Aromatherapy

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.

It has been used in various forms for thousands of years and references to such treatment may be found in texts of ancient Egypt, India and China.

A French chemist called René-Maurice Gattefossé coined the term aromatherapy in the early 20th century, to describe the process of using plant oils therapeutically. There is a story that while he was working in a perfume factory, he burnt his hand and swiftly put some lavender oil on the burn. He was so impressed by how quickly and cleanly the burn healed, he began to study the healing powers of plant oils.

The concentrated oils are aromatic and volatile. They are extracted, usually by steam distillation, from flowers, leaves, roots, grasses, peel, resin or bark. 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.

There has been considerable interest in "complementary and alternative medicine" with a House of Lords Select Committee Report in November 2000¹ and a subcommittee of the Royal College of Physicians set up to examine certain aspects. They reported in Clinical Medicine in 2003,² formerly the Journal of the Royal College of Physicians.

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.³ Users tend to be older and 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.⁴ A survey, conducted in 2001, estimated that one in two practices in England now offer their patients some access to CAMs.⁵ Aromatherapy is increasing in popularity but some of this is not so much the management of specific complaints as people who buy something with a pleasant aroma to enhance the pleasure of a relaxing bath.

The list of conditions that may be treated by aromatherapy include:

• Anxiety, stress or insomnia
• Muscular aches and pains
• Headaches
• Asthma
• Eczema
• Digestive problems
• Menstrual or menopausal problems

These are all problems in which a high level of placebo response may be anticipated or in which the relief of stress and tension may be assumed to be beneficial.

People may be treated by an aromatherapist, or they can buy certain aromatherapy oils over the counter at pharmacies, health shops and other outlets and treat themselves. An aromatherapist will probably massage oils into the skin. For self-treatment they may be added to a bath or inhaled using steaming water, a diffuser or an incense burner. The Aromatherapy Consortium states than inhalation should not be used for asthmatics. There is also a wide range of toiletries containing essential oils and some are claimed to increase wellbeing or have some healing properties.

The aromatherapist will ask questions about medical history, general health and lifestyle. This will help decide which essential oils are most appropriate for the individual. After selecting and blending appropriate essential oils, the aromatherapist will usually apply the oils in combination with massage.

A session normally lasts for 60 to 90 minutes, and usually costs between £20 and £40.

It is said that the following are contraindications or reasons for caution:

• It should be avoided in the first trimester of pregnancy
• It should be avoided with severe asthma
• It should be avoided with a history of allergies
• Pregnant women as well as people with a history of seizures should avoid hyssop oil
• People with hypertension should avoid stimulating essential oils such as rosemary and spike lavender
• Oestrogen-dependent tumors, such as breast cancer or ovarian cancer, are a contraindication to use of oils with oestrogen-like compounds such as fennel, aniseed, sage, and clary-sage
• Caution should be exercised when considering use of aromatherapy for patients receiving cancer chemotherapy.

• The oils should not be ingested unless there has been specific instruction to that effect by the therapist
• There can be allergic reactions including rash, headache, liver and nerve damage. The incidence of allergy to fragrances, such as perfume, is about 1% of the population but the incidence of allergy to essential oils is not well documented.⁶
• Some oils may be teratogenic and so all should be avoided in the first trimester
• Oils that are high in phenols, such as cinnamon, can cause skin irritation. The oil may be diluted with water or a base massage oil such as almond or sesame oil before application. Avoid near the eyes.
• Essential oils are highly volatile and flammable so they should never be used near an open flame
• Animal studies suggest that active ingredients in certain essential oils can interact with some drugs, but studies in humans are needed to confirm this. Eucalyptus, for example, may increase the rate of metabolism of barbiturates and other drugs.
• The essential oils sold in shops are often mislabelled and dosage may be unreliable.

It can be very difficult to extract the differences that may be due to the pleasant aromas, relaxation and physical touch of aromatherapy from any pharmacological benefit. It may be argued if double blind trials are either feasible or necessary as the sensations are a crucial part of the treatment.

• A systematic review from Exeter appeared in the College Journal in 2000. They concluded that studies suggest that aromatherapy massage has a mild, transient anxiolytic effect. The effects 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.⁷
• Aromatherapy may well be safe and effective in a number of psychiatric disorders. This may have a neuropharmacological component.⁸
• A Cochrane review of symptomatic treatment in cancer concluded that massage and aromatherapy massage confer short term benefits on psychological wellbeing, with the effect on anxiety supported by limited evidence. Effects on physical symptoms may also occur. Evidence is mixed as to whether aromatherapy enhances the effects of massage. Replication, longer follow up, and larger trials are need to accrue the necessary evidence.⁹
• A Cochrane review of aromatherapy for dementia was rather unsatisfactory in outcome.¹⁰ It concluded that treatment showed benefit for people with dementia in the only trial that contributed data to the review, but there were several methodological difficulties with this study. More well designed large-scale RCTs are needed before conclusions can be drawn on the effectiveness. Several other issues need to be addressed, such as whether different aromatherapy interventions are comparable and the possibility that outcomes may vary for different types of dementia.
• A Cochrane review of "complementary and alternative therapies for pain management in labour"¹¹ found that the level of evidence about aromatherapy was too poor to permit a conclusion.
• It may be a useful treatment for pain, including pain in multiple sclerosis ¹²
• There is evidence that the massage of essential oils into the scalp is more beneficial than the carrier oils alone in the treatment of alopecia areata.¹³

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.

The quality of trials and the level of evidence, as is so often the case with CAM, is poor but there are some suggestions that there may be a neuropharmacological as well as psychological effect.

By and large, side-effects are not a great problem although the extent of allergic reaction to the products used is very poorly documented. Toxicity does not seem to be a great problem although the caveat about use in the first trimester of pregnancy would seem prudent. There is still great potential for more adverse events to occur if new or more concentrated products are used than are traditionally employed. Professional regulation would seem wise for this reason and to prevent the inappropriate treatment of people with serious but treatable disease.

The House of Lords Select Committee was very keen on the regulation of all forms of CAM.¹ So far this applies only to chiropractors and osteopaths. Aromatherapists are developing mechanisms for self-regulation including requirements of training.¹⁴