11 Complementary and alternative medicine in palliative care

Complementary and alternative medicines (CAM) comprise a diverse array of treatment modalities that are not presently considered part of conventional/mainstream medicine. CAM emphasize a holistic approach towards healthcare, i.e. they are based on the belief that mind, body and spirit are interconnected and that health depends on wholeness and balance between them.

In palliative and supportive care, CAM is primarily used to increase the client’s well-being, e.g. by alleviating pain and other symptoms of the disease, improving sleep, reducing stress and anxiety, or by reducing the adverse effects of conventional treatments. They are often used as an addition to conventional treatments. Some CAM modalities claim a direct effect in the prevention or treatment of cancer. Widely practised treatments are acupuncture, aromatherapy, herbalism, homeopathy, hypnotherapy, reflexology, relaxation and spiritual healing.

The individual therapies described in this chapter will be considered under four headings: alternative medical concepts; mind–body interventions, biologically based therapies and manipulative therapies.

A central tenet of CAM is the strong belief in the uniqueness and wholeness of the individual and the power of the body to heal itself.

Often, patients who consult complementary practitioners have chronic conditions that are difficult to manage, such as HIV infection, multiple sclerosis, rheumatological conditions and cancer. The interest in CAM in the palliative care setting is perhaps not surprising given the inherent need for the terminally ill to feel supported with regard to physical, psychosocial and emotional domains, in achieving an acceptable quality of life.

Precisely what constitutes complementary medicine differs considerably between countries. Different historical developments and traditions have meant that therapies such as herbal medicine and massage are firmly established in mainstream medicine in many European countries, while they are often classified as complementary outside Europe. Regardless of these national differences and inconsistencies in many surveys, there is evidence that CAM is used by a sizeable proportion of both adult and paediatric populations (see Table 11.1).

Prevalence studies in patients with life-threatening or chronic illnesses from Europe and the US report an average CAM use in cancer patients of 35–40%. Another survey reports CAM use in cancer patients to be between 7% and 54%. Small surveys in the UK have reported similar results.

An increasing number of departments of oncology in Britain employ at least one type of CAM practitioner in the palliative care setting, with most hospices now offering a range of complementary therapies for their patients. Initially, therapists were largely volunteers but units increasingly recognize CAM as part of basic and expected care. Today, there are an estimated 120 000 CAM practitioners in the UK.

One important and consistent finding is that the majority of CAM use does not occur instead of conventional medical care, but in addition to it. A number of explanations for patients seeking CAM have been proposed. Perhaps the most obvious reason for trying CAM is that, persuaded for instance by the media, or by personal past experience, many consumers are convinced that CAM is effective and improves psychosocial functioning. CAM is often also wrongly perceived as the only medicine that addresses the cause of an illness rather than the symptoms.

Certain fundamental premises of most forms of CAM contribute to its persuasive appeal. One of these is the perceived association of CAM with nature. It is linked with certain terminology such as ‘natural’ rather than ‘artificial’, or ‘pure’ as opposed to ‘organic’: ‘natural’ is also often somewhat naively equated with ‘safe’. Another fundamental component of CAM is ‘vitalism’. The enhancement or balancing of life forces or psychic energy, which is central to many forms of CAM, has an intuitive appeal to patients because of the non-invasive notion of healing from within. Many therapies have long intellectual traditions and sophisticated philosophies contributing to their credibility and authority. Spirituality, which bridges the gap between the domains of medical science and (religious) belief, is a further element in the appeal of CAM. CAM’s approach tends to be more person-centred; the language is one of unity and holism in contrast to the often distant, reductionist terminology of normative science.

The main reasons why people use CAM can be categorized in ‘push’ and ‘pull’ factors.

Negative attitudes towards research in the palliative care setting, which encompass ethical and methodological issues, particularly when patients are reaching their last few weeks of life, are pertinent. In addition, there are those who argue that scientific evaluation of CAM in the palliative care setting is not needed since patients feel better after therapy. But these attitudes, and the relative lack of research evidence, have long been a barrier to collaboration between conventional and complementary practitioners. The provision of CAM in mainstream care can, however, only be based on solid evidence and research efforts have been demonstrably increased over the last decade. The evidence for or against CAM treatments in palliative care that have been tested in controlled clinical trials are discussed in the respective therapies sections below.

A common reason for using CAM is that it is erroneously considered safe, certainly safer than conventional medicines. Even when a particular therapy’s effectiveness is in doubt it is often still taken because of the belief that ‘it may not work but it won’t do any harm’. Although some CAM treatments are associated with only mild and rare risks, others are harmful in a number of ways. Herbal medicines have been associated with toxicity, herb–drug interactions and contamination. Acupuncture and chiropractic have been associated with serious adverse events such as pneumothorax or stroke, hypnosis may be associated with negative physiological and psychological effects.

