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Complementary medicine in the year 2000: new medicine for a new millenium?
COMPLEMENTARY THERAPIES --M-
Complementary medicine in the year 2000: new medicine for a new millenium? P. TURNER St Bartholomew’s Hospital, London, UK
Will the major changes taking place in conventional medicine and its delivery in the health care system be matched by changes in various forms of complementary medicine? This was the subject of a Symposium in London on 6 October, 1992, organised by Charterhouse Conference and Communications Company Ltd, and co-chaired by Dr Peter Fisher (Royal Homoeopathic Hospital, London) and Professor Paul Turner (St Bartholomew’s Hospital, London).
phasized for better measures of quality of life in order to quantify outcome of treatment. Professor Brian Berman (USA), who is Director of the University of Maryland MultidisciplinaryPain Center, discussed current concepts on the nature of the painful experience and described the integrated approach to pain management in his Center which depends upon an integration of complementary medicine into orthodox medical care.
HOMOEOPATHY
In an opening paper, Dr Fisher provided statistical evidence of rapid growth in the homoeopathic market in Europe and worldwide, and reviewed current developments in the preparation of homoeopathic pharmacopoeias in response to demands of regulatory authorities. Several controlled trials have produced evidence strongly suggestive of efficacy of some homoeopathic medications, but Dr R W Davey (London) emphasized the need for audit to improve homoeopathic practice, quality control of homoeopathic medicines, and development of a plausibletheory to explain retention of bio-informationby ultramoleculardilutions. Dr A Clover (TunbridgeWells, London) then discussed the relevance of homoeopathic medicine in improving the quality of life and, perhaps, the prognosis of patients with malignant disease. She outlined a programme of care integrating conventional medicine, surgery and radiotherapy with complementary treatment including iscador, acupuncture, dietetic advice, relaxation, therapeutic massage and homoeopathy. In discussion following her presentation, the need was em-
NUTRITIONAL AND DIETETIC THERAPY
A session on nutritional and dietetic treatment was opened by Professor John Garrow (London). Using examples from published studies, he emphasized the importance that nutritional treatments, and methods for assessing nutritionalstatus, should beproperly tested by raudomised controlled trials. He believed that recent experience with the evaluation of dietary treatment at the Bristol Cancer Help Centm illustrated the terrible consequences of trials which am not strictly designed and executed. Not only do we still not know if the Bristol diet helps or hinders patients with breastcancer, but a great deal of distress was caused in the process of attempting to find out. Dr Alan Stewart (Hove) while agreeing on the need for well-con-
PaulTurner
CBE. MD, PRCP, FFPM. Professor of Clinical Pharmacology, St Bartholomew’s Hospital, London EClA 7BE, UK.
168
Complementary medicine in the year 2000
studies,claimed that there is no scientificjustification for a complacent attitude that nutritional deficiencies are rare in adult and other populations in the United Kingdom. He dealt in some detail with nutritional tmatments of various forms of arthritis,pointing out that some are associated with changes in bowel histology as part of a syndrome of intolerance or allergic reaction to dairy products or grains. He concluded by calling for improved undergraduate and postgraduate training in nutrition, as well as better funded and coordinated research into nutritional treatments. Finally in that session, Dr Stephen Wright (London) reviewed the chemistry and metabolism of the essential fatty acids. He explained their biochemical roles in cellular function which underlie their therapeutic effects in atopic eczema, breast pain and some other inflammatory diseases,and suggestedthat the recognition by the Department of Health that such nutritional agents have a therapeutic role could be regarded as the beginning of a revolution in modem medical treatment. trolled
ACUPUNCTURE Dr Anthony Campbell (London) opened a session on acupuncture with an historical review of its development in China and introduction to the West. He explained the differences between traditional and modem versions of acupuncture, and briefly reviewed the disorders that he believed from his own experiencecan be helped by its use, includingmusculoskeletal disorders,gastro-intestinaldisorders such as diverticnlar disease and ulcerative colitis, gynaecological problems such as dysmenorrhoea and hot flushes, headaches, migraine, trigeminal neuralgia and carpal tunnel syndrome, and some kinds of allergy. He stated that there is no proof that acupuncture can reverse tissue changes caused by disease or slow the progress of disease. but that it is safest to regard it as a way to relieve symptoms. A critical review of the literature on acupuncture was presented by Dr G ter Riet (Maastricht, The Netherlands). He and his colleagues had found 51 controlled clinical trials on the effectiveness of acupuncture in chronic pain. The studies were reviewed using a list of 18 pmdefined criteria of good methodology, particular weight being given to randomization,study size, adequate description of the procedure, and blinding of patients to treatment allocation. The analysis showed that all trials were of a poor quality, the results of the better trials being highly contradictory and providing only doubtful evidence of efficacy. Dr Anthony Jones (London),however, believed that acupuncture is an important therapeutic component of the pain clinic, and presented interesting preliminary data from studies using positive emission tomography to quantify blood flow changes and opiate receptors in different parts of the human central nervous system He was optimistic that this technique will provide important information on pain mechanisms in man and the
169
influence of therapeuticinterventions such as acupuncture on them.
