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| A good foot rub |
"There are a finite number of diseases in humans and they have patterns. Good, experienced physicians recognize these patterns quickly, especially for common diseases in primary care. Medical students and interns are notorious for taking hours to evaluate patients because they are learning and do not know what they are doing or how to interpret the information they are gathering. Of course naturopaths, with an education consisting of pseudo-medicines like homeopathy, acupuncture and hydrotherapy and no postgraduate training, never get the opportunity to see and learn these patterns. So it is not a surprise they take hours to see a patient. It is the hallmark of the inexperienced novice." ScienceBasedMedicine
"When the institution of medicine in the West incorporated scientific methods as the standard of determining which treatments were safe and effective, and in understanding disease, over time almost everything that constituted 'traditional Western medicine' was overturned." ScienceBasedMedicine
I've spent some of my medschool winter holiday surfing with mates in the sunshine, doing yoga on beaches & rooftops, eating well on home turf, and generally feeling revitalised as a consequence. I've also browsed the Holland & Barrett (health supplement shop) shelves to see what they're offering, and chatted with alternative health aficionados from as far afield as Costa Rica and Australia. As usual, these approaches we the public have to attempt to influence our own health are often quite distinct from the therapies we medics learn about in the classroom. I wrote an earlier review which reviewed and confirmed the position that behaviours (e.g. smoking, activity levels, obesity) in a developed country (the US) far outweigh the importance of medical care (by perhaps 4x) for our health. So again setting medical care aside, I here aim to explore what alternative therapies have to offer to this model.
As we begin, we should consider the limitations that (1) research may not have been funded into all of these alternative approaches (large companies rarely stand to make a mint from it), (2) effectiveness and safety are important: a lack of research into for effectiveness may also imply a lack of research into risks.
Review of nutritional supplements à la Holland & Barrett (£700m market, UK; £400m in sports nutrition)
Now, there are perhaps 50,000 licensed drugs in the UK that you can get from your doctor or pharmacy, and a whole set more of supplements, herbal medicines etc. that you can buy too. Some of these do work - I was surprised. Not dramatically, but they may help. Some of them don't help. Here are a few highlights:
>Common colds: Zinc reduces length of common colds by 1 day (the average cold duration is perhaps 8 days), and is protective as a prophylactic treatment; in high physical stress individuals (e.g. marathon runners), Vitamin C reduces cold risk by 50% (NHS Choices 2011)
>Joint pain: glucosamine minimally reduces pain (NHS Choices 2011), omega-3 reduces pain in rheumatoid arthritis - and is contained in cod liver oil (Kremer et al., 1999)
>Skin firmness: hydrolysed collagen (Borumand, 2014)
>Infectious diarrhoea, IBS, lactose intolerance, and potentially necrotising enterocolitis: probiotics (NHS overview)
>IBS: enteric coated peppermint oil capsules (dry tea bags have lower levels of menthol oil in any case, and if present in the stomach this can relax the cardiac sphincter, leading to GORD)
>Chronic venous insufficiency and oedema: grape seed extract (University of Maryland)
>Hypertension & heart disease: Co-enzyme Q10 improves outcomes (DiNicolantonio et al., 2015)
>Slimming: vinegar (Kondo, 2009)
No effects (or no evidence of effects based on current research): Ginkgo & ginseng (dementia & cognitive decline), echinacea (common cold); chondroitin (joints), omega-3 fish oil (CVD, brain function) (NHS Choices 2011). Also no strong evidence exists for coconut oil (various claims), turmeric (anti-inflammatory), oral aloe vera (diabetes), cranberry tablets (UTI), myrrh (mouth ulcers).
Unsafe but effective (many things!): e.g. in slimming: guar gum, ephedra herb/ephedrine, tapeworm pills, laxatives (NHS Choices 2011)
The **effective** complementary therapies for specific diseases
Some of these complementary therapies also work - though, only for a very small range of medical conditions. Yet lots of the complementary therapies don't work at all to resolve health problems:
>Accupressure stimulation of point PC6 (those little metal travel wristbands) reduces postoperative nausea and vomiting - this has equivalent effects to antiemetics according to a Cochrane review
>Aromatherapy: ginger and blended ginger oil reduces postoperative nausea when inhaled (ginger is also recommended by NICE for morning sickness); lemon balm oil reduces dementia-related agitation when applied to skin
- Naturopathy - based on a belief in 'vitalism' or a life-force. Consists of herbalism/accupuncture/reiki/colonic irrigation/hydrotherapy/energy therapy. There is no evidence that the doctrine confers benefit beyond the subcomponents listed above Quackwatch
- Energy/touch therapy, e.g. Reiki, Healing Touch, Therapeutic touch, biofield, distant healing - inconclusive evidence in pain, placebo only, no reliable evidence.
