Research Database -
International Updates

Alternative Medicine/
Complementary Therapies

Issue 74

CHEZ and colleagues, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FLA, USA, assessed the opinions and knowledge of medical students on complementary and alternative medicine (CAM) in a medical school with no course on the subject.
Methods: Third-year medical students were offered a questionnaire on CAM during their 8-week rotation on obstetrics and gynaecology.
Results: The majority of students had some experience/knowledge of CAM therapies, were aware that most Americans used CAM, believed that some CAM therapies were useful, did not think such therapies were a risk to public health, and had little knowledge or understanding of safety issues concerning 10 common CAM therapies. Most students would neither refer patients for CAM therapies nor dissuade them from using them. Male and female student responses were similar. Responses did not differ with the time of year of the rotation.
Conclusion: Medical students showed interest in the clinical usefulness of 10 CAM therapies but had insufficient knowledge regarding safety issues. Doctors would be better prepared to answer patients’ questions about CAM if such topics were included in the medical school curriculum.
Chez RA et al. A survey of medical students’ opinions about complementary and alternative medicine. American Journal of Obstetrics and Gynecology 185 (3): 754-7. Sep 2001.

WHITING and colleagues, National Health Service Centre for Reviews and Dissemination, University of York, York, UK, pfw2@york.ac.uk, evaluated available data (57 references) on the effectiveness of interventions used in treating or managing chronic fatigue syndrome (CFS) in adults and children.
Background: Treatment and management of CFS has involved a range of interventions, for which effectiveness remains an issue of debate.
Methods: The reviewers searched 19 specialist databases up to January or July 2000 (and updated using PubMed to end-October 2000), and obtained further information from other sources including citations, Internet, experts and on-line requests for articles. Studies evaluated were randomized (RCTs) or non-randomized (CTs) controlled trials investigating interventions in patients diagnosed with CFS according to any criteria. Two reviewers independently assessed study inclusion. 44 studies (36 RCTs and 8 CTs) out of an initial 350 identified met the inclusion criteria. Data was extracted by one reviewer and checked by a second. Two reviewers carried out validity assessment; disagreements were resolved by consensus. Evaluation was by a qualitative synthesis. Studies were grouped according to type of intervention and outcomes assessed.
Results: Individual trials included between 12 and 326 subjects (a total of 2801 in the 44 trials). 38 different outcomes were evaluated by approximately 130 different scales or types of measurement. Studies were grouped into 6 different categories: behavioural, immunological, pharmaceutical, supplements, complementary/alternative, and other interventions. In the behavioural trials, there were positive findings for graded exercise and cognitive-behavioural therapy; these also scored highly on the validity assessment. In immunological trials, some limited effects were seen with immunoglobulin and hydrocortisone; the overall evidence was, however, inconclusive. There was insufficient evidence on which to assess the effectiveness of the other 4 trial categories.
Conclusion: The interventions used to treat or manage CFS showed mixed results in terms of effectiveness, and conclusions about effectiveness need to be considered alongside the methodological inadequacies of the studies. Graded exercise therapy and cognitive-behavioural therapy showed promising results. Further research is needed into these and other interventions using standardized outcome measures.
Whiting P et al. Interventions for the treatment and management of chronic fatigue syndrome: a systematic review. Journal of the American Medical Association (JAMA) 286 (11): 1360-8. Sep 2001.
Comment: Now that the medical profession in the UK has finally acknowledged the existence of chronic fatigue syndrome (CFS), perhaps they might take on board the not insignificant number of trials referred to in the above research; however, in view of the dissent from the psychiatric profession, who still think CFS is a psychological disorder, I for one will not be holding my breath.

