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CHAPTER 2: DISCIPLINES EXAMINED
Definitions of the Various CAM Therapies
2.1 The therapeutic disciplines which were either
included in the Committee's Call for Evidence or from whom evidence
was received are listed in Box 1. The list is not intended to
be all-inclusive but rather it is an attempt to provide an indication
and framework of the main types of therapy we have considered
without attempting to resolve the difficulties inherent in formulating
an exact definition of CAM. We broadly follow the definitions
of each therapy given in Box 1. The Committee was happy to receive
evidence from representatives of any therapy or discipline that
considered itself to be either complementary or alternative to
mainstream medicine. Broadly, in the opinion of the Committee,
these therapies and disciplines fall into three broad groups:
- The first group embraces
what may be called the principal disciplines, two of which, osteopathy
and chiropractic, are already regulated in their professional
activity and education by Acts of Parliament. The others are acupuncture,
herbal medicine and homeopathy. Our evidence has indicated that
each of these therapies claim to have an individual diagnostic
approach and that these therapies are seen as the 'Big 5' by most
of the CAM world.
- The second group contains
therapies which are most often used to complement conventional
medicine and do not purport to embrace diagnostic skills. It includes
aromatherapy; the Alexander Technique; body work therapies, including
massage; counselling; stress therapy; hypnotherapy; reflexology
and probably shiatsu; meditation and healing.
- The third group embraces
those other disciplines in Box 1 which purport to offer diagnostic
information as well as treatment and which, in general, favour
a philosophical approach and are indifferent to the scientific
principles of conventional medicine, and through which various
and disparate frameworks of disease causation and its management
are proposed. These therapies can be split into two sub-groups.
Group 3a includes long-established and traditional systems of
healthcare such as Ayurvedic medicine and Traditional Chinese
medicine. Group 3b covers other alternative disciplines which
lack any credible evidence base such as crystal therapy, iridology,
radionics, dowsing and kinesiology.
2.2 We will be using these groups as our basis for
the discussion of the different therapies throughout this report.
2.3 The evidence that we received from almost all
the different therapies said that at the point of diagnosis, if
the practitioners thought that their treatment would not work,
they would refer their patients to an orthodox medical practitioner.
We were encouraged by this sentiment, even though it was not universal.
Box 1
Short and Simplified Descriptions of CAM Disciplines
Group 1: Professionally Organised Alternative Therapies
Acupuncture — Originating from China, acupuncture involves inserting small needles into various points in the body to stimulate nerve impulses. Traditional Chinese acupuncture is based on the idea of 'qi' (vital energy) which is said to travel around the body along 'meridians' which the acupuncture points affect. Western Acupuncture uses the same needling technique but is based on affecting nerve impulses and the central nervous system; acupuncture may be used in the West as an anaesthetic agent and also as an analgesic.
Chiropractic — Used almost entirely to treat musculo-skeletal complaints through adjusting muscles, tendons and joints and using manipulation and massage techniques. Diagnostic procedures include case histories, conventional clinical examination and x-rays. Chiropractic was originally based on the idea that 'reduced nerve flow' led to disease.
Herbal medicine — A system of medicine which uses various remedies derived from plants and plant extracts to treat disorders and maintain good health. Another term for this type of treatment is phytotherapy.
Homeopathy — A therapy based on the theory of treating like with like. Homeopathic remedies use highly diluted substances that if given in higher doses to a healthy person would produce the symptoms that the dilutions are being given to treat. In assessing the patient homeopaths often take into account a range of physical, emotional and lifestyle factors which contribute to the diagnosis.
Osteopathy — A system of diagnosis and treatment, usually by manipulation, that mainly focuses on musculo-skeletal problems, but a few schools claim benefits across a wider spectrum of disorders. Historically differs from chiropractic in its underlying theory that it is impairment of blood supply and not nerve supply that leads to problems. However in practice there is less difference than might be assumed. Mainstream osteopathy focuses on musculo-skeletal problems; but prior to osteopathy gaining statutory protection of title, other branches of this therapy purported to diagnose and treat a range of disorders. One such branch is now known as cranio-sacral therapy, which should be considered as a distinct therapy which would fall into Group 3.
Group 2: Complementary Therapies
Alexander Technique — Based on a theory that the way a person uses their body affects their general health. This technique encourages people to optimise their health by teaching them to stand, sit and move according to the body's 'natural design and function'. This is, in essence, a taught technique, rather than a therapy.
