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Recent NICE guidelines have recommended that patients suffering from persistent, non-specific low back pain should be offered ‘one of the following treatment options, taking into account patient preference: an exercise programme, a course of manual therapy, or a course of acupuncture’.1 No previous document by NICE has been so explicitly positive about complementary/alternative medicine (CAM). This, it seems, is a good occasion to review the totality of the recommendations from NICE guidelines in respect to CAM.
As of July 2009, NICE have published 88 clinical guidelines.2 We have reviewed 83 of these (five have been replaced and were no longer available). The majority of these documents make no mention of CAM at all, often, it seems, for good reason; there are many conditions for which there is no evidence-based CAM option. Several guidelines refer to ‘holistic’ care, nutrition, vitamin therapy, and exercise, which some might view as CAM. For example, those relating to chronic and/or degenerative conditions explicitly recognise the need for holistic patient care and management, or focus on dietary and lifestyle interventions. A small number of the guidelines recognise various forms of CAM as an effective treatment. For instance, the depression guidelines state that St John's Wort is more effective than placebo. Yet the use of St John's wort is not recommended ‘because of uncertainty about appropriate doses, variation in the nature of the preparations, and potential serious interactions with other drugs’.1
Many of the guidelines which do incorporate CAM state or imply that patients themselves should determine the value of CAM by trial and error, or make statements such as ‘some patients may find CAM useful’. The majority of these documents refer to CAM with the assertion that ‘further research is needed’ or that ‘evidence is insufficient for firm recommendations’. In a number of instances (for example, guidelines relating to anxiety, type 2 diabetes, hypertension, and stroke) the impression is given that there is little evidence to indicate that CAM approaches may be valuable, while reasonably sound data do exist.3 In other instances, the evidence for CAM is hopeful but the NICE verdict is discouraging. For example, the osteoarthritis guidelines state that ‘results from acupuncture studies are mixed’. Yet several systematic reviews of acupuncture for osteoarthritis have drawn positive overall conclusions.4–6 Acupuncturists have therefore argued that this NICE guideline ‘gives the reader a distinctly negative impression of acupuncture. This could be against patients' best interests …’.7 The opposite scenario could be true for the recent back pain guidelines.1 It has been argued that they over-estimated the effectiveness and under-estimated the risks of spinal manipulation.8
In conclusion, our analysis shows that many NICE guidelines have evaluated CAM. But there is a substantial degree of inconsistency: some are comprehensive, while others are not. The decision of whether or not to consider CAM for any given topic appears to be somewhat arbitrary. Generally speaking, this inconsistency seems to be at odds with NICE's excellent track record of evaluating conventional treatments, by utilising a transparent and rigid hierarchy of evidence for its recommendations. We therefore suggest that, in future, NICE should evaluate CAM by the same standards as conventional medicine.