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Specific Complementary Therapies

Acupuncture / acupressure

What is known
Acupuncture is widely used in the general community for pain and nausea, as well as other symptoms. Although there are now numerous studies including systematic reviews, they present conflicting findings as a result of major methodological problems in the studies.This limits their usefulness. The most rigorous summaries of the evidence available are contained in the Cochrane database, and a recent review of these shows that the strongest evidence for effectiveness for acupuncture / acupressure relates to chemotherapy-induced and post-operative nausea and vomiting. [1,2] Of the thirty-two Cochrane reviews included, twenty-five of them failed to demonstrate the effectiveness of acupuncture. Five reviews arrived at positive or tentatively positive conclusions and two were inconclusive. Based on this highest level of evidence it is not appropriate at this time to recommend the routine use of acupuncture for pain, insomnia, or other symptoms. [1-5]

What it means in practice
Chemotherapy-induced and post-operative nausea and vomiting are specific, time-limited symptoms. It may not be possible to directly extrapolate from these to the chronic nausea or other types of nausea and vomiting experienced by some palliative care patients. Perhaps controversially, several authors have argued that there is already enough evidence for acupuncture and / or acupressure to be included as an important modality within palliative care. [6,7]

Antioxidants

What is known
A systematic review looking at trials of antioxidants for reducing the toxicities of chemotherapy [9] has reported that the majority of included studies reported a decrease in toxicities of chemotherapy, whilst a few reported no difference, and only one study, of Vitamin A, showed an increase in toxicity. The thirty-three studies reviewed were of glutathione (11), melatonin (7), vitamin A (1), an antioxidant mixture (2), N-acetylcysteine (2), vitamin E (5), selenium (2), L-carnitine (1), Co-Q10 (1) and ellagic acid (1). The study concluded that certain antioxidant supplements may reduce adverse reactions including neurotoxicity, asthenia, stomatitis / mucositis, and weight loss. The authors suggest that this topic is worth further research, and that future, larger studies would need to standardise doses and routes of administration of antioxidants, and tumour types and chemotherapy regimens.

What it means in practice
It is possible that in future some types of antioxidants may be used to reduce the dose-limiting toxicities of chemotherapy, allowing people to be maximally treated. Importantly, this systematic review did not show that using these antioxidants reduced the effectiveness of chemotherapy: the outcomes of patients treated with antioxidants in these studies were not significantly worse than those who did not receive such treatment. This study did not include patients receiving radiotherapy, and only looked at studies of certain chemotherapeutic agents. It provides preliminary information. Many unanswered questions still remain about which agents should be used and how.

Aromatherapy

What is known
A review [9] provides some evidence that aromatherapy and / or massage have short-term effects on cancer patients’ well-being, mainly by reducing anxiety. Another systematic review looking at the effect of aromatherapy on patients with depression, including depression related to chronic medical conditions, showed some benefit associated from aromatherapy. [10] The mechanism by which aromatherapy may act is not known.

What it means in practice
Aromatherapy is frequently used as a form of supportive therapy in palliative care, often in conjunction with massage. It has a low risk of adverse events, and appears to have benefits that can contribute to patients’ quality of life, although these do not seem to be sustained.

Chinese Herbal Medicine

What is known
Chinese herbal medicines have been used alongside standard cancer treatments to reduce treatment toxicity and to improve treatment outcomes and quality of life. A large number of studies have been done, and forty nine were included in a systematic review of their effectiveness for patients with cancer. [11] All except one were of poor quality. However the authors comment that the majority of the studies suggest clinical benefits in terms of improved treatment side effects, quality of life, and performance status. Some studies appeared to demonstrate tumour regression and increased survival. Whilst the evidence is not strong enough to draw any firm conclusions, the generally positive findings suggest that well-designed studies are needed to explore these outcomes. A second review looked at studies of Chinese herbal medicines used for cancer pain [12] and also found that despite the poor quality of the studies, there appeared to be some benefits in relation to pain outcomes and reduced medication side effects of usual analgesics.

What it means in practice
Chinese herbal medicines include a very varied group of substances, which may be difficult to identify and study when they are used in routine practice, as distinct from in a clinical trial when treatments are more likely to be standardised. There is evidence that some of these medicines may well be of clinical benefit in a palliative care population. However further study is needed to identify their possible place in the treatment of patients with cancer. The risk of adverse effects and drug interactions is also important to consider when palliative care patients use these medicines.

