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At the heart of general practice since 1960

A practical guide to complementary medicine

GP Dr Richard Halvorsen gives a personal view on the use of alternative therapies to treat common ailments

Orthodox medicine is second to none for many acute and life-threatening conditions. But it serves us less well for some of the chronic, debilitating conditions such as low back pain, osteoarthritis and IBS that we see so much of in general practice.

Twenty years' experience has taught me that treatments known as complementary or alternative medicine can fill the therapeutic vacuum. There is mounting evidence to support my clinical experience.

The therapies I most often use or recommend are 'the big five' – osteopathy, chiropractic, acupuncture, homoeopathy and herbal medicine – along with dietary manipulation and/or nutritional supplementation.

Let's take a brief look at the evidence base for these treatments.

Osteopathy and chiropractic

These two manipulative therapies are broadly similar. Perhaps they should not even be considered alternative as they have been statutorily regulated since 2000.

Though both are widely used for low back pain, the evidence is not strong, being best for the use of osteopathy in acute and subacute low back pain. The RCGP guidelines recommend considering manipulation for patients who do not recover quickly.

Other musculoskeletal conditions are frequently treated, but without good evidence of effectiveness. However, patients' experience would suggest benefit in some people.

Acupuncture

This 2,000-year-old Chinese therapy, involving inserting needles under the skin, is gaining popularity with both patients and doctors in the UK. There is good evidence for its effectiveness in helping low back pain, neck pain, OA of the knee, prophylaxis of migraine and chronic headaches, and nausea and vomiting (I often use it for morning sickness).

Homoeopathy

This is the most controversial of the major complementary and alternative therapies, despite there being several homoeopathic hospitals within the NHS. Its advocates and critics hold equally strong views. Many find the use of submolecular dilutions implausible, but the lack of an understandable mechanism of action is not proof of ineffectiveness. A meta-analysis by Linde et al in The Lancet in 1997 concluding that the likelihood of clinical benefit from all RCTs was 2.45 times that of placebo (statistically significant with confidence intervals of 2.05 to 2.93) attracted inevitable criticism.

Homoeopathy has evidence of efficacy for hay fever, asthma, influenza, URTI and glue ear. I often use homoeopathic remedies for self-limiting conditions in children, especially when there is pressure to prescribe from parents. Homoeopathy is certainly safer than unnecessary antibiotics.

Herbal medicine

This has the strongest evidence base of all complementary therapies. This is not surprising if one remembers that many conventional drugs, such as digoxin, morphine, quinine and pilocarpine, are derived from naturally occurring plants. The effectiveness of the following herbal remedies is supported by systematic analyses: St John's wort for depression; ginkgo biloba for dementia and intermittent claudication; saw palmetto for BPH and horse chestnut for chronic venous insufficiency (Ernst E. BMJ 2000;321:395-6). A double-blind RCT in the BMJ in 2005 showed St John's wort to be as effective as paroxetine (20 to 40mg/day) but with fewer side-effects.

Conditions I treat with complementary therapies

Osteoarthritis

I often use acupuncture, which I find especially helpful in OA of the knee. The herb devil's claw (400 to 500mg of dried extract tds) has been shown to relieve musculoskeletal pain in several RCTs. Glucosamine (500mg tds), a substance naturally occurring in cartilage, is probably even more effective when combined with chondroitin (400mg tds). Magnetic bracelets were shown in a BMJ RCT to relieve the pain of OA of the knee and hip.

IBS

This is often a challenging condition to treat. Both hypnotherapy and acupuncture can reduce symptoms. Most RCTs report beneficial effects from peppermint oil, which is listed in the BNF. Autogenic training, a deep relaxation technique, can help, particularly where stress contributes to symptoms. Some patients, but only some, show an impressive improvement with exclusion diets.

Migraine

The majority of double-blind placebo-controlled RCTs demonstrate the efficacy of feverfew in migraine prophylaxis; the usual dose is 50 to 140mg of the powdered extract daily in divided doses. Meta-analyses suggest benefit from both relaxation and biofeedback. Acupuncture is as effective a prophylactic as ß-blockers. Excluding foods that trigger an attack can be extremely useful; however, finding the offending foods is largely trial and error as there are no reliable diagnostic tests.

Menopausal symptoms

Several RCTs have confirmed the effectiveness of the herb black cohosh (8mg of the standardised extract daily in divided doses) in relieving menopausal symptoms. Following a few recent case reports of liver damage following the use of this herb, I avoid using it in patients with a history of liver disease. St John's wort (300mg tds) is particularly useful when psychological symptoms predominate.

Soy protein (20 to 60g daily) reduced hot flushes in several RCTs; this effect is probably a result of its high content of phytooestrogens. Concern that these plant-derived oestrogens may increase the risk of breast cancer is in part allayed by population studies suggesting a protective effect. Relaxation training can also reduce symptoms.

Availability of treatments

• Osteopaths and chiropractors are

regulated and so GPs are not responsible for the outcome of any referral.

• Choose a medical acupuncturist who is a member of the British Medical

Acupuncture Society (BMAS), or a lay acupuncturist who is accredited by the British Acupuncture Council (BAcC).

• Medical homoeopaths can be found via the British Homeopathic Association (www.trusthomeopathy.org).

• Herbal medicine practitioners have

diverse backgrounds, but are working

towards statutory regulation. The best bet is to go via the National Institute of Medical Herbalists (tel. 01392 426022).

All the herbal and homoeopathic remedies are available OTC at a pharmacist. Most of the commonly used ones will be on the shelves, but all of them can be ordered in.

Both herbal and homoeopathic remedies are prescribable on FP10s, though herbal remedies are unlicensed. The EMIS drug database contains scores of homoeopathic remedies, accessed by entering * before the remedy name, as well as a few herbal and nutritional supplements.

Where can GPs learn more?

• British Institute of Musculoskeletal

Medicine (www.bimm.org.uk) offers several courses suitable for GPs.

• British Medical Acupuncture Society (www.medical-acupuncture.co.uk) runs an excellent introductory course over two weekends.

• The Faculty of Homeopathy (www.trusthomeopathy.org) runs

postgraduate courses for doctors.

• A week-long course, Integrating

Complementary Therapies in Everyday

Practice, is being held at the Royal London Homeopathic Hospital from 16 to 20 April this year. For further information telephone 020 7391 8823/4.

• The Desktop Guide to Complementary and

Alternative Medicine: an evidence-based approach. Editor Professor Edzard Ernst,

published by Mosby, 2005 (second edition), is an excellent critical look at the evidence for and against various complementary and alternative therapies for common medical problems.

Richard Halvorsen is a GP trainer and appraiser in London and has studied both homoeopathy and acupuncture -– he has incorporated complementary therapies into his NHS general practice

Competing interests None declared

key points

• St John's wort is as effective as paroxetine for depression and better tolerated

• GPs can learn enough acupuncture to start safely practising after a two-weekend course

• There is good evidence for the effectiveness of many herbal remedies

• GPs can prescribe homoeopathic preparations on EMIS

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