Evidence-Based Complementary Medicine

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Table of Contents

Abstract
Reflections on evidence-based complementary medicine
Background
The legal standing of complementary medicine
Application of evidence-based practise to complementary medicine
Is there enough evidence to practice complementary medicine
Clinical applications of complementary medicine
The future of complementary medicine
Conclusion
References

Abstract

Complementary medicine is becoming increasingly popular with patients and medical professionals. Randomized controlled studies are essential to gain full accreditation of this treatment modality. The aim of this essay is to review in brief the evidence-based practice in complementary medicine.

Reflections on evidence-based complementary medicine

Hippocrates’s theory of practising medicine depended on the assumption that physicians should treat the human body as a whole, not as parts framed together. Hippocrates presumed the blessing of humans is its capacity for natural healing and believed the proper practice of medicine is to allow medications to help the natural healing process. Besides, Hippocrates noticed that individual variations in response to disease as well as in the capacity of healing exist. The Greek philosopher (father of medicine), explaining this observation, assumed that ideas and thoughts stem from the brain. It is the difference among individuals in positive ideas and thoughts, which makes the different responses to disease and to healing. Hippocrates, thus, laid the foundations of complementary medicine (Chiappelli and others, 2006).

Evidence-based medical practice has become a hot topic. The aim of this work is to review in brief, yet comprehensively, the evidence-based practice of complementary medicine.

Background

Evidence-based medicine is incorporating the best research data, clinical experience and knowledge and patient standards and value. The aim is to create a patient-clinician coalition to maximize both treatment response and quality of life. The need for evidence-based practice evolved because of the rapid advances in medical knowledge so standard textbooks are outdated. In other words, evidence-based medicine practice links research with practice. The roots of the argument around evidence-based practice have developed because of the following limitations, first, the lack of logical, consistent, and rational studies. Second, applying evidence to individual patients and the possible lack of skill in the interpretation and applying certain evidence may not be easy. Third, nonmedical researchers occasionally research the evidence (Jones-Harris, 2003). The term best available evidence is wide and flexible. The Australian guide to the development, implementation and evaluation of clinical practice guidelines issued by the National Health and Medical Research Council (NHMRC, 1998) classified evidence upon which patient advice is given according to level, quality, strength, and relevance. Evidence level is using the study design as a marking sign of the degree to which it cuts out preconceived notions. Quality of evidence is the inherent characteristic of the studying methods used to reduce possible bias in the study. Relevance of the study is how close the research question is to the clinical problem, while the strength of evidence expresses the value, reproducibility and how accurate the intervention effect is. The strength of evidence includes statistical data as the P-value and confidence interval; it includes also non-statistical data as exclusion clinically insignificant effects (NHMRC, 1998).

The National Center for Complementary and Alternative Medicine (NCCAM, 2007), defines complementary medicine as a collection of various medical and healthcare systems, practices and products that are not considered at present a part of conventional medicine. As the name implies, the use of these practices is associated with conventional medications. On the other hand, Alternative medicine is a collection of healthcare systems used to replace conventional medicine as using a special diet for a particular medical condition instead of surgery or medication (NCCAM, 2007). Integrated medicine uses integrated conventional and complementary medications for which there is high-quality evidence in both patient safety and clinical effectiveness (NCCAM, 2007).

The legal standing of complementary medicine

In 2001, the World Health Organization issued a world review on the legal status of complementary medicine. In the USA, Congress created the Office of Alternative Medicine within the National Institutes of Health, the Act of June 1993, expanded this office staff and responsibilities. 42.1 % of American adults used at least one complementary or alternative medical modality in 1997, an increased from 33.8% in 1991. In different socio-economic groups, the rate of using complementary therapy was 32 to 54% of adult Americans with a 45.2% increase in spending. Complementary medicine regulatory mechanisms in the US include laws of a license, scope of practice, malpractice, professional discipline and access to treatment. In the UK, complementary medicine is available in public hospitals after establishing the British Council on Complementary Medicines in 1982. Since then, statistics estimate that 12.5% of adult British have visited a complementary medicine clinic, 90% of those individuals will try it again if they need it. The British General Medical Council regulates and keeps a register of qualified complementary-alternative medicine doctors as a part of the medical profession. In Australia, Chinese immigrants practised Chinese medicine in the 19^th Century. A study performed in 1996 estimated 48% of the Australian population has attended complementary medicine treatments at least once with almost 66% of attendants are females and 44% of cases are rheumatic or neurological. The number of teaching programs of Chinese medicine in Australian Universities is increasing and with the increasing interest of the public, graduates are capable of sharing in public health. Practising contemporary medicine is illegal unless the practitioner is qualified and registered (WHO, 2001). The regulation of complementary medicine in Australia is the responsibility of the Office of Complementary Medicines created by the Commonwealth Therapeutic Goods Administration in 1999. Complementary medicine control remains the responsibility of the Australian State governments and the practices of complementary medicine practitioners are liable to review by healthcare complaints authorities (Kerridge and McPhee, 2004).

