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Which complementary andalternative therapies benefitwhich conditions? A survey ofthe opinions of 223 professionalorganizations

L. Long, A. Huntley, E. ErnstDepartment of Complementary Medicine, School of Postgraduate Medicineand Health Sciences, University of Exeter, UK

Edzard Ernst,Department ofComplementary Medicine,School of PostgraduateMedicine and HealthSciences, 25 Victoria ParkRoad, University of Exeter,EX2 4NT, UK,

Complementary Therapies in Medicine

doi:10.1054/ctim.2001.0453, available

SUMMARY. With the increasing demand and usage of complementary/alternativemedicine (CAM) by the general public, it is vital that healthcare professionals can makeinformed decisions when advising or referring their patients who wish to use CAM.Therefore they might benefit from advice by CAM-providers as to which treatment canbe recommended for which condition. Aim: The primary aim of this survey was todetermine which complementary therapies are believed by their respectiverepresenting professional organizations to be suited for which medical conditions.Method: 223 questionnaires were sent out to CAM organizations representing a singleCAM therapy. The respondents were asked to list the 15 conditions they felt benefitedmost from their CAM therapy, the 15 most important contra-indications, the typicalcosts of initial and any subsequent treatments and the average length of trainingrequired to become a fully qualified practitioner. The conditions and contra-indicationsquoted by responding CAM organizations were recorded and the top five of each weredetermined. Treatment costs and hours of training were expressed as ranges. Results:Of the 223 questionnaires sent out, 66 were completed and returned. Takingundelivered questionnaires into account, the response rate was 34%. Two or moreresponses were received from CAM organizations representing twelve therapies:aromatherapy, Bach flower remedies, Bowen technique, chiropractic, homoeopathy,hypnotherapy, magnet therapy, massage, nutrition, reflexology, Reiki and yoga. The topseven common conditions deemed to benefit by all twelve therapies, in order offrequency, were: stress/anxiety, headaches/migraine, back pain, respiratory problems(including asthma), insomnia, cardiovascular problems and musculoskeletal problems.Aromatherapy, Bach flower remedies, hypnotherapy, massage, nutrition, reflexology,Reiki and yoga were all recommended as suitable treatments for stress/anxiety.Aromatherapy, Bowen technique, chiropractic, hypnotherapy, massage, nutrition,reflexology, Reiki and yoga were all recommended for headache/migraine. Bowentechnique, chiropractic, magnet therapy, massage, reflexology and yoga wererecommended for back pain. None of the therapies cost more than £60 for an initialconsultation and treatment. No obvious correlation between length of training andtreatment cost was apparent. Conclusion: The recommendations by CAM organizationsresponding to this survey may provide guidance to health care professionals wishing toadvise or refer patients interested in using CAM. C© 2001 Harcourt Publishers Ltd

(2001) 9, 178–185 C© 2001 Harcourt Publishers Ltd 178online http://www.idealibrary.com on

Which CAM benefits which conditions? 179

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INTRODUCTION

Complementary/alternative medicine (CAM)commonly used in many countries including tUK,1 Germany,2,3 USA4,5 and Australia.6 The inci-dence of CAM use by defined patient populatioe.g. those suffering from rheumatic disease7

acquired immunodeficiency syndrome (AIDS8

dermatological conditions9 or cancer,10 has beenrelatively well established. Consumer’s demahas led to considerable support for CAM toprovided by national healthcare systems (e.g11).In the UK, 64% of people seeking CAMconsult their general practitioner or hospital spcialist first,12 and 24% concurrently receive orthdox care.13 It is vital that primary care physicianand other health care professionals can makeformed choices when referring patients on to CAproviders. Yet they often feel uncertain as to whpatients might benefit from which treatments. Vious solutions have been sought for this probleIn an integrated healthcare practice in GlastonbUK, for instance, each CAM practitioner suppliea list of conditions for which they considered thetherapy to be particularly appropriate.14 This wasdeemed necessary, at least initially, as neitherCAM practitioners nor the doctors were familiwith one another’s work.

There is a lack of reliable data for informinphysicians on which CAM therapies are best suifor which conditions. This investigation is an atempt to start filling this gap. Its primary aimto determine which forms of CAM are believedbe suited for which conditions by their respectiprofessional organizations.

METHODS

Five hundred and twenty six addresses of CAMganizations had been generated by the Departmof Complementary Medicine at Exeter UniversiIt included 364 addresses of all UK CAM orgnizations generated by a systematic survey spsored by the UK Department of Health15. Further-more it included 162 addresses from outsideUK which were compiled over 7 years at our Dpartment. To the best of our knowledge it repsents the most comprehensive address list of Corganizations collected to date. There was nostriction regarding the professional status of prtitioners represented by the CAM organizatioOf the 526 addresses, 303 were excluded becthey did not correspond to organizations represeing single therapies. Thus 223 questionnaires wsent out.

