What should allied health professionals do when their patients ask them about 'alternative' medicine?

Introduction

'Alternative' medicine is a huge business. Boiron, who operate globally selling homeopathic products, made a profit in 2015 of €73.9 million. Cupping as an 'alternative' therapy was given a huge boost in publicity during the 2016 Olympics, when athletes were noted to be covered with the large characteristic bruises.

So what? People can spend their money on anything they like. The Daily Mail, Croc shoes, jeans worn so low they reveal that the wearer's gluteal fold, detox diets and other fad diet regimes, Nestle products... facial tattoos?

Health care professionals are expected to be non-judgmental, after all. But we are health care professionals with a duty of care, firstly to our patients and secondly to the health of the nation, for whom we need to apply "the evidence of what we know works to achieve the step-change in the nation’s health that we all seek."


Is it, therefore, the duty of health care professionals to inform and advise members of the public about the evidence for, and likelihood of, benefits and risks of Complementary and 'Alternative' Medicine (CAM), particularly our patients who ask us or tell us about their use of  CAM?

We have a Bachelor of Science degree; we have expertise in functional anatomy, physiology, and mechanisms of injury, disease and repair. Surely we are qualified to comment, and obliged to do so?


I believe that CAM with no evidence to support its efficacy should not be used in either the NHS, or within physiotherapy practice - NHS or private. But there is evidence suggesting that CAM is widely used within the profession and that our Bachelor of Science degree does not prepare us adequately for appraising the evidence. This is a problem for the health of our patients and the profession itself.

Why should we say anything?

Before I became immersed in research, I worked as a musculoskeletal physiotherapist and as a rotational children's physiotherapist. In both roles, my patients (or parents of children) often asked for advice about the relative merits of 'alternative' medicine but I felt that I wasn't well equipped to answer these questions.

But then one family were keen to try an alternative therapy that promised much greater benefits than those proposed by medical treatment and physiotherapy. The family, desperate for help for their child with a rare and profoundly disabling condition, was low income but willing to do anything - including find and spend the several thousand pounds that this treatment would cost. 

On investigation, I found that the treatment was based on a premise which contradicted the currently established mechanisms of neurological repair; it suggests that improving breathing in disabled children would permit "restorative brain growth" in damaged neural tissue. At extra cost, time spent in an oxygen tank containing 100% oxygen would increase this growth further. There was no research investigating this technique other than an unpublished exploratory study which found no functional benefits (this remains the only research on this technique today). I advised the family that there were unlikely to be benefits from the treatment, based on its proposed mechanism, and that there was no acceptable levels of evidence for any benefits. I also found an anecdote on the Chartered Society of Physiotherapy's interactive forum from a physiotherapist whose caseload included a family already undertaking the same technique. This family, as part of their 'therapy', were told to withdraw from all physiotherapy and associated interventions such as standing frames - the child's physical condition deteriorated to such a severe extent that they became the subject of a Child Protection case.

This anecdote and my experience with the family alarmed me, and I subsequently explored different 'alternative' medicines. I dislike 'alternative' medicine as a description. It isn't an alternative to medicine unless it has been scientifically tested and shown to work - in which case it becomes medicine. Dara O' Briain puts it far better than I ever could, and if you have time, Tim Minchin's song Storm also is worth ten minutes. 

But that's not all. It's scarier than that

Why should health professionals get involved? What's the harm? 

Firstly, a former colleague explained to me that she has no problem with her patients seeking alternative medicine interventions because "they do no harm." 

This assertion is arguable, if not demonstrably misinformed, and I believe that as health care professionals we have a duty of care to inform the public of potential harm, as well as more effective options. For more examples, homeopaths sell prophylactic malaria kits - pure quackery - and chiropractors inform parents who have their babies' spines 'adjusted' that the babies do not then need their vaccinations.

The Chartered Society of Physiotherapy supports quackery

Some physiotherapists are heavily involved in what is as far from evidence-based practice as one can get. There is even a Chartered Society of Physiotherapy-funded Clinical Interest Group for Energy Medicine. 

