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A Critical Appraisal of Complementary and Alternative Medicine
SUMMARY
Numerous forms of complementary and alternative medicine (CAM) are used with the aim of controlling pain. Many doctors now tend to accept CAM, and all too frequently the subject is discussed uncritically. This chapter focuses on acupuncture, chiropractic treatment, massage therapy, homeopathy, and herbal medicine. In particular, it reviews the clinical evidence for or against the effectiveness of these interventions, discusses the risks associated with these treatments, and provides a critical evaluation of the data. Each form of CAM has to be evaluated on its own merit, yet the message that seems to emerge is that very few forms of CAM reduce pain in a clinically relevant way.
Introduction
Complementary and alternative medicine (CAM) has become an important subject mainly because it is used by many consumers, particularly by patients suffering from pain. Most of the numerous surveys on this topic agree that pain is the symptom that leads patients most frequently to use CAM (e.g., ) ( Table 43-1 ). The thought process of many CAM users seems to be that conventional treatment will not help ( ), and most CAM practitioners claim that their interventions are effective for managing a range of pain syndromes ( ). This state of affairs necessitates a critical appraisal of CAM, which is the aim of this chapter.
Table 43-1
Types of Pain Common in Users of CAM ( N = 86,131)
Data from the U.S. Millennium Cohort Questionnaire; Jacobson IG, White MR, Smith TC, et al 2009 Self-reported health symptoms and conditions among complementary and alternative medicine users in a large military cohort. Annals of Epidemiology 19:613–622
| TYPES OF PAIN | PERCENTAGE OF RESPONDENTS USING CAM AND SUFFERING FROM THIS TYPE OF PAIN |
|---|---|
| Severe headache | 16.7 |
| Pain in arms, legs, or joints | 14.6 |
| Menstrual cramps | 12.9 |
| Back pain | 12.8 |
| Unusual muscle pain | 9.1 |
| Chest pain | 6.3 |
| Stomach pain | 2.6 |
CAM, complementary and alternative medicine.
Expectations and Attitudes
Only a few years ago, most health care professionals were skeptical about the value of CAM ( ). More recent data, however, suggest that this attitude has now changed considerably. For instance, a 2010 survey of 600 U.S. rheumatologists disclosed a widespread favorable opinion about CAM; in particular, their attitude toward acupuncture, some oral supplements, meditation, and massage therapy was generally positive ( ).
Our systematic review of studies investigating patient aspirations revealed that the most prominent expectations were the hope of influencing the natural history of the disease, preventing disease, suffering fewer side effects, having control over one’s health, and experiencing relief of symptoms ( ).
Definitions of Complementary and Alternative Medicine and Scope of this Chapter
Experts struggle to find an adequate definition of CAM ( Table 43-2 ), and no globally accepted wording currently exists. Because CAM is an umbrella term for a plethora of treatments (and some diagnostic techniques) that have little else in common other than being excluded from mainstream medicine, the task of creating a positive definition is difficult, perhaps even impossible. In this chapter I focus on specific modalities rather than CAM in general. In particular, I critically evaluate the following treatments: acupuncture, chiropractic, massage therapy, and herbal medicine. To minimize selection and random bias, I rely on systematic reviews when possible.
Table 43-2
Four Definitions of Complementary and Alternative Medicine
| DEFINITION | SOURCE |
|---|---|
| “A group of diverse medical and health-care systems, practices and products that are not presently considered to be part of conventional medicine.” | National Center of Complementary and Alternative Medicine, USA http://nccam.nih.gov/health/whatiscam/#1 |
| “A broad set of health-care practices that are not part of a country’s own tradition and not integrated into the dominant health-care system. Other terms sometimes used to describe these health-care practices include ‘natural medicine,’ ‘non-conventional medicine’ and ’holistic medicine.’” | World Health Organization 2004 Guidelines on developing consumer information on proper use of traditional, complementary and alternative medicine. World Health Organization, Geneva, p xiii |
| “A broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs, other than those intrinsic to the particular society or culture in a given historical period.” | Cochrane Collaboration http://www.compmed.umm.edu/Cochrane |
| “Diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, satisfying a demand not met by orthodoxy, or diversifying the conceptual framework of medicine.” | Ernst E, Resch K L, Mills S, et al 1995 Complementary medicine—a definition. British Journal of General Practice 309:107–111 |
Acupuncture
Acupuncture normally involves the insertion of needles into the skin for therapeutic purposes. It is used by approximately 4% of the general U.S. population, often to treat pain ( ). Acupuncture points can be stimulated not only by needle insertion but also by pressure (acupressure), heat (moxibustion), electric currents (electroacupuncture), laser light (laser acupuncture), bee venom, or other means. Treatment can be focused on specific areas of the body (e.g., auricular acupuncture), it can follow the principles of traditional Chinese medicine (TCM), or it can be guided by the diagnostic concepts of mainstream medicine. Acupuncturists adhering to the philosophy of TCM believe in life energies (yin and yang), meridians, acupoints, and other principles and use diagnostic methods (e.g., tongue or pulse diagnoses) that are unknown to conventional doctors. Western doctors tend to use acupuncture in the belief that it alleviates pain through its effects on neurotransmitters ( , ).
