Alternative and Holistic Medicine

Holistic medicine means consideration of the complete person, physically, mentally and socially, in the management of a condition. This is not the preserve of those who work outside of mainstream medicine but is how we should all function. Alternative practitioners tend to spend a great deal of time with their patients, perhaps devoting an hour to a detailed history. Irrespective of the value of their treatment, this leaves the customer very impressed and satisfied.

For conventional medicine the seminal work by Michael Balint, The Doctor, the Patient and his Illness, first published in the 1957, represents an important landmark in seeing the patient as a whole rather than as isolated pathology.¹ Perhaps bad habits start in medical school, referring to patients as "the mitral stenosis in bed 7" or "the lobar pneumonia in bed 13". A holistic approach is good practice and has been strongly advocated by the Royal College of General Practitioners for many years.

Consultation analysis has been discussed in detail elsewhere, and this shows that doctors no longer see patients as walking pathology. 1984 saw the publication of both Doctors talking to patients by Byrne and Long² and The Consultation: An Approach to Learning and Teaching by the Pendleton group.³ These approaches, including Balint, sought to ask questions such as:

• Why has the patient decided to consult?
• What does he think is the problem?
• What does he fear may be the problem?
• What is he hoping to achieve from the consultation?

Those who use such techniques cannot be accused of lacking a holistic approach. However, with only 10 minutes allocated per consultation, the desired level is difficult to achieve. The doctor has to learn, almost intuitively, what to include and what to exclude.

The term complementary and alternative medicine applies to therapeutic practice and techniques outside the realms of mainstream medicine. They may be practiced by those with a medical qualification, as may be the case with acupuncture or homeopathy, or another relevant qualification such as physiotherapy, as may be the case with manipulation. However, most such practitioners have no relevant qualification unless provided by their own people and these may be of dubious value.

One of the great dangers of those with no medical background being involved in diagnosis and treatment is that they may fail to recognise a serious and treatable condition, causing delay whilst they ply their useless remedies. This is one reason for registration of CAM practitioners, to ascertain that they are appropriately trained and that they also comply with certain ethical standards. There has been considerable interest in "complementary and alternative medicine" with a House of Lords Select Committee Report in November 2000⁴ and a subcommittee of the Royal College of Physicians set up to examine certain aspects. They reported in Clinical Medicine in 2003,⁵ formerly the Journal of the Royal College of Physicians.

The House of Lords Select Committee was very keen that there should be professional standards, registration and accountability in all aspects of CAM.⁴ To date, only chiropractors and osteopaths have the professional bodies to maintain standards. Others may still manipulate, so long as they do not call themselves chiropractors or osteopaths. There is a British Acupuncture Council but it has no legal authority at present. Acupuncture and homeopathy are likely to be the next specialities to require compulsory registration.

There are a great many approaches that may be classified as CAM. There are also activities such as yoga and tai chi where there may be health benefits claimed as may also be true of various diets, but it is questionable if they should really be classified as CAM. The following list will be discussed in turn:

• Acupuncture
• Homeopathy
• Manipulation
• Herbal medicine
• Aromatherapy
• Reflexology
• Hypnosis
• Macrobiotic diet
• Chelation therapy
• Faith healing.

In the UK, 47% of people have used complementary and alternative medicine (CAM) at some times in their lives and 10% use some form of CAM each year.⁶ Users tend to be older, female and over 90% is purchased outside of the NHS. At least 10% of hospital physicians also use CAM as part of their clinical practice.⁷ A survey, conducted in 2001, estimated that one in two practices in England now offer their patients some access to CAMs.⁸

Acupuncture may have originated 4,000 years ago or longer. It started in China and still maintains an air of oriental mystique. Acupuncture has its own article and so will be considered only briefly here.

The basis of the treatment is the insertion of needles along pre-ordained lines. The needles are often stimulated after insertion. This may be by manual rotation but nowadays electronic techniques are often employed. Other variations include use of laser beams and acupressure in which the skin is pressed but not penetrated. Moxibustion is sometimes used with acupuncture but it will not be considered here.

Japanese techniques tend to use finer needles and more superficial insertion but the principles of Chinese, Japanese and Korean acupuncture are similar.

Evidence

A very good attempt has been made to produce sham acupuncture for the purpose of double blind RCTs. The matter is discussed much more fully in the article. It has also been the subject of a number of Cochrane reviews. The outcomes have been variable but never a ringing endorsement.

For some forms of treatment there appears to be moderate benefit. For some there appears to be no significant benefit. For many, the methodology is too poor to permit meaningful analysis.

Despite this rather ambivalent outcome, acupuncture is practised very extensively alongside western medicine in China. It is often used as an anaesthetic for operations, even for open heart surgery with cardio-pulmonary bypass but it is used in association with considerable sedation and infiltration with local anaesthetic.