The confidential questionnaire was purpodesigned and asked what CAM therapy the ornization represented. Our aim was to target ornizations that represented a single CAM therabut those that covered more than one therapy w

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asked to photocopy the form for each. The respdents were asked to list the top 15 conditions thfelt benefited from their CAM therapy, the top 1contra-indications, the typical costs of initial anany subsequent treatments and the average leof training (in hours) a fully qualified practitionewould require. Participants were asked to fillas much of the form as they felt appropriate.sample of the questionnaire is obtainable from tauthors.

The questionnaires were sent out on 1st Febary 2000 and a reminder followed to nonrespondents 1 month later. Responses werelected until the closing date of 30 April 2000. Ainformation was entered into Excel spread sheand presented by descriptive statistics.

Only data from therapies for which we receivetwo or more questionnaire responses were usethe present analysis. We determined those incations which CAM organizations thought benfited most from CAM therapies. Therapies wegrouped into physical therapies, mind/body theapies or complementary medicines. By countihow frequently conditions and contra-indicationwere quoted, the top five of each were determinfor each therapy. Treatment costs and hourstraining were expressed as ranges.

RESULTS

Of the 223 questionnaires sent out, 66 wereceived from separate addresses. Several onizations sent back more than one complequestionnaire (obviously completed by differeindividuals within that organization): this is noincluded in the response rate although all tdata were pooled and used for analysis of coditions treated/contraindications etc. Twenty-squestionnaires were returned unopened, foursponded by stating they did not wish to participaand four wrote to say that the questionnaire wnot suitable/applicable for their organization. Ththe response rate was 34%. The range of CAMganizations contacted is listed in Table 1.

There were two or more responses frotwelve therapies: aromatherapy (n= 11), Bachflower (n= 2), Bowen technique (n= 2), chiro-practic (n= 2), homoeopathy (n= 4). hypnother-apy (n= 5), magnet therapy (n= 2), massage(n= 8), nutrition (n= 3) reflexology (n= 11),Reiki (n= 2) and yoga (n= 2).

When the answers from all the questionnairwere pooled, the most common conditions deemto benefit from CAM, in descending order of frequency, were: anxiety/stress, headaches/migraback pain, respiratory problems including asthminsomnia, cardiovascular problems and musloskeletal problems. Table 2 lists the 25 mofrequently cited conditions and the therapies avocated for treating them.

180 Complementary Therapies in Medicine

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Table 1 List of therapies represented bycomplementary and alternative medicineorganizations, responding to survey

QuestionnairesTherapy sent out Response

Acupuncture/TCM 20 1Alexander technique 3 1Aromatherapy 20 10Art Therapy 2 1Ayurvedic medicine 2 1Bach flower remedies 5 2Biodanza 1 1Bowen technique 3 2Chiropractic 10 2Counselling & 2 1

PsychotherapyHerbal medicine 7 1Homoeopathy 23 4Hypnotherapy 11 5Kinesiology 4 1Magnet therapy 2 2Massage 18 7Music therapy 1 1Neural therapy 4 1Neuro-Linguistic

Programming (NLP) 1 1Nutrition 4 3Osteopathy 3 1Polarity 1 1Radionics 2 1Rebirthing 1 1Reflexology 8 8Reiki 3 2Spiritual healing 1 1Tai Chi 1 1Yoga 5 2

Other therapies represented by professionalorganizations which were contacted but did notrespond:Shamanic healing & counselling, Cranio sacral therapy,Ophthalmic Somatology, Dream analysis,Bioharmonics, Crystal therapy, Chelation therapy,Progressive relaxation, Colour therapy, Spa therapy,Temperature therapy, Oxygen therapy, Organ extracttherapy.

The answers to the questions of which indiviual therapies are deemed to benefit which contion are summarized in Tables 3, 4 & 5. Of thetherapies with just two responses, no consenwas found in terms of the conditions treated acontra-indications and the limitations of these damust be noted. None of the therapies cost mthan £60 for an initial consultation and treatme(Tables 3–5). There was no clear correlation btween the length of training and cost of treatme

DISCUSSION

The rapid increase in public demand for CAMmeans that communication and co-operatiwith orthodox health services is increasingdesirable16, especially considering that many patients use CAM concurrently with orthodomedicine17. Also, it is likely that the public willincreasingly seek clarification on the limitationof the various CAM therapies. Indeed, a rece

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report to the UK Department of Health recommended that a clearer articulation of competenand limitations to treatment by CAM practition-ers may be a basis for improved liaison with othehealth services and may lead to wider acceptanof their contribution.18 Such an approach may alsohelp to promote public confidence in CAM andprovide information to doctors for assessing theapies or advising patients who wish to use CAMTo the best of our knowledge, this is the first suvey of CAM organizations asking for their viewson treatment benefit, safety and cost. Its resumay provide a useful guide to healthcare profesionals: they give some indication as to which coditions are most commonly being treated by CAMproviders and which treatments might be best fwhich conditions.