Cognitive Behavioural Therapy (CBT)

What is known
Cognitive Behavioural Therapy is a psychological technique that can be taught to patients to help with many health and psychological problems, including in cancer patients to reduce self-perceived distress and pain. A systematic review [13] has looked at studies of CBT for distress and pain in patients with breast cancer, and has shown significant improvements in these symptoms in the treatment group. The benefit was largest when the treatment was given individually rather than as a group session, and there was no difference in its impact according to whether the patients had metastatic cancer or not.

What it means in practice
CBT may be a helpful modality for some patients, but requires the input of a specialised practitioner. This evidence relates to a particular group of patients – women with breast cancer, only some of whom had metastatic disease. The effectiveness of the same intervention in other groups would need to be investigated.

Homeopathy

What is known
A systematic review [14] has investigated the effectiveness of homeopathy for treating anxiety. Eight randomised controlled studies were identified, and their results were contradictory. The authors concluded that the evidence available is not strong enough to draw any conclusions about the effectiveness of homeopathic treatment for anxiety. Many trials of homeopathy have been done in conditions not related to palliative care, and there has been controversy in the literature about the interpretation of the findings of these studies: a number of systematic reviews have concluded that homeopathy produces only non-specific placebo effects.

What it means in practice
The populations for the included studies varied, but some were patients with anxiety relating to cancer or other medical problems. Other patients included had solely anxiety problems. Overall, the evidence as it relates to a palliative care population is not strong enough to recommend using homeopathy to treat anxiety, or any other symptoms.

Hypnosis

What is known
A recent systematic review [15] sought out studies of hypnotherapy specifically for a palliative care population, and found only one randomised controlled trial. Twenty six other studies were found, mostly case studies, and these looked at the use of hypnotherapy for a range of problems. The authors concluded that there is not yet enough evidence to assess the potential effectiveness of hypnotherapy for palliative care symptoms. Two other systematic reviews [16,17] have focused on the use of hypnotherapy in paediatric patients, where it has been studied as a treatment for anxiety / distress and pain (especially procedure related pain), and chemotherapy induced nausea and vomiting.

What it means in practice
Despite methodological limitations, these studies suggest that hypnosis may potentially be an effective treatment for procedural pain, nausea and distress in children with cancer. Its effectiveness in adults is not so well established. The suggestibility of patients who are to receive hypnotherapy is an area that needs more study.

Massage

What is known
There has been a considerable amount of research addressing the effectiveness of massage for various palliative care symptoms including pain, nausea, anxiety, anger, depression, stress and fatigue. A recent systematic review [18] of this body of research described the results of these studies as encouraging, but not overwhelmingly positive. Another review [19] identified the areas where massage may be beneficial as anxiety, pain and nausea, but agreed that the efficacy of massage is not yet proven. Despite this, and because of very minimal potential to cause harm, a number of reviews have argued for the inclusion of massage as a treatment modality for cancer patients [20,21] whilst some authors suggest that massage be offered on a case-by-case basis but cannot be justified as part of routine care. [22] There are some very specific contraindications to massage in a palliative care population which need to be considered, including low platelet counts, bony metastases or pathological fractures, or malignant wounds.

What it means in practice
Although the evidence base is not compelling, the overall safety and the acceptability of massage to palliative care patients has been demonstrated by the uptake of these therapies within services. Many palliative care services now offer massage as a complementary therapy - most often with the aim of improving the well-being of patients and their carers.

Meditation / relaxation

What is known
Two systematic reviews have assessed the effectiveness of stress reduction therapies based on mindfulness meditation for patients with cancer. [23,24] Both suggested that mindfulness meditation-based strategies appeared likely to be of benefit, and one identified a dose response relationship between the practice of mindfulness meditation and improved psychosocial outcomes such as sleep, mood and stress. Another review analysed studies of guided imagery as a meditation and relaxation technique. [25] It suggested that whilst no benefit had been demonstrated in relation to particular physical symptoms, several studies suggested improvement in anxiety, comfort and emotional response in the context of chemotherapy from using guided imagery.

What it means in practice
Meditation and relaxation strategies are self-care approaches which are used by many palliative care patients, and are frequently offered by palliative care services. There is some evidence that they are psychosupportive. In addition, once the skills have been acquired these techniques can often be used independently, and they are regarded as generally safe.

Music therapy

What is known
Systematic reviews of the effectiveness of music therapy in palliative care [26] and for patients with multiple sclerosis [27] have identified a number of studies which suggest possible improvements in symptoms related to pain, mood, and other psychosocial variables. However methodological problems of many of the studies were also noted. Studies examining music therapy have been mainly qualitative and uncontrolled studies.