There are also more general safety issues associated with CAM as a whole. CAM can be dangerous when it causes the patient either to be misdiagnosed or if it delays access to life-saving treatments. CAM is potentially dangerous when patients self-medicate. Often, patients do not tell their doctors about their CAM use, and doctors usually fail to ask patients about it.

The notion that CAM is safe and harmless can be dangerously misleading. The situation is not helped by a serious level of under-reporting of adverse events. To date, no effective system is in place for recording and analysing the occurrence of adverse events.

There is no legislation that restricts the practice of CAM in the UK. Osteopathy and chiropractic are the only two complementary professions that, so far, have achieved statutory regulation in the UK. Since the House of Lords Report on Complementary and Alternative Medicine in 2000 there has been a move towards regulation, but progress is slow as there is considerable fragmentation within the various therapeutic disciplines. Initiatives for regulating acupuncture and herbal medicine are underway. The Faculty of Homeopathy trains and examines medical doctors, veterinary practitioners and other medical professionals, while the Society of Homeopaths is the regulatory body mainly for non-medically qualified practitioners; membership is, however, not compulsory.

The General Medical Council (GMC) provides guidelines regarding the accountability of doctors considering making a referral or delegating a patient’s care.

It is important that patients consult a CAM practitioner who is fully qualified and a member of a recognized body or association and holds professional liability insurance cover, and also that the recognized body has a code of ethics and conduct, as well as a complaints and disciplinary procedure.

Useful resources of how to find a practitioner are:

The use of CAM alongside conventional medicine in palliative care is increasing and is perceived as contributing to improvements in symptom control, well-being and satisfaction. It is seen as an important component of best practice in cancer care and is supported by the National Cancer Strategy, and the NICE Guidance on Support and Palliative Care for Adults with Cancer. It is, however, important to use treatment modalities backed up by research evidence and not to deceive patients.

Alternative medical systems are complete systems of theory and practice. Examples of alternative medical systems developed in Western cultures are homeopathy and naturopathy. Others have evolved apart from and earlier than the conventional medical approach used in the West, e.g. such as traditional Chinese medicine and Ayurveda.

The history of acupuncture dates back 2000 years. It is an integral part of traditional Chinese medicine (TCM) and based on its principles. Acupuncture involves the stimulation of certain points on the body by inserting fine needles, whereas acupressure involves firm manual pressure on these points.

The workings of the human body are thought to be controlled by a vital force or energy called ‘qi’ (pronounced chee) which circulates between organs along channels called meridians. The twelve main meridians are thought to correspond loosely to twelve major functions or organs of the body. On these meridians, more than 350 acupuncture points have been defined, and it is believed that qi energy must flow through each of the meridians and organs for health to be maintained. The acupuncture points are situated along the meridians and through these the flow of qi can be altered. Traditional acupuncture theory is based on the concept of yin and yang, which should be in balance: any imbalance (particularly blockage or deficiency) in the continuous flow of energy causes illness. Acupuncture point stimulation redresses this balance, allowing the healthy unimpeded flow of qi.

There are many different schools of acupuncture. Western medical acupuncturists relate acupuncture points to various physiological andanatomical features such as peripheral nerve junctions. The concept of ‘trigger points’, has also been recognized, whereby areas of increasedsensitivity within a muscle cause referred pain in relation to a segment of the body.

There is no evidence to confirm the physical existence of qi or the meridians. However, attempts have been made to explain the effects of acupuncture within a conventional physiological framework. It is known that acupuncture stimulates A delta nerve fibres which enter the dorsal horn of the spinal cord and mediate segmental inhibition of pain impulses carried in the slower unmyelinated C fibres. Through their connections with the midbrain, descending inhibition of C fibre pain impulses is also enhanced at other levels of the spinal cord. It is also known that acupuncture stimulates the release of endogenous opioids and other neurotransmitters such as serotonin, which are involved in the modulation of pain.

Acupuncture is used, for example, in the management of pain, anxiety, fatigue and digestive disorders.

Acupuncture may be delivered in a number of different ways. Between four and ten needlepoints are typically selected. These points are often located in areas where they represent the relevant local, regional and distant meridians. Needlepoints may also be centred around the area of pain.

In the UK, the practice is to use sterile disposable needles which are usually inserted to a depth of about 5 millimetres (or more deeply into muscle). Needles are left in situ for approximately 15 minutes. Needle sizes differ, but typically measure up to about 30mm long and 0.25mm in diameter. It is possible that the sensation of ‘de qi’ (pronounced dechee) which causes feelings of soreness or numbness at the point of needling is necessary both to indicate that the anatomically correct site has been needled and that the treatment will work well. However, the treatment is also often considered successful in the absence of de qi or any sensation at the point of skin puncture.