MANIPULATIVE THERAPY In the fiit of two presentations on manipulative therapy, Dr Alan Breen (Bournemouth) reviewed the history of such treatments and explained the differences between chiropractic, osteopathy and orthopaedic medicine. Dr John Mathews (London) then reviewed clinical t.riaIscarried out to evaluate the treatments. Although the literature is conflicting, and most trials have deficiencies which are open to criticism, some trials have provided evidence, in appropriate patients, of efficacy of manipulative treatment.
THE WAY FORWARD In the final session gloves came off and a staunch offensive against,anddefence of, complementarymedicine took place. Dr Peter Skrabauek (Dublin) suggested that there has been a gradual shift among its practitioners from the use of the term ‘alternative’ which they regard as too combative and confrontational, to ‘complementary’ which is more conciliatory and facilitating their ultimate aim to achieve incorporation in the body of orthodox medicine. Whatever the term used, however, he claimed that they believe in an alternativemedical reality, altemative laws of the universe, and aim to undermine people’s confidence in medicine and science. The fact that complementary medicine is seriously discussed in medical science, he suggested, means that medicine is not yet quite a science. The way forward is not to regress to anachronistic, pseudo scientific modes of thinking and to introduce them into medical curricula, but to build on the rational core at the heart of modem medicine. Human beings, he reminded the audience, are credulous creatures, and history abounds with examples of absurd or fraudulent claims of cures. It is, therefore, essential to have some kind of demarcation of the absurd. He concluded that alternative beliefs are non-scientific, not because they are untestable, although some of them are, but because they am unfalsifiable. This case was vigorously opposed by Dr David Taylor Reilly (Glasgow)who claimed that the Research Council for Complementary Medicine Research Fellowship in Complementary Medicine in the University of Glasgow had demonstratedthat the divide between complementary and mainstream medicine can be bridged without compromising scientific or clinical standards. He agreed that complementary medical techniques require evaluation, but this should emphasize outcome rather than process, until a sufficiently large body of evidence was available to permit hypothesis generation on mechanisms involved. It is wrong, he suggested, to discuss all forms of com-
170 ComplementaryTherapiesin Medicine : Conferencereport
plementary medicine together. ‘IndividuaIisedevidence profiles’ should be derived for each, using methodology tailored for the purpose. The increasing demand for training in complementary medicine by medical practitioners, he said, indicates the need for it to be included in the undergraduate medical curriculum, and in continuing medical education. In the final presentation of the day, Professor Turner said that clinical research depended on observation,measurement and experiment. Complementary medicine is still limited largely to observation. There is little measurement, and hardly any experiment. Experiment is possible, however, as recent work by the late Professor John Dundee in Belfast has shown with acupuncture in vomiting produced by cancer chemotherapyand postoperative narcotic drugs. Several groups have carried out placebo-controlled trials of homoeopathic medicines in musculoskeletal and allergicdiseases with some evidence of efficacy. However, major problems have been encountered.
Firstly, quality control of homoeopathic remedies of high dilution is difficult, if not impossible. Secondly, the statistical interpretation of the data has been criticised, raising basic issues of the appropriate designs of clinical trials of such preparationsin the future. Another problem which had to be addressedwas that of publication bias. If this is to be avoided, he suggested that all trials commenced should be notified to an appropriate body. All trial data should be deposited with that body when a trial was completed or discontinued. The results of all completed trials should be published without delay, and also of all trials discontinued because of lack of efficacy or of adverse events. The public and the health professions should be educated on the need for therapeutic evidence rather than pseudoscientific or philosophical theory. Finally, Professor Turner reminded the audience of a quotationfrom Bishop Richard Holloway: ‘The burden of proof will always be with those who are making the unusual claim.’