LINDE and colleagues, Institute for Social Medicine, Epidemiology, Charite, Humboldt-University, Berlin, Germany, Klaus.Linde@1rz.tu-muenchen.de, examined the quality of methodologies used in randomized controlled trials (RCTs) in three areas of complementary medicine (homeopathy, herbal medicine and acupuncture).
Methods: The authors analysed 207 RCTs identified for inclusion in five previously published systematic reviews on homeopathy, herbal medicine (Hypericum for depression; Echinacea for common cold) and acupuncture (for asthma and chronic headache). They used a validated assessment scale (the Jadad scale) and analysed single quality items.
Results: The quality of the methods used in the different trials varied widely. Most trials had serious short-comings in reporting and/or methods. Most trials failed to adequately describe concealment of treatment allocation [blinding] or report drop-outs or withdrawals. Homeopathy and herbal medicine trials reported adequate allocation concealment more often (32% and 26%) than did acupuncture trials (6%). Herbal medicine trials had better summary scores than homeopathy and acupuncture trials. Larger trials published more recently in journals listed on MEDLINE and in English had fewer methodological short-comings than trials not meeting these criteria.
Conclusion: Clinical trials of complementary therapies frequently have important methodological weaknesses, the types of which vary considerably across interventions.
Linde K et al. The methodological quality of randomized controlled trials of homeopathy, herbal medicine and acupuncture. International Journal of Epidemiology 30 (3): 526-31. Jun 2001.
Comment: What Linde et al report above is beyond reproach, with regard to methodology of randomized controlled trials (RCTs). The problem is, however, that in the enthusiasm for this brand of ‘evidence-based medicine’ (RCTs), other important and not invalid (in the eyes of other scientists and clinicians) methods of clinical research don’t get mentioned. The message that gets communicated to the outside world is not that the methodology is imperfect, rather that there is no research and no evidence. We are being taken over by the RCT brigade.

LA VAQUE and ROSSITER, Clinical Psychophysiology Center, Rogers Memorial Hospital, Wilwaukee, Wisconsin 53704, USA, tlavaque@gbonline.com, discuss the problems of designing clinical trials with meaningful control groups, particularly in relation to investigating psychophysiological therapies, while adhering to current ethical principles of conduct for biomedical research.
Background: It is considered unethical to carry out clinical studies using placebo or sham procedures (i.e. interventions considered to have no active treatment effect) as control treatments, when safe and effective standard therapies/treatments are available. On the other hand, trials investigating psychophysiological therapies [such as biofeedback or hypnosis] are often criticised for not having a placebo or sham treatment group with which to compare the experimental intervention.
Discussion: The authors review the history of this problem, discuss the ethical standards for human research derived from the Nuremberg Code and the Declaration of Helsinki, and then look at the specific case of researching EEG biofeedback therapy for treating patients with attention-deficit/hyperactivity disorder (ADHD), traumatic brain injury or depression.
Conclusion: The writers conclude that when clinical studies involve patients with a disorder for which there is a known effective treatment, then this should be the comparator group (i.e. active treatment control – examining treatment equivalence). However, when studies investigate experimental treatments for disorders for which there is no known effective treatment, then a sham- or placebo-controlled comparator group is acceptable.
La Vaque TJ, Rossiter T. The ethical use of placebo controls in clinical research: the Declaration of Helsinki. Applied Psychophysiology and Biofeedback 26 (1): 23-37. Mar 2001.
Comment: See comments above.

Issue 73

JACOBS and colleagues, Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, The Netherlands, g.dekruyf@AZU.nl, analysed the characteristics of patients with rheumatoid arthritis (RA) who make use of complementary or alternative medicine (CAM).
Methods: 262 randomly chosen patients with RA filled out self- assessment health status and pain questionnaires. Differences between the group of patients making use of both CAM and conventional treatment (n=52) and the group who relied only on conventional treatment prescribed by their rheumatologists (n=210) were explored with regard to: demographic characteristics; duration of RA; levels of physical, psychological and social functioning; and pain-coping behaviour.
Results: Females used CAM more often than males. Those who used CAM were younger than those who did not. No differences were found between the two groups with respect to: duration of RA; physical, psychological or social functioning; or pain coping. However, the perceived impact of RA on several domains of life was higher among CAM users. The groups did not differ in terms of medical consumption, except that CAM users visited medical specialists for RA-related complaints less than those who relied solely on conventional treatments.
Conclusions: The higher impact of RA, in the absence of worse disease, perceived by CAM users in several domains of life (especially psychosocial functioning) could be the reason they use CAM. This suggests that CAM cannot be substituted by additional conventional treatment prescribed by the rheumatologist, but rather by psychosocial intervention.
Jacobs JWG et al. Why do patients with rheumatoid arthritis use alternative treatments? Clinical Rheumatology 20 (3): 192-6. 2001.

