to the front and publicly discard the wheelchairs that they have allegedly depended upon for many years.

There is some evidence that CAM may work for certain conditions but, for many conditions, the evidence is of poor quality and it is impossible to draw a firm conclusion about its effectiveness. However, we must remember that this is not the same as evidence of lack of efficacy. More research is needed in this area.

Further reading & references

  1. What Is Complementary and Alternative Medicine? National Center for Complementary and Alternative Medicine, last updated July 2011
  2. House of Lords Select Committee on Science and Technology. 6th report, session 1999-2000. Complementary and alternative medicine. November 2000
  3. Lewith GT, Breen A, Filshie J, et al; Complementary medicine: evidence base, competence to practice and regulation. Clin Med. 2003 May-Jun;3(3):235-40.
  4. British Acupuncture Council; BAcC represents acupuncturists trained in traditional acupuncture in the United Kingdom.
  5. Wye L, Sharp D, Shaw A; The impact of NHS based primary care complementary therapy services on health BMC Complement Altern Med. 2009 Mar 6;9:5.
  6. Samarasekera U; Pressure grows against homeopathy in the UK. Lancet. 2007 Nov 17;370(9600):1677-8.
  7. Effective Health Care. Acupuncture. An objective assessment (from the York Centre and published by the Royal Society of Medicine). Centre for reviews and dissemination, University of York; Vol. 7 No. 2, Nov 2001
  8. Kmietowicz Z; NHS should stop funding homoeopathy, MPs say. BMJ 2010; 340:c1091
  9. British Homeopathic Association and Faculty of Homeopathy
  10. Lewith GT et al; Complementary medicine: evidence base, competence to practice and regulation. Clinical Medicine, Journal of the Royal College of Physicians, Volume 3, Number 3, 1 May 2003 , pp. 235-240(6)
  11. Rao ML, Roy R, Bell IR, et al; The defining role of structure (including epitaxy) in the plausibility of Homeopathy. 2007 Jul;96(3):175-82.
  12. Shang A, Huwiler-Muntener K, Nartey L, et al; Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy.; Lancet. 2005 Aug 27-Sep 2;366(9487):726-32.
  13. Nuhn T, Ludtke R, Geraedts M; Placebo effect sizes in homeopathic compared to conventional drugs - a systematic Homeopathy. 2010 Jan;99(1):76-82.
  14. Hartog CS; Elements of effective communication--rediscoveries from homeopathy. Patient Educ Couns. 2009 Nov;77(2):172-8. Epub 2009 Apr 15.
  15. Introduction to Homeopathy, NHS Evidence - CAM; NHS library information on complementary and alternative medicine
  16. Complementary medicine: information for primary care clinicians, Dept of Health, June 2000
  17. Sixth Report. Complementary and Alternative Medicine, House of Lords Select Committee on Science and Technology, November 2000
  18. Linde K, Allais G, Brinkhaus B, et al; Acupuncture for tension-type headache. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587.
  19. Linde K, Allais G, Brinkhaus B, et al; Acupuncture for migraine prophylaxis. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001218.
  20. Cheong YC, Hung Yu Ng E, Ledger WL; Acupuncture and assisted conception. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006920.
  21. Trinh K, Graham N, Gross A, et al; Acupuncture for neck disorders.; Cochrane Database Syst Rev. 2006 Jul 19;3:CD004870.
  22. Ezzo JM, Richardson MA, Vickers A, et al; Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting.; Cochrane Database Syst Rev. 2006 Apr 19;(2):CD002285.
  23. Low back pain; NICE Clinical guideline (May 2009)
  24. Lee A, Fan LT; Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting; Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003281
  25. MacPherson H, Thomas K, Walters S, et al; The York acupuncture safety study: prospective survey of 34,000 treatments by BMJ. 2001 Sep 1;323(7311):486-7.
  26. International Institute of Reflexology; Website with information about reflexology and reflexology training.
  27. Ernst E, Koder K, An overview of reflexology, DARE – (Database of Abstracts of Reviews of Effects), Centre for reviews and disemination, University of York
  28. Vickers A, Zollman C; ABC of complementary medicine. The manipulative therapies: osteopathy and chiropractic. BMJ. 1999 Oct 30;319(7218):1176-9.
  29. Introduction to Osteopathy, NHS National Library for Health, last updated Dec 2009
  30. Rothwell DM, Bondy SJ, Williams JI; Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001 May;32(5):1054-60.
  31. Haldeman S, Carey P, Townsend M, et al; Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ. 2001 Oct 2;165(7):905-6.
  32. Whedon JM, Quebada PB, Roberts DW, et al; Spinal epidural hematoma after spinal manipulative therapy in a patient undergoing anticoagulant therapy: a case report. J Manipulative Physiol Ther. 2006 Sep;29(7):582-5.
  33. No authors listed; United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ. 2004 Dec 11;329(7479):1381. Epub 2004 Nov 19.
  34. Assendelft WJ, Morton SC, Yu EI, et al; Spinal manipulative therapy for low back pain; Cochrane Database Syst Rev. 2004;(1):CD000447
  35. European guidelines for the management of acute nonspecific low back pain in primary care; COST B13 Working Group (2004)
  36. European guidelines for the management of chronic non-specific low back pain, COST B13 Working Group (2004)
  37. Aromatherapy Council
  38. Complementary medicine: information pack for primary care groups, Dept of Health, June 2000
  39. Perry N, Perry E; Aromatherapy in the management of psychiatric disorders: clinical and neuropharmacological perspectives. CNS Drugs. 2006;20(4):257-80.
  40. Trattner A, David M, Lazarov A; Occupational contact dermatitis due to essential oils. Contact Dermatitis. 2008 May;58(5):282-4.
  41. Safe Alternative Medicine; Expert advice on alternative medicine, accessed March 2012
  42. Cooke B, Ernst E; Aromatherapy: a systematic review. Br J Gen Pract. 2000 Jun;50(455):493-6.
  43. Using herbal medicines safely; Medicines and Healthcare products Regulatory Agency (MHRA), 2012
  44. British Society of Clinical Hypnosis; their aim is to promote and assure high standards in the hypnotherapy profession
  45. Macrobiotic diet, CancerHelp UK

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Michelle Wright
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
19/04/2012
Document ID:
1791 (v24)
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