Stimulation of the acupuncture point can be increased by gentle turning/manipulation of the needles, using a small electric current, laser beams or ultrasound. Acupuncture studs remain in situ and may be pressed by the patient as necessary to give more sustained stimulation. In moxibustion, the needles are heated by smouldering a substance called moxa over the points.

Acupuncture treatments are often given once a week for 6–8 weeks and thereafter as necessary.

Good evidence exists to support acupoint stimulation in treating the nausea and vomiting induced by chemotherapy: adjunct stimulation with needles and electroacupuncture reduced the incidence of acute vomiting but not nausea, while acupressure reduced nausea but not vomiting.

For relieving cancer pain some encouraging short-term results have been reported, but there is not enough evidence available to make any firm conclusions. Similarly, insufficient evidence is available for the relief of cancer-related fatigue, chronic obstructive pulmonary disease, dyspnoea, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, pain associated with cystic fibrosis and chronic heart failure. Hence, acupuncture is unlikely to be beneficial for neuropathic pain associated with AIDS/HIV.

Acupuncture is generally considered to be a relatively safe form of treatment with a low incidence of serious side-effects if practised by a skilled practitioner. Some events, such as nausea and syncope, can be mild and transient. While there is no official mechanism for reporting adverse events, there have, however, been accounts of pneumothorax, septicaemia, spinal injuries and hepatitis B/C transmission. The use of acupuncture studs in the ear may result in perichondritis of the underlying cartilage.

Acupuncture should be used with care in any patient in whom there is a risk of infection or bleeding. It should be avoided in patients with valvular heart disease. Acupuncture to spinal muscles should be safe unless there is an unstable spine, in which case it is contraindicated. Extra care should be exercised in those patients receiving their first acupuncture treatment as they may react strongly, with dizziness and drowsiness. The initial treatment should be given supine and patients should be advised not to drive or to operate machinery for a few hours.

Homeopathy was founded by the German physician Samuel Hahnemann (1755–1843). This method often uses highly diluted preparations of a variety of different substances. Homeopathy is based on two key principles. The first is that ‘like cures like’. Here, patients are given preparations whose effects when administered to healthy subjects correspond to the manifestations of the disorder (symptoms, clinical signs and pathological states) in the unwell patient. For instance, hayfever, which presents with lacrimation, stinging and irritation around the eyes and nose, might be treated with the remedy Allium cepa, derived from the common onion. According to the second principle, remedies are prepared by a process of serial dilution and succussion (vigorous shaking). The greater the number of times this process of dilution and succussion is performed, the greater the potency of the remedy. Homeopathic medicines are diluted so much that they are unlikely to contain even a single molecule of the original substance.

Prescribing strategies vary considerably. In ‘classical’ homeopathy, practitioners aim to identify a single medicine that is needed to treat a patient, taking into account current illness, medical history, personality and behaviour. ‘Complex’ homeopathy involves the prescription of combinations of medicines.

Common homeopathic medicines include those made from plants (such as belladonna, arnica and chamomile), minerals (e.g. mercury and sulphur), animal products (e.g. sepia (squid ink) and lachesis (snake venom), and more rarely, biochemical substances (such as histamine or human growth factor).

Many different, often chronic and recurring conditions are treated with homeopathic medication. Self-prescription for various conditions such as the common cold, bruising, hayfever and joint sprains is common.

A very detailed history is taken in order to find the optimally matching drug (‘similimum’). Information is also gathered about mood and behaviour, likes and dislikes, responses to stress, personality and food reactions. A ‘symptom picture’ is thus built up and matched to a ‘drug picture’ described in the homeopathic Materia Medica. One or more homeopathic medicines are then prescribed, usually in pill form, either as one or two doses or on a more regular basis.

A patient’s initial symptom picture commonly matches more than one drug picture. Follow-up allows the practitioner to define the best medication for a particular patient.

Controlled clinical results report encouraging but not fully convincing results for homeopathic treatment of chemotherapy-induced stomatitis and radiodermatitis. No convincing effects of homeopathy have been reported for general radiotherapy-related side-effects, menopausal symptoms in breast cancer survivors and oestrogen withdrawal in breast cancer patients.

The effectiveness of homeopathic remedies for HIV/AIDS has not been established. Overall, there is no convincing evidence of the effectiveness of any homeopathic remedy for any condition.

Serious adverse effects of homeopathic medicines are rare. However, symptoms may become acutely and transiently worse (aggravation reactions) after starting treatment and patients should be warned of this possibility. The occurrence of an aggravation reaction is interpreted by homeopaths as a sign that the treatment will be beneficial.

The more serious issue is the view of some practitioners who adamantly believe that conventional medication reduces the efficacy of homeopathic remedies. Serious adverse effects have occurred when patients have failed to comply with conventional medication.

Mind–body medicine uses a variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms.