JOHNSON and KURTZ, Department of Family and Community Medicine, College of Osteopathic Medicine, Michigan State University, East Lansing, 48824-1316, USA, investigated whether osteopathic manipulative treatment (OMT) is becoming a ‘lost art’ in the profession.
Methods: In April 1998, a two-page questionnaire was mailed to 3,000 randomly selected osteopathic physicians in the USA to assess factors affecting their use of OMT. Descriptive statistics, linear regression analyses and ANOVA techniques were used to test the differences.
Results: The response rate was 33.2%. Over 50% of respondents used OMT on less that 5% of their patients. ANOVA revealed that OMT use was significantly affected by practice type, graduation date and family physicians versus specialists. Among specialists, 58% of the variance regression was attributed to barriers to use, practice protocol, attitudes and training. Among family physicians, 43% of the variance regression was attributed to barriers to use, practice protocol and attitudes. The eventual level of OMT use was related to whether postgraduate training had been undertaken in osteopathic, allopathic or mixed staff facilities, particularly for osteopathic specialists.
Conclusion: The findings support the assertion that OMT is becoming a lost art among osteopathic practitioners. Osteopathic as well as allopathic medical educators and policymakers should address the impact of the diminished use of OMT on both US health care and the unique identifying practices associated with the osteopathic profession.
Johnson SM, Kurtz ME. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Academic Medicine 76 (8): 821-8. Aug 2001.

PLOTKIN and colleagues, Department of Microbiology, Chicago College of Osteopathic Medicine of Midwestern University, USA, Bplotk@Midwestern.edu, assessed the impact of osteopathic manipulative treatment (OMT) as an adjunct to standard psychiatric treatment of women with depression.
Methods: In this randomized, controlled, pilot clinical trial, premenopausal women with newly diagnosed depression received either control treatment (osteopathic structural examination only; n=9) or OMT (n=8). Attending psychiatrists and psychologists were blinded to group assignments. There were no significant differences between the groups with respect to age or severity of disease. All women also received conventional therapy (paroxetine hydrochloride (Paxil) plus weekly psychotherapy for 8 weeks).
Results: After 8 weeks, 100% of the OMT group and 33% of the control group tested normal by psychometric evaluation. There were no significant differences or trends between groups in levels of cytokine production (IL-1, IL-2, IL-4, IL-6 or IL-10) or in levels of anti-HSV-1, anti-HSV-2 and anti-EBV antibodies. No pattern to the osteopathic manipulative structural dysfunctions was recorded.
Conclusions: The findings of this pilot study indicate that OMT may be a useful adjunctive treatment for alleviating depression in women.
Plotkin BJ et al. Adjunctive osteopathic manipulative treatment in women with depression: a pilot study. The Journal of the American Osteopathic Association 101 (9): 517-23. Sep 2001.

Comment: Although this preliminary trial produced highly promising findings, it is impossible to assess the contribution of the ‘placebo’ factor, since the women obviously were not ‘blind’ to whether or not they were receiving OMT (unlike the psychometric assessors). This also highlights the methodological difficulties encountered in designing many trials assessing complementary/alternative therapies, particularly manipulative therapies. However, it should be possible, with careful investigation into the methodology, to design a trial that incorporates a more meaningful control group that receives ‘sham’ OMT, along the lines that have been used in some acupuncture trials.

Issue 72

VANDENBROUCKE and DE CRAEN, Department of Clinical Epidemiology, Leiden University Medical Center, Building 1, PO Box 9600, 2300 RC Leiden, The Netherlands, vdbroucke@mail.medfac.leidenuniv.nl, review (31 references) evidence for a substantial subjective element in the way physicians frequently evaluate scientific theories and facts, and discuss whether rational medical science is compatible with physicians’ behaviour.
Discussion: Reflecting on the scientific behaviour of adherents of conventional medicine towards one form of alternative medicine (homeopathy) illustrates how physicians reject seemingly solid evidence due to its incompatibility with theory. Further, physicians also do the same within conventional medical science – sometimes they discard a theory because of new facts; at other times they cling to a theory despite the facts. The authors highlight the seeming contradiction and discuss whether it still permits the building of rational medical science. The authors propose that rational science is compatible with physicians’ behaviour provided that physicians acknowledge the subjective element in the evaluation of science, as exemplified in the crossword analogy by the philosopher Haack. This type of thinking fits well with the Bayesian approach to decision making that has been advocated for decades in clinical medicine. It does not lead to complete and uncontrollable subjectivity because discernment between rivalling explanations is still possible through argument and counterargument.
Vandenbroucke JP, de Craen AJ. Alternative medicine: a ‘mirror image’ for scientific reasoning in conventional medicine. Annals of Internal Medicine 135 (7): 507-13. Oct 2001.

