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Complementary therapies an overview

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					Complementary therapies:
      an overview

        Hugh MacPherson
      Senior Research Fellow
   Department of Health Sciences
        hm18@york.ac.uk
 What is CAM (Complementary
  and Alternative Medicine)?
The Cochrane Collaboration defines CAM as:

• a broad domain of healing resources that
  encompasses all health systems, modalities, and
  practices,

• other than those intrinsic to the politically
  dominant health systems of a particular society
  or culture in a given historical period.
Estimated number of ―big five‖*
consultations per year in UK**:
      chiropractic                7.5 million
      osteopathy                  7.3 million
      acupuncture                 3.1 million
      herbal medicine             1.5 million
      homeopathy                  1.3 million
              Total:              21 million
   *House of Lords Report 2000   **Thomas et al 2001
Adult use of complementary
      therapies 1997/8
Effectiveness gaps in primary
care – according to GPs
perceptions*
 Musculoskeletal           95%
 Depression                45%
 Eczema                    36%
 Chronic pain              32%
 Irritable bowel           32%

                   * Fisher et al 2004
  Musculo-skeletal problems
Patient defined problems        Percentage of patients
for all five therapies*:        consulting CAM for
                                musculo-skeletal
     23%   Back
                                problems*:
     19%   Low back
     13%   Neck
                                  osteopathy      54%
     9%    Sciatica
                                  acupuncture     38%
     7%    Arthritis
                                  chiropractic    31%
     7%    Shoulder
                                  herbal medicine 8%
     4%    Knee
                                  homeopathy      7%
     3%    Hip
           *Thomas et al 1991              * Thomas 2003
  Underlying principles

Therapies acts as catalyst for change:
  Self-healing is triggered
  Each therapy has its own mechanism(s)
  Longer-term effects due to some sort of
     physiological relearning
        Patients of osteopaths
             appreciate:
• having their problem validated as real and
  deserving of care
• receiving an meaningful explanation on the
  nature and causes of their problem
• a treatment strategy that was directed
  towards the actual experience of low back
  pain
• a prognosis and strategy for improvement
• a preventative strategy.

Ref: Kane 1993
Provision of CAM on the NHS

   75% of population want CAM on NHS

 BUT

   Only 10% actually access CAM on the NHS
         (i.e. 90% pay for CAM out-of-pocket)


                           Refs: Thomas 2003, FIH 2005
Barriers to complementary
therapies on the NHS
 Inertia – resistance to change

 Regulation

 Financial concerns within NHS

 Mixed evidence of effectiveness,
       and the placebo question
And is it all placebo?

    ―Many clinicians are clear that they can see
    a role for homoeopathy, even if it does
    perform no better than placebo. I (would
    prioritise) randomised controlled (albeit
    unblinded) trials comparing ―visiting a
    homoeopathy clinic‖ against ―general
    practitioner's treatment as usual‖, since
    this might be the clinical question of more
    interest to patients—ie, not ―do the pills
    work better than placebo‖ but ―will the
    experience of visiting a homoeopath help
    me to feel better?‖
                                    Ben Goldacre The
And is it all placebo?              Lancet 2008; 371:98
                                    5-986


    ―Many clinicians are clear that they can see
    a role for homoeopathy, even if it does
    perform no better than placebo. I (would
    prioritise) randomised controlled (albeit
    unblinded) trials comparing ―visiting a
    homoeopathy clinic‖ against ―general
    practitioner's treatment as usual‖, since
    this might be the clinical question of more
    interest to patients—ie, not ―do the pills
    work better than placebo‖ but ―will the
    experience of visiting a homoeopath help
    me to feel better?‖
 Current regulation of therapies
Osteopathy - statutory (1993)
Chiropractic - statutory (1994)
Acupuncture - statutory soon (2009-10?)
Herbal medicine - statutory soon (2009-10?)
Homeopathy - self-regulatory
The fundholding experience

– CAM provision required GP champions –
  personal vision and commitment
– Some new services – extending choice to
  patients
– Based on belief in benefits of service to
  practice and patients
– Credible evidence needed to support
  funding requests
– Financial insecurity of NHS-funded
  services                   Sustaining Complementary Therapy
                                      Provision in Primary Care: Lessons from
                                      Existing Services. Thomas CTiM 2000
Since the end of fundholding …
• Dearth of policies on CAM provision
• Many PCTs levelling down provision
• Demand for/provision of CAM services
  seen as more relevant if designed to solve
  an existing NHS problem (e.g. waiting times for
  orthopaedic referrals)
• Opportunities with practice-based
  commissioning……
Reasons to consider expanding
provision with practice based
commissioning
   Growing evidence for some therapies for
 specific conditions

   Patient choice, linked with appropriate
 referral

   Preventative healthcare agenda

   Potential cost-savings
       Specialist databases
• AMED (Alternative Medicine Database)
   – British Library - access by license
     www.bl.uk/
• Complementary and Alternative Medicine
  Evidence On-Line (CAMEOL)
  http://www.rccm.org.uk/
• Cochrane Library – 5000 RCTs and 60
  systematic reviews:
  www.cochrane.org
Bibliography:

Fisher, P., Van Haselen, R., Hardy, K., Berkovitz, S., & McCarney, R.
2004, "Effectiveness gaps: a new concept for evaluating health service and
research needs applied to complementary and alternative medicine",
J.Altern.Complement Med, vol. 10, no. 4, pp. 627-632.
House of Lords 2000, Report of the Select Committee on Science and
Technology: Complementary and Alternative Medicine, The Stationary
Office, London.
Kane M 1993, The patient's perspective: a qualitative study of low back
pain and osteopathic treatment, Masters Thesis, University of Exeter.
MacPherson H, Sinclair-Lian N, Thomas K. Profiles of acupuncture
patients: a national survey. Complementary Therapies in Medicine, 2006;
14(1): 20-30.
Thomas KJ, Nicholl JP, & Coleman P 2001, "Use and expenditure on
complementary medicine in England: a population based survey. 9:2-11.",
Complementary Therapies in Medicine, vol. 9, pp. 2-11.
Thomas, K. J., Carr, J., Westlake, L., & Williams, B. T. 1991, "Use of non-
orthodox and conventional health care in Great Britain", BMJ, vol. 302,
no. 6770, pp. 207-210.