Relaxation therapy uses a range of techniques for eliciting the ‘relaxation response’ of the autonomic nervous system. This results in decreases in oxygen consumption, heart rate, respiration and skeletal muscle activity and in the normalizing of blood supply to the muscles. One of the most common techniques is progressive muscle relaxation, which consists of progressive clenching followed by the conscious relaxation of all the muscles in the body in parallel with concentration on breathing control. Other relaxation techniques involve passive muscle relaxation, refocusing or imagery. In imagery-based relaxation, the idea is to visualize oneself in a place or situation associated with relaxation and comfort.

Relaxation therapies are commonly used for the relief of anxiety, stress disorders, musculoskeletal pain and headaches.

Relaxation is usually taught in groups or by listening to tapes. With progressive muscle relaxation, the muscle groups are systematically contracted, then relaxed in a predetermined order while the patients lie on their back. In the early stages, an entire session will be devoted to a single muscle group. With practice, it becomes possible to combine muscle groups and then eventually relax the entire body all at once. Several months of daily practice are needed in order to be able to evoke the relaxation response within seconds.

In cancer palliation, relaxation has been shown to be a useful adjunct for preventing nausea and vomiting associated with chemotherapy and other treatment-related symptoms in patients undergoing, for example, radiotherapy, bone marrow transplantation or hyperthermia. It has also proved to have a significant effect on anxiety. Encouraging effects have been reported for the reduction of tension and amelioration of the overall mood, but not enough data are available.

Similarly, data from rigorous trials into the benefits of relaxation therapy are too scarce to make any recommendations for its use in cancer-related fatigue, hot flushes in breast cancer patients, dyspnoea associated with chronic obstructive pulmonary disease and chronic heart failure.

Relaxation techniques are not associated with any serious safety concerns. They are, however, contraindicated in schizophrenic or actively psychotic patients. Those techniques requiring inward focusing may intensify depressed mood.

You see things; and you say, ‘Why?’ But I dream things that never were; and I say, “why not?”

George Bernard Shaw (1921), Back to Methuselah, Part 1, Act 1

Hypnotherapy involves the induction of deep physical and mental relaxation, inducing an altered state of consciousness which leads to a greatly increased susceptibility to suggestion. Once patients are guided into a hypnotic trance, they may recall memories not easily accessed by their conscious minds. The dissociation between the conscious and the unconscious mind can be used to give therapeutic suggestions, thereby encouraging changes in behaviour and the relief of symptoms. The goal of hypnotherapy is to gain self-control over behaviour, emotions or physiological processes. A fundamental principle of hypnotic phenomena is that the hypnotized individual is under his own control and not that of the hypnotist.

Hypnotherapy is more commonly used for anxiety, for disorders with a strong psychological component (such as asthma and irritable bowel syndrome) and for conditions that are modulated by levels of arousal, such as pain.

Sessions typically last between 30 and 90 minutes, with an average course comprising 6–12 sessions. The initial visit involves gathering a history and discussion about hypnosis, suggestion and the client’s expectations of the therapy; various tests for hypnotic suggestibility may also be conducted. The hypnotic state is achieved by first relaxing the body, then shifting attention away from the external environment towards a narrow range of objects or ideas suggested by the therapist. Sometimes hypnotherapy is carried out in group settings.

In children with cancer, hypnosis has potential as a clinically valuable intervention for procedure-related pain and distress. It has also been shown to be helpful for anticipatory and post-chemotherapy nausea, again particularly in children. More data are required for its usefulness in the relief of pain, anxiety, fatigue and of hot flushes in patients with breast cancer.

Hypnosis is generally safe when it is practised by a clinically trained professional. It can, however, sometimes exacerbate psychological problems and is contraindicated in psychosis and personality disorders.

Guided imagery is a visualization technique based on the notion that the mind can affect the body. It uses imagination and mental images to encourage physical healing, promote relaxation and bring about a change in attitude or behaviour. Stimulating the brain through visualization may have direct effects on the endocrine and nervous systems and may lead to changes in immune and other functions.

Imagery is commonly used by those patients undergoing conventional cancer treatment or surgery, for stress and anxiety as well as chronic pain conditions.

Imagery is generally taught in small classes. Sessions usually last for 20–30 minutes, or longer if needed, once or twice weekly for several weeks. Patients will either sit in a chair or lie on a treatment table or a floor mat. Sessions usually begin with general relaxation exercises and then move on to more specific visualization techniques, introduced by the practitioner. Patients will be led to build a detailed image in their mind. Patients with cancer, for example, may be asked by their practitioner to picture their cancer being attacked by their immune system, their tumours shrinking or their body freeing itself of cancer.

In cancer patients, guided imagery seems to be psychosupportive, decreasing anxiety and depression and increasing comfort. Although some encouraging effects on cancer-related pain have been reported, the available data are insufficient to make any firm recommendations. Guided imagery may increase oxygen saturation in patients with chronic obstructive pulmonary disease, but further data are required to make any firm recommendations. Not enough data are available for its usefulness in patients with AIDS and multiple sclerosis; it is unlikely to be beneficial for chemotherapy-associated nausea and vomiting.