Energy Medicine was shown to be charlatanism by a remarkable young lady who is the youngest person ever to publish in a peer-reviewed medical journal. Aged just nine years old, Emily Rosa designed and carried out a school science project, an elegant single-blind study on 21 energy medicine (therapeutic touch) 'healers'. The results showed that energy medicine  'healers' can detect an energy field no more than by chance. 

Can you imagine, if you'd never heard of reiki or energy medicine, and you were supervising a student on a musculoskeletal or neurology or respiratory placement, and you asked what they were planning to do with the low back pain/acute stroke/consolidated lung patient. "Oh, I am just going to hold my hands near them and direct healing energy at them."

Energy medicine: literally, 'wishful thinking'. 

It won't surprise many physiotherapists that there is also a Clinical Interest group for acupuncture, a modality which has been subjected to thousands - I think over five thousand - clinical trials. There is still no evidence that it actually works and NICE guidelines now state that acupuncture should not be offered as a treatment option for low back pain. 

NHS physiotherapy teams providing quackery on tax payers' money

According to a thread on the interactive CSP website, an entire team within an NHS Trust is about to start using cupping. The thread suggests that cupping is already in widespread use with physiotherapists.

Cupping is chiropractic nonsense, and this take down and ridicule of cupping AND chiropractic is satisfying for those of us who despair of the gullibility of the press and, sadly, health care professionals who adopt and use these unproven, fanciful therapies. ⚠ Warning: it is probably painful for those of kind and empathic disposition. Even I felt a twinge of compassion for the chiropractor until I remembered he calls himself a doctor, fleeces people, and advises parents not to vaccinate their children. 

They also perform grade 5 manipulations of babies' spines, (at 3 mins 18 seconds - again, not for the faint of heart, it makes me feel physically sick). 

Lack of critical thinking? Lack of applied knowledge? Gullibility?

As with chiropractic, homeopathy, and most forms of 'alternative' medicine, the rationale for craniosacral therapy is nonsense - the light touch (of eight grams) of a practitioner's finger tips manipulating the (fused!) skull bones of the recipient to affect a cure of all sorts of medical problems. A comparison of three physical therapists who used craniosacral therapy to evaluate 'craniosacral rate' (their diagnostic variable) of 12 children all found different rates for each child (their inter rater correlation was -0.02). In other words, each therapist diagnosed a different condition for each child.

In reality, even if I were to bang my head repeatedly against the desk (something I feel like doing when I read about physiotherapists embracing some of these alternative therapies), I would not realign my skull bones a nanometre. Anybody possessing knowledge of human anatomy or a science-based degree should immediately recognise this. Neurosurgeons need drills and saws to move the skull. 

Yet within the Clinical Interest Group for Energy Medicine there is a physiotherapy group promoting the use of craniosacral therapy within the profession. 

I even know of a paediatric physiotherapist who took her child for craniosacral therapy. Apparently, her child's colic (for which there is no known medical intervention) stopped immediately after a few sessions of craniosacral therapy. My own son had colic, and that stopped immediately after a few days of doing nothing.

Critical appraisal of evidence and applied anatomy

For these reasons, I wonder if there is not enough training given to health care professionals to critically appraise evidence. On one thread of the interactive Chartered Society of Physiotherapy's website, set up to argue against the CSP's support of the Energy Medicine Clinical Interest Group and now in its ninth year of debate, one physiotherapist scornfully remarked that science is rubbish anyway - how can a trial be 'controlled' if it is 'randomised'? This suggests a profound lack of training and understanding of basic science methodology. 

Where's that desk...

And despite expertise in advanced and applied anatomy, there are physiotherapists who believe in craniosacral therapy -  that the pressure of a few grams to the skull can regulate the flow of cerebrospinal fluid around the brain. That's an absurd proposition, and proven as such.

Is there any argument for the use of untested therapies?

Elite sports

Leading sports physiotherapist Chris Morgan once discussed with me how elite sport offers time and resources unavailable to many clinicians, such as those working in the NHS. In these cases, he and his medical team can bring to bear perhaps a multitude of evidence-based medical and rehabilitation interventions to maximise recovery. 

