Poles apart

Should physios be delivering complementary therapies, given that doubts have been cast over their efficacy? Robert Millett sheds light on a topic that divides the profession

The practice of professional complementary and alternative medicine (CAM) therapies has been officially sanctioned by the CSP for nearly 30 years, allowing acupuncture, reflex therapy, energy medicine and craniosacral therapy to fall within the scope of UK physiotherapy practice.

But their inclusion within the physio’s armoury continues to be controversial and many members are concerned that CAM therapies lack an established clinical and scientific evidence base to support their validity.

Earlier this year the society’s Annual Representative Conference heard an emergency motion calling on the CSP to prevent damage to the profession’s reputation ‘by putting an immediate end to the endorsement of alternative health interventions’ that lack sufficient clinical evidence.

The proposal was rejected but it did serve to highlight the polarised viewpoints that the subject engenders among physios.

The motion was lodged by the London Regional Networks. Matthew Wyatt, Council representative for London and a senior NHS physio, said it sparked a ‘vital debate’ about the importance of using scientific evidence to safeguard the profession.

‘There should be no double standard in physiotherapy,’ says Mr Wyatt. ‘Just one science based, ethical, and holistic standard.’

Mr Wyatt explained that the motion had been prompted by a blog post on the site of Pulse, a GP publication. It was written by Edzard Ernst, professor emeritus in complementary medicine at the Peninsula College of Medicine and Dentistry, University of Exeter, in early January.

In his blog Professor Ernst criticised the CSP for promoting complementary health interventions, deriding them as ‘neither plausible nor supported by clinical evidence’.

Lack of evidence

Simon Truett, an NHS commissioner in Kent and a former physiotherapist, objects strongly to NHS resources being spent on complementary therapies and cites a lack of research as the fundamental factor.

‘In Medway we have actively declined requests for funding unproven treatments as we believe it is an irresponsible use of taxpayer’s money,’ said Mr Truett.

‘As a physiotherapist I would no more recommend the use of homeopathy, reflexology, or rebalancing chakras than I would recommend the use of magic beans.’

Like many other physios, Mr Truett suspects that including such treatments within the scope of physiotherapy could potentially damage the credibility of the profession as a whole.

Mark Clemence, a clinical specialist physiotherapist, agrees that the practice of CAMs should be outside the professional standards and practice of UK physiotherapy.

‘The CSP is committed to clinical practice which is evidence based but energy medicine and other alternative medicine therapies lack any significant evidence base,’ he says.

The general consensus in the medical community is that an evidence-based medicine framework should be used to assess health outcomes.

As such most new drugs and treatments are subjected to systematic reviews, with strict protocols in place to test their effectiveness.

Professor Ernst believes all CAMs should be tested for ‘efficacy effectiveness and safety’ in the same way. Speaking to Frontline he said:

‘When we follow this path, we find that, for some modalities and some indications, the evidence is promising; for some it is disappointing, for some it is negative and for some it is too flimsy to provide any judgement at all.’

In response to such views, practitioners of CAMs are quick to point out that there is, in fact, a wealth of historical evidence for their therapies’ effectiveness.

The majority of this ‘evidence’, however, is considered by mainstream medicine to be subjective, anecdotal and scientifically unsubstantiated.

A CAM therapy may be backed-up by thousands of successful case histories or positive personal testimonies, but these are deemed scientifically ‘worthless’ because they may have no control group and only peer-reviewed data evidence is clinically acceptable.

Unfortunately, there is a shortage of rigorous research into CAMs and the insufficient number of studies that have been conducted make it difficult to yield any concrete conclusions.

The lack of clinical data is to a large extent a financial issue. Without the backing of pharmaceutical sponsors, or commercial ventures, funding for research on CAMs is severely limited and independently conducting quality, large scale studies would prove incredibly expensive.

Growing support

Jo Smith-Oliver, a committee member of the Association of Chartered Physiotherapists in Energy Medicine, says there is growing evidence to support holistic approaches in healthcare and that the research supporting CAM therapies is mounting.

Various bodies have been set up to support the integration of science and medicine with a deeper understanding of life. These include the Scientific and Medical Network and the British Holistic Medical Association.

‘There is also a wealth of periodicals, including the Journal of Alternative and Complementary Medicine,’ says Ms Smith-Oliver.

‘And in many of these research papers the evidence is based on qualitative, as well as, or instead of, quantative information.’

Physios on both sides of the debate agree that further research is essential. But many champions of CAMs argue that applying randomised control trials to holistic, person-focused therapies is akin to trying to push a square peg into a round hole – in that the methodology is an inappropriate testing tool for the benefits of CAMs and their potential impact on the overall wellbeing of an individual.

In 2009 the King’s Fund published a report by an independent advisory group whose remit was to build a consensus on the appropriate research methods for CAMs.

The group, chaired by Dame Carol Black, national director for health and work and Nuffield Trust chairman, recommended that research on CAMs should, in the first instance, be comparative in nature and mainly examine cost-effectiveness.

Such trials would primarily test for reduced costs and the delivery of better health outcomes, rather than seeking to establish clinical effectiveness or identify the precise mechanisms of action.

Vivienne Dascanio, chair of the Acupuncture Association of Chartered Physiotherapists, agrees with their conclusions regarding a comparative approach for future research.

‘I don’t think we should abandon randomised control trials but they should be developed to be fit for purpose,’ she says.

Among the general public, however, the issue of evidence is a less pressing matter.

In the wider marketplace, CAMs are proving their financial ‘efficiency’  by continually attracting a wealth of both new and repeat customers who are more than willing to pay for treatments in the private sector.

Almost six million people in the UK use complementary therapies every year and this figure is continually rising, according to research from market analyst Mintel.  

However, it remains unclear whether this market success is simply due to a placebo-inspired ‘feel good factor’ among customers, or if it actually hints at the clinical effectiveness of the treatments involved.

Supporters of CAMs would say their ever increasing popularity indicates that the proverbial ‘proof’ may be ‘in the pudding’.

‘Many of these disciplines have been practised for over 5,000 years and they wouldn’t have lasted more than a few decades if they hadn’t been any good,’ says John Cross, chair of The Association of Chartered Physiotherapists in Energy Medicine.

‘You can’t always scientifically quantify these things but with the advent of quantum physics I am confident that one day mainstream science will adequately prove all the rationale behind these practices.’

For now, however, many questions remain and the difference of opinion among physiotherapists forms the basis for the longest running discussion on the interactive CSP message boards.

The online debate, which focuses on the inclusion of energy medicine within the scope of practice, began with a post made in October 2008 and continues to attract fresh responses. Few topics have generated such sustained and passionate contributions.

As Nigel Senior, CSP online communications manager, says: ‘It’s indicative of the strong level of interest within the profession regarding these themes.’ fl

To join the debate log on to iCSP (www.csp.org.uk/icsp)and search for ‘does energy medicine belong in physiotherapy’ (members only)

Author
Robert Millett

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