Aromatherapy — Use of plant extract essential oils inhaled, used as a massage oil, or occasionally ingested. Common in France but practised there by medical doctors only. Can be used to alleviate specific symptoms or as a relaxant.
Bach and other flower remedies -— The theory behind flower remedies is that flowers contain the life force of the plant and this is imprinted into water through sun infusion which is used to make the flower remedy. Flower remedies are often used to help patients let go of negative thoughts; usually flower remedies are ingested.
Body work therapies, including massage — Therapies that use rubbing, kneading and the application of pressure to address aches, pains and musculo-skeletal problems. Often used as a relaxant.
Counselling stress therapy — A series of psychical therapies that attempt to help patients to work through their thoughts and to reflect on their lives so as to maximise wellbeing.
Hypnotherapy — The use of hypnosis in treating behavioural disease and dysfunction, principally mental disorders.
Meditation — A series of techniques used to relax a patient to facilitate deep reflection and a clearing of the mind (see Maharishi Ayurvedic Medicine below).
Reflexology — A system of massage of the feet based on the idea that there are invisible zones running vertically through the body, so that each organ has a corresponding location in the foot. It has also been claimed to stimulate blood supply and relieve tension.
Shiatsu — A type of massage originating from Japan which aims to stimulate the body's healing ability by applying light pressure to points across the body. Relies on the meridian system of 'qi' in a similar way to traditional Chinese medicine and acupuncture.
Healing — A system of spiritual healing, sometimes based on prayer and religious beliefs, that attempts to tackle illness through non-physical means, usually by directing thoughts towards an individual. Often involves 'the laying on of hands'.
Maharishi Ayurvedic Medicine * — A system which promotes transcendental meditation, derived from the Vedic tradition in India. Recommends the use of herbal preparations similar to those used in Ayurvedic Medicine (see below) and Traditional Chinese medicine (see below).
Nutritional medicine — Term used to cover the use of nutritional methods to address and prevent disease. Uses diets and nutritional supplements. Often used to address allergies and chronic digestive problems. The difference between nutritional medicine and dietetics is that nutritional therapists work independently in accordance with naturopathic principles and focus on disorders which they believe can be attributed to nutritional deficiency, food intolerance or toxic overload. They believe these three factors are involved in a wide range of health problems. Dieticians usually work under medical supervision, using diets to encourage healthy eating and tackle a narrower range of diseases. Nutritional therapists often use exclusion diets and herbal remedies to tackle patients' problems.
Yoga — A system of adopting postures with related exercises designed to promote spiritual and physical well-being.
Group 3: Alternative Disciplines
3a: Long-established and traditional systems of healthcare
Anthroposophical medicine — 'Anthroposophy' describes people in terms of their physicality, their soul and their spirit. Anthroposophical medicine aims to stimulate a person's natural healing forces through studying the influence of their soul and spirit on their physical body.
Ayurvedic Medicine — An ancient discipline, originating in India, based upon the principle of mind- spirit-body interaction and employing natural herbs, usually mixtures, in treatment.
Chinese Herbal Medicine* — (See Traditional Chinese medicine below) A tradition of medicine used for thousands of years in China, which has its own system of diagnosis. Uses combinations of herbs to address a wide range of health problems.
Eastern Medicine (Tibb)* — Tibb is a tradition which synthesises elements of health philosophy from Egypt, India, China and classical Greece. It literally means 'nature'. The concept of wholeness and balance permeates the principle of Tibb. Imbalance is thought to cause disease. It is thought to occur on four levels: physical, emotional, mental and spiritual. Tibb uses a range of treatments including massage, manipulation, dietary advice and herbal medicine, and a psychotherapeutic approach to restore imbalances which are considered the cause of disease.
Naturopathy — A method of treatment based on the principle that the natural laws of life apply inside the body as well as outside. Uses a range of natural approaches including diet and herbs and encourages exposure to sun and fresh air to maximise the body's natural responses.
Traditional Chinese medicine — The theory behind Traditional Chinese medicine is that the body is a dynamic energy system. There are two types of energy - Yin qi and Yang qi - and it is thought if there is an imbalance in Yin and Yang qi then symptoms occur. Traditional Chinese medicine uses a number of treatment methods to restore the balance of Yin and Yang qi; these include acupuncture, herbal medicine, massage and the exercise technique Qigong.