The most obvious limitation of this survey isits low response rate. The explanation for thisprobably complex and certainly speculative. Manforms of CAM (e.g. homoeopathy, spiritual heaing, Reiki) do not subscribe to the biomedicaclassification of diseases. Thus, these organiztions would have had difficulties answering ouquestions, or felt they were not applicable. Similarly, some organizations representing the moestablished disciplines (e.g. chiropractic and oteopathy), may have considered their therapy tomainstream rather than CAM. Other reasons minclude a level of distrust and/or non co-operatiowith this type of survey which could be seen tdefine CAM usefulness solely in terms of conventional medical criteria. Furthermore, individualised approaches to treatment cannot be acrately reflected with this kind of survey, and CAMorganizations may have felt that it could not fullyrepresent what their therapy has to offer. Moreover the topic of our investigation may not havbeen thought of as important by some CAM organizations. Finally, writing to organizations is leslikely to elicit a response than addressing individuals in person. Nevertheless, with 66 organizatioreplying, this is the largest survey of its kind antherefore a first step towards answering the quetions we posed. Future surveys should perhapscover the entire scope of CAM, but focus on thmost established complementary and alternatdisciplines.19

It is widely accepted that CAM therapies caprovide beneficial non-specific effects that aroften associated with clinically relevant outcomeBut can they have specific effects beyond a placeresponse? It is interesting to compare the resuof our survey with the trial evidence regardineffectiveness for the three most frequently citeconditions found in this survey: stress/anxietheadaches/migraine and back pain (Table 2). Acording to our results, aromatherapy, Bach flowremedies, hypnotherapy, massage, nutritioreflexology, Reiki and yoga are all recommendefor stress/anxiety (Table 2). There is supportin

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Table 3 Physical therapies

Therapy Range[No. of Top 5 conditions Top 5 Treatment cost Subsequent of hoursquestionnaires] treated contraindications First∗ (££) (££) of trainingAromatherapy [11] anxiety/stress pregnancy 21–50 21–40 200–500

musculoskeletal recent surgeryinsomnia thrombosisheadaches/migraine fractures/woundshormonal problems some medications

Reflexology [11] headaches/migraine unstable pregnancy 11–30 11–30 100–500back pain acute infections/fevermusculoskeletal deep vein thrombosismenstrual/PMT surgical/medical emergencystress/mental veruccas/mycosis

Bowen technique [2] no obvious trend, no obvious trend, “no 21–30 21–30 100–180however, large number response to treatment”of musculoskeletal quoted twiceconditions quoted

Massage [8] stress & tension contagious & infectious 11–50 11–50 100–1000back pain diseaseheadache & migraine broken skinneck/shoulder pain cancerinsomnia exacerbation of chronic

conditionskin disease

Chiropractic [2] no obvious trend no obvious trend 31–50 21–50 3000–5000

∗Consultation and treatment.

Table 4 Mind/body therapies

Therapy Range[No. of Top 5 conditions Top 5 Treatment cost Subsequent of hoursquestionnaires] treated contraindications First∗ (££) (££) of trainingYoga [2] no obvious trend no obvious trend 5–40 5–20 500–5000Hypnotherapy [5] anxiety/stress psychosis 31–50 31–50 300–1600

phobias/nervous habits schizophreniasmoking epilepsylack of confidence some depressionsdepression influence of drugs/drink

Reiki [2] no obvious trend: pain, no obvious trend, 1/2 11–50 11–40 1000depression & stress respondees quoted “notquoted twice applicable”

Magnetic therapy [2] no obvious trend: lower no obvious trend, pace <10–40 <10–40 500back pain cramps & makers & pregnancyaches quoted twice quoted twice


Table 5 Complementary medicines

Therapy Range[No. of Top 5 conditions Top 5 Treatment cost Subsequent of hoursquestionnaires] treated contraindications First∗ (££) (££) of trainingBach flower [2] no obvious trend no obvious trend <10–20 <10–20 12–100Nutrition [3] arthritis/rheumatism medical emergencies 21–> 60 11–40 100–3000

chronic fatigue/ME eating disordershypertension chemotherapyCandida antibiotic dependentulcers steroid dependent

Homoeopathy [4] conditions that can be medical emergencies 31–> 60 10–50 500–3000regulated by the organism’s indication for surgerylife force/treated no responseconstitutionally oral medicationspresenting symptom, e.g. contraindicatedeczema, arthritis, menstrual pregnancy if remedy issymptoms, attention deficit inappropriate for thisdisorder treated by treating the conditionperson and not the condition



Table 6 Summary of clinical evidence from controlled clinical trials for therapies recommended forstress/anxiety

Therapy Summary of published clinical evidence

Aromatherapy A systematic review of aromatherapy20 included six RCTs concerning the use of aromatherapyfor anxiety and well-being. With one exception, they all suggest positive effects.