Acupuncture is probably used by more registered doctors than any other form of CAM. It is popular in pain clinics, for back pain and in palliative care despite the lack of good evidence of its superiority over placebo.

Homeopathy also has its own article with much more detail. The concept is to take something that causes symptoms like the disease, such as onions for hayfever as they also cause watering eyes and running nose, and serially dilute them until they are no longer toxic. The degree of dilution is so great that only the more concentrated medicines contain a few molecules of the original substance. Anything beyond 6C (diluted 100-fold 6 times) probably contains none of the original molecules.

It was popular in the 19th century when at least it was much less toxic than other medicines such as mercury and bismuth or purgation and blood letting. As the scientific medicine of the 20th century advanced, homeopathy fell from favour although a number of homeopathic hospitals were incorporated into the NHS in 1948. Homeopathy is known to be favoured by the Royal Family.

The report of the Royal College of Physicians says that "Despite its apparent implausibility, homeopathy is among the most popular forms of CAM, with an estimated 470,000 regular users in the UK, and sales growing by around 12% annually.".⁶

Evidence

Homeopathy has been subjected to double blind RCTs, although the quality of methodology is often poor. There have been many papers on homeopathy and a paper in the Lancet in 1997⁹ extracted just those of adequate methodology and performed a meta-analysis. The conclusion was that homeopathy is effective. However, very few of the papers used had significance at the 5% level whilst not a single one showed that placebo was superior. This should have been a stark warning of selective publication and failure to note it was severely criticised in the BMJ in 2001¹⁰ when the matter was examined again. This time funnel plotting and cut and fill was used to detect "unpublished papers". The conclusion was that there was severe publication bias and that homeopathy is no better than placebo. The article on homeopathy discusses this and other evidence much more fully. The Centre for Reviews and Dissemination, University of York has published a paper called "Is this the end for homeopathy?".¹¹ The evidence is strongly against homeopathy but it is unlikely to die yet.

Manipulation also has its own article in which it is discussed much more fully. Osteopaths and chiropractors are the only form of CAM regulated by a statutory body. However, there are about 150 different schools of manipulation and only those two are controlled.

The article describes the mechanism by which manipulation may work. Potential dangers of manipulation appear to have been overstated although caution should be exercised when manipulating the neck. The elderly or those with known arterial disease should be excluded as should anyone with rheumatoid arthritis or a neurological disease.

Evidence

The article discusses the difficulties of sham manipulation to obtain a placebo control for trials. If the intervention is effective, it is for musculo-skeletal conditions and manipulation should not be seen as a system of healing. Despite extensive research of variable quality, it is impossible to be firm about its place, if any, in treatment. It is far more likely to be beneficial for musculoskeletal disorders such as simple back pain or neck pain than for other disorders such as dysmenorrhoea or glue ear. Cranial osteopathy for asthma is useless.

There are many publications but most are of poor quality. Systematic reviews are a good way of assessing the evidence, but there have been so many publications and so many systematic reviews that there have even been two systematic reviews of the systematic reviews.^12,13 Neither was greatly enthusiastic about benefit of the technique.

The negative reviews of manipulation have perhaps been too rigorous in their expectations and they have interpreted failure to demonstrate clear and convincing benefit by vigorous methodology as evidence for lack of efficacy. However, it does seem that if manipulation is beneficial, it is more so in the short than the medium or long term. Individual success stories may also be diluted in the numbers in trials. Spinal manipulation may well have a part to play in treatment regimens but its precise place is yet to be determined. Complications are rare but do occur.

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. Nicholas Culpeper's work in the 17th century was seminal. Bearing in mind the origins of such drugs as digoxin, aspirin, quinine and penicillin it would be surprising if other plants or micro-organisms did not also offer therapeutic potential. It would also be surprising if they did not have adverse effects. If digoxin had been discovered recently, it would not have received a product licence as the ratio of toxic to therapeutic dose is too low.

The above named drugs have been thoroughly tested for efficacy, toxicity, drug interactions and teratogenicity. The same is not true of the many herbal remedies that are for sale. In addition there are often problems of variation in potency between batches and correct doses are not established.

As explained in the article on St John's wort, this is probably the best researched of all the various herbal remedies and yet the evidence available about it falls pitifully short of that required to obtain a licence to promote it as a drug. Would those who claim that it is as safe and effective as other antidepressants be happy to have Prozac or Seroxat for sale in health food shops or supermarkets? St John's wort is.

The problem with herbal remedies is that they may well have pharmacological properties. As such they can be expected to have exactly the same problems. Ideally, before any herbal remedy is allowed to be marketed there are a number of questions that should be answered, as for conventional medicines:

• Is potency reliable or is there marked variation between batches?
• Is it effective? This needs double blind RCTs of appropriate size, not a few testimonials.
• What is the appropriate dose? This may also include calculating doses for children if it is to be recommended.
• What is the toxic dose?
• What is the adverse effect profile?
• What interactions are there with other drugs that may commonly be used simultaneously?
• Is it teratogenic? If that question cannot be answered, there must be warnings about pregnancy.

