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Complementary Medicine And Irritable Bowel Syndrome

Complementary Medicine And Irritable Bowel Syndrome

‘Complementary medicine’ refers to a group of therapeutic and diagnostic disciplines that exist largely outside the places where conventional health care is provided and are not usually available on the Nation Health Service. These disciplines were previously known as ‘alternative medicine’, but their increasing use alongside conventional medicine has led to the term ‘complementary medicine’. Unfortunately, this has only increased the considerable confusion over what exactly complementary medicine is, and what position the various disciplines included under this term should hold in relation to conventional medicine.

COMPLEMENTARY MEDICINE AND THE PLACEBO RESPONSE

My doctor tells me that his practice is ‘evidence based’. He is sceptical about complementary medicine and feels it is mostly a placebo response. What is a placebo response?

A placebo response is the measurable, observable or felt improvement in health that cannot be attributed to the treatment itself but stems from a belief in, or indeed the process of, being treated. In the placebo effect, the doctor’s belief in the treatment and the individual’s faith in the doctor are mutually reinforcing. The result is a powerful remedy that is almost guaranteed to produce an improvement. This is very useful in clinical medical practice but makes it difficult to determine how effective any treatment actually is.

How long does the placebo response last?

The placebo response has been shown to last up to 3 months.

How do we know if a treatment works?

The scientific method of evaluating treatments is designed to reduce the effect of the placebo response. It usually involves what is called a ‘randomised double-blind placebo-controlled trial’. In one of these, subjects are randomly allocated to receive either the treatment being tested or a sham, ineffective treatment – the placebo. Both the true treatment and the placebo look exactly the same, and people do not know which they are getting. That is what is meant by being ‘blinded’ to the treatment, which is coded as, for example, ‘X’ or ‘Y’. In a double-blind study, the person assessing the success or failure of the treatment also does not know which treatment the ‘subject’ has had, so cannot, either consciously or unconsciously, influence the result. At the end of the study, the code is broken and the success of the two treatments can be compared.

In many medical conditions, the response to the placebo (sham or ineffective treatment) is surprisingly high. In irritable bowel syndrome (IBS), placebo response rates are usually between 30% and 50%, although they can be higher than this. In other words, many people are made better by treatments that are known to have absolutely no physical or biochemical effects. If a drug is to be regarded as effective in conventional medicine, it must prove itself consistently and significantly more effective than a placebo.

Can complementary medical treatments be tested using one of these double-blind placebo-controlled trials?

Some therapists claim that, for their treatments to be effective, they need to treat the person as a whole. This means altering the treatment to suit the individual. As this process involves a close interaction with the therapist, and the treatment has to be adjusted, it is difficult to give a placebo. It is also difficult for the individual and the therapist to be ‘blinded’ to the treatment, as described in the previous question. Furthermore, conventional medicines are tested by comparing a large group of people receiving one treatment with another large group receiving a different treatment or placebo. In complementary medicine, people with the same condition may end up receiving different individualised treatments, so it may not fit into the usual ‘medical model’ and cannot be tested in the conventional way.

Despite this, some complementary medicines, particularly some herbal remedies and Chinese medicines, have been tested in a few randomised double-blind placebo-controlled trials, sometimes with successful results.

Should I try complementary medicines for my irritable bowel syndrome?

Compared with conventional medicines, complementary medicines are largely untested, and their effectiveness has yet to be proved. Their use is mostly limited to disorders that conventional medicine does not treat satisfactorily. For example, 30 years ago it would have been reasonable to try complementary medicine for peptic ulcers. But in 1976, cimetidine (Tagamet), the first drug specifically designed to reduce acid secretion became available. Today, conventional medicines for peptic ulcers are so effective and safe that if they fail to work, the diagnosis should be questioned. Cimetidine, and the drugs that followed in its wake, revolutionised the treatment of peptic ulcers. It would be stupid to use an alternative treatment for this condition.