- VortexHealing - no evidence (and no evidence of anyone seeking evidence!)
A new approach to wellbeing and stress reduction: valuing non-medical health interventions
As we read above, when it comes to treating disease, nutritional/herbal supplements and 'alternative' therapies are only effective in a rare minority of cases of disease. But, this might be to miss the point slightly. How do we qualify the wellbeing we get from a good foot rub, a pleasant-smelling room, a calm practitioner on a beautiful country retreat, a day in the surf, a revitalising meal or drinking session with a group of friends, the attention and engagement with someone who is confident that they're working with a therapy that has aeons of history, or a silent meditation in a giant religious building?
Extraordinarily, wellbeing extends lives. Wellbeing incorporates features of low negative affect (emotion), high positive affect, sense of purpose in life and satisfaction, among other factors (Maccagnan et al., 2015). High wellbeing (compared to low wellbeing) is estimated to improve life expectancy by 6 years when controlling for exercise, smoking and alcohol consumption (Diener & Chan, 2011 in Maccagnan et al., 2015). Stressful social circumstances are also considered to be responsible for 20% of early deaths (see previous article). Wellbeing is correlated with healthy behaviours (not smoking, physical exercise, healthy diet, sun protection) and independently reduces risk of stroke and the common cold (Maccagnan et al., 2015). We also know that positive emotion reduces cortisol levels, and improves neuroendocrine, inflammatory and cardiovascular responses (Ong, 2011; Maccagnan et al., 2015). So - wellbeing/stress reduction constitutes a relevant proxy target for reducing the burden of ill health.
The mechanism of wellbeing extending lives: could it be positive connectedness? A consistent feature of alternative therapy is of social connectedness with the practitioner - an important UK topic given the prevalence of social disconnectedness and perceived isolation (e.g. affecting 1/3 of the elderly population). Now come my conjectures: some of these alternative therapies may have their persistent appeal and mechanism beyond placebo through the process of doing something absorbing, pleasurable and connecting with a confident, caring professional 'friend', be that talking, experiencing a physical therapy by a practitioner, laughter. This complete absorption in a state of consciousness outside ourselves may be a beneficial mechanism in other activities too, be that a shared consciousness in a group of friends, an absorbing 'presentness' in the physical world (for example waves crashing over your head). Somehow, I suggest, the process of connecting positively with others and becoming absorbed in experiences quite different from our everyday stresses distract us beneficially from the internal monologue, provide perspective, and enhancing wellbeing.
So should we doctors be recommending alternative therapies? Cost-aside, if a non-medical therapy does you no harm and makes you feel good, it likely has health value (money and time permitting). The longer the feeling lasts the more worthwhile it is; in our high-stress and low-connectedness lives the more absorbing and personally connecting it is better. An optimal schedule could perhaps even be determined for such therapies, based on how long the benefits endure, e.g. one article on massage draws from experiences in psychological therapy "increasing time intervals between sessions (e.g. 1, 4, 10 intervening days) is more effective over the long-term compared to a uniform schedule (e.g. 5, 5, 5 intervening days) of treatment delivery" (Tsao, 2007). In a roundabout way, this offers me some theoretical context for not deriding, but in fact recommending such alternative therapy to my patients, in the right circumstances.
£4,000 p.a. is the average value to a UK citizen of doing regular physical exercise
£55,000p.a. is the average value to a UK citizen of meeting friends once or twice a month
£85,000 p.a. is the average value to a UK citizen of getting together with friends every day or nearly every day
Similarly, taking holidays significantly increases wellbeing - and accounts for a large amount of real spending:
£25bn is spent annually on domestic tourism (i.e. by Brits in Britain)
£39bn is spent annually on overseas tourism (i.e. by Brits abroad)
£117bn is spent annually on leisure by Brits
£151bn is spent annually on healthcare in the UK across public and private sectors.
If we compare these annual expenditures on leisure and tourism (£181 billion per year) to the total spend on alternative medicine (a total of approximately £5 billion per year), we can see that the amounts spent on alternative medicine are comparatively small.
This should serve to temper the resistance of the medical community to these alternative therapies. Since much of that leisure and tourism money is going towards wellbeing-focused activities, and much of alternative therapy may be considered similar wellbeing-focused activity, we should not undermine those alternative therapies any more than we should clamour to undermine people's choice to go on holiday. Only, perhaps, when those alternative therapies are proposed as a *substitute* (rather than a supplement) for effective medical care.
A postscript - religion and meditation as a wellbeing activity (£1 billion annual spend on Church of England)
Now I'm in my thirties, I've joined the age that one religious leader shuffled on) - so I want to give a brief nod to religious affiliation (or lack of it) as a health consideration.