None of this applies and an uneducated and gullible public is subjected to unsubstantiated claims about both efficacy and safety. There may well be many "herbal thalidomides" that are being sold but have not yet been identified.

Aromatherapy is based on the use of "essential" or concentrated plant oils. The oils are usually massaged into skin, put in a bath or inhaled. There are some 400 essential oils extracted from plants all over the world. Some of the popular oils used in aromatherapy today include chamomile, lavender, rosemary and tea tree.

The article on aromatherapy describes the consultation, contraindications and suitable conditions to treat. They are all conditions in which a high placebo response may be expected.

Efficacy

The evidence base is discussed in the article. The question, "Does aromatherapy work?" must be met by the question, "What do you want it to do?" The pleasant aroma, the tactile sensation and the effect of massage and attention are bound to lead to a sensation of relaxation and wellbeing. This may be very valuable in a number of conditions in which tension, anxiety and a psychosomatic component are involved. Hence it is unsurprising to find that it is beneficial in pain, especially in palliative care and for menstrual disorders and menopausal symptoms. This begs the question of whether it is simply the pleasant ambience that is therapeutic of whether the absorption of essential oils, through the skin or respiratory tract, has a pharmacological effect too.

This used to be known as zone therapy. Reflexology has its own article. It is 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. How it may work is unclear although it has been suggested that the lines of chi, as used in acupuncture, may be involved.

Suitable conditions include premenstrual syndrome, menopausal symptoms, pain, nausea and vomiting in early pregnancy, mental health in primary care and chronic fatigue syndrome. A striking observation is that every one of these conditions may be expected to have a very high placebo response rate.

Evidence

The York Centre for Reviews and Dissemination has produced possibly the only review of scientific publications about reflexology.¹⁴ Only 7 trials were included, 5 were RCTs and there was a total of 214 participants overall. All of the studies had methodological flaws, including small sample size. The results are discussed in the article on reflexology. Benefits ranged from mild to none.

Hypnosis may be practiced by medically qualified people, clinical psychologists or those without qualifications. The last are to be avoided. It may be used to aid relaxation, to help in pain control or to examine suppressed memories. It must be used with skill and care as adverse events, including the implantation of false memories, may occur. The British Society of Clinical Hypnosis¹⁵ can help in finding a registered practitioner. Both competence and ethics are essential.

Conditions amenable to treatment include stopping smoking, nail biting, weight control, healthy eating, sports performance, exam nerves, irrational fears and phobias, stress management, compulsive behaviour, anxiety and panic attacks, stress related stomach and digestive problems, childbirth, some skin problems, pain control, stress related high blood pressure, self confidence, compulsions and compulsive behaviour and some sexual problems. There have been a number of systematic reviews, including Cochrane reviews of the various topics.

There is no doubt that diet is very important and that it can have a profound influence on arterial disease and cancer. However, there is concern over "fad" and "trendy" diets of unproven value that may be inadequate in terms of effective nutrition, especially in children.¹⁶

Macrobiotic diets are promoted by testimonials, especially from celebrities rather than evidence based medicine. A typical macrobiotic meal would be brown rice with green lentils, broccoli and white fish, followed by fruit salad with apple, pear and apricot, with spring water or dandelion tea. Dairy products, chocolate, caffeine, tap water, meat, eggs, poultry, honey and tropical fruits are not recommended. Alcohol, such as beer and whisky is allowed occasionally.

A good, wholesome diet is very important for ideal weight, health and avoiding some common diseases. However, there is a danger that some diets, applied too strictly, may lead to nutritional deficiency.

Lactobacilli are discussed elsewhere.

Chelation therapy is of proven value in Wilson's disease, haemochromatosis and some forms of poisoning in which there is an excess of a substance that needs to be removed from the body but it has also been advocated for other disorders including arterial disease, Alzheimer's disease and autism. One London clinic advertises: "Chelation therapy is a valuable option to consider in advanced heart disease, arterial disease (of legs and neck) and stroke recovery. Although it is given by medical doctors through an intravenous drip, it is essentially a detox process and is naturopathic in concept." A systematic review in 1997 found it to be totally useless.¹⁷

A boy of 5 who went to the USA for chelation therapy for autism died as a result of treatment. The rationale for treatment is that autism is caused by toxicity from mercury in the preservative of some vaccines. There is no evidence to support this. There is no evidence to link the MMR vaccine to autism and the MMR vaccine has never contained a mercury preservative.

Faith healing is by no means new and 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 indulge in faith healing in which people come to the front and publicly discard their wheelchairs that they have allegedly depended on for many years.