ASHER and colleagues, Department of Surgery and Pediatrics, Dartmouth Medical School, Hanover, New Hampshire, USA, reviewed (89 references) current research on complementary and alternative medicine (CAM) relating to rhinitis, sinusitis, tinnitus, vertigo and head and neck oncology.
Discussion: The widespread interest in the use of CAM by patients in the USA has been established by multiple surveys. A third of the US population uses some form of CAM, and an estimated 23 billion dollars is spent annually on these therapies. Because of the prevalent usage of CAM among patients, it is important that physicians have some knowledge of this subject. With this purpose in mind, this report reviews the current research on CAM as it relates to common disorders of the head and neck: rhinitis, sinusitis, tinnitus, vertigo and head and neck oncology.
Asher BF et al. Complementary and alternative medicine in otolaryngology. The Laryngoscope 111 (8): 1383-9. Aug 2001.

Issue 71

SANTA-ANA, James Madison University, Harrisonburg, Virginia, USA, c_santa_ana@hotmail.com, defines complementary and alternative medicine (CAM) for the benefit of healthcare administrators, discusses its rising popularity, identifies its adoption in hospitals, describes the barriers to its implementation, and suggests factors administrators need to consider in implementing CAM in healthcare organizations.
Discussion: As a result of increased consumer awareness, personal preference and limitations of conventional medicine, many people are turning to CAM. Society is starting to favour a more comprehensive style of healing incorporating all aspects of wellness. Public use of CAM has increased markedly in the last 3 decades. In 1999, it was reported that 39 million people sought advice or treatment from a CAM provider and 42% of Americans used some form of alternative therapy. Many Americans see CAM as an effective alternative to traditional medicine. In response to demand, many community hospitals are striving to be innovative providers, and new alternative medicine clinics, hospital departments and research centres are emerging, if slowly, throughout the USA. There remains, however, limited understanding of what CAM includes and how it influences health service organizations. Healthcare administrators need to understand this new market and its implementation in the healthcare setting. The author uses an analytical framework to suggest factors for administrators to consider in CAM implementation in their organizations.
Santa-Ana CF. The adoption of complementary and alternative medicine by hospitals: a framework for decision making. Journal of Healthcare Management 46 (4): 250-60. Jul-Aug 2001.

MUR and colleagues, Universitaetsklinik fuer Innere Medizin, Innsbruck, Austria, investigated whether reflex zone foot massage therapy (FRZM) could bring about changes in intestinal blood flow.
Background: One possible mechanism of FRZM is an effect on organ-associated blood flow.
Methods: In a randomized, placebo-controlled, [single-blind], clinical trial, 32 healthy adults (19 F, 13 M) received either foot massage on reflex zones assigned to the intestines (active treatment) or foot massage on zones unrelated to the intestines (placebo). Measures of blood flow velocity, and peak systolic and end-diastolic velocities in the superior mesenteric artery before, during and after foot massage were calculated. The resistive index, as a parameter of vascular resistance, was also calculated.
Results: During foot massage, subjects receiving active treatment showed a significant reduction in the resistive index (p=0.021), suggesting an increase in blood flow in the superior mesenteric artery and the subordinate vascular system. No significant changes in the resistive index were seen in placebo subjects.
Conclusion: The results support the assumption that FRZM improves blood flow in the organs considered to be associated with specific foot zones, at least during the therapy process.
Mur E et al. (Influence of reflex zone therapy of the feet on intestinal blood flow measured by color Doppler sonography). Forschende Komplementaermedizin und Klassische Naturheilkunde 8 (2): 86-9. Apr 2001.