Sadly, people with irritable bowel syndrome are still waiting for the miracle cure. In irritable bowel syndrome, conventional medicines can be disappointing, and if you can afford the expense, complementary alternatives may be worth trying; the placebo response itself may help you and shows the power that positive thought can have.

Sometimes people can feel pressurised to line up on one side or the other of the debate on conventional medicine. Although it may be contradictory to believe strongly in the scientific method while trying complementary medicines, holding on to contradictory belief systems – and acting on both – is very human. We suspend belief every day to enjoy novels and films. And, contrary to the evidence before us, many people believe in the eventual triumph of the England cricket and football teams! You never know what will work. Sometimes you just have to try as it may be right for you.

Have I got anything to lose by trying complementary medicine?

You need to be sure first that you do not have a condition that is more amenable to conventional medicine than irritable bowel syndrome. Complemen tary medicine does not work for bowel cancer, and it’s foolish to try for a placebo response or something better while delaying a conventional medical diagnosis and treatment. Similarly, complementary medicine has little to contribute to coeliac disease or inflammatory bowel disease. You also usually have to pay for complementary medicine, and the expense can soon mount up, so it’s worth making sure that you’ve tried conventional treatments as well.

 

HERBAL MEDICINE

What are herbal medicines, and how do they differ from conventional medicines?

Many conventional drugs are based on herbal remedies or plants. The best known examples are aspirin, which comes from willow bark, and morphine, which comes from the opium poppy. Modern medicine and pharmacology have tried to isolate any active ingredient, purify it and modify it to make it more potent or to decrease its side effects.

By contrast, herbalists use unpurified plant extracts. Herbal preparations are likely to contain several active constituents, especially if several different herbs have been used together. Moreover, the constituents in two samples of a particular herbal drug may be in different proportions. Herbalists claim that combining several constituents reduces the toxicity of the whole treatment, a concept they call ‘buffering’, and that the interaction between the different herbs means that the treatment is more effective. Chinese herbs, for example, are selected and combined in formulas based on principles that have no relation to biochemistry. The vast majority of herbal treatments use formulas containing four or more herbs. By contrast, conventional practice tries to limit the number of drugs being taken whenever possible.

Do herbalists make a diagnosis?

Herbal practitioners take a history and may perform a physical examination. They concentrate on everyday processes such as appetite, digestion, urination, defecation and sleep. They take a dietary history and work to improve the diet and encourage other lifestyle changes. So they do make a diagnosis, but their system of doing so is different from that of Western medicine.

Are any herbal remedies recommended by conventional doctors?

Peppermint oil and aloe vera are frequently recommended and widely available without prescription for irritable bowel syndrome.

What other herbal medicines are used for irritable bowel syndrome?

Ginger is traditionally used for nausea. It is said to enhance emptying of the stomach while at the same time reducing spasm in the bowel. This should make it very useful for irritable bowel syndrome, but surprisingly no studies have evaluated its efficacy. Iberogast (see below) is used for dyspepsia and irritable bowel syndrome. Chinese herbal medicine is also widely available in the UK.

Does peppermint oil work in irritable bowel syndrome?

The main active ingredient of peppermint oil is menthol. Applied to the smooth muscle of the intestine, menthol has a direct relaxing effect, reducing spasm. Peppermint oil is now so commonly used as an antispasmodic that it has acquired a place in conventional medicine. There are a number of small studies in people with irritable bowel syndrome that mostly confirm a modest benefit over a placebo (dummy) treatment. There are usually no side effects, although a few people may complain of heartburn.

What is aloe vera, and does it work for irritable bowel syndrome?

Aloe, or Aloe vera, is a cactus-like plant with a long history as a ‘natural’ remedy. Processing the leaves produces two compounds: aloe latex, or aloe juice, from the outer layer of the leaves, and aloe gel, which comes when the leaves are pulped. Aloe juice is a bitter-tasting, yellow fluid containing substances called anthraquinones. This makes it a stimulating laxative and it is used for this purpose.