Although guided imagery and visualization are generally safe, they are contraindicated in those with severe mental illness, latent psychosis and personality disorders.

Meditation refers to a range of practices aimed at focusing and controlling attention to suspend the strategies of thoughts and relax body and mind. It is believed to result in a state of greater physical relaxation, mentalcalmness and psychological balance. Meditation comprises a very diverse array of practices, most of which are rooted in Eastern religious or spiritual traditions (e.g. transcendental meditation, Sahaja yoga/meditation, mindfulness meditation as well as meditative prayer). They are based on listening to breathing, repeating a mantra, detaching from the thought process or self-directed mental practices. Meditation is aimed at inducing physiological changes, e.g. altering the fight or flight response. It is believed to reduce activity in the sympathetic nervous system and increase activity in the parasympathetic nervous system. The specific mechanisms remain, however, unknown.

Meditation is often used for the relief of anxiety, asthma, stress, drug and alcohol addiction, epilepsy, heart disease, hypertension.

Two common approches to meditation are mindfulness meditation and transcendental mediation. In mindfulness meditation the meditator learns to concentrate on the sensation of the flow of the breath in and out of the body and focus on what is being experienced, without reacting to or judging that experience. Eventually the meditator should learn to experience thoughts and emotions in normal daily life with greater balance and acceptance. Transcendental meditation uses a mantra or e.g. a word, sound, or phrase repeated silently, in order to prevent distracting thoughts from entering the mind. Eventually this should allow the mind to come to a quieter state and the body into a state of deep rest.

Meditators are initially instructed by a teacher in several sessions and should then practise regularly twice daily for 15–20 minutes. Continuous regular practice is expected to increase the effects.

Positive results in patients at the end of life have been reported for mood disturbance, anxiety, depression, anger/hostility, emotional suppression, psychological distress, stress, intrusive images, confusion and coping mechanisms. For other symptoms and signs there are not enough data available for and including nausea and vomiting, quality of life, sleep disturbance and fatigue.

Meditation may improve the quality of life in patients with chronic heart failure, but not enough data are available. For stress, anxiety or anger in AIDS patients, there are too few data available to make any recommendations.

Although meditation is generally safe, patients suffering from psychiatric problems who wish to take up meditation should be supervised by a qualified psychiatrist or psychotherapist experienced in the use of such techniques in a therapeutic context. People with epilepsy or those at risk of developing epilepsy should consider the theoretical risk of precipitating attacks before proceeding.

Spiritual healing uses spiritual means in treating disease. A healer and a patient interact with the intention of generating improvements or a cure of the illness. Healers believe they channel ‘energy’ (for example, of cosmic or divine origin) into patients which helps the body heal itself. The concept is not supported by scientific plausibility.

Healing is used to alleviate symptoms and recovery in a variety of clinical situations including anxiety, pain and general well-being.

Spiritual healing is generally given in two ways, laying-on of hands or distant healing. In the former, healers hold their hands near to but not touching (or only lightly touching) the body, detecting areas of concern and transmitting ‘energy’ into the patient’s body, which allegedly enhances self-healing. In the latter, healers send signals mentally as meditation, prayer or healing wishes from a location that can be many miles away from the patient.

A session may last 30–60 minutes. Typically, weekly sessions are prescribed. A series of treatments may consist of 6–10 sessions, which may be repeated regularly.

Many varieties of healing are available. While therapeutic touch is the most familiar, there is also: Reiki, derived from Japanese traditions; Shamanism which may include chanting and dancing; intercessory prayer; Johrei; faith healing; psychic healing; and paranormal healing

There is not enough evidence available to support spiritual healing as a treatment for any condition. Although encouraging results for healing touch on cancer-related pain are available, the data are not sufficient to make any firm recommendations. Spiritual healing has shown encouraging results in reducing anxiety levels and increasing well-being, but studies are methodologically weak. Not enough data are available for its efficacy in reducing anxiety in AIDS patients.

Healing is generally a safe treatment and has no known serious side-effects, although it is contraindicated in those patients with psychiatric illnesses.

In creative therapies art, music, prose and poetry are used as alternative forms of expression and communication. Therapy may release suppressed deep fears and feelings and evoke memories that, with careful and sensitive guiding by the therapist, may be used in trying to help the patient work through them constructively and positively. Receptive music therapy uses the analgesic and anxiolytic properties of music, which are mainly due to the lowering of stress levels and stress hormone production similar to the relaxation response.

Art and music therapies are popular in palliative care, helping with the patients’ feelings of loss, fear, anger, guilt, anxiety and depression.