Data suggests religion also improves wellbeing. This may be through the mechanisms of (1) social support, (2) a framework providing unique meaning for one's life, and (3) mutual respect regardless of personal circumstances. In particular, it buffers against the effects of economic deprivation - reported across US and NZ studies. (Hoverd & Sibley, 2013). Mindfulness-based meditation has also reported small to moderate effects on psychological stress (Goyal et al., 2013).
Light relief to finish - some alternative therapy is not beyond deserving ridicule
>Common colds: Zinc reduces length of common colds by 1 day (the average cold duration is perhaps 8 days), and is protective as a prophylactic treatment; in high physical stress individuals (e.g. marathon runners), Vitamin C reduces cold risk by 50% (NHS Choices 2011)
>Joint pain: glucosamine minimally reduces pain (NHS Choices 2011), omega-3 reduces pain in rheumatoid arthritis - and is contained in cod liver oil (Kremer et al., 1999)
>Skin firmness: hydrolysed collagen (Borumand, 2014)
>Infectious diarrhoea, IBS, lactose intolerance, and potentially necrotising enterocolitis: probiotics (NHS overview)
>IBS: enteric coated peppermint oil capsules (dry tea bags have lower levels of menthol oil in any case, and if present in the stomach this can relax the cardiac sphincter, leading to GORD)
>Chronic venous insufficiency and oedema: grape seed extract (University of Maryland)
>Hypertension & heart disease: Co-enzyme Q10 improves outcomes (DiNicolantonio et al., 2015)
>Slimming: vinegar (Kondo, 2009)
Unsafe but effective (many things!): e.g. in slimming: guar gum, ephedra herb/ephedrine, tapeworm pills, laxatives (NHS Choices 2011)
Review of complementary and alternative therapies for diseases (£4.5 billion market, UK)
The **effective** complementary therapies for specific diseases
Some of these complementary therapies also work - though, only for a very small range of medical conditions. Yet lots of the complementary therapies don't work at all to resolve health problems:
>Accupressure stimulation of point PC6 (those little metal travel wristbands) reduces postoperative nausea and vomiting - this has equivalent effects to antiemetics according to a Cochrane review
- Acupuncture: recommended by NICE for chronic lower back pain, tension-type headaches, migraine. The location of the needles may not matter, and the effect size is small.
>Alexander technique: recommended by NICE for improving movement in Parkinson's disease
>Osteopathy and chiropractic - as good as conventional therapy for persistent lower back pain
>Traditional Chinese medicine - I've only found effectiveness as an adjunct to Western medicine in schizophrenia. Extraction and purification of artemisinin (antimalarial) has recently made the technology transfer to Western medicine - reinforcing that efficacy is a prerequisite for this transition, but also suggesting to me that it's worth waiting until careful research has bottomed out which of the thousands of traditional Chinese medicines actually work without causing harm.
>Ayurveda - yoga is recommended for lower back pain (Cochrane), may also help asthma symptoms (Cochrane).
>Ayurveda - yoga is recommended for lower back pain (Cochrane), may also help asthma symptoms (Cochrane).
The **ineffective** complementary therapies (i.e. they are not effective for any specific diseases):
Here be charlatans:
- Homeopathy - no evidence
Here be charlatans:
- Homeopathy - no evidence
- Reflexology - no evidence, minor effect noted on urinary symptoms in one study of MS patients
- Massage - no strong evidence in lower back pain or for neck pain, pressure ulcers, cancer pain. Any benefits tends to be transient. Cochrane ; Cochrane (and hence you won't find NHS physios doing it)
- Traditional Chinese medicine (TCM) There is no strong evidence from Cochrane of effectiveness of any other Chinese herbal medicine for any condition in isolation (e.g. resistant hypertension, vasomotor menopausal symptoms, hypothyroidism, oesophageal cancer, and many more). Note that TCM is based on pre-scientific philosophy of (a) yin/yang which offers no predictive power; (b) energy meridians for which no evidence exists, (c) the Galen-like five-phase theory of wood/metal/earth/fire/water to describe bodily function ScienceBasedMedicine.
- VortexHealing - no evidence (and no evidence of anyone seeking evidence!)
A new approach to wellbeing and stress reduction: valuing non-medical health interventions
As we read above, when it comes to treating disease, nutritional/herbal supplements and 'alternative' therapies are only effective in a rare minority of cases of disease. But, this might be to miss the point slightly. How do we qualify the wellbeing we get from a good foot rub, a pleasant-smelling room, a calm practitioner on a beautiful country retreat, a day in the surf, a revitalising meal or drinking session with a group of friends, the attention and engagement with someone who is confident that they're working with a therapy that has aeons of history, or a silent meditation in a giant religious building?