Aloe gel is used as a non-greasy base for skin creams and is claimed to have therapeutic properties. The mechanical separation process is not always complete, so aloe latex can be found in some aloe gels. Aloe gel has been claimed as a remedy for irritable bowel syndrome, but there are no published studies on this. Nevertheless, I have seen people who have found it helpful as an antispasmodic, and it is often recommended as something to try, particularly in constipation-predominant irritable bowel syndrome.

Does Chinese herbal medicine work?

Chinese herbal medicine is widely practised in the UK. Practitioners take a medical history and tailor the treatment to the individual’s clinical presentation. Consequently, people with the same diagnosis may actually receive different treatments. This individualisation of treatment is common in complementary medicine and makes it difficult to scientifically test the effectiveness of particular treatments.

One interesting scientific study of Chinese herbal medicine for irritable bowel syndrome in Australia was published in the Journal of the American Medical Association in 1998. In this study, 106 people with irritable bowel syndrome were randomly divided into three treatment groups. One group received individualised Chinese herbal medicine, another received standard herbal Chinese medicine, and the third group received a placebo (inactive treatment). All the patients consulted a Chinese herbalist, and all the treatments were provided in capsules so that the people themselves and the gastroenterologists assessing them were unaware of who was receiving which treatment.

After 16 weeks of treatment, 33% of those receiving the placebo had improved, which is a typical result for an irritable bowel syndrome study (for a discussion on the placebo effect, see earlier in the section). However, the Chinese herbs gave a significantly better result: 76% of those taking the standard Chinese herbs, and slightly less – 64% – of those with individualised herbal preparations improved with the treatment.

Moreover, the improvement seemed to last, and it lasted better in those who had received the individualised treatment. The study subjects were again assessed 14 weeks after the end of treatment. This time, 63% of the standard treatment group still felt improved, compared with 75% of the individualised treatment group and 32% of the placebo-treated group.

No serious side effects were noted during this study. Only two patients withdrew, one because of headaches and one because of gastrointestinal discomfort. Chinese medicine has been associated with liver function problems, but no such problem was noted here.

The authors concluded that Chinese herbal medicine worked for irritable bowel syndrome, and that individualised treatment worked better. They suggested that the individualised Chinese herbal treatment may have been able to address the individuals’ underlying problems, possibly by including herbs with sedative or anti-anxiety properties. The standard Chinese herbal medicine for irritable bowel syndrome had no sedative properties and was a formulation considered to improve bowel function.

Surprisingly, I can find no other scientific studies of Chinese herbal medicine for irritable bowel syndrome that have been published in English.

What is Iberogast, and might it work for my irritable bowel syndrome?

Iberogast is a combination of herbs: bitter candytuft, chamomile flower, peppermint leaves, caraway fruit, licorice root, lemon balm leaves, celandine herbs, angelica root and milk thistle fruit.

A study from Germany published in 2003 compared the efficacy of Iberogast with a simplified six-herb preparation (bitter candytuft, chamomile flower, peppermint leaves, caraway fruit, licorice root and lemon balm leaves), with the single herb bitter candytuft and with a placebo (inactive treatment) in irritable bowel syndrome. This was a reasonably large study with about 50 people randomly allocated to each group.

After 28 days of treatment, the result was judged to be good or very good in 38.5% of those receiving the placebo, which is typical of irritable bowel syndrome studies. However, the Iberogast and the simplified six-herb preparation were significantly better – 64.7% of people in the study and 72.6% of physicians judged the efficacy to be good or very good. By contrast, the bitter candytuft on its own was no better than the placebo. There were no significant side effects from the herbal preparations, and the results of blood tests taken during the study remained normal.

Iberogast is available commercially in Europe and the USA. I sometimes suggest to people that they try it, although in the UK it is difficult to obtain and usually has to be ordered from abroad.

