Complementary medicine

British Medical Journal, Sept 16, 2000 by Andrew Vickers

Given that many complementary medicine techniques are defined in terms of a static historical tradition, discussing recent advances in complementary medicine is almost a contradiction in terms. None the less, few acquainted with complementary medicine would deny that substantive shifts in its scientific base and organisational structure have occurred recently. These shifts might indicate that complementary medicine is becoming more integrated. Integration, as used here, means that similar clinical, scientific, and regulatory standards are being applied across all forms of health care. If a list was written of what patients care about (for example, the clinical relationship), what researchers feel is important (for example, control of bias), what clinicians hold critical (for example, clinical competence), or what matters to purchasers (for example, cost effectiveness) there would probably be no reference to the historically and politically contingent concepts of "conventional" and "complementary" medicine. Integration has obvious implications for the access to and availability of care. It also implies that clinicians agree on their respective roles so that patients feel that they are receiving care as part of a coordinated service. In this article I review a number of signs that complementary medicine is becoming increasingly integrated.

Methods

This review is largely a personal reflection on recent changes in complementary medicine. Research has been supplemented by email discussions with colleagues based in the United Kingdom. The major source of original research material was the Cochrane Library, an electronic database of randomised trials and systematic reviews.

Applied research

The quantity of applied health research on complementary medicine is growing rapidly, and the quality is improving. The number of randomised trials of complementary treatments has approximately doubled every five years,[1] and the Cochrane Library now includes nearly 50 systematic reviews of complementary medicine interventions.

Much of this evidence involves small numbers of patients and is of poor methodological quality; however, high quality systematic reviews of complementary medicine have been published recently which provide a reliable basis for making healthcare decisions. For example, a Cochrane systematic review of St John's wort (Hypericum perforatum) for mild to moderate depression included 27 trials with a total of more than 2000 participants.[2] The review found that St John's wort was superior to placebo and equivalent to tricyclic antidepressants but had fewer adverse effects. Although not all questions have been answered, particularly those of safety,[3] the review does provide a basis for making treatment decisions. Another Cochrane review of a botanical medicine examined the effects of Saw palmetto (Serenoa repens) on benign prostatic hyperplasia. Eighteen studies with a total sample size of nearly 3000 patients were included. Clear benefits were shown for urinary symptoms and peak urine flow.[4] Other recent, high quality systematic reviews have found acupuncture to be effective for pain[5 6] and nausea[7] but not for helping smokers to quit.[8]

One consequence of the increase in the availability of high quality data is that guidelines and consensus statements published by conventional medical bodies have supported the value of complementary medicine. In the United Kingdom guidelines from the Royal College of General Practitioners recommend physiotherapy, chiropractic treatment, or osteopathy within six weeks of the onset of persistent uncomplicated back pain.[9] The BMA recently published a report supporting the use of acupuncture.[10] In the United States, the National Institutes of Health have issued consensus statements supporting the use of hypnosis for pain related to cancer and the use of acupuncture for pain and nausea.[11 12] Acupuncture, hypnosis, and relaxation techniques are included in guidelines on the management of pain associated with cancer that have been published by the US National Comprehensive Cancer Network.[13]

These shifts highlight an improved awareness among researchers of the importance of complementary medicine and an improved awareness among complementary medicine practitioners of the importance of research. These changes have led to increased funding and the establishment of complementary medicine research units at sites of research excellence. Some of the ongoing research studies are shown in the box. In the United Kingdom, the NHS recently funded two trials of acupuncture for treating chronic pain. In Germany, a centre for research into complementary medicine at the Technische Universitat in Munich has produced a series of important systematic reviews.[2 5 14] And in the United States, a centre for research into complementary medicine at the National Institutes of Health has a $68m (45m [pounds sterling]) budget and supports a large number of trials and research centres. The United States also has a large number of units for research into complementary medicine that are based at conventional research institutions such as the University of Maryland, Columbia University in New York, Harvard University in Massachusetts, and Memorial Sloan-Kettering Cancer Center in New York. These institutions provide the sort of intellectual and practical infrastructure essential for high quality research; this support has long been missing in complementary medicine. For example, a phase I trial of a botanical cancer treatment planned at Memorial Sloan-Kettering has been developed by a team that includes experts in complementary medicine research, a statistician who is an expert in developing novel designs for phase I studies, an expert in assessing quality of life, and senior oncologists with extensive experience in clinical research. The researchers have access to a large number of patients who are receiving the highest standard of care. These basic prerequisites for conducting high quality research into complementary medicine would not have been in place several years ago.