What it means in practice
Although strong evidence of clinical benefit is not yet available, music therapy has been adopted as one of the complementary therapies frequently offered to patients by palliative care services. It as a supportive therapy with few adverse effects which appears to be generally well accepted and tolerated by patients.

Pain treatments (complementary)

What is known
A systematic review assessed the evidence to support a range of complementary therapies for the treatment of neuropathic pain [28] and identified twenty studies for inclusion. The therapies for which studies were reviewed included acupuncture, electrostimulation, herbal medicine, magnets, dietary supplements, imagery, and spiritual healing, and found the evidence was strongest for topical capsaicin. There was also some evidence to support the potential effectiveness of cannabis extract, magnets, carnitine, and electrostimulation, which the authors argue should be studied further. Other therapies were not shown to be of benefit.

Cochrane reviews of the role of Transcutaneous Electrical Nerve Stimulation (TENS) for chronic pain [29] and for cancer pain [30] found few studies of sufficient quality to include in the systematic reviews. Both of the studies that were identified in the review of the role of TENS in cancer pain showed no greater benefit than placebo.

What it means in practice
Neuropathic pain is a problem for some patients with cancer and can be difficult to treat. Topical capsaicin has been used for neuropathic pain in clinical practice for some time, often for non-malignant neuropathic pain such as that caused by diabetes, but one of the limitations of the treatment is that because it is a topical treatment it is difficult to use in pain which is diffuse or involves a large area of the body. There are also some adverse effects which must be taken into account: in some studies, for instance in patients with HIV related neuropathic pain, there was a worsening of pain in patients using capsaicin. The other therapies identified as having some potential to improve neuropathic pain have not been adopted in routine care at this stage, and the research findings are very preliminary.

TENS has been used as one of the treatments for chronic non-malignant pain in many clinical settings for some years, despite the inadequate evidence for its benefits for any type of pain. It has not been well studied in a palliative care population, and cannot be routinely recommended at this time.

Reflexology

What is known
A systematic review of 5 trials of reflexology [31] found a small amount of evidence to support the effectiveness of reflexology in a palliative care population, however it also noted that in a number of the studies there was similar or greater benefit experienced by the group receiving the sham (placebo) massage. Breathlessness, fatigue, anxiety and pain were symptoms that were thought to have improved, although overall the quality of the studies was poor and the benefits were not sustained. Adverse effects were not sought in any of these studies.

What it means in practice
The evidence for reflexology is not strong and much of the research which has been done is subject to considerable bias. Questions about the efficacy of this therapy and any potential adverse effects related to it cannot be answered at present.

Reiki

What is known
Reiki is a spiritual healing technique which is promoted as having holistic benefits for patients. Despite its growing popularity and availability in some supportive care settings, little research on the outcomes of reiki is available for the palliative care population. A systematic review [35] has collected the evidence and found that those studies which have been done are small and varied in methodology, and most involve healthy people. Two small uncontrolled studies suggest some improvement in pain control in patients with cancer. Methodological issues identified in the systematic review relate to how to develop a placebo technique for use in placebo controlled studies of reiki.

What it means in practice
There is little evidence available to support the usefulness of reiki for palliative care patients at this stage. The literature is very scanty. Questions about the efficacy of this therapy and any potential adverse effects related to it cannot be answered at present.

Tai Chi and Qi Gong

What is known
Tai Chi has been investigated in a number of studies; of the four studies included in a recent systematic review [32] all involved women with breast cancer at various stages. Of these, two reported benefits in terms of psychosocial symptoms for the patients involved, however all of the studies were methodologically flawed and the evidence is therefore not persuasive. No adverse events were reported in any of these studies.

A systematic review of studies of Qi Gong in cancer patients identified nine clinical trials, which were generally of poor quality. Of these studies, two suggested a life-prolonging effect of Qi Gong, however because of the methodological difficulties, the results of these studies were not convincing.

What it means in practice
At this stage the benefits of Tai Chi for cancer patients have not been clearly demonstrated, although it appears to be both safe and acceptable. Tai Chi has been widely adopted in Western communities for the promotion of general well-being. The authors of the systematic review comment that on theoretical grounds, benefit would be anticipated from Tai Chi, and that further well-designed studies would be valuable. Qi Gong is a health maintenance practice which is important within the Chinese community, and is usually used in the context of traditional Chinese medicine. Whilst there is not strong evidence to support specific health benefits for either of these therapies at this stage, they may contribute to the well-being of their users.