3b: Other alternative disciplines
Crystal therapy — Based on the idea that crystals can absorb and transmit energy and that the body has a continuing fluctuating energy which the crystal helps to tune. Crystals are often placed in patterns around the patient's body to produce an energy network to adjust the patient's energy field or 'aura'.
Dowsing — Traditionally used as a way to identify water sources underground. Is not itself a therapy but is used by a range of other disciplines to answer questions through intuitive skills. Often used in conjunction with Radionics.
Iridology — A method of diagnosing problems and assessing health status that relies on studying the iris of the eye and noting marks and changes.
Kinesiology — A manipulative therapy by which a patient's physical, chemical, emotional and nutritional imbalances are assessed by a system of muscle testing. The measurement of variation in stress resistance of groups of muscles is said to identify deficiencies and imbalances, thus enabling diagnosis and treatments by techniques which usually involve strengthening the body's energy through acupressure points.
Radionics — A type of instrument-assisted healing which attempts to detect disease before it has physically manifested itself. It is based on the belief that everyone is surrounded by an invisible energy field which the practitioner tunes into and then attempts to correct problems which have been identified. Practitioners believe it can be done over long distances. Instruments are a focus of the healer's intent and include sugar tablets which carry the healing 'idea'.
* We received evidence about these therapies although they were not included in our original Call for Evidence
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2.4 An important point that has been raised in many
submissions to us is that the list of therapies supplied in our
Call for Evidence vary hugely in the amount and type of supportive
evidence that is available (e.g. the Natural Medicines Society
- P 155, and the British Medical Acupuncture Society - P 40).
Many submissions assert that several of the disciplines, especially
those listed in our third group, have no significant evidence
base to support their claims for safety and efficacy and as such
should not be considered alongside well-established and generally
accepted CAM therapies such as osteopathy or chiropractic. Some
submissions have complained that we have grouped all these therapies
together and that many have nothing in common. They complain that
it may be damaging to the better-established CAM professions and
disciplines to group them with those which have no evidence base.
We understand these views and it is for this reason that we propose
the grouping given above.
2.5 It is well recognised by all of those involved
in medical practice that many illnesses and diseases are self-limiting
and are cured or have their worst effects overcome by the human
body's natural resources (the vis medicatrix naturae) without
specific medical intervention. In many others spontaneous remissions,
often unexpected or even inexplicable, occur. When such events,
however, follow the administration of various medicines or therapies,
these developments are often used by practitioners of both conventional
and CAM to suggest efficacy. But the history of medical science
demonstrates clearly that anecdotal "evidence" of this
nature is unsafe, even though there have been some cases in which
such findings have led to well-designed research projects which
have either confirmed or refuted the original anecdotal conclusion.
Such research (appropriate methods are discussed in Chapter 7)
is essential in order to produce a sound evidence base relating
to efficacy.
2.6 Many CAM therapies are based on theories about
their modes of action that are not congruent with current scientific
knowledge. That is not to say that new scientific knowledge may
not emerge in the future. Nevertheless as a Select Committee on
Science and Technology we must make it clear from the outset that
whilst we accept that some CAM therapies, notably osteopathy,
chiropractic and herbal medicine, have scientifically established
efficacy in the treatment of a limited number of ailments, we
remain sceptical about the modes of action about many of the others.
2.7 While in the time available for our Inquiry we
have not been able to carry out detailed investigations into all
of the therapies listed in Box 1, and while the question of efficacy
was not included in our initial terms of reference, in the absence
of a credible evidence base it is our opinion that the therapies
listed in our Group 3 cannot be supported unless and until convincing
research evidence of efficacy based upon the results of well designed
trials can be produced. Such evidence must be capable of showing
that the effects of any therapeutic discipline are superior to
those of the placebo effect (see paras 3.19-3.34). It is our view
that for those therapies in our Group 3, no such evidence exists
at present.
2.8 We are, however, satisfied that many therapies
listed in our Group 2 give help and comfort to many patients when
used in a complementary sense to support conventional medical
care even though most of them also lack a firm scientific basis.
Nevertheless in relieving stress, in alleviating side effects
(for example of various forms of anti-cancer therapy) and in giving
succour to the elderly and in palliative care they often fulfil
an important role.