Bach flower remedies Two controlled clinical trials exist testing the effectiveness of Bach flower remedies in thetreatment of examination stress in university students.21,22 Neither trial reported a significantspecific effect of ‘five flower remedies’ on anxiety above placebo, although a non-specificbeneficial effect for both treatment and placebo was observed.22

Hypnotherapy Four controlled trials have found hypnotherapy to be beneficial for state anxiety,23–26 althoughone crossover study produced a negative result.27

Massage Six controlled trials28–33 support beneficial effects of massage on anxiety.Nutrition A clinical trial showed that dietary supplements reduced anxiety, as measured in a quality of life

scale, in dieting individuals when compared to placebo,34 indicating possible benefits ofnutrition for anxiety.

Reflexology A single controlled trial showed that treatment with reflexology reduced anxiety in patientssuffering from this condition.35

Yoga Two clinical studies indicate a beneficial effect of yoga on stress management: a controlled trialshowed beneficial effects of Sahaja yoga on stress management in patients with epilepsy,36

while an uncontrolled study of one year’s duration showed improvements in obsessivecompulsive disorder in patients who practised yoga regularly.37

RCT = Randomized clinical trial

Table 7 Summary of clinical evidence from controlled clinical trials for therapies recommended forheadache/migraine


Aromatherapy One RCT on the effectiveness of topically applied peppermint oil for headaches reported significantanalgesic effects compared to placebo.38

Chiropractic A recent systematic review suggests that spinal manipulation has a useful effect on tension,cervicogenic and post-traumatic headaches, with five of the six studies reporting benefit.39 Twostudies showed positive effects of spinal manipulation on migraine,40,41 although another studyfound no positive benefits above a control treatment.42

Hypnotherapy Self-hypnosis appears to be more effective that waiting list control in the treatment of headache,43

although it is unclear whether it is superior to other forms of relaxation. Different combinations oftherapies including hypnotherapy have been compared to various control interventions in severaltrials44,45 with favourable results.

Massage One RCT showed beneficial effects of massage on migraine headaches,46 while an uncontrolled studyshowed improvements in chronic tension headache in patients treated with massage.47

Nutrition Nutrition has been shown to be important in the treatment of migraine, as the incidence of migraine isaffected by food allergy in both children48 and adults.49

Reflexology Two trials support the use of reflexology for headache. A large observational study found that 81% ofpatients with headache were helped or cured at 3-months follow-up50 while a single RCT showed apositive non-significant trend in the same condition.51

Yoga Yoga, in addition to standard medication, produced significant reduction in headache activity whencompared to standard medication alone in an RCT of subjects with mixed migraine and tensionheadache.52

RCT = Randomized clinical trial

Table 8 Summary of clinical evidence from controlled clinical trials for therapies recommended forback pain


Chiropractic The evidence for chiropractic is generally positive although methodological flaws in most of the trialsperformed to date prevent definitive conclusions.53

Magnet therapy A recent pilot study reported no benefits of the use of magnets in the treatment of chronic low backpain.54

Reflexology There is no strong trial evidence in support of reflexology.55

Massage While a review of clinical trials concluded that there is no strong trial evidence in support of massagetherapy,56 a recent positive RCT57 supports the view that massage is beneficial for this condition.

Yoga Data from clinical trials on yoga is promising,58 but too scarce to allow any firm judgement.RCT = Randomized clinical trial


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clinical evidence, of varying methodological quaity, for all these therapies with the exceptioof Reiki (Table 6). The second most frequencited condition emerging from our survey wheadache/migraine, with aromatherapy, Bowtechnique, chiropractic, hypnotherapy, massanutrition, reflexology, Reiki and yoga recommended as suitable treatments (Table 2). Wthe exception of Bowen technique and Reiall appear to be supported by clinical eviden(Table 7). Back pain is the condition that brinpatients most frequently to try CAM (3) and, acording to the present findings, the following trements are recommended as promising: Bowtechnique, chiropractic, magnet therapy, massreflexology and yoga (Table 2). Clinical trials hainvestigated the effectiveness of all these therafor back pain, with the exception of Bowen tecnique (Table 8). Hence it appears that, in genethe recommendations by CAM organizationssupported by trial evidence.

In conclusion, this survey yields potentialuseful data regarding the applicability of CAMclinical settings. As a first step in bringing reliabinformation about CAM to the attention of healcare professionals, this survey’s findings may pvide some guidance to those physicians wiing to advise or refer patients interested in usCAM.

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