Many churches, including traditionally reserved sections of the Church of England, have taken to healing services but they are not to be confused with the hysteria of the charismatic performances. They do not try to portray their role as a substitute for medical care but more as an adjunct. However much we may try to be holistic, patients may have spiritual needs that are not within out remit. This is where religious organisations can help. They may be beneficial in helping the person to live in peace with his disease and perhaps we should not always equate healing with cure.

It is important to try to understand the motivation for turning to CAM. There are many reasons, most of them misguided.

Safe and natural

The concept that somehow CAM techniques are natural and, by implication, conventional medicine is not, does not bear scrutiny. There is an implication that natural means invariably effective and invariably safe. Considering the array of toxins in nature, claiming that anything natural is invariably safe is quite astounding. Because techniques, and particularly herbs with pharmacological properties, have not been researched for evidence of efficacy or toxicity does not mean that they can be assumed to be both effective and safe. Thalidomide was once thought of as a very safe drug. No one would contemplate the pharmaceutical industry marketing products on the tenuous claims that sustain most CAM.

Doctors are often accused of being narrow-minded in rejecting CAM. Its advocates are being narrow-minded by refusing to look at the evidence. Professor Ernst from Exeter is seen by many in the CAM community as being antagonistic to their cause. This he denies. He says that he is trying to validate CAM by putting it on the same evidence base as conventional medicine. We must maintain the standards of scientific medicine and be vocal against junk science. Those who reject science reject sense.

Time and spirituality

Patients may receive more time, empathy and emotional support from an alternative therapist. They may feel that there is a more mystical and spiritual component that they like. This feel good factor must not be confused with efficacy. They may feel that their own doctor has little time or understanding for their problems. This is one reason why a holistic approach is important. It is also more likely to lead to compliance with treatment.

Patients may also turn to other sources when they feel that conventional medicine has let them down. Perhaps they have an incurable disease. The idea that their disease can be cured by some little known therapy that has been secretly practiced through the centuries is fanciful beyond belief. If it works, would not someone have noticed and promoted it through conventional channels?

It is not only serious incurable diseases where patients may turn to CAM. In eczema, psoriasis and IBS they may wish to take control of their disease where they feel that conventional medicine has failed to cure them. Therapies that encourage relaxation may be useful in these conditions but some can be counterproductive and even dangerous. There are well documented cases of "herbal remedies" for childhood eczema that have been found to contain potent topical corticosteroids.^18,19

Unfounded claims

It is not uncommon to find claims being made for CAM that are frankly preposterous. A practitioner in Great Yarmouth proclaims that reflexology is supported by over 4,000 scientific papers. A search of PubMed to write the article on the subject uncovered none. The term scientifically proven usually means there is no supporting evidence whatsoever.

The illogical approach of some people was well illustrated with regard to phyto-oestrogens. The million women trial²⁰ was an excellent piece of work that showed that HRT was basically very safe but there are some causes for concern, especially in high risk groups. Because it is always the negative rather than positive aspects that are highlighted in the media, some women chose to switch to phyto-oestrogens as more natural and safer. Why plant oestrogens should be "more natural" than mammalian oestrogens when women are mammals, not plants defies explanation. Phyto-oestrogens are very weak and have not been assessed to see if they produce the desired effects, especially protection from osteoporosis. They have also not been assessed for safety with regard to breast cancer or gynaecological cancers or cardiovascular disease. Nevertheless, there was an industry eager to cash in on ignorance.

The public is very gullible and needs to be protected. If a vendor makes unsubstantiated claims for the product he is selling he contravenes the Trades Descriptions Act. If a person coaxes others to part with money under false pretences, this is fraud. If a person makes unfounded claims for the safety and efficacy of a form of healing, he does so with impunity.

HRH the Prince of Wales claims that much CAM has been tried and tested over the years. He is half right. It has been tried but not tested.

Talk to patients and find out what they are doing and why. Try to sound knowledgable and objective. If a patient is taking the usual medication for irritable bowel syndrome but also having some aromatherapy, this may well be beneficial and is unlikely to do harm. On the other hand, if parents have decided that their children should have homeopathic vaccines, they are putting them at risk. Tell them that these vaccines do not induce an antibody response against the diseases and the Faculty of Homeopathy says that all children should have conventional vaccines. They are being responsible.

Vigorous testing of all forms of treatment is to be encouraged. If it is good it should be exploited, regardless of its background. If it is bad, let this be known. We need scientific objectivity and the courage to be honest. Often the situation is that there is lack of evidence of effectiveness, which is not the same as evidence of lack of effectiveness. It is not reasonable to assume efficacy and safety until proven otherwise. Indeed, the opposite is safer. Anecdotes are not the same as evidence and we must not be ashamed to promote evidence.