2.9 We recognise that deciding which therapeutic
disciplines fall under the title of CAM is controversial. Those
listed in our Call for Evidence ranged from several which are
already being integrated into conventional medicine to others
which are plainly far removed from conventional medicine, or even
purport to offer an alternative system of healthcare. But we listed
them together to reflect the fact that each was considered as
a healthcare intervention not commonly considered to fall within
the ambit of conventional medical practitioners. Most share common
problems such as lack of research activity; a limited or non-existent
evidence base; lack of acceptance by the conventional medical
world; and sparse, if any, provision under the NHS. All experience
these problems to different degrees.
2.10 We received a huge amount of written evidence
from a wide range of interest groups, and we extended our deadline
twice to give as many people as possible the opportunity to submit
evidence. Over 55 oral hearings were held. The issues considered
in this report are intended to be relevant to any therapeutic
discipline which aims to improve the health of individuals or
populations and which is not traditionally considered part of
conventional medicine.
2.11 This report discusses not only therapies that
are complementary or alternative to conventional medicine; we
also took evidence from people who used CAM in dental and veterinary
practice.
Differing Philosophies
2.12 CAM therapies may differ from conventional medicine
not only in their methods but also in some of their underlying
philosophies. The way that many CAM disciplines define health,
illness and the healing process can depart significantly from
the beliefs that underlie the practice of conventional medicine.
It is essential to consider the different paradigms from which
conventional medicine and CAM approach healthcare as these have
implications for research and integration. A spectrum exists between
reductionism and holism and different practices in both conventional
medicine and CAM span the spectrum.
2.13 We are aware that it is a fallacy to say that
there is one philosophy that underlies all CAM disciplines. Evidence
submitted to us by Mr Roger Newman Turner, a practising osteopath
and naturopath, suggests that the term "complementary and
alternative medicine" defines the therapies by their position
outside of conventional medicine, rather than by any common philosophy.
In fact, the CAM therapies come from hugely diverse backgrounds.
However, there are some principles which most CAM therapies seem
to share (P 87).
2.14 The World Health Organisation's definition of
health is: "a state of complete physical, mental and social
well-being, and not merely the absence of disease or infirmity"[15].
However, Mr Newman Turner pointed out that conventional medical
treatment has focused on the elimination of symptoms and disease
processes. Many CAM therapies emphasise the other features of
the definition of "health" with attributes such as good
energy, happiness and a sense of wellbeing being more central
outcomes. Moreover the emphasis of much of CAM is often on strengthening
the whole organism rather than directly attacking the pathology
(such as an infection or tumour). CAM therapies use different
vocabularies to understand these emphases, with treatment concepts
such as detoxification and tonification, and with different cultural
concepts of "energy" as recuperative forces in the body
(notably in forms of medicine originating in Asia).
2.15 Most CAM therapies also apply a non-Cartesian
view of health, making less distinction between the body, mind
and spirit as distinct sources of disease. The language used in
CAM often tends to imply that all these dimensions of the human
condition should be viewed in the same therapeutic frame. Evidence
we have received from other witnesses has also stressed repeatedly
that CAM therapies take a highly individualistic approach to treatment.
This often results in patients receiving a combination of treatments
tailored to their specific needs. This is different from the conventional
medical approach which may involve prescribing a standard drug
and a similar treatment regime for patients with the same underlying
pathology.
2.16 Nevertheless, many witnesses and organisations
from conventional medicine emphasised the view that 'holistic
medicine' is nothing more than good medical practice, and that
conventional preventative medicine also concentrates on maintaining
health and preventing disease. It is true that constraints of
time, as we have mentioned, tend to reduce the attention that
can be paid to the patients' emotional and social problems.
2.17 Some CAM therapies, and especially those in
the Group 3a, have very specific philosophies that have evolved
over centuries of use. Often these have developed into views about
how the body functions and how disease is caused. Sometimes these
are linked to the dominant religious philosophies of their country
of origin. Examples include Ayurvedic medicine, and Traditional
Chinese medicine. However, there is no established evidence base
supporting these. The lack of an evidence base is even more evident
in the case of those therapies we classify in Group 3b, and these
must be subject to rigorous appraisal. Many conventional medical
scientists, while accepting the validity of accumulative empirical
observation, believe that those therapeutic disciplines that are
based principally on abstract philosophy and not on scientific
reasoning and experiment have little place in medicine. Professor
Lewis Wolpert of the Academy of Medical Sciences told us that:
"Medicine aims to base itself upon science. I am sorry that
any complementary or alternative medicine procedure for which
one can see no reasonable scientific basis should be supported"
(Q 1404).
