Complementary Therapies

Key Messages

  • Complementary therapies are widely used in the Australian community, with nearly 50 per cent of Australians using them and are often adopted by palliative care patients. [1]
  • Many specialist palliative care services now offer complementary therapies – most often mind-body and 'touch therapies'- as part of their supportive care for patients and their carers. Guidelines are available to help develop good clinical practice for this aspect of patient care (see below).
  • Clinicians are often not informed or aware that their patients are using complementary therapies. It is important to actively seek this information, in order to explore patients’ expectations and to minimise the risk of drug interactions or adverse effects.
  • Patients should be counselled about reliable information sources and advised to seek out appropriately trained complementary therapists. Professional organisations for specific complementary therapies have lists of accredited practitioners.
  • The National Center for Complementary and Alternative Medicine (NCCAM) provide up to date information regarding complementary therapies, as does Cancer Council Australia.
  • Herbal therapies and supplements can be associated with drug interactions or other risks. Up to date online information is available from the Memorial Sloan Kettering’s Integrative Medicine Department website About Herbs which can help health care providers advise patients about potential positive and negative effects of these treatments.

  

  

  

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Evidence Summary

Definition

Complementary therapies are defined by the US National Center for Complementary and Integrative Health (NCCIH) as 'a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine. In a palliative care context they are described as evidence based, supportive adjuncts to palliative care used to control or ease symptoms, enhance physical, mental and spiritual well-being, and optimize quality of life for patients and families. [2] 
When non-mainstream or non-conventional practices are used in place of mainstream medicine then this is called ‘alternative medicine’. When the complementary practices are used alongside traditional medicine then this called ‘complementary medicine’. When the two approaches are both used in a coordinated way then this is called ‘integrative medicine’. The terms ‘complementary therapy’ or ‘complementary and alternative medicine (CAM) are often used to describe the broad range of therapies and practices that are non-conventional or non-traditional medical therapies or practices. The National Health and Medical Research Council (NHMRC) replaced the term Complementary and Alternative Medicine (CAM) with ‘Complementary Medicine’ (CM) which also includes traditional, indigenous medicine. [3]

Complementary therapies are widely used in the general Australian community. In a recent cross-sectional survey 63 per cent of Australian adults used some form of CM, with 36 per cent consulting a Complementary Medicine practitioner and 52 per cent using a complementary therapy of some kind. [1] The same survey revealed that those using CM were more likely to be female, be highly educated and have a chronic disease. [1] This is supported by other research which also suggested patients from rural communities were less likely to access CM, possibly due to the lack of available services. [4] Therefore, patients who transition to palliative care services are likely to have accessed some form of CM or may be considering using complementary therapies alongside their other health care. Many complementary therapies promote relaxation and reduce anxiety and stress, which may assist patients and carers to cope better with everyday life. Patients may have a variety of reasons for using CM and these might include wanting a therapeutic response, wanting control, a strong belief in CM, CM as a last resort, and finding hope. [5,6] A number of specialist palliative care services now offer a range of complementary therapies for their patients, and for their patients’ families and carers. The types of therapies that are included in studies on CM are inconsistent, however, the most commonly researched would include massage, aromatherapy, relaxation, meditation, acupressure, or art and music therapy. Spiritual care, counselling and group therapy are often not included in CM research although many clinicians would consider them to be a complementary therapy. [2]

An evidence base is now developing which provides support for the role of some therapies in improving the symptoms and / or quality of life of palliative care patients, although for some complementary therapies very little evidence is available. When CM like herbs or supplements are taken orally, topically or by some other route, it is important to consider the possibility of drug interactions and side effects. As well as potential drug interactions some natural products may also have unexpected side effects due to renal or hepatic impairment. Complementary therapy use should therefore be regularly monitored throughout the course of a person’s illness.

The development of complementary therapies has been strongly driven by consumer demand, and the process of evaluating the efficacy, benefits, and occasionally harms associated with this rapidly growing health sector has been somewhat slower. Legitimate therapies which are supported by evidence have been integrated into many health services and are commonly used as adjuncts to mainstream health care approaches. [2] Those therapies which have little to no evidence to support their use have been characterised as ‘alternative’ and some are considered potentially harmful. [2] The treatments listed here have some high level evidence – positive or negative - which is relevant to their use in a palliative care population. The list of therapies is not exhaustive, as not all therapies that are commonly used have had sufficient research done to allow systematic reviews of the evidence to be completed. The following section is organised by grouping the more common therapies under their respective therapeutic classes. Where possible the evidence supporting a therapy used to manage a specific condition has been included in the patient management pages for that symptom.