Yoga

What is known
A systematic review was done of studies of yoga where the objective was improved psychosocial adaptation of patients with cancer. [33] Ten studies were included, most of the patients involved were women with breast cancer, and the studies were of reasonable quality overall. There were some positive results. However the variability of the interventions studied and other methodological problems mean that it is not yet possible to clearly identify the benefits of yoga in this population.

What it means in practice
This review suggests that there are some potential psychosocial benefits from yoga, although the population studied may not be equivalent to a palliative care population. Yoga as a therapeutic intervention in a palliative care population is likely to require modification of the usual yoga practices. Further studies are needed to explore the potential benefits of specific types of yoga practice for palliative care patients.

Related CareSearch pages

Complementary Therapies
CareSearch information for Clinical practice

Finding out more

  • The following book (with associated CD) is recommended as an evidence-based summary of the literature on complementary therapies. It is not a free online resource but is extremely comprehensive.
    • Ernst E, Pittler MH, Wider B. The desktop guide to complementary and alternative medicine: An evidence based approach. 2nd ed. Philidelphia, PA: Mosby Elsevier; 2006.

Links to detailed information

These databases contain valuable information for clinicians, and also for patients seeking evidence-based information about complementary therapies. 

  • National Center for Complementary and Alternative Therapy 
    Has an overview of complementary and alternative therapies and information and factsheets designed for patients
  • Memorial Sloan Kettering Cancer Center website: About Herbs 
    Contains detailed information for clinicians about botanicals and other complementary therapies that are frequently used by cancer patients, including summaries of known effects, adverse effects and interactions
  • Office of Dietary Supplements 
    Specific information for clinicians on dietary supplements, antioxidants and botanicals; also a useful set of factsheets for patients, and online resources about informed decision-making to help patients evaluate information about complementary and alternative therapies.