Effectiveness of Acupuncture
Numerous clinical trials of acupuncture have been published, some of which are rigorous ( ). Their results have been far from uniform, however. Systematic reviews that critically evaluate the totality of these data by and large arrived at cautious or negative conclusions. Table 43-3 provides recent examples. According to this body of evidence, acupuncture might be better than placebo in alleviating pain in the following situations: tension-type headache ( ), neck pain ( ), musculoskeletal pain ( ), post-surgical pain ( ), and osteoarthritis ( ). However, even for these conditions, important caveats remain, and our conclusions regarding the trial data can only be tentative at best ( , ).
Table 43-3
Conclusions from Recent Systematic Reviews of RCTs of Various Forms of Acupuncture
| CONDITION (DATE) | NUMBER OF PRIMARY STUDIES | CONCLUSION (QUOTE) | REFERENCE |
|---|---|---|---|
| Any pain ∗ | 17 | Auriculotherapy may be effective for the treatment of a variety of pain, especially post-operative pain. | |
| Labor pain † | 10 | The evidence from RCTs does not support the use of acupuncture for controlling labour pain. | |
| Any pain ‡ | 4 | … more rigorous studies are required before the effectiveness … can be determined. | |
| Fibromyalgia § | 5 | The notion that acupuncture is an effective symptomatic treatment for fibromyalgia is not supported by the results from rigorous clinical trials. | |
| Low back pain ¶ | 35 | The data do not allow firm conclusions. | |
| Tension-type headache § | 11 | … acupuncture could be a valuable treatment.… | |
| Neck pain § | 14 | … confirms short-term effectiveness and efficacy.… | |
| Any chronic pain § | 51 | … inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. | |
| Musculoskeletal pain ¶ | 11 | … results provide suggestive evidence for the effectiveness.… | |
| Postoperative pain ∗ | 9 | The evidence … is promising but not compelling. | |
| Rheumatoid arthritis ¶ | 4 | … RCTs failed to show specific effects of acupuncture.… | |
| Osteoarthritis ¶ | 18 | Sham-controlled RCTs suggest specific effects of acupuncture for pain.… | |
| Perioperative pain ¶ | 19 | … this review does not support the use of acupuncture as an adjunct to standard anaesthetic procedures during surgery. | |
| Cancer pain § | 7 | The notion that acupuncture is effective … is not supported by … rigorous clinical trials. |
RCT, randomized controlled trial.
† Needle acupuncture with or without electrical stimulation or auricular acupuncture.
¶ Needle acupuncture with or without electrical stimulation.
Safety of Acupuncture
In general, acupuncture is considered to be a safe treatment. About 10% of patients complain of very minor and transient adverse effects such as minor bleeding or pain during needling ( ). In addition, several hundred serious complications, mostly attributable to poor training of the acupuncturist, have occurred ( ). Frequently, they are caused by tissue trauma (pneumothorax) or infection introduced via acupuncture needles, and at least 86 deaths have been documented ( ).
Critical Evaluation
Assessing 32 systematic reviews of acupuncture published between 1996 and 2005, concluded that such assessments are frequently uncritical and “have often overstated effectiveness by including studies likely to be biased.” Reviewing sham-controlled trials of acupuncture for osteoarthritis, concluded, “Most of the benefits of acupuncture for pain syndromes result from the treatment ritual and patient-provider interaction.” Considering that many acupuncture trials originate from China, a country that until recently generated only positive results ( ), bias is likely to distort the clinical evidence. Excluding bias in acupuncture trials can be difficult. The discussion of what constitutes an ideal placebo or sham, for instance, has been raging for well over a decade. Therapists cannot easily be blinded, yet the influence of the acupuncturist’s communication style can be significant ( ). Essentially, this means that the findings of many acupuncture trials might be falsely positive.
There are no national monitoring systems for adverse effects of acupuncture comparable to pharmacovigilance schemes. Thus, under-reporting of adverse effects is likely to be considerably larger than with drugs, and the aforementioned complications of acupuncture might be merely the tip of a much larger iceberg. In many countries, acupuncturists are not well regulated, and therefore their lack of competence might put patients at risk.
Our understanding of how acupuncture might work has grown ( , ) but is still far from complete. Recent functional magnetic resonance imaging studies have lent much support to our acceptance of acupuncture. Yet a recent review of these data suggested that the “activations reported by some of these studies were probably not a direct result of acupuncture stimulation but rather attributable to … methodological problems” ( ). For this and other reasons, many experts remain skeptical about the biological plausibility of acupuncture ( ).
Acupuncture is commonly recommended as a repetitive or regular treatment. Long series of sessions are therefore more the rule than the exception. This means that the direct and indirect costs involved can be considerable. Considering that even in the most positive studies, effect sizes tend to be small, it remains questionable whether acupuncture represents value for money.
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