Extraordinarily, wellbeing extends lives. Wellbeing incorporates features of low negative affect (emotion), high positive affect, sense of purpose in life and satisfaction, among other factors (Maccagnan et al., 2015). High wellbeing (compared to low wellbeing) is estimated to improve life expectancy by 6 years when controlling for exercise, smoking and alcohol consumption (Diener & Chan, 2011 in Maccagnan et al., 2015). Stressful social circumstances are also considered to be responsible for 20% of early deaths (see previous article). Wellbeing is correlated with healthy behaviours (not smoking, physical exercise, healthy diet, sun protection) and independently reduces risk of stroke and the common cold (Maccagnan et al., 2015). We also know that positive emotion reduces cortisol levels, and improves neuroendocrine, inflammatory and cardiovascular responses (Ong, 2011; Maccagnan et al., 2015). So - wellbeing/stress reduction constitutes a relevant proxy target for reducing the burden of ill health.
The mechanism of wellbeing extending lives: could it be positive connectedness? A consistent feature of alternative therapy is of social connectedness with the practitioner - an important UK topic given the prevalence of social disconnectedness and perceived isolation (e.g. affecting 1/3 of the elderly population). Now come my conjectures: some of these alternative therapies may have their persistent appeal and mechanism beyond placebo through the process of doing something absorbing, pleasurable and connecting with a confident, caring professional 'friend', be that talking, experiencing a physical therapy by a practitioner, laughter. This complete absorption in a state of consciousness outside ourselves may be a beneficial mechanism in other activities too, be that a shared consciousness in a group of friends, an absorbing 'presentness' in the physical world (for example waves crashing over your head). Somehow, I suggest, the process of connecting positively with others and becoming absorbed in experiences quite different from our everyday stresses distract us beneficially from the internal monologue, provide perspective, and enhancing wellbeing.
So should we doctors be recommending alternative therapies? Cost-aside, if a non-medical therapy does you no harm and makes you feel good, it likely has health value (money and time permitting). The longer the feeling lasts the more worthwhile it is; in our high-stress and low-connectedness lives the more absorbing and personally connecting it is better. An optimal schedule could perhaps even be determined for such therapies, based on how long the benefits endure, e.g. one article on massage draws from experiences in psychological therapy "increasing time intervals between sessions (e.g. 1, 4, 10 intervening days) is more effective over the long-term compared to a uniform schedule (e.g. 5, 5, 5 intervening days) of treatment delivery" (Tsao, 2007). In a roundabout way, this offers me some theoretical context for not deriding, but in fact recommending such alternative therapy to my patients, in the right circumstances.
Alternatives to the alternative: economic data on non-medical approaches to wellbeing
There are clearly lots of things we spend time and money on that affect wellbeing, including the alternative therapies indicated above.
When one study asked Brits to quantify the value of various social experiences (using a neat methodology of translating social experiences into financial terms by identifying the incremental income gain that would offer the same increase in wellbeing):
£2,000 p.a. is the average value to a UK citizen of regularly attending a social group, e.g. a lunch club£4,000 p.a. is the average value to a UK citizen of doing regular physical exercise
£55,000p.a. is the average value to a UK citizen of meeting friends once or twice a month
£85,000 p.a. is the average value to a UK citizen of getting together with friends every day or nearly every day
Similarly, taking holidays significantly increases wellbeing - and accounts for a large amount of real spending:
£25bn is spent annually on domestic tourism (i.e. by Brits in Britain)
£39bn is spent annually on overseas tourism (i.e. by Brits abroad)
£117bn is spent annually on leisure by Brits
£151bn is spent annually on healthcare in the UK across public and private sectors.
If we compare these annual expenditures on leisure and tourism (£181 billion per year) to the total spend on alternative medicine (a total of approximately £5 billion per year), we can see that the amounts spent on alternative medicine are comparatively small.
A postscript - religion and meditation as a wellbeing activity (£1 billion annual spend on Church of England)
Now I'm in my thirties, I've joined the age that one religious leader shuffled on) - so I want to give a brief nod to religious affiliation (or lack of it) as a health consideration.
Data suggests religion also improves wellbeing. This may be through the mechanisms of (1) social support, (2) a framework providing unique meaning for one's life, and (3) mutual respect regardless of personal circumstances. In particular, it buffers against the effects of economic deprivation - reported across US and NZ studies. (Hoverd & Sibley, 2013). Mindfulness-based meditation has also reported small to moderate effects on psychological stress (Goyal et al., 2013).
So - although this won't redirect my considered approach to faith, I might therefore also think to enquire in consultation (alongside smoking, alcohol, exercise, social support) about patients' perceived stress and patients' participation in regular religious or meditative activities. I may even suggest it among the options they have available when they're looking to improve their health.
Homeopathic A&E (by Mitchell & Webb)
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ReplyDeleteName: Dr. Osaro Enoma
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