2.18 Evidence that we have received has suggested
that conventional medicine allows any therapy proven to be effective
to be subsumed into the medical curriculum (P 244). It is suggested
that efficacious therapies are readily accepted and are not required
to fit into any particular philosophy. Those who support the application
of "normal science" pragmatism to CAM treatment have
been accused by some complementary practitioners of trying to
subsume the best of CAM therapy into their own paradigm, and yet
of leaving much of what CAM sees as important (its philosophy)
out in the cold.
2.19 Other submissions have suggested that conventional
medical scientists and practitioners are inherently biased against
CAM. Sir Iain Chalmers, Director of the UK Cochrane Centre, suggests:
"Many in the 'orthodox' medical world remain either sceptical
about the desirability of this trend [towards increasing use of
CAM] or hostile to it. This scepticism seems to result partly
from unwillingness within the 'orthodox' mainstream to apply a
single evidential standard when assessing the effects of healthcare"
(P 223).
2.20 Medical training is now taking full account
of many aspects of healthcare, including much of what CAM regards
as important, with an increased emphasis on behavioural science,
communication skills, counselling, patient-doctor interaction
and patient-orientated practice and partnership. And many doctors,
despite constraints of time and unremitting pressure, practise
holistic medicine. Mr Wainwright Churchill, a traditional acupuncturist
and Chinese herbal medicine practitioner from whom we received
evidence, pointed out that this pragmatic approach to evaluating
CAM satisfies those who see advantages in CAM therapies but believe
their theoretical frameworks are invalid (P 256).
2.21 We have been told that even some CAM disciplines
with reasonable proof of efficacy are not yet being incorporated
into NHS practice. Like Sir Iain Chalmers, mentioned above, other
witnesses have suggested there is a non-pragmatic, deep-seated
prejudice held by some members of the conventional scientific
establishment against the entire CAM field and its philosophy.
Other evidence has, however, suggested that such prejudice is
diminishing steadily. And it is equally the case that the evident
hostility felt towards conventional medicine by some CAM practitioners
has had dangerous consequences in delaying unacceptably life-saving
conventional treatment. Many such practitioners have in the past
shunned the conventional scientific emphasis on rigorous testing
and denied the need for research 'because I know it works', or
because they believe testing procedures are biased and neglect
to measure important aspects of the CAM encounter (see Chapter
7). However, these extreme attitudes do seem to be changing, with
better communication between the practitioners of the two fields
and moves towards integrated medicine.
2.22 Evidence received during the course of our Inquiry
has made it clear that many conventional scientists and doctors
believe that the procedures, principles and efficacy of CAM should
be scrutinised by the methods of conventional science. Many CAM
practitioners resent this attitude, believing it to be indicative
of a lack of understanding and sympathy towards CAM within mainstream
healthcare. The fact that CAM and conventional medicine approach
health from different perspectives, has caused antipathy between
the two sides. Conventional medicine accuses CAM practitioners
of being "anti-scientific" and illogical and many CAM
practitioners accuse conventional medicine of taking an over-simplistic
view of illness and of neglecting important areas of a patient's
experience. However, in recent years, many practitioners in conventional
and complementary medicine have begun to take a more open-minded
view. In the conventional medical profession there is increasing
support for the view that medical practitioners and other healthcare
professionals should begin to work with CAM practitioners. Evidence
from the Academy of Medical Royal Colleges confirmed that "pressure
is now coming on the medical profession, to look around them and
see all other practitioners and make sure it all works well for
the patient" (Q 299). Integrated healthcare programmes are
thus beginning to develop.
2.23 During our Inquiry we visited the Marylebone
Health Centre which is an inner London NHS GP practice where GPs
and CAM therapists work together for the benefit of the patient
and where, through their collaboration, they have gained increasing
respect for each other's approaches (see Appendix 4). We have
been made aware of many similar collaborative ventures within
the NHS, both in primary and secondary care: this will be discussed
in Chapter 9. Agreement is also being reached over approaches
to research. The different philosophical approaches may make it
hard to design trials with methods that are acceptable to both
conventional and CAM practitioners, but as Chapter 7 discusses,
novel methods that are acceptable to conventional science and
that take into account concerns of both paradigms are being developed.
Finally, how important it is to understand and agree on the mechanisms
of actions behind a treatment will be considered in Chapter 4.
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