Complementary medicine in the year 2000: new medicine for a new millenium? P. TURNER St Bartholomew’s Hospital, London, UK
Will the major changes taking place in conventional medicine and its delivery in the health care system be matched by changes in various forms of complementary medicine? This was the subject of a Symposium in London on 6 October, 1992, organised by Charterhouse Conference and Communications Company Ltd, and co-chaired by Dr Peter Fisher (Royal Homoeopathic Hospital, London) and Professor Paul Turner (St Bartholomew’s Hospital, London).
phasized for better measures of quality of life in order to quantify outcome of treatment. Professor Brian Berman (USA), who is Director of the University of Maryland MultidisciplinaryPain Center, discussed current concepts on the nature of the painful experience and described the integrated approach to pain management in his Center which depends upon an integration of complementary medicine into orthodox medical care.
HOMOEOPATHY
In an opening paper, Dr Fisher provided statistical evidence of rapid growth in the homoeopathic market in Europe and worldwide, and reviewed current developments in the preparation of homoeopathic pharmacopoeias in response to demands of regulatory authorities. Several controlled trials have produced evidence strongly suggestive of efficacy of some homoeopathic medications, but Dr R W Davey (London) emphasized the need for audit to improve homoeopathic practice, quality control of homoeopathic medicines, and development of a plausibletheory to explain retention of bio-informationby ultramoleculardilutions. Dr A Clover (TunbridgeWells, London) then discussed the relevance of homoeopathic medicine in improving the quality of life and, perhaps, the prognosis of patients with malignant disease. She outlined a programme of care integrating conventional medicine, surgery and radiotherapy with complementary treatment including iscador, acupuncture, dietetic advice, relaxation, therapeutic massage and homoeopathy. In discussion following her presentation, the need was em-
NUTRITIONAL AND DIETETIC THERAPY
A session on nutritional and dietetic treatment was opened by Professor John Garrow (London). Using examples from published studies, he emphasized the importance that nutritional treatments, and methods for assessing nutritionalstatus, should beproperly tested by raudomised controlled trials. He believed that recent experience with the evaluation of dietary treatment at the Bristol Cancer Help Centm illustrated the terrible consequences of trials which am not strictly designed and executed. Not only do we still not know if the Bristol diet helps or hinders patients with breastcancer, but a great deal of distress was caused in the process of attempting to find out. Dr Alan Stewart (Hove) while agreeing on the need for well-con-
PaulTurner
CBE. MD, PRCP, FFPM. Professor of Clinical Pharmacology, St Bartholomew’s Hospital, London EClA 7BE, UK.
168
Complementary medicine in the year 2000
studies,claimed that there is no scientificjustification for a complacent attitude that nutritional deficiencies are rare in adult and other populations in the United Kingdom. He dealt in some detail with nutritional tmatments of various forms of arthritis,pointing out that some are associated with changes in bowel histology as part of a syndrome of intolerance or allergic reaction to dairy products or grains. He concluded by calling for improved undergraduate and postgraduate training in nutrition, as well as better funded and coordinated research into nutritional treatments. Finally in that session, Dr Stephen Wright (London) reviewed the chemistry and metabolism of the essential fatty acids. He explained their biochemical roles in cellular function which underlie their therapeutic effects in atopic eczema, breast pain and some other inflammatory diseases,and suggestedthat the recognition by the Department of Health that such nutritional agents have a therapeutic role could be regarded as the beginning of a revolution in modem medical treatment. trolled
ACUPUNCTURE Dr Anthony Campbell (London) opened a session on acupuncture with an historical review of its development in China and introduction to the West. He explained the differences between traditional and modem versions of acupuncture, and briefly reviewed the disorders that he believed from his own experiencecan be helped by its use, includingmusculoskeletal disorders,gastro-intestinaldisorders such as diverticnlar disease and ulcerative colitis, gynaecological problems such as dysmenorrhoea and hot flushes, headaches, migraine, trigeminal neuralgia and carpal tunnel syndrome, and some kinds of allergy. He stated that there is no proof that acupuncture can reverse tissue changes caused by disease or slow the progress of disease. but that it is safest to regard it as a way to relieve symptoms. A critical review of the literature on acupuncture was presented by Dr G ter Riet (Maastricht, The Netherlands). He and his colleagues had found 51 controlled clinical trials on the effectiveness of acupuncture in chronic pain. The studies were reviewed using a list of 18 pmdefined criteria of good methodology, particular weight being given to randomization,study size, adequate description of the procedure, and blinding of patients to treatment allocation. The analysis showed that all trials were of a poor quality, the results of the better trials being highly contradictory and providing only doubtful evidence of efficacy. Dr Anthony Jones (London),however, believed that acupuncture is an important therapeutic component of the pain clinic, and presented interesting preliminary data from studies using positive emission tomography to quantify blood flow changes and opiate receptors in different parts of the human central nervous system He was optimistic that this technique will provide important information on pain mechanisms in man and the
169
influence of therapeuticinterventions such as acupuncture on them.