KESSLER and colleagues, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA, kessler@hcp.med.harvard.edu, presented data on time trends in complementary and alternative medical (CAM) therapies in the USA over the past half-century.
Background: Many people in the USA use CAM therapies, but little is known about the time trends in use.
Methods: A nationally representative telephone survey of 2,055 respondents (household residents aged 18 years or older) in 48 contiguous US states, which obtained information on current use, lifetime use and age at first use for 20 CAM therapies.
Results: More than a third of the US population was currently using CAM therapy in the year of the interviews (1997). 67.7% of respondents had used at least one CAM therapy in their lifetime. Lifetime use increased steadily with age across three age cohorts: about 3 of every 10 respondents in the pre-baby boom cohort; 5 of 10 in the baby boom cohort; and 7 of 10 in the post-baby boom cohort reported using some type of CAM therapy by age 33 years. Of respondents who ever used a CAM therapy, almost half continued to use many years later. There was increased use of a wide range of CAM therapies over time. Growth was similar across all major sociodemographic sectors of the study sample.
Conclusion: Use of CAM therapies by a large proportion of the study sample is the result of a secular trend that began at least half a century ago. Continuing demand for CAM therapies is likely to affect health care delivery for the foreseeable future.
Kessler RC et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Annals of Internal Medicine 135 (4): 262-8. Aug 2001.

MATTHEES and colleagues, Minnesota State University Moorhead, 56563, USA, aimed to describe complementary and alternative medicine (CAM) use by lung transplant patients and to determine whether CAM users differ from non-users with respect to health status, quality of life or medical adherence.
Methods: 145 lung transplant recipients were mailed a survey seeking CAM, quality of life and adherence information.
Results: 99 of the 145 survey recipients responded. 88% used at least 1 form of CAM (median, 2; range, 0-17). The most common forms were prayer (68%), support groups (43%) and relaxation techniques (31%). 44% of CAM users reported discussing CAM with their [primary health care] providers. CAM users were adherent to their transplant regimen. There were few differences between CAM users and non-users. Education, high symptom burden, female sex and depression symptoms were associated with various types of CAM use.
Conclusion: Most lung transplant recipients were using CAM. [Health care] providers need to explore potential for interaction or enhancement between CAM and standard therapy to optimize care.
Matthees BJ et al. Use of complementary therapies, adherence, and quality of life in lung transplant recipients. Heart and Lung; The Journal of Critical Care 30 (4): 258-68. Jul-Aug 2001.

WILES and ROSENBERG, Department of Geography, Queen’s University, Ontario, Kingston, K7L 3N6, Canada, 7jlw@qsilver.queensu.ca, reviewed (46 references) literature seeking to explain the use of alternative medicines, therapies and practices in developed countries.
Methods: Using the Statistics Canada 1996-97 National Population Health Survey-Health File, the reviewers examined the profiles of alternative service users. They also explored critiques of conventional medical practice.
Results and Discussion: The analysis showed that use of alternative health care is still limited to a relatively small segment of Canadians whose profile is similar to those in other developed countries. Women, individuals with higher incomes, and the better educated are more likely to use alternative medicines, therapies and practices. The authors propose that the analysis of alternative health care be situated within the geographies of consumption.
Wiles J, Rosenberg MW. ‘Gentle caring experience’. Seeking alternative health care in Canada. Health and Place 7 (3): 209-24. Sep 2001.

CASLEY-SMITH, Lymphoedema Association of Australia, Malvern, SA, casley@enternet.com.au, describes pioneering work carried out by the author, using electron microscopy, on the pathophysiological changes that occur [in lymphoedema], and the transport from blood vessels, through interstitium to the lymphatics and lymphatic uptake. The author discusses how further work, carried out in collaboration with colleagues, has produced a better understanding of lymphatic drainage and has led to the application of this work in the treatment of lymphoedema.
Casley-Smith JR. Changes in the microcirculation at the superficial and deeper levels in lymphoedema: the effects and results of massage, compression, exercise and benzopyrones on these levels during treatment. Clinical Hemorheology and Microcirculation 23 (2-4): 335-43. 2000.
Comments: Please also see the article Manual Lymphatic Drainage by Brina Eidelson in this issue.