References 

  1. Lee J, Dodd M, Dibble S, Abrams D. Review of acupressure studies for chemotherapy-induced nausea and vomiting control. J Pain Symptom Manage. 2008 Nov;36(5):529-44. Epub 2008 Apr 28.
  2. Ernst E. Acupuncture: what does the most reliable evidence tell us? J Pain Symptom Manage. 2009 Apr;37(4):709-14. Epub 2008 Sep 11.
  3. Ezzo JM, Richardson MA, Vickers A, Allen C, Dibble SL, Issell BF, et al. Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD002285.
  4. Lee H, Schmidt K, Ernst E. Acupuncture for the relief of cancer-related pain--a systematic review. Eur J Pain. 2005 Aug;9(4):437-44. Epub 2004 Nov 11.
  5. Cheuk DK, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005472.
  6. Pan CX, Morrison RS, Ness J, Fugh-Berman A, Leipzig RM. Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review. J Pain Symptom Manage. 2000 Nov;20(5):374-87.
  7. Standish LJ, Kozak L, Congdon S. Acupuncture is underutilized in hospice and palliative medicine. Am J Hosp Palliat Care. 2008 Aug-Sep;25(4):298-308. Epub 2008 Jun 6.
  8. Block KI, Koch AC, Mead MN, Tothy PK, Newman RA, Gyllenhaal C. Impact of antioxidant supplementation on chemotherapeutic toxicity: a systematic review of the evidence from randomized controlled trials. Int J Cancer. 2008 Sep 15;123(6):1227-39.
  9. Wilkinson S, Barnes K, Storey L. Massage for symptom relief in patients with cancer: systematic review. J Adv Nurs. 2008 Sep;63(5):430-9.
  10. Yim VW, Ng AK, Tsang HW, Leung AY. A review on the effects of aromatherapy for patients with depressive symptoms. J Altern Complement Med. 2009 Feb;15(2):187-95.
  11. Molassiotis A, Potrata B, Cheng KK. A systematic review of the effectiveness of Chinese herbal medication in symptom management and improvement of quality of life in adult cancer patients. Complement Ther Med. 2009 Apr;17(2):92-120. Epub 2008 Dec 25.
  12. Xu L, Lao LX, Ge A, Yu S, Li J, Mansky PJ. Chinese herbal medicine for cancer pain. Integr Cancer Ther. 2007 Sep;6(3):208-34.
  13. Tatrow K, Montgomery GH. Cognitive behavioral therapy techniques for distress and pain in breast cancer patients: a meta-analysis. J Behav Med. 2006 Feb;29(1):17-27. Epub 2006 Jan 7.
  14. Pilkington K, Kirkwood G, Rampes H, Fisher P, Richardson J. Homeopathy for anxiety and anxiety disorders: a systematic review of the research. Homeopathy. 2006 Jul;95(3):151-62.
  15. Rajasekaran M, Edmonds PM, Higginson IL. Systematic review of hypnotherapy for treating symptoms in terminally ill adult cancer patients. Palliat Med. 2005 Jul;19(5):418-26.
  16. Richardson J, Smith JE, McCall G, Pilkington K. Hypnosis for procedure-related pain and distress in pediatric cancer patients: a systematic review of effectiveness and methodology related to hypnosis interventions. J Pain Symptom Manage. 2006 Jan;31(1):70-84.
  17. Richardson J, Smith JE, McCall G, Richardson A, Pilkington K, Kirsch I. Hypnosis for nausea and vomiting in cancer chemotherapy: a systematic review of the research evidence. Eur J Cancer Care (Engl). 2007 Sep;16(5):402-12.
  18. Ernst E. Massage therapy for cancer palliation and supportive care: a systematic review of randomised clinical trials. Support Care Cancer. 2009 Apr;17(4):333-7. Epub 2009 Jan 13.
  19. Wilkinson S, Barnes K, Storey L. Massage for symptom relief in patients with cancer: systematic review. J Adv Nurs. 2008 Sep;63(5):430-9.
  20. Hughes D, Ladas E, Rooney D, Kelly K. Massage therapy as a supportive care intervention for children with cancer. Oncol Nurs Forum. 2008 May;35(3):431-42.
  21. Russell NC, Sumler SS, Beinhorn CM, Frenkel MA. Role of massage therapy in cancer care. J Altern Complement Med. 2008 Mar;14(2):209-14.
  22. Lafferty WE, Downey L, McCarty RL, Standish LJ, Patrick DL. Evaluating CAM treatment at the end of life: a review of clinical trials for massage and meditation. Complement Ther Med. 2006 Jun;14(2):100-12. Epub 2006 Mar 29.
  23. Matchim Y, Armer JM. Measuring the psychological impact of mindfulness meditation on health among patients with cancer: a literature review. Oncol Nurs Forum. 2007 Sep;34(5):1059-66.
  24. Smith JE, Richardson J, Hoffman C, Pilkington K. Mindfulness-Based Stress Reduction as supportive therapy in cancer care: systematic review. J Adv Nurs. 2005 Nov;52(3):315-27.
  25. Roffe L, Schmidt K, Ernst E. A systematic review of guided imagery as an adjuvant cancer therapy. Psychooncology. 2005 Aug;14(8):607-17.
  26. Hilliard RE. Music Therapy in Hospice and Palliative Care: a Review of the Empirical Data. Evid Based Complement Alternat Med. 2005 Jun;2(2):173-178. Epub 2005 Apr 7.
  27. Ostermann T, Schmid W. Music therapy in the treatment of multiple sclerosis: a comprehensive literature review. Expert Rev Neurother. 2006 Apr;6(4):469-77.
  28. Pittler MH, Ernst E. Complementary therapies for neuropathic and neuralgic pain: systematic review. Clin J Pain. 2008 Oct;24(8):731-3.
  29. Nnoaham KE, Kumbang J. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD003222.
  30. Robb K, Oxberry SG, Bennett MI, Johnson MI, Simpson KH, Searle RD. A cochrane systematic review of transcutaneous electrical nerve stimulation for cancer pain. J Pain Symptom Manage. 2009 Apr;37(4):746-53. Epub 2008 Sep 14.
  31. Wilkinson S, Lockhart K, Gambles M, Storey L. Reflexology for symptom relief in patients with cancer. Cancer Nurs. 2008 Sep-Oct;31(5):354-60; quiz 361-2.
  32. Lee MS, Pittler MH, Ernst E. Is Tai Chi an effective adjunct in cancer care? A systematic review of controlled clinical trials. Support Care Cancer. 2007 Jun;15(6):597-601. Epub 2007 Feb 21.
  33. Smith KB, Pukall CF. An evidence-based review of yoga as a complementary intervention for patients with cancer. Psychooncology. 2009 May;18(5):465-75.
  34. Ernst E, Pittler MH, Wider B. The desktop guide to complementary and alternative medicine: An evidence based approach. 2nd ed. Philidelphia, PA: Mosby Elsevier; 2006.
  35. Herron-Marx S, Price-Knol F, Burden B, Hicks C. A systematic review of the use of Reiki in health care. Alternative and Complementary Therapies. 2008 Feb;14(1):37-42.

This page was created on 14 December 2009