Natural Products

This class of therapeutic products includes herbal medications, or botanicals, vitamins and minerals, probiotics and antioxidants. 

As with many complementary therapies the role of herbal medications, or botanicals, in a palliative care setting is under researched. Products like ginger have been promoted as antiemetics, but there is low quality evidence to support its use. [7,8] Research into the use of cannabis and cannabinoid products has increased as cannabis has gained popularity in the community. [9,10] Medicinal cannabis is available in a number of settings as tablets or liquid medication, but the plant based product is still widely available and is commonly consumed orally or by inhalation. A number of research studies have examined the effectiveness of cannabis to reduce the more common symptoms in palliative care, such as pain, nausea, weight loss, poor appetite and anxiety. [10] A recent systematic review found low quality evidence to support its use in any of the mentioned symptoms. [10]

The use of specific vitamins and minerals in palliative care should be guided by diagnosed deficiencies. [11] It is reasonable, however, to suspect deficiencies given the course of many life-limiting illnesses. Guidelines on nutrition and cancer recommend standard doses of vitamins and trace elements based on a patient’s specific dietary intake. [11] Specific vitamins have been identified in systematic reviews for their effect at treating symptoms such as mucositis, appetite loss, weight management, fatigue, nausea and vomiting. [8,11,12] The research base is small and possible recommendations are limited by the low quality of the evidence. Vitamin E has shown some promising results for treating mucositis. [11,12] Vitamin C supplementation showed some positive results in treating fatigue, appetite loss and nausea. [13] Many of the studies reported adverse effects, particularly gastrointestinal side effects. [13]

There is low quality evidence to support the use of probiotics in treating gastrointestinal symptoms in palliative care. [11] There have been some positive results with probiotics to improve body weight, when used in combination with other therapies. [13]

Other botanical based products, such as herbal products, may be used by patients or recommended by non-traditional health practitioners but there is no research identified in the literature examining their effects. [14] Those natural products utilised in Chinese Medicine are discussed later.

What it means in practice
Identifying patients with dietary deficiencies may be particularly useful in the early stages of palliative care. Guidelines on nutritional supplements are available. [11] Natural products, such as botanicals and supplements can be associated with drug interactions or other risks. Up to date online information is available from the Memorial Sloan Kettering’s Integrative Medicine Department website About Herbs which can help health care providers advise patients about potential positive and negative effects of these treatments.

Antioxidants

Antioxidants are naturally occurring substances that may reduce cell damage associated with ‘oxidative stress’. Antioxidants are found in fruits and vegetables and include vitamin C, vitamin E, selenium, carotenoids (beta-carotene), lutein and lycopene. They are used in oncology patients to limit the toxic effects of chemotherapy but have limited evidence for use. [15,16] The use of antioxidants may be harmful in some cancers so careful consideration should be taken before initiating their use. [16] Over 47 per cent of those using complementary therapies use dietary supplements (including antioxidants), mostly in the form of multivitamins. [1] There are no specific trials using antioxidants in a palliative care setting. Much of the research on these products comes from preventative health associated with noncommunicable diseases, or anti-ageing.  In a recent systematic review and meta-analysis of 49 studies examining the role of antioxidants in preventing disease, based on 287 304 people, the authors were unable to find supporting evidence for their use. [17] The authors did find an increased risk of all-cause mortality with vitamin A and β-carotene when used in high doses. [17] The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines for nutrition in cancer suggest the use of high-dose micro-nutrients be avoided. [11]

What it means in practice
Patients referred to palliative care services may be taking antioxidants as part of their health care plan. The use of these micronutrients should be evaluated against the cost and overall health benefit they provide. The US National Center for Complementary and Alternative Medicine (NCCAM) recommend a diet high in fruits and vegetables over using supplementation wherever possible. [18]

Mind-body Practices

These are practices that concentrate on the interactions between the mind and the body and consider health as being directly influenced by emotional, spiritual, mental, physical and behavioural factors. These practices include acupuncture, hypnosis, yoga, meditation and music therapy and are generally well accepted therapies in the Australian community.

