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" Introduction Complementary medicine is defined as diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy or by diversifying the conceptual frameworks of medicine1. Complementary medicine has become an important issue mainly because of its popularity. For example, a survey of 4741 UK asthma sufferers showed that 59 per cent of them had tried one or other form of complementary treatment for their condition2. The pros and cons of specific complementary treatments for asthma are discussed below with reference to randomised controlled trials (RCTs). An RCT is a study in which people are allocated at random to receive one of several clinical interventions. One intervention is regarded as the standard of comparison, or control. Usually RCTs seek to measure and compare different events that are present or absent after the participants in the study receive the interventions. These events are called outcomes. The complementary treatments discussed include:  acupuncture homoeopathy exclusion diets and other nutritional approaches breathing techniques  hypnosis relaxation techniques  chiropractic herbal medicine massage.   Acupuncture  A systematic review3 looking at the use of complementary medicine in the treatment of asthma and asthma-like symptoms assessed seven acupuncture studies. Two of these studies suggested that real acupuncture was superior to sham acupuncture (eg sticking needles into non-acupuncture points). The other five studies found no significant advantage and the authors therefore concluded that, &amp;#039;it is not yet possible to make any recommendations&amp;#039;. Considering that acupuncture is not associated with frequent risks (eg tissue trauma, such as pneumothorax, or infection, such as hepatitis); and that it possibly has a large and clinically relevant placebo effect because it is often associated with great expectations, the pros and cons depend on an individual&amp;#039;s opinion. Someone who considers only evidence from trials would not advocate the use of acupuncture, whereas someone with a more practical clinical stance might believe that it is worth trying, if only for its placebo effect. Homoeopathy A systematic review4 of all RCTs on homoeopathy included only three studies. Two of them suggested a benefit beyond placebo on at least one outcome measure. The authors concluded that the evidence was insufficient to assess the possible role of homoeopathy in the treatment of asthma. Weighing the pros and cons of homoeopathy for asthma, one therefore arrives at much the same conclusions as for acupuncture. Exclusion diets About 2 to 6 per cent of asthma sufferers are hypersensitive to foods5 and experience worsening symptoms when they eat certain foods. It is reasonable therefore for these individuals to exclude the offending foodstuff from their diet. Curiously, the effectiveness of this approach has not been clearly confirmed through RCTs. On balance, it seems that this technique is worth trying in patients for whom hypersensitivity to foods has been established. Other nutritional approaches The role of vitamins, minerals and essential fatty acids in the management of asthma remains unclear. There are some data that suggest that the addition of such nutrients could have a positive effect. However, not enough trials have been done. As a result there is, at present, no compelling evidence that other nutritional approaches are effective in the treatment or prevention of asthma6. Breathing techniques Many breathing techniques (including yoga) are promoted for alleviating the symptoms of asthma. A systematic review of all the available trial evidence found some promising, albeit not compelling, evidence for yoga and conventional physiotherapeutic techniques7. Moreover, there is some (again, not compelling) evidence to suggest that the Buteyko technique is of some benefit8. This technique, developed over 50 years ago by Russian scientist Konstantin Pavlovich Buteyko, is a set of simple breathing exercises to encourage shallow breathing. On balance, therefore, these methods are worth trying with adequate supervision.  Hypnosis Hardly any RCTs have tested the effectiveness of hypnosis for asthma9. Two small trials yielded encouraging results10,11 but it is unclear to what extent this benefit was due to placebo effects. Nonetheless, the balance of the evidence seems positive and so hypnosis, under adequate medical supervision, seems to be worth trying for suitable patients. Relaxation techniques A systematic review of all RCTs on this topic had mixed results. Two studies showed no benefit while another two did suggest improvement. A further two studies demonstrated statistically significant but clinically irrelevant effects. One trial of Jacobsonian relaxation (a technique in which relaxation is learnt by tensing and relaxing skeletal muscle) in boys was followed by clinical improvement. In view of the overall safety of relaxation therapy