Issue 70

DIEGO and colleagues, Touch Research Institute, University of Miami School of Medicine, Miami, FL 33101, USA, compared the effects of massage therapy with those of progressive muscle relaxation therapy in HIV-positive adolescents.
Methods: HIV-positive adolescents (mean CD4=466 mm-3) were recruited to the study from a large urban university hospital’s outpatient clinic and randomly assigned to receive massage therapy (n=12) or progressive muscle relaxation (n=12) twice a week for 12 weeks. Subjects were assessed for depression, anxiety and immune changes before and after the treatment period.
Results: Subjects who received massage therapy reported feeling less anxious, were less depressed and showed enhanced immune function at the end of the 12-week study period compared with subjects who experienced relaxation therapy. Immune changes included increased natural killer cell number (CD56) and CD56+CD3-. The HIV disease progression markers CD4/CD8 ratio and CD4 number also showed increases in the massage therapy group only.
Conclusion: Massage therapy but not progressive muscle relaxation caused reductions in anxiety and depression and improvements in immune parameters in HIV-positive adolescents.
Diego MA et al. HIV adolescents show improved immune function following massage therapy. The International Journal of Neuroscience 106 (1-2): 35-45. Jan 2001.

KABOLI and colleagues, University of Iowa College of Medicine, Division of General Internal Medicine, Iowa City 52242, USA, carried out a study to determine the prevalence of complementary and alternative medicine (CAM) use and to identify factors associated with its use in older patients with arthritis.
Methods: The researchers conducted a population-based telephone survey of 480 elderly patients with arthritis to obtain data on demographics, co-morbidities, health status, arthritis symptoms and the use of CAM and traditional providers and treatments for arthritis.
Results: 28% of respondents reported using CAM providers and 66% reported using one or more CAM treatments. Factors independently related to CAM provider use (p<0.05) included podiatrist or orthodontist use, physician visits for arthritis, and fair or poor self-reported health. Physical or occupational therapist use, physician visits for arthritis, chronic obstructive pulmonary disease, and alcohol abstinence were each independently associated with CAM treatment use. Rural residence, age, income, education, and health insurance type were unrelated to CAM use.
Conclusion: Many older patients with arthritis reported seeing CAM providers, and most used CAM treatments. Use of CAM for arthritis was most common among those patients with poorer self-assessed health and higher use of traditional health care resources.
Kaboli PJ et al. Use of complementary and alternative medicine by older patients with arthritis: a population-based study. Arthritis and Rheumatism 45 (4): 398-404. Aug 2001.

DYSON-HUDSON and colleagues, Center for Research in Complementary and Alternative Medicine, Kessler Medical Rehabilitation Research and Education Corp, West Orange, NJ 07052, USA, tdyson-hudson@kmrrec.org, conducted a study to determine the effectiveness of acupuncture and Trager Psychophysical Integration in decreasing chronic shoulder pain in wheelchair users with spinal cord injury (SCI).
Methods: In this prospective clinical trial, 18 subjects with chronic SCI and chronic shoulder pain who used wheelchairs as their primary means of mobility were randomized to receive either 10 acupuncture or 10 Trager treatments over a 5-week period. A 5-week pre-treatment baseline period and a 5-week post-treatment follow-up period were included. The main outcome measures were changes in performance-corrected Wheelchair User’s Shoulder Pain Index (PC-WUSPI) scores during baseline, treatment and follow-up periods, assessed by ANOVA.
Results: The mean PC-WUSPI at entry was 48.9. There were no significant changes in the mean PC-WUSPI scores during the pre-treatment baseline period. Mean PC-WUSPI scores decreased significantly during treatment in both the acupuncture (53.4%; 23.3 points) and Trager (53.8%; 21.7 points) groups. The reduced PC-WUSPI scores were maintained in both groups throughout the 5-week post-treatment follow-up period.
Conclusion: Acupuncture and Trager are both effective treatments for reducing chronic shoulder pain associated with functional activities in persons with SCI.
Dyson-Hudson TA et al. Acupuncture and Trager psychophysical integration in the treatment of wheelchair user’s shoulder pain in individuals with spinal cord injury. Archives of Physical Medicine and Rehabilitation 82 (8): 1038-46. Aug 2001.

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