Both art and music therapists work in a wide range of settings using art or music to achieve therapeutic goals. Art therapy combines traditional psychotherapeutic theories and techniques with an understanding of the psychological aspects of the creative process, especially the affective properties of the different art materials. In music therapy, the most basic distinction is between receptive music therapy (listening to music played by the therapist or recorded music) for relaxation and pain relief and active music therapy (the patient is involved in music-making) as a form of expression.

Only preliminary data exist for the evaluation of art therapy. They relate to improving coping resources in women with primary breast cancer undergoing radiotherapy and increasing positive and collaborative behaviour in children during painful procedures.

Music therapy has been shown to be beneficial for procedure-related anxiety. In a range of conditions, music therapy has shown encouraging effects but there are not enough data available to draw any firm conclusions. Clinical music therapy might improve quality of life in patients with terminal cancer; preliminary data are positive for psychological problems in cancer palliation; and it may have some effect in relieving nausea and vomiting associated with chemotherapy. Similar encouraging, yet only preliminary, results have been reported for recorded music as an adjunct during routine chest physiotherapy for cystic fibrosis, for reducing agitation and aggressive behaviour in Alzheimer patients, strengthening of respiratory muscles through the coordination of breath and speech in multiple sclerosis, and for motor, affective and behavioural functions in Parkinson’s patients. The data are methodologically too limited in patients with dementia.

There are no known safety concerns associated with art or music therapy.

Plants have been used for medicinal purposes since the dawn of humanity. They form the origin of many modern medicines, e.g. digoxin from Digitalis purpurea (foxglove) or salicin from Salix spp. (willow). Herbal extracts contain plant material with pharmacologically active constituents. The active principle(s) of the extract, which is in many cases unknown, may exert its effects at the molecular level and may have, for instance, enzyme-inhibiting effects (e.g. escin). A single main constituent may be active, or a complex mixture of compounds produces a combined effect. Known active constituents or marker substances may be used to standardize preparations.

Modern Western herbalism or phytomedicine as practised in many European countries such as Germany is integrated into conventional medicine with compulsory education and training for physicians and pharmacists. It follows the diagnostic and therapeutic principles of conventional medicine.

Other more traditional systems include Chinese herbal medicine, which is based on the concepts of yin and yang and qi energy. In China, ill health is seen as a pattern of disharmony or imbalance and Chinese herbal medicines are believed to harmonize these energies and ultimately restore health. In Japan, this system of traditional herbal medicine has evolved into kampo. Ayurveda, the traditional Indian medical system, frequently uses herbal mixtures. Characteristic of these systems is a high degree of individualization of treatments. In contrast to modern phytomedicine, all traditional herbal medicine systems predominantly use complex mixtures of different herbs.

Herbal medicine is generally used for a wide range of conditions. In palliative care it is used for anxiety, depression, pain, radiation-induced dermatitis, chemotherapy-induced nausea and vomiting, hot flushes and quality of life, as well as for the prevention and treatment of cancer.

During an initial treatment session the practitioner will usually take the patient’s medical history. Information may also be sought on the patient’s personality and background, which may influence the selection of herbs. Individualized combinations of herbs may be prescribed. Follow-up appointments may be arranged and the herbal preparations and regimen reviewed. The regimen depends largely on the nature and severity of the condition, but consists generally of either one or two appointments per week for a treatment period ranging from one to several weeks. Medication is usually administered orally in the form of tablets, capsules, tinctures or teas. Topical applications, e.g. ointments and compresses, are also used.

No convincing evidence exists for any herbal medicine in the treatment of cancer. The effectiveness of a range of herbal medicines in cancer palliation is unclear due to insufficient data being available: cannabinoids for pain-control, appetite or quality of life; ginkgo (Ginkgo biloba) for lymphoedema; ginseng (Panax ginseng) for fatigue and quality of life; marigold (Calendula officinalis) for radiation-induced dermatitis in breast cancer; the Chinese herbal remedy huangqi for nausea and vomiting induced by chemotherapy. Aloe vera showed no convincing effects on radiation-induced skin irritation or oral mucositis. The results regarding black cohosh (Actaea racemosa) on hot flushes are contradictory and it has been associated with liver damage. Cranberry (Vaccinium macrocarpon) and phytoestrogens showed no efficacy in the treatment of prostate cancer symptoms or for hot flushes, respectively.

In patients with AIDS the effectiveness of boxwood (Buxus sempervirens) as well as tea tree oil (Melaleuca alternifolia) for oral candidiasis are unknown. Many different preparations of Chinese herbal mixture exist but the data are not encouraging for their use in patients with AIDS. No evidence of effectiveness is available for St John’s Wort (Hypericum perforatum) on antiviral activity or for topical application of capsaicin to reduce pain.

Ginkgo (Ginkgo biloba) improves cognition and function in Alzheimer’s disease. The Kampo medicine choto-san might lead to a general improvement. Not enough data are available for Huperzia serrata, lemon balm (Melissa officinalis) and sage (Salvia officinalis). Ginseng (Panax ginseng) is likely to be ineffective for improving somatic symptoms, depression and anxiety.