MANIPULATIVE THERAPY In the fiit of two presentations on manipulative therapy, Dr Alan Breen (Bournemouth) reviewed the history of such treatments and explained the differences between chiropractic, osteopathy and orthopaedic medicine. Dr John Mathews (London) then reviewed clinical t.riaIscarried out to evaluate the treatments. Although the literature is conflicting, and most trials have deficiencies which are open to criticism, some trials have provided evidence, in appropriate patients, of efficacy of manipulative treatment.
THE WAY FORWARD In the final session gloves came off and a staunch offensive against,anddefence of, complementarymedicine took place. Dr Peter Skrabauek (Dublin) suggested that there has been a gradual shift among its practitioners from the use of the term ‘alternative’ which they regard as too combative and confrontational, to ‘complementary’ which is more conciliatory and facilitating their ultimate aim to achieve incorporation in the body of orthodox medicine. Whatever the term used, however, he claimed that they believe in an alternativemedical reality, altemative laws of the universe, and aim to undermine people’s confidence in medicine and science. The fact that complementary medicine is seriously discussed in medical science, he suggested, means that medicine is not yet quite a science. The way forward is not to regress to anachronistic, pseudo scientific modes of thinking and to introduce them into medical curricula, but to build on the rational core at the heart of modem medicine. Human beings, he reminded the audience, are credulous creatures, and history abounds with examples of absurd or fraudulent claims of cures. It is, therefore, essential to have some kind of demarcation of the absurd. He concluded that alternative beliefs are non-scientific, not because they are untestable, although some of them are, but because they am unfalsifiable. This case was vigorously opposed by Dr David Taylor Reilly (Glasgow)who claimed that the Research Council for Complementary Medicine Research Fellowship in Complementary Medicine in the University of Glasgow had demonstratedthat the divide between complementary and mainstream medicine can be bridged without compromising scientific or clinical standards. He agreed that complementary medical techniques require evaluation, but this should emphasize outcome rather than process, until a sufficiently large body of evidence was available to permit hypothesis generation on mechanisms involved. It is wrong, he suggested, to discuss all forms of com-
170 ComplementaryTherapiesin Medicine : Conferencereport
plementary medicine together. ‘IndividuaIisedevidence profiles’ should be derived for each, using methodology tailored for the purpose. The increasing demand for training in complementary medicine by medical practitioners, he said, indicates the need for it to be included in the undergraduate medical curriculum, and in continuing medical education. In the final presentation of the day, Professor Turner said that clinical research depended on observation,measurement and experiment. Complementary medicine is still limited largely to observation. There is little measurement, and hardly any experiment. Experiment is possible, however, as recent work by the late Professor John Dundee in Belfast has shown with acupuncture in vomiting produced by cancer chemotherapyand postoperative narcotic drugs. Several groups have carried out placebo-controlled trials of homoeopathic medicines in musculoskeletal and allergicdiseases with some evidence of efficacy. However, major problems have been encountered.
Firstly, quality control of homoeopathic remedies of high dilution is difficult, if not impossible. Secondly, the statistical interpretation of the data has been criticised, raising basic issues of the appropriate designs of clinical trials of such preparationsin the future. Another problem which had to be addressedwas that of publication bias. If this is to be avoided, he suggested that all trials commenced should be notified to an appropriate body. All trial data should be deposited with that body when a trial was completed or discontinued. The results of all completed trials should be published without delay, and also of all trials discontinued because of lack of efficacy or of adverse events. The public and the health professions should be educated on the need for therapeutic evidence rather than pseudoscientific or philosophical theory. Finally, Professor Turner reminded the audience of a quotationfrom Bishop Richard Holloway: ‘The burden of proof will always be with those who are making the unusual claim.’