But when the athlete is in a race against time to recover from injury for for a one-off event that defines their sporting career - perhaps the European Cup final or the Olympic games - then perhaps every little amount helps, no matter how tiny, to help the athlete recover. The psychological benefits can be as helpful to these athletes as much as any tiny or negligible physical effect. At these times, Chris suggests that “1%ers” could support physiological and psychological recovery of a sportsperson, but stresses they are totally worthless unless they are used only in support of evidence-based treatments.

Against this are the celebrities whose fame seems to lend huge authority to their opinions. 

Jenny McCarthy is a famous proponent of 'alternative' medicine and has been vocal in the argument that autism is caused by vaccines. It isn't, vaccines are harmless and not vaccinating is dangerous. The power of 'celebs' to influence inappropriate health care decisions over and above the advice of experienced scientists and medical professionals is a strange phenomenon of modern society. And it's potentially dangerous.

In the NHS

The potential for harm from untested and unproven 'alternative' therapies has already been mentioned. There are suggestions that Steve Jobs might have survived pancreatic cancer if he had not opted for quackery over the best known treatments of the day.

The NHS is underfunded in so many resources, and physiotherapy teams have been decimated. It is essential that in the limited time physiotherapists have to assess and treat patients they are using evaluations and treatments based on the best evidence.

Physiotherapists in elite sports have more opportunities for implementing 1%ers, for example when the athlete is relaxing, resting from a rehabilitation exercise or receiving a passive treatment. There is also a world of difference between launching an athlete into their career-defining event and raison d'etre, and a postman, painter and decorator, builder etc who returns to a labour-intensive, physically-demanding role with limited paid sick leave.

Private practice

In private practice, physiotherapists are also bound by a professional code. I suggest it is unethical and immoral to take money from (often) desperate patients for unproven and often patently worthless therapies.

What do you think?

Should physiotherapists engage in 'alternative' medicine? 

I could have written pages about various types of nonsense that unethical individuals sell to unwary and ill-prepared members of the public, members of the public who are in despair as they search for a cure to their medical problems. Physiotherapists have specific training and a code of conduct which obligates them to use only interventions with evidence to support them, and certainly not to fleece patients.

As I sit here and write this blog, Horizon (a BBC Science programme) is presenting evidence for healthy eating food fads. This includes a story about a multi-millionaire currently in prison who lied about being a medical doctor and bought his PhD from an online site. He promotes a diet as a cure for cancer. He's made millions of dollars but of course many people have died and the treatment cost them thousands of dollars/pounds. 

What happens when you add Supplements to Complementary and Alternative Medicine?  It reveals SCAM. 

Do physiotherapists have an obligation to advise patients and the public of the evidence for 'alternative' medicine, following objective scientific appraisal of the evidence?

I strongly believe so. But I have suggested that critical thinking and appraisal is beyond some therapists - particularly those who are using 'alternative' medicine in private practice. I have seen use of these therapies defended by the physiotherapist by the cry of 'I have seen the patient get better with my own eyes!'. This supports not the benefits of the 'alternative' medicine but my assertion that these physiotherapists lack critical thinking and objectivity. This has to be addressed.

Finally...

This isn't supposed to be an inflammatory piece, although I accept that it is going to upset some physiotherapists. But I want them to engage in reflective thinking, to consider the evidence and scientific rationale for their 'alternative' therapies, and comment below. But please address my evidence and arguments, and don't resort to attacking me personally. To lighten the mood I leave you with another brilliant comedy take down of 'alternative' medicine. 

I wrote this blog for two reasons, and reiterate that I welcome comments. 

• I wanted to know what physiotherapists thought of the suggestion they have a responsibility to advise the public on the evidence for, and known benefits and risks of, different health interventions; and 

• to voice my disquiet and disappointment at the lack of science-based practice and the failure of the profession and HPCP to address some serious limitations in our professional training and conduct. Is the use of 'alternative' medicine against the principles of evidence-based physiotherapy? What are the HPCP for, if not to regulate this?