Acupuncture / Acupressure

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 review of these shows that the strongest evidence for effectiveness for acupuncture / acupressure relates to chemotherapy-induced and post-operative nausea and vomiting. [19,20] Of the thirty-two Cochrane reviews included, twenty-five 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. [19-22] A recent review of acupuncture in a palliative care setting demonstrated short term benefit of reducing symptoms but was unable to establish medium or long term benefits. [14] There is limited good quality research on acupuncture in paediatrics but some promising results for its use to reduce nausea and vomiting. [8]

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. There is some support from the literature to include acupuncture as part of a therapeutic package of care. [23]

Aromatherapy

Aromatherapy is the use of essential oils and can be used in conjunction with massage or acupuncture or on its own. Essential oils can be inhaled or absorbed through the skin and is mostly used to reduce pain, anxiety, depression, nausea and insomnia but has been suggested for other symptoms. [14,24] There is low quality evidence to support the use of aromatherapy in pain management. [25] A review provides some evidence that aromatherapy and / or massage have short-term effects on cancer patients’ well-being, mainly by reducing anxiety. [26] While another review examining the effects of aromatherapy on children demonstrated adverse outcomes and increased anxiety. [8] A systematic review looking at the effect of aromatherapy on patients with depression, showed some benefit associated from aromatherapy. [27] There is some promising research on the positive effects of aromatherapy at reducing chemotherapy induced nausea. [27]

What it means in practice
Aromatherapy is frequently used as a form of supportive therapy in palliative care and there is evidence that it is more effective when used in conjunction with massage. [14] 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.

Hypnosis

A recent systematic review examined the role of hypnotherapy specifically in a palliative care population, and found only two studies. [14] While both studies demonstrated some benefit for the participating patients the quality of the research was such that recommendations about use cannot be made. Two other systematic reviews 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. [28,29] While the studies reported promising results the research in this field is limited by poor methodology.

What it means in practice
Research into the use of hypnosis to manage symptoms in palliative care is limited. [30] Hypnosis may potentially be an effective treatment for some symptoms but this is likely to depend on the suggestibility of patients who are to receive hypnotherapy.

Massage

There has been a considerable amount of research addressing the effectiveness of massage for various palliative care symptoms including pain, nausea, anxiety, depression, stress and fatigue. A recent systematic review described the results of these studies as encouraging, but not overwhelmingly positive. [14] Another review examining the use of massage to reduce symptoms in children with cancer indicated some positive outcomes but the quality of research is low. [31] 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. [32,33] Others suggest that massage be offered on a case-by-case basis but cannot be justified as part of routine care. [34] 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

Two systematic reviews have assessed the effectiveness of stress reduction therapies based on mindfulness meditation for patients with cancer. [35,36] 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. [37] 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. A recent review found that combining meditation with massage improves participant’s quality of life in a palliative care setting. [14]

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 psych supportive. In addition, once the skills have been acquired these techniques can often be used independently, and they are regarded as generally safe.

Music Therapy

Music therapy is becoming more widely accepted in the health care system and is being used in various settings for behaviour modification and to reduce stress, anxiety and improve quality of life. Systematic reviews of the effectiveness of music therapy in palliative care have identified a number of studies which suggest possible improvements in symptoms related to pain, mood, and other psychosocial variables. [14,38-40] A recent study established the effectiveness of receptive music therapy on reducing the burden of symptoms for people with dementia. [40] The methodological problems of many of the studies were also noted in the systematic reviews.

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 is a supportive therapy with few adverse effects which appears to be generally well accepted, cost effective and tolerated by patients.

Reiki

Reiki is an energy therapy 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. One review examined the potential benefits of reiki to improve pain and quality of life but was unable to establish any benefit. [14] Some authors suggest that reiki is simple to learn and as it may provide benefit to the patient should be trialled, however, there is no quality evidence to recommend its use. [41]

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 limited. Questions about the efficacy of this therapy and any potential adverse effects related to it cannot be answered at present.

Reflexology

A systematic review of 5 trials of reflexology found a small amount of evidence to support the effectiveness of reflexology in a palliative care population. [42] 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. [42] 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 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 that 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.

