What are complementary and alternative treatments?

Complementary and alternative medicine:

• tends to be holistic and includes therapies from various historical and cultural backgrounds
• often needs you to take an active part in your own treatment with lifestyle changes (e.g. diet, exercise, meditation or psychological exercises)
• features therapies that are diverse in nature and origins. The ways in which these therapies are thought to work are also diverse, although many are based on the idea of enabling your body’s ability to heal itself.

Conventional medicine:

• mainly focuses on understanding and correcting the underlying problems that are causing your symptoms. In many instances these aren’t fully understood, although there have been major advances in recent years, especially in rheumatoid arthritis, with much of the research being funded by Versus Arthritis
• is often criticised for treating your condition and not you as a person, expecting you to accept the diagnosis and treatment
• is increasingly recognising the importance of your involvement and choice in your treatment, and many argue this is due to the influence of complementary and alternative medicine approaches.

What’s similar?

Both styles of treatment emphasise the quality of the relationship between you and the practitioner. A good relationship is important for a successful outcome. Often, both conventional and complementary and alternative medicine approaches are used – this is called integrated medicine.

People use complementary and alternative medicine because:

• they wish to use treatments that are more natural and help them feel more in control
• they have persistent pain
• they have concerns about the side-effects of medication
• their symptoms aren’t fully controlled by conventional medicine.

Because there are many types of complementary and alternative medicine, it’s impossible to generalise about whether they work or not. Effectiveness might be judged by whether you feel better but it also may relate to measurable improvement in your condition or general well-being.

Generally speaking, complementary and alternative medicine is relatively safe, although you should always talk to your doctor before you start treatment. There are some risks associated with specific therapies, for example some herbal therapies may have significant side-effects or may interact with prescribed medication.

In many cases the risks associated with complementary and alternative medicine are more to do with the therapist than the therapy. This is why it’s important for you to go to a legally registered therapist or one who has a set ethical code and is fully insured.

Generally speaking, the NHS does not provide complementary and alternative therapies for people with arthritis or related conditions. However, there is a lot of local variation, so you may need to ask.

Some NHS organisations employ chiropractors and osteopaths. Many NHS physiotherapists use acupuncture, and some occupational therapists, clinical psychologists and nurses are trained in relaxation or meditation techniques.

The Royal London Hospital for Integrated Medicine (RLHIM) in central London is an NHS centre for integrated and complementary medicine. You need to be referred by your GP.

If you have private health insurance, it may cover complementary and alternative therapy so check with your insurer.

It’s hard to say for sure whether complementary and alternative therapies would work for you, as everyone responds differently to the treatments. Many of these therapies require your active participation and a certain amount of belief in the possible outcome. This is the placebo effect – the psychological hope and belief that a treatment will help.

A lot of scientific research is aimed at finding out whether changes in patients’ conditions are due to natural variations in the condition, or due to what are called ‘non-specific effects’ such as a belief that the treatment will work. However, if you find that complementary therapies work for you then this may be a more importanr consideration than how or why the therapy works.

There are some key points to consider if you’re thinking about using complementary and alternative medicine.

• What am I hoping to achieve? Pain relief? More energy? Better sleep? Reduction in medication?
• Who is the therapist? Are they qualified, registered and insured?
• Am I happy with the therapy? It’s not much use going to an acupuncturist if you have a needle phobia! Or seeing a therapist who’s going to advise drastic lifestyle changes that you won’t be able to stick to.
• Are there any risks? Are they safe?
• What are the financial costs?
• Is there any evidence for their effectiveness?

What do I need to do?

• Be realistic – There are no miracle cures for arthritis (be suspicious of anyone, or any website, promising a miracle cure).
• Tell your doctor – Many people assume that their doctors will disapprove, but in fact most doctors will be interested to find out what has helped you. Some therapies, especially herbs, can interfere with prescription medicines or cause abnormal blood tests. It’s important that you discuss their use with your doctor before starting treatment.
• Keep taking your prescribed medication, unless advised otherwise by your doctor – If you’re hoping to reduce your prescribed medication, don’t do so suddenly. The general rule is to continue the prescribed medicine until you start to improve, then gradually reduce it. Some medications are long-acting, so you may not notice the effects of reducing it immediately. This is another reason to talk to your doctor.