Application of evidence-based practise to complementary medicine

The answer to this question needs to settle the disagreements between the skilful art of complementary medicine and the science of conventional medicine. The first disagreement is between standardization sought for by evidence-based medicine (EBM) and the individual planning of complementary medicine (CM). The second divergence is between the beliefs of randomized controlled studies as the gold standards of EBM and disagreement with these beliefs in CAM (Yamey, 2000). There are two viewpoints to the application of EBM in CM. The external viewpoint is the one of practising medical practitioners of whether and when to refer a patient with migraine to a CM practitioner. The second is the internal viewpoint of CM practitioners about questions that arise during their course of practice as to how long should the acupuncture needle stay in a migraine patient, or how many sessions such a patient needs. The main difficulty was the shortage of research data properly examining these questions (Vickers, 1998).

However, starting from 2004, voluminous evidence reports about CM treatment became available involving a wide range of topics. Yet, there are three challenges in front of evidence-practice reviewers; the first is to recognize the evidence about CM treatments. Second, is how to evaluate the quality of each study, and finally, how to deal with the rare adverse effects of treatment (Shekelle and others, 2005). Shekelle and others, 2005, suggested that improving evidence-based reports in CM comes through searching specific databases of CM and extending keywords. They also suggested the use of non-English reports as voluminous literature comes from China and South East Asia, searching for an alternative to placebo as it is not safe in CM, and clearly address the question of rare adverse effects. Coulter and Willis, 2004, considered the popularity of using CM in Australia, a response to sociological changes rather because of reasons internally attributed to medicine. They recognized the problem of the extent of use of CM in a unified hypothesis, and the direction to evidence-based practice may provide some answers, yet will not resolve the question of consistent compatible use of CM.

Is there enough evidence to practice complementary medicine

The Royal Australian College of General Practitioners and the Australian Integrative Association issued a joint position statement in 2004. The report assumed increasing recognition and acceptance of complementary medicine by general practitioners, increasing attention to CM by medical specialists, particularly in gynaecology, rheumatology, oncology and paediatrics. There is growing scientific evidence presented by scientific research studies assessing the efficiency of CM and systematic reviews are accessible through peer-reviewed journals. However, there is an increasing need for the medical profession to be fully informed of CM and its treatment methods.

Clinical applications of complementary medicine

In the context of applying CM in clinical settings, three questions need answers. Is it safe; is it useful; and what patients should expect from CM? Questions on safety are variable. Examples of such questions are what about sterilization and possible injury by an acupuncture needle. Do patients lose valuable time trying complementary medicine instead of directing their attention to conventional medical treatments? What are the possible complementary treatments for adverse reactions? In this perspective, two statistical facts are worth mentioning; first, epidemiological studies suggest that diet, lifestyle and environmental factors influence the course of many diseases so these studies suggest that such factors influence 75% of cancer cases. CM can be safely practised in this area of patient care. Another statistical finding is mortality because conventional medicine hazards and adverse drug reactions are rated high among the causes of death both in the US and Australia (Churchill, 1999). Myers and Cheras, 2004, studied the safety of CM and inferred most Australian consumers consider CM products safe. However, the increasing use of both CM products and pharmaceutical drugs may be a reason for possible adverse drug effects. The Therapeutic Goods Administration developed a two levels system for drug regulation based on possible risks. In this system, CM products are low-risk products and despite that, they are under continuous assessment of quality and safety. Moreover, producers of these products have to hold evidence for questioning of these products efficacy. Myers and Cheras, 2004, suggested since there are few studies on the adverse effect of CM products and even fewer studies on the interaction of these products with pharmaceutical drugs, more funding and study of this issue should be a priority.