Tai Chi and Qigong

Tai Chi has been investigated in a number of studies examining its potential to reduce various symptoms such as depression and fatigue and improve quality of life. A systematic review examining the effects of Tai Chi in patients with heart failure found positive effects on depression and cardiovascular outcomes [43], while another review established a short term positive effect in treating fatigue related to cancer. [44] The authors were unable to establish long term benefits. There is conflicting outcomes when Tai Chi is used to improve quality of life, with one review establishing a positive effect in patients with Parkinson’s disease, [45] and another review unable to demonstrate any effects in patients with cancer. [46] The research in this area is of low to moderate quality and a number of studies are limited by bias. [46]

A systematic review of studies of Qigong in cancer patients identified two clinical trials, which were generally of poor quality. These studies were unable to demonstrate positive outcomes but due to the methodological difficulties, the results of these studies were not convincing. [46]

What it means in practice
At this stage the benefits of Tai Chi for palliative 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. Qigong is a health maintenance practice, which is important within the Chinese community and is usually used in the context of traditional Chinese medicine. Whilst evidence is not strong to support specific health benefits for either of these therapies at this stage, they may contribute to the well-being of their users.

Yoga

Yoga is a widely accepted practice in Australia and is recognised as providing overall positive health benefits. A systematic review has been conducted for studies of yoga where the objective was improved psychosocial adaptation of patients with cancer. [47,48] There were some positive results although it is unclear if these results would be as positive in advanced stages of the disease. The authors were unable to make recommendations for children. Another review established positive results for patients using yoga to reduce cancer related fatigue but this was also found in groups undertaking different types of exercise and was not found to be specific to yoga. [49] One review examining mind body interventions in people with heart failure was able to demonstrate improvement in some cardiovascular markers as well as quality of life. [43] Similarly these results were found in other forms of exercise.

What it means in practice
Yoga has demonstrated some positive effects in some studies in cancer and other life-limiting illnesses, but these effects may be difficult to replicate in the palliative care population more broadly. 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.

Other Complementary Health Approaches

Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) has been practiced as long as traditional western medicine. Practitioners use a combination of herbal medications, acupuncture and other practices to develop holistic treatment plans for their patients. Many of the practices used in TCM are the subject of clinical trials and the systematic reviews pertinent to palliative care are listed above. In this section systematic reviews and clinical evidence relating to Chinese herbal medicine will be discussed. It is worth noting that Chinese herbal medicines are prepared based on traditional knowledge and there have been instances where the herbal product was contaminated with undeclared material, including drugs, heavy metals and animal products. [50]

There is limited research specific to palliative care. A recent review examining the effects of Chinese herbal medicine injections for the treatment of acute episodes in Chronic Obstructive Pulmonary Disease found that when injections were combined with usual care, then particular combinations were associated with improved outcomes. [51] Forty nine TCM studies were included in a systematic review of their effectiveness for patients with cancer. [52] All except one were of poor quality, however, the authors commented that the majority of the studies suggested 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 [53] 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 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.

Homeopathy

A systematic review [54] 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. The NHMRC has a Statement on Homeopathy (87kb pdf) that concludes 'that there are no health conditions for which there is reliable evidence that homeopathy is effective'.

What it means in practice
Population groups included in reported studies varied, but some were patients with anxiety relating to cancer or other medical problems. Others 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.

Indigenous Medicine

As with TCM, indigenous medicine has been practiced for many thousands of years. The research into traditional, indigenous medicine is limited however is growing. A recent systematic review identified the use of traditional indigenous medicine ranges from 20 percent to over 50 per cent in indigenous communities from different countries including Australia. [55] A major finding of this review was that health care professionals attitudes’ toward indigenous medicine influenced whether a person disclosed they were using it to the health professional. This could have serious implications for overall care and potential medication interactions. This is a field which is developing.

Evidence Gaps

  • Investigation of complementary therapies is still developing. Many studies in the literature have been poorly designed or have methodological problems which make their findings unreliable. Developing appropriate ways of studying complementary therapies is quite challenging, and requires attention to standardising the interventions, ensuring adequate numbers of participants, eliminating bias, and ensuring good blinding procedures. This is an evolving area of clinical research.
  • There is limited research into the animal-assisted therapy. Animal-assisted therapy has been used effectively in paediatric palliative care to promote wellbeing and has been introduced to a few adult services. [56-58] There is also early stage research on the role of pet robots in dementia care. [59]

 

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Overview Articles

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.

Guidelines

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 Integrative Health
    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.

Last updated 08 November 2019