 

HYPNOSIS

What is hypnosis?

Hypnosis involves inducing a deeply relaxed state of mind in which the person’s normal critical faculties are bypassed, allowing a state of heightened receptivity to suggestions. Once the person is in this state, sometimes called a hypnotic trance, the therapist makes therapeutic suggestions to encourage changes in behaviour or relieve symptoms.

Hypnosis is not sleep. Neither are subjects in a hypnotic state under the control of the hypnotist. The subject has to co-operate for the hypnotic state to be achieved. While the subject is hypnotised, he or she still has free will but has enhanced attention to what is being said. In conventional hypnosis, people approach the suggestions of the hypnotist, or their own ideas, as if they were reality. If the hypnotist suggests that your tongue has swollen up to twice its size, you’ll feel a sensation like this in your mouth and you may have trouble talking.

How is this hypnotic state induced?

There are different methods of inducing hypnosis, but in every case subjects must want to be hypnotised. They must also believe that they can be hypnotised, and they must be made to feel comfortable and relaxed.

The fixed-gaze induction or eye-fixation method was popular in the early days of hypnosis and is the method we tend to see in films. The hypnotist waves a pocket watch in front of the subject. The idea is to get the subject to focus on an object so intently that he or she tunes out any other stimuli. As the subject focuses, the hypnotist talks to him or her in a low tone, lulling the subject into relaxation. However, this method does not work on a large proportion of the population.

The most common method used by therapists is called progressive relaxation and imagery. The hypnotist speaks to the subject in a slow, soothing voice, gradually bringing on complete relaxation and easing the subject into full hypnosis. Self-hypnosis training, as well as relaxation and meditation audiotapes, uses this method too.

What happens in gut-directed hypnotherapy?

Hypnosis as a treatment for irritable bowel syndrome involves the use of what has been termed ‘gut-directed hypnotherapy’. This was first developed by Dr P. J. Whorwell at the University Hospital of South Manchester in 1984 and currently comprises weekly 1-hour sessions for up to 12 weeks. Each session consists of inducing and deepening the hypnotic state, followed by ‘ego-strengthening’ suggestions relevant to the individual. These are accompanied by further suggestions and interventions, such as inducing warmth in the abdomen using the hands, and imagery directed towards controlling and normalising gut function. The sessions are supported by audiotapes used at home for self-hypnosis.

Does gut-directed hypnotherapy work for irritable bowel syndrome?

Hypnotherapy cannot be evaluated in the same way as drug therapy. A double-blind placebo-controlled trial, which is what is used to evaluate conventional medicines (see above), is impossible because co-operation and rapport are needed between the client and therapist to achieve a hypnotic trance, and there is no such thing as a placebo hypnosis.

Even so, hypnosis for irritable bowel syndrome has been studied extensively since 1984 and has proved to be superior to psychotherapy combined with placebo pills. Positive results for hypnotherapy have been consistently obtained in mostly non-randomised uncontrolled studies. In these studies, all the subjects get the same treatment, and the object is to see how many will benefit. The problem with such studies is that it is impossible to know whether the improvement is a real effect of the treatment or a placebo effect.

Even so, hypnotherapy seems to consistently improve the symptoms of irritable bowel syndrome. Moreover, this improvement seems to be maintained. For example, in an audit of over 200 people with irritable bowel syndrome treated with hypnotherapy in Manchester, 71% felt better at the end of the treatment. When they were reviewed by questionnaire 6 years later, 81% of those who had improved felt that this improvement had been maintained. To the best of my knowledge, no study has compared hypnosis with active medical treatment.

Can you give me some examples of the suggestions that are made to people while they are in a hypnotic state?

A person with constipation-predominant irritable bowel syndrome might be asked to imagine the bowel as a river:

"Imagine your bowel as a stagnant river, its water murky, polluted, foul-smelling, full of drifting rubbish that clogs its channels. Now see the river beginning to flow, gently at first, then faster and clearer, through green grassy meadows, with the sun shining overhead."