In chronic obstructive pulmonary disease the effects of Chinese herbal mixtures, ginseng (Panax ginseng) on lung function and ivy (Hedera helix) leaf extract for dyspnoea are not clear. Studies of pomegranate (Punica granatum) juice were negative.

In chronic heart failure, extracts from the leaf and flower of the hawthorn (Crataegus spp.) improve maximal workload, while milk vetch (Astragalus spp.) has been shown to improve left ventricular ejection fraction. The evidence for shengmai, a combination product including Panax ginseng, Ophiopogon japonicus and Schisandra chinensis, is inconclusive due to the low quality of the studies. Not enough data are available to make any firm recommendations for Ayurvedic medicines, Chinese medicines, Ginseng (Panax ginseng) and Kanlijian.

St John’s Wort (Hypericum perforatum) has been shown to be effective in the treatment of mild to moderate depression.

The results so far from studies of cannabis (Cannabis sativa) for multiple sclerosis are somewhat contradictory, but some data suggest there is an improvement in mobility, pain and sleep. It might also reduce the number of incontinence episodes but not enough data are yet available. It is unlikely to be beneficial in reducing tremor. Some preliminary data for Ginkgo (Ginkgo biloba) suggest it may improve fatigue, symptom severity and functionality but not cognitive function.

In Parkinson’s disease, preliminary data are encouraging for the use of Mucuna pruriens, a traditional Ayurvedic herbal medicine, which is a natural source of L-dopa. Cannabis (Cannabis sativa) is unlikely to reduce tremor.

Because plant extracts have pharmacological effects, their potential for adverse effects and interactions needs to be considered. They vary for each individual herb and should be evaluated individually. St John’s Wort (Hypericum perforatum), for example, interacts with warfarin and the contraceptive pill, while kava kava (Piper methysticum) has been associated with liver damage. In general, those patients taking herbal medication on a regular basis should receive regular follow-up and appropriate biochemical monitoring. Patients should always be asked about self-prescription use of herbal medicine. There is currently no reporting system for adverse events and interactions of herbal medicines.

Other safety issues associated with herbal medicines are toxicity, contamination (in particular traditional Chinese medicines), adulteration, misidentification or quality issues.

Aromatic plants, and the infusions prepared from them, have been employed in medicines and cosmetics for thousands of years. Aromatherapy uses oils extracted from plants, which are usually referred to as ‘essential oils’. These are the pure, concentrated hydrophobic liquids containing the volatile essences of plants: flowers (e.g. rose), leaves (e.g. peppermint), barks (e.g. cinnamon), fruits (e.g. lemon), seeds (e.g. fennel), grasses (e.g. lemongrass), bulbs (e.g. garlic) and other plant substances. Fresh plant material usually yields 1–2% by weight of essential oil on distillation. A typical essential oil contains a complex mixture of over 100 different chemical compounds which give the oil its smell, therapeutic properties and, in some cases, its toxicity. Essential oils are highly toxic if ingested undiluted.

Essential oils are considered to act not only on the body, by stimulating physiological processes, but also on the emotions and the mind. Odour stimulates the olfactory senses and these relay to the limbic system, which is central to the emotions and memory. In turn, the limbic system is associated with the hypophyseal–pituitary axis which regulates the endocrine system, affecting a person’s reactions to fear, anger, metabolism and sexual stimulus.

Usually, diluted essential oils are applied to the skin through gentle massage. The individual choice of oil is determined by the experience of the therapist. Occasionally, essential oils are also used in baths or diffusers. One session typically lasts around 1 hour. A full series may include about ten sessions.

Aromatherapy in combination with massage has positive short-term effects on psychological well-being in cancer patients, with the effect on anxiety supported by limited evidence. However, the effects on physical symptoms such as nausea are not supported by sufficient evidence. Evidence is mixed as to whether aromatherapy enhances the effects of massage.

Encouraging results have been reported for reducing agitation and neuropsychiatric symptoms in dementia patients and symptom control and well-being in patients with Alzheimer’s disease, but there are insufficient data to make any firm recommendations. Aromatherapy failed to show benefits in terms of symptom control in cancer patients, pain control, anxiety or quality of life in hospice patients, as well as on psychological outcomes during radiation therapy.

Essential oils should not be taken orally or used undiluted on the skin. Some oils cause photosensitivity. Allergic reactions are possible with all oils. Some oils have carcinogenic potential and certain oils should be avoided in cancer patients.

Patients with cancer are often highly sensitive to the sense of smell, which may have altered due to chemotherapy. Certain smells can be very nauseating, and this should be assessed with the patient before therapy.

These therapies in CAM are based on manipulation and/or movement of one or more parts of the body. Some examples include chiropractic or osteopathic manipulation, and massage.