The second question, is CM useful, does it really work? It is not enough to say that CM has existed for more than thousands of years, in the time of science, CM practitioners should hold enough means to prove the true benefit of the treatment lines. The approach should be to test whether these modalities are effective before exploring, by basic science research, what are the active components (efficacy driven testing). The WHO encourages the regular steady pursuit of the efficacy of CM products and the US National Institutes of Health adopted this approach (Leung, 2001). Finally, what do patients and physicians expect from CM? Richardson, 2004 examined what patients expect from CM, the results suggested that cure, relief of symptoms and problem understandings are the commonest expectations. The study showed that the commonest reason to go for Cm is the failure of conventional medicine to relieve some of the patient’s complaints and patients need to be treated as individuals, not as cases. These results show how important patient counselling before starting treatment is. Cohen and others, 2005, surveyed 2000 Australian general practitioners for what they think of CM. Almost one third responded and opinions varied from effective non-medicinal treatments (acupuncture, massage, yoga, meditation), safe although may be ineffective (aromatherapy, spiritual healing) to risky medicinal treatments (herbal medicine, osteopathy). The risk as shown in the survey results comes from inadequate, inexperienced practice or delay in diagnosis rather than from the medications themselves.

The future of complementary medicine

Ernst, 2005, suggested the aim of CM researchers in the future should be to create confidence in areas overshadowed by confusion and to work on the basis that scientific evidence is based on a systematic recognized methodology. There are few encouraging achievements, perhaps the most important of which is the integration of CM in National Health Services of Many advanced countries, however, this creates an overload of responsibility on complementary medicine practitioners and researchers.

Conclusion

The main difficulty in researching CM is the difference in concepts and philosophy with conventional medicine. CM is gaining popularity among patients and physicians especially in the areas not covered by conventional treatments. However, more meta-analytical research and evidence-based research is needed in the domains of possible side effects, interaction with conventional pharmaceutical drugs and the efficiency of CM treatment techniques in helping patients.

References

Chiappelli, F, Prolo, P and Cajulis, O S. Evidence-base Research in Complementary and Alternative Medicine 1: History. Advance Access Publication, 453-458. eCAM 2005: 2(4). doi: 10:1093/ecam/neh106.

Jones-Harris, A R. (2003). The evidence-based case report: a resource pack for chiropractors. Clinical Chiropractic, 6, 73-84.

National Health and Medical Research Council (NHMRC). (1998). A guide to the development, implementation and evaluation of clinical practice guideline. Canberra: Commonwealth of Australia. 2008. Web.

National Center for Complementary and Alternative Medicine (2007). CAM Basics. 2008. Web.

The World Health Organization. (2001). Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review. Geneva: Xiaorui Zhang (Editor).

Kerridge, I H and McPhee J R. (2004). Ethical and legal issues at the interface of complementary and conventional medicine. MJA, 181, 164-166.

Yamey G. (2000). Can Complementary medicine be evidence-based? West J Med., 173(1), 4-5.

Vickers A. (1998). Evidence-Based Complementary Medicine. Evidence-Based Medicine, 3, 168-9.

Shekelle, P G., Morton, S C. Suttorp, M J. et al. (2005). Challenges in Systemic Reviews of Complementary and Alternative Medicine Topics. Ann Intern Med, 142, 1042-1047.

Coulter, I D and Willis, E M. (2004). The rise and rise of complementary and alternative medicine: a sociological prospective. MJA, 180, 587-589.

The Royal Australian College of General Practitioners and the Australian Integrative Medicine Association. (2004). Joint Position Statement of the RACGP and AIMA: Complementary Medicine. 2008.

Churchill, W. (1999). Implications of Evidence Based Medicine for Complementary & Alternative Medicine. Journal of Chinese Medicine, 59, 32-35.

Myers, S P and Cheras, P A. (2004). The other side of the coin: safety of complementary and alternative medicine. MJA, 181, 222-225.

Leung, PC (2001). Evidence-based alternative medicine. HKMJ, 7(4), 332-333.

Richardson, J (2004). What Patients Expect From Complementary Medicine: A Qualitiative Study. American Journal of Public Health, 94(6), 1049-1053.

Cohen, M M, Penman, S, Pirotta, M, and Da Costa, C. (2005). The Integration of Complementary Therapies in Australian General Practice: Results of a National Survey. The Journal of Alternative and Complementary Medicine, 11(6), 995-1004.

Ernst E. (2005). The future of complementary medicine. The Pharmaceutical Journal, 275, 699-700.

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