There are two main groups of complementary and alternative therapists: those who are legally registered and those who aren't:

Osteopaths and chiropractors are legally recognised professionals just like doctors, nurses, occupational therapists and physiotherapists. This means their training is regulated by a body set up by the government and by law they must register with this body in order to practise. They must be insured, and they can be struck off and prevented from practising if they’re incompetent or unethical.

There are proposals for legal regulation of medical herbalists and acupuncturists, but at the time of writing these practitioners aren’t legally registered. If you consult a practitioner who is not a member of a legally registered health profession, they should:

• have an agreed code of ethics
• be insured in case something goes wrong with your treatment
• be a member of an organisation that promotes self-regulation and doesn’t make unreasonable claims about their treatments.

Where can I find a therapist?

For legally registered therapists, you can contact the appropriate regulatory body.

For therapists not currently required to register by law, such as aromatherapists, Alexander technique teachers and massage therapists, there’s a voluntary regulatory body, the Complementary and Natural Healthcare Council (CNHC). The CNHC can provide details of therapists registered with them.

Research into complementary and alternative medicine is continuing all the time. We previously gathered research for two detailed authoritative reports on the following subjects:

• Our Complementary and alternative medicines for rheumatoid arthritis, osteoarthritis and fibromyalgia (PDF 1.4 MB) looks at compounds that are taken by mouth and applied to the skin.
• Our Complementary and alternative therapies for rheumatoid arthritis, osteoarthritis, fibromyalgia and lower back pain (PDF 2.3 MB) looks at treatments delivered by complementary therapists, such as acupuncture, meditation and yoga.

In the reports the complementary and alternative treatments were scored an effectiveness rating between 1 (lowest) to 5 (highest). The treatments were also categorised according to their safety.

It has previously been shown that fish oils, which contain abundant amounts of omega-3 fats, are a useful complementary therapy for patients with rheumatoid arthritis. We're supporting research based at Queen Mary University of London to understand how omega-3 fats in these oils exert their anti-inflammatory and healing effect. The results of this study could pave the way for new treatments in the future.

We're also supporting research at the University of Southampton, looking at whether different aspects of patients' treatment experience influence treatment success, and whether this varies depending on the type of treatment. This project will focus on patients receiving complementary therapies such as acupuncture and osteopathy, as well as physiotherapy. The results will ultimately allow patients to receive therapies in a way which means they have the greatest chance of success.

Compounds included in the report:

• are taken by mouth or applied to the skin
• have been tested in at least one RCT
• could be sourced in June 2011 from a national high-street retailer or through a UK-based internet supplier (overseas retailers were included only where an address and contact details were provided and their website stated that they ship to the UK).

The information on compounds is based on evidence from randomised controlled trials (RCTs). Evidence was found and evaluated by experts in the fields of rheumatology, complementary medicine and nutrition, and it has also included input from a patient representative. They considered trials where the compound was compared with a conventional treatment or a placebo (a dummy pill which doesn’t contain any active ingredient).

They only found evidence from RCTs for 31 compounds. Many of those studied have only been tested in a single or just a few studies, which makes it difficult to be sure whether they work or not.

We’ve also only included trials in which results have been analysed on an ‘intention to treat’ basis. This means that if a participant is randomly allocated to receive ‘treatment A’, their results are analysed as if they received that treatment (even if they decided not to take the medication). This is the best method of analysis to avoid bias.

If several trials have been conducted, we’ll often summarise the information from a published review, including the proportion of participants withdrawing and the main reported side-effects from individual studies.

What are randomised controlled trials (RCTs)?

RCTs give the best type of evidence on whether any treatment works. Participants (people taking part in trials) in RCTs are randomly allocated to one treatment group. At the end of the study, results are evaluated according to whether participants on a new treatment, for example, had a better outcome than participants on an existing treatment.