Massage is one of the oldest healthcare practices in existence. It was documented in Chinese texts more than 4000 years ago and has been used in Western healthcare since Hippocrates in the fourth century BC. Massage therapy is the manipulation of the soft tissues of the body for therapeutic purposes. It consists of manual techniques that include applying pressure and traction. The friction of the hands as well as the mechanical pressure exerted on cutaneous and subcutaneous structures affect all body systems, in particular the musculoskeletal, circulatory, lymphatic and nervous systems.

Massage is widely used in the treatment of a variety of conditions including lymphoedema, stress, anxiety, back and other pain, and insomnia. Through the relaxation of muscle tension and the relief of anxiety, massage therapy may reduce blood pressure and heart rate. Massage may also enhance the immune system. Abdominal massage may be useful for constipation.

Either the whole body or relevant specific parts may be treated. The practitioner may play background music depending on the patient’s preference. Patients may be encouraged to breathe steadily and to communicate with the therapist. Oils, including aromatherapy oils, may also be used, depending on the individual patient and the aims of treatment. Massage usually lasts one hour, and one or two sessions per week for a treatment period of 4–8 weeks are recommended initially.

Both massage and/or aromatherapy have been shown to have positive effects on the well-being of cancer patients in general, and on anxiety in particular. The question whether essential oils are important remains unanswered. It has also been shown to be beneficial for the relief of anxiety of various causes.

Encouraging results exist for the effect of massage in chemotherapy-related nausea as well as anxiety and depression in multiple sclerosis, but further data are required. Although massage may improve quality of life, anxiety and low mood in HIV patients, its effects on immune function are not clear. For Alzheimer’s disease there is only a limited amount of reliable data available which prevents any firm conclusions.

The relaxing effects of massage may have some, albeit non-specific, influence on the well-being of most patients.

Massage is comparatively safe and adverse effects are extremely rare. There is no evidence that it encourages the spread of cancer, although it is contraindicated where it might damage tumour or frail normal tissue, particularly in treatment-related areas.

It is generally contraindicated in patients who have advanced heart disease, phlebitis, thrombosis and embolism, kidney failure, infectious diseases, contagious skin conditions, acute inflammation, infected injuries, unhealed fractures, conditions prone to haemorrhage and psychosis. It is also contraindicated in the acute flare-up of rheumatoid arthritis, eczema, goitre and open skin lesions.

( For aromatherapy massage, see the Aromatherapy section, p. 833.)

The therapeutic use of hand and foot pressure for the treatment of pain and various illnesses existed in China and India over 5000 years ago.

It is suggested that there are ten longitudinal, bilateral reflexes or zones running along the body which terminate in the hands and feet. All systems and organs are reflected onto the skin surface, particularly that of the palms and soles. By applying gentle pressure to these areas it is possible to relieve blockages or imbalances of energy along the zone. It is believed that specific organs as well as the interrelationship between organs and bodily systems can be influenced to regain and maintain emotional, physical and spiritual homeostasis resulting in the relief of symptoms and facilitating the prevention of illness and the promotion of healing.

Malfunction of any organ or part of the body is thought to cause the deposition of tiny calcium and uric acid crystals in the nerve endings, particularly in the feet. These deposits are then broken down and eliminated by gentle pressure. This is referred to as ‘detoxification’, which may lead to a ‘healing crisis’ including ‘flu-like symptoms, a feeling of being light headed and lethargic, feeling cold 3–4 days’ post-treatment, a reduction in blood pressure, an increase in excretory functions and an alteration in sleep pattern.

Reflexology is used for a variety of clinical problems. Of particular relevance to palliative care are control of pain and anxiety, induction of deep relaxation and improvement in sleep.

Although there are different schools of teaching in the application of reflexology, the underlying principles are consistent. The foot is treated by applying gentle pressure along each zone systematically until the dorsum, sides and sole have been covered. The practitioner then repeats the treatment on the other foot. Initially, gentle massage and stroking movements are used, followed by deep thumb and finger pressure. The reflex areas on the foot may feel tender or painful if ‘blocked’, but is relieved as the treatment works and the ‘blockage’ is removed. Treatment may take up to an hour and be repeated weekly as necessary.

There is no convincing evidence of the effectiveness of reflexology from controlled clinical trials to support its use for any indication, including symptom control in chronic obstructive pulmonary disease, agitation in dementia, motor sensory and urinary symptoms in multiple sclerosis. It is unlikely to be beneficial in improving quality of life in patients with cancer.

Contraindications to reflexology include its use in the first trimester of pregnancy. Care should be taken in patients with depressive and manic states, epilepsy and acute conditions.

Patients receiving reflexology may notice an increase in urination and body discharges, leading to fears that medicinal drugs such as chemotherapy agents might be eliminated more quickly from the body and thus be less effective. However, there is no evidence for this.