Similarly, for a person with diarrhoea:

"Imagine your bowel as a river, flowing fast, raging through a canyon, swirling and bubbling. Now see the canyon opening into a valley, lush and green. The water slows, flowing serenely through quiet fields."

Is hypnosis safe?

Adverse reactions to hypnosis are rare. There are reports of hypnosis exacerbating psychological problems when unexpected thoughts and feelings come through during or after hypnosis. People may be distressed by reliving previous traumas, and there have been cases of ‘false memories’ being induced in psychologically vulnerable people. The most common suspected adverse reactions to hypnosis include drowsiness, dizziness, stiffness, headaches and anxiety.

How does hypnosis work?

We don’t really know how hypnosis works. You can think of it as a form of psychological therapy that directly addresses the subconscious mind. That it works in irritable bowel syndrome shows just how much the mind and body interact in this condition.

How available is hypnotherapy? Is it easy to get hypnotherapy?

Hypnotherapy is widely available (but not usually on the NHS in the UK). It isn’t difficult to find a hypnotherapist. You can search on Internet search engines such as Google for hypnosis, or gut-directed hypnotherapy, or look in the Yellow Pages. Some societies offer lists of therapists, their qualifications and the conditions they treat. These include the British Society of Clinical Hypnosis and the National Register of Hypnotherapists and Psychotherapists. The problem is knowing whom to go to. There is a lack of effective regulation of hypnotherapists, and your family doctor or specialist may not know any of the local practitioners. It is best to contact the two societies above if you want to try this form of treatment.

 

ACUPUNCTURE

What is acupuncture?

Acupuncture has been used in China for over 2500 years. It began to achieve prominence in the West after an American journalist travelling with President Nixon to China in 1972 was treated successfully with acupuncture for complications after his appendix had been removed. Since then, it has gained considerable acceptance. Some family doctors and physiotherapists use acupuncture themselves, others refer patients, and many people refer themselves.

Acupuncture involves stimulating specific points on the skin by inserting needles. The needles are then used to stimulate these points mechanically or with a small electrical current. In traditional Chinese medicine, health is thought to depend on the body’s ‘motivating energy’, called Qi (pronounced chee), moving in a smooth and balanced way through a series of channels beneath the skin; these channels are called meridians.

Qi consists of equal and opposite qualities – Yin and Yang – and when these become unbalanced, illness may result. By inserting fine needles into the channels of energy, an acupuncturist can alter the flow of Qi to restore its natural balance. The flow of Qi can be disturbed by a number of factors, including emotional states, poor nutrition, weather conditions, hereditary factors, infections, poisons and trauma. Acupuncture aims to restore the balance between the individual’s physical, emotional and spiritual aspects.

Is there a difference between traditional Chinese acupuncture and the acupuncture used in the West?

Western-style or medical acupuncture, as practised mostly by doctors and physiotherapists, uses a more limited range of acupuncture techniques on the basis of a Western medical diagnosis. The Chinese concepts underlying acupuncture are largely not used. Instead, acupuncture points are thought to correspond to physiological and anatomical features or ‘trigger points’; stimulating these leads to activation of parts of the central nervous system. There is some evidence for this from functional MRI (magnetic resonance imaging) and PET (positron electron tomography) brain scans. There is also some evidence that acupuncture causes the brain to release its own pain control molecules, called endorphins.

What is acupuncture used for?

Acupuncture appears to be effective for nausea and vomiting, especially after operations or chemotherapy. It is frequently used for chronic pain, although the evidence for its effectiveness is still inconclusive. Is acupuncture used for irritable bowel syndrome? Acupuncture is used for irritable bowel syndrome, but there is no evidence to say whether or not it is effective. There have been surprisingly few studies published in English, and only one double-blind study, the type of study that is best suited to seeing whether a treatment works (see earlier in this section for an explanation of a double-blind study). In that study, 25 patients at a hospital in Israel each had four acupuncture treatments – two true treatments and two sham treatments with needles placed at the ‘wrong’ acupuncture points. The first true treatment led to a significant improvement in symptoms compared with the first sham treatment. However, the second true treatment was ineffective, so the study was inconclusive.