RCTs of complementary medicines often use a placebo to allow the effect of treatment to be compared when the patients don’t know which treatment they received.

Types of study where participants choose the treatments they take are more difficult to interpret than RCTs because participants with more serious disease might have opted for one treatment and others with milder disease another. Also, participants who choose their treatment do so because they believe it’ll be effective, which might influence how they respond to it and evaluate it.

The complementary and alternative medicines assessed for the report have been given an effectiveness score of between 1 and 5 and a safety score of green, amber or red.

How was effectiveness measured?

Effectiveness is measured by improvements in:

• pain
• movement
• general well-being.

Based on the evidence available from clinical trials and other supporting information, each complementary medicine has been put in one of five categories:

1. No evidence overall to suggest that the compound works or only a little evidence which is outweighed by much stronger evidence that it doesn’t work.
2. Only a little evidence to suggest the compound might work. Evidence often comes from a single study which has reported positive results, so there are important doubts about whether or not it works.
3. Some promising evidence to suggest that the compound works. Evidence will be from more than one study but there may also be some studies showing that it doesn’t work, so we’re still uncertain whether compounds in this category work or not.
4. Some consistency to the evidence from more than one study to suggest that the compound works. There are still doubts from the evidence that it works, but on balance it’s more likely to be effective than not.
5. Consistent evidence across several studies to suggest that this compound is effective.

These classifications are based on the results of studies overall, so a medicine has been classified as effective if:

• a greater proportion of people taking this medicine improved compared with, for example, those taking placebo
• roughly the same proportion of people improved compared to another group taking a conventional drug which is known to be effective.

It doesn’t mean that everyone taking the medicine will improve.

For medicines which we think aren’t effective, the proportion of people reporting improvement when taking these medicines was the same as people taking the placebo, for example.

Sometimes we describe differences in improvement as ‘significant’. This means that we’re fairly sure that the differences between groups didn’t happen just by chance. It doesn’t necessarily mean that the differences are large.

Data is interpreted in this way for conventional medicines – the evidence for conventional treatments doesn’t reach level 5 in all the conditions for which they’re prescribed.

How was safety measured?

We’ve also categorised all compounds according to their safety (assuming that they’re taken within the range of recommended doses – compounds which are well tolerated at the recommended doses may have serious side-effects when taken at higher doses.)

We’ve classified the compounds using a traffic-light system:

Green: Mainly minor and infrequent reported side-effects. Users should check possible side-effects in the product information leaflet.

Amber: Commonly reported side-effects (even if they’re mainly minor symptoms) or more serious side-effects.

Red: Serious reported side-effects. Users should consider carefully before deciding whether to take these medicines.

Some compounds have very little information on side-effects so we’ve not been able to classify them. These compounds have been given an amber rating alongside the statement, ‘No information’.

It’s important to remember that most conventional medicines have side-effects, but we generally have more information to work out what these effects are and how often they happen.

How was the quality of the trial measured?

The quality of RCTs can vary, which affects how reliable the results are. The trials included in the report were judged based on a scoring system called the Jadad scale, which scores from 1 (very poor quality) to 5 (very good quality). To make it easier to use, we’ve collapsed the scale into two categories:

• low quality (Jadad score below 3)
• good/high quality (Jadad score 3 or above).

We’ve marked trials with low quality with the symbol‡. These studies were given a lower weighting when we came to our conclusions.

If you want to read more about this information, we’ve published the following papers:

• Macfarlane GJ, El-Metwally A, De Silva V, Ernst E, Dowds GL, Moots RJ on behalf of the Arthritis Research UK Working Group on Complementary and Alternative Medicines. Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review. Rheumatology (Oxford). 2011; 50(9):1672–83.
• De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ on behalf of Arthritis Research UK Working Group on Complementary and Alternative Medicines. Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review. Rheumatology (Oxford). 2011; 50(5):911–20.
• De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ on behalf of Arthritis Research UK Working Group on complementary and alternative medicines. Evidence for the efficacy of complementary and alternative medicines in the management of fibromyalgia: a systematic review. Rheumatology (Oxford). 2010; 49(6):1063–68.