and at least some indication that it is beneficial, relaxation techniques seem to be worth trying. Chiropractic  Perhaps surprisingly, chiropractic is often promoted for asthma. The concept is that spinal manipulation could improve lung function by freeing restrictions of rib movements and reducing muscle tension. Two RCTs, however, clearly showed that chiropractic is not useful beyond a placebo effect for asthma12,13. Herbal medicine A systematic review has found 17 RCTs of herbal medicinal products for asthma14. The overall quality of the trials was poor. Six studies concerned the use of traditional Chinese medicine, four of which reported a clinically significant increase in FEV1 of 15 per cent or more (FEV1 is the forced expiratory volume in one second - a measure of lung function). However, it is difficult to interpret the validity of trials of traditional Chinese medicine because of:  inadequate trial methods  lack of standardisation of dosages of active ingredients (eg ephedrine)  different classifications of asthma used  lack of reports of adverse effects, patient dropout or withdrawal rates.   Five RCTs investigated the use of Tylophora indica with asthma. This evidence was also inconclusive, with three of the studies reporting very significant benefits and two (more recent) trials finding no improvement at all. Other traditional herbal medicines that have been tested include Picrorrhiza kurroa, Solanum species, Boswellia serrata, Saiboku-to (a traditional Japanese herbal medicine), marijuana and dried ivy extract. In all cases, the evidence was inconclusive. The bottom line therefore is that herbal remedies cannot be recommended for the treatment of asthma. Massage Massage is calming and potentially beneficial for asthma, but has rarely been investigated for this condition. In one recent study, children were randomised to receive 20 minutes of either massage or relaxation instruction from their parents15. Children aged six to eight years who received massage had improvements in short-term anxiety and lung function at 30 days, which was significantly better than the relaxation controls. In the older children aged 9 to 11 years, there was no significant difference between the two treatment groups. Thus the role of massage therapy in the treatment of asthma seems to be minor. Conclusion Even though some complementary therapies show promise and deserve to be investigated in more detail, at present there is no compelling evidence to show that any such treatment does more good than harm in the treatment of asthma. It is very important to realise that complementary treatments are no substitute for recognised medical treatments of asthma, and that under-treated asthma can cause both serious illness and death. Do not stop prescribed asthma treatment suddenly and always consult your doctor before commencing any natural treatment for asthma.  References 1. Ernst E, Resch KL, Mills S, Hill R, Mitchell A, Willoughby M, White A. Complementary medicine - a definition. Br J Gen Pract 1995; 45: 506.  2. Ernst E. Complementary therapies for asthma: what patients use. J Asthma 1998; 35: 667-671.  3. Linde K, Jobst K, Panton J. Acupuncture for the treatment of asthma bronchiale. The Cochrane Library, 1997, Issue 2.  4. Linde K, Jobst KA. Homoeopathy for chronic asthma. The Cochrane Library, 2000, Issue 1.  5. Monteleone CA, Sherman AR. Nutrition and asthma. Arch Intern Med 1997; 157: 23-34.  6. Huntley AL, White A, Ernst E. Complementary medicine for asthma. FACT 2000; 5: 111-116.  7. Ernst E. Breathing techniques - adjunctive treatment modalities for asthma? Eur Respir J 2000 in press.  8. Berlowitz D, Denehy L, Johne DP, Bish RM, Walters EH. The Buteyko asthma breathing technique. Med J Aust 1995; 162: 53.  9. Gruber W, Eber E, Zach M. Alternativmedizin und asthma bronchiale. Monatsschr Kinderheilkd 1997; 145: 786-796.  10. Maher-Loughnan GP, Macdonald N, Mason AA, Fry L. Controlled trial of hypnosis in the symptomatic treatment of asthma. BMJ 1962; 2: 371-376.  11. Ewer TC, Stewart DE. Improvement in bronchial hyper-responsiveness in patients with moderate asthma after treatment with a hypnotic technique: a randomised controlled trial. BMJ 1986; 293: 1129-1132.  12. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O&amp;#039;Shaughnessy D, et al. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. N Engl J Med 1998; 339: 1013-1020.  13. Nielson NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma and chiropractic spinal manipulation: a randomised clinical trial. Clin Exp Allergy 1995; 25: 80-88.  14. Huntley A, Ernst E. Herbal medicinal products for asthma: a systematic review. Thorax (in press).  15. Field T, Henteleff T, Hernandez-Reif M et al. Children with asthma have improved pulmonary manipulation as adjunctive treatment for childhood asthma. J Pediatr 1998; 132: 854-858.   Last updated 31.07.2005 "^^<http://www.w3.org/2001/XMLSchema#string>
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