Are there any side effects with acupuncture?

Serious side effects such as viral hepatitis B infection caught from a needle, or a collapsed lung after it has been penetrated by a needle, have been reported but are very rare. In one study of Swedish physiotherapists, minor bleeding or bruising occurred after nearlyone in five treatments. Headache, fainting, nausea or fatigue have been reported to occur after about one in a thousand treatments.

 

COLONIC HYDROTHERAPY

What is colonic hydrotherapy?

Colonic hydrotherapy, or colonic irrigation, involves water at a very low pressure and a controlled temperature being slowly introduced into the colon through a tube passed into the rectum through the anus (the back passage). It is performed by a trained therapist, often in combination with abdominal massage. The idea is to wash away faecal matter and pipe it away with the waste water. There is no mess and no smell. A colonic treatment lasts between 45 and 60 minutes.

Are there any side effects?

During colonic irrigation, the colon muscles will sometimes contract suddenly, expelling considerable amounts of liquid and waste into the rectum. This may feel like cramping or gas, and may create a feeling of urgency to empty the rectum. Such episodes, if they do occur, are brief and easily tolerated. There are no reports of any serious side effects.

Does colonic hydrotherapy work for irritable bowel syndrome?

There are no studies on this, so it is difficult to comment. I have had several patients with difficult constipation who have benefitted. I imagine that, for most people, laxatives would have a similar effect. The laxatives that we use to prepare the bowel before a barium enema or colonoscopy usually leave it sparkling clean!

 

CONCLUSION

Hard-and-fast scientists often tend to be sceptical about the underlying theories and assumptions of complementary medicine. A large part of the benefit that some people experience may be attributable to the placebo effect – their belief in their therapist and the treatment – rather than being a true effect of the treatment. Sometimes people who use a different complementary medicine every few months, enthuse about each until the benefit wears off and then move on to another therapy. But does it really matter if they are benefitting from a placebo effect as long as they feel better? Doesn’t this just show what positive thinking can do?

Medicine clearly has much to discover, and it is likely that some complementary medicines will find a place within conventional medicine. How they work will be determined, the active ingredients will be purified, and the side effects and risks will undoubtedly be documented.

People tend to believe that complementary medicines are harmless, whereas conventional drugs have side effects. But we know about the side effects of these drugs as they have been extensively tested and regulated. This is not, however, the case with complementary medicine. We simply don’t know what effects they may have in the short or long term. A potent treatment without the risk of side effects is unfortunately as rare as a free lunch! Even so, it is unusual to see a patient who has been harmed by complementary medicine.

As we’ve seen, treating irritable bowel syndrome is often a matter of experimenting, and I generally encourage people to try treatments that appeal to them, as we can’t predict what will work in each individual case.

 

SUMMARY

  • Most complementary treatments have not been tested to anything like the same degree as conventional treatments.
  • Their proponents feel that the scientific model used in medicine may not apply to complementary treatments.
  • Complementary treatments are mostly used in conditions that are not well served by conventional medicines.
  • We all see people who have benefited from complementary medicine.
  • The benefit of complementary treatments may lie to a large extent in the placebo effect – we don’t yet know.
  • Some complementary treatments have been tested in irritable bowel syndrome patients with positive results, but such studies have been few in number and of a small scale.
  • The complementary treatments that have some evidence of efficacy in irritable bowel syndrome include gut-directed hypnotherapy, Chinese medicine, peppermint oil and Iberogast.
  • We are unlikely for some time to have information on how well these treatments work. In the meantime, the placebo effect alone shows the enormous power of positive thinking, and you may also derive extra benefits.

 

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