It wasn’t talking to the therapists that made me reconsider, because I knew they would be positive about their treatments; it was talking to the doctors and professors. People like Professor Bernadette Carter, of the University of Central Lancashire, Professor Edzard Ernst, of Peninsula Medical School in Exeter, Dr Mike Cummings, of the British Medical Acupuncture Society, or Professor Paul Dieppe, of Bristol University. All trained in conventional medicine. All sober, thoughtful individuals with not a scented candle between them. All saying that we need to think hard about complementary medicine and to think with an open mind.
These words were rattling around my head as I worked on a book, The Whole Story: Alternative Medicine on Trial?, investigating the crunch question about complementary medicine: how do we know what works? What kind of research do we need, how should it be designed and what type of evidence would make us sure? Looking back through my notes I found a sentence I wrote shortly after I started writing my Body&Soul column, What’s the Evidence?, in which I evaluate whether alternative medicine really works. “What’s the Evidence? looks at complementary therapies through the eyes of Western medicine.” That was, and is, true, but I have come to question the scope of that vision. There are good arguments that Western medical research is blinkered with respect to complementary therapies.
At the heart of any debate about whether treatments are effective is evidence. The thrust of modern practice is towards evidence-based medicine — the best treatments being those with the biggest body of high-quality scientific research to support them. But as any barrister knows, evidence is open to interpretation. Was it collected properly? How was it analysed? Did the investigators miss a crucial fact? I was prepared for this when I started writing What’s the Evidence?, hunting down what, if any, research data there was to support the claims of many different complementary therapies. I knew it wouldn’t be clear-cut and that experts would disagree with each other. What I didn’t expect was so much debate around the very nature of clinical research itself.
As a trained biochemist who has also worked as a research scientist, I know that clinical trials are a complex set of compare-and-contrast exercises. Collect a set of patients, split them into two or more groups, give one the experimental treatment and the others a known therapy or a placebo, and see how they compare. This works well for drugs and all licensed pharmaceuticals have to go through many trials of this kind.
Problems start to appear, though, when you try to apply a drug-testing regime to a non-drug based treatment. Take physiotherapy, for example. A key element of a drugs trial is that the doctors giving the medication do not know whether they are handing out the experimental drug or merely a sugar pill. With physiotherapy it is impossible for the therapist not to know what type of treatment he or she is administering, instantly a potential source of bias. T he treatment also changes over time. A drug is a drug is a drug, but physiotherapists will adjust the treatment they give depending on the condition of the patients: as they improve, so the exercises change. So any trial of physiotherapy is not looking at a single drug but at a changing treatment regime dependent on the state of the patient.
Then there is the issue of the relationship between the therapist and the patient. This is clearly an element of physiotherapy; a patient is likely to work harder for a therapist they get on with rather than one they take exception to. But this is brought into stark relief when considering “talking therapies”, such as psychiatric counselling. Here the success of the treatment depends heavily on the individual relationship between the psychiatrist and the patient. That will vary dramatically from patient to patient. A clinical trial produces an average answer — 70 per cent of patients experienced a 40 per cent improvement. What, though, is an average therapeutic relationship? Where the personal relationship is good, the patients might have a big improvement but a poor one could possibly make things worse. With such a wide range of results, an average is virtually meaningless.
Clinical trials also struggle when more than one thing is going on at a time; what’s known as a complex intervention. A visit to the GP can be a complex intervention. You might come away with a prescription and advice to cut down on greasy chips, and to get more exercise. All three might impact on your problem, but in a clinical trial these will be looked at one at a time. Doing all of them at the same time makes it difficult to work out which is having what impact.
All these examples — physiotherapy, psychiatry and a trip to the GP — are common medical practices and all pose problems for standard clinical trials. None of these problems is new and medical researchers consider them in designing their studies. The difficulties are, however, writ large when researching complementary therapies. A homoeopath, for example, starts with a detailed inquiry into your life and habits, and tailors the treatment to your individual needs. The homoeopath would also work to develop a relationship with you and the treatment they offer changes over time. They might also advise on diet or lifestyle. So in one treatment you have the elements that clinical trials struggle with: individual relationships, evolving treatments and a complex intervention. These are some of the reasons why many researchers argue that the standard tools of clinical research are poor at examining complementary medicine. It doesn’t mean it’s impossible, but applying a drugs trial to an acupuncture session is unlikely to produce useful data.
However, as researchers tackle complementary therapies, a number of tantalising results are beginning to emerge. A pilot study in 2001 by Professor Bernadette Carter, at the University of Central Lancashire, backs the idea that Bowen therapy, a form of manipulation, can significantly improve frozen shoulder, a condition that doctors and physiotherapists agree takes many months to heal and for which they can do little. Or take a small trial of reflexology for childhood constipation, conducted in 2000, by Jenny Gordon, of Napier University in Edinburgh: results suggest that it might help with this otherwise intractable problem. A big study published before Christmas showed acupuncture to be effective for arthritis of the knee. The team of researchers, from the University of Maryland School of Medicine in the US, included 570 patients in the trial which was published in the reputable Annals of Internal Medicine.
It’s important to remember, though, that trials also produce negative results. That’s part of the process of working out what is effective and what is not. There’s also the issue of the unscientific explanations offered for how complementary therapies might work — such as ultra-diluted chemicals having a healing effect in homoeopathy or areas on your feet reflecting the state of your body’s organs in reflexology.
But because we don’t understand how a thing works doesn’t make it ineffective. We should not reject these therapies because they are outside medical orthodoxy and their explanations are unscientific. We should approach them with an open mind, develop the right tools to study them and, if they turn out to be effective, use them. This does not mean I’ve become a convert to complementary therapies. I’m a scientist, swayed by evidence, and not assertion.
Of all the the arguments for exploring complementary therapies properly, two stand out. Last October the Welsh Secretary, Peter Hain, floated the idea of providing complementary therapies on the NHS, apparently with support from Tony Blair. NHS funds are not a bottomless pit, so there is the problem of deciding what treatments to allow and for which conditions. That has to be done on the basis of evidence, not just “a friend of mine says treatment X is brilliant”. Proper research could also produce a prize that science itself should value — a better understanding of medicine as a whole.
Toby Murcott’s new book, The Whole Story: Alternative Medicine on Trial?, published by Macmillan (£16.99), is available from Times Books First at £13.59, plus p&p, call 0870 1608080, or visit www.timesonline.co.uk/
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