3.  WHICH PATIENTS BENEFIT
FROM COMPLEMENTARY THERAPIES?


There is currently very little information available, for GPs who wish to refer patients to complementary therapies, about which patients, and which conditions, are likely to respond best to which kind of therapy. Although the number of clinical trials being undertaken on complementary therapies is growing, at present the amount of ‘evidence’ of this kind is still limited, and GPs are having to rely heavily on either the experience of their colleagues or patients (Reilly and Taylor 1993), or on ‘audit’ type studies like the present one (Lewith and Davies, 1996). The availability in the present study of a range of therapies, to which patients with a wide range of conditions were referred, provided a particularly valuable opportunity for a systematic analysis of the patient response to the therapies provided.

Although patients’ own assessments of change did not provide a particularly useful measure of difference between groups, SF36 scores did provide a surprisingly sensitive scale for this purpose. These scores showed significant variations in the level of change following treatment, for patients referred with problems of different levels of chronicity and severity, with different types of problem, and according to their prior experience of complementary medicine and attitude to health and treatment. The main tests used were T tests (2 tailed) comparing the mean change scores (ie. between SF36 scores on referral and on completion of treatment) between different subsets of patients. In some cases (eg. re severity of problem on referral) correlation analysis was used.


3.1  Type, chronicity and severity of problem

As has already been noted, the majority of patients referred to the service were those who had chronic and established health problems. However, comparison of results between patients showed that those who had had their problems for over a year showed significantly less change in their condition following treatment, compared to those referred with shorter term problems. This not unexpected result showed up on all the SF36 dimensions, apart from those related to general health and emotional functioning (Table 20). This result has implications, both for the way the service is used, and for the level of success indicated by the present evaluation, since it suggests that if it was used for more patients with acute and short-term problems, the results in terms of patient improvement may have been even more marked.

Table 20  Change by length of time with problem

Dimensions on SF36 scale	Mean change for patients with problem for year or more	Mean change for patients with problem for less than year
Physical functioning	2.1	12.2***
Physical role performance	9.1	31.2**
Body pain	8.5	18.2**
General health	.4	2.2
General vitality	1.6	8.2**
Social functioning	5.2	12.7*
Emotional role performance	7.7	3.3
Mental health	2.7	6.2*
Total questionnaires	88	63

*** The difference between the two groups was significant at .001
* * The difference between the two groups was significant at .05
* The difference between the two groups was significant only at .1

However, when patients with different levels of severity of problem on referral were compared, this showed that the more severe the problem on referral (ie. the lower the SF36 score on referral) the greater the level of improvement following treatment (Table 21). However, the significance level of these correlations is not particularly high, and the relationship did not show up so clearly when change scores were compared between patients who assessed their own condition to have been severe/less severe on referral.

Table 21  Link between change and severity of problem

Dimensions on SF36 scale	Correlation between score on referral and level of change
Physical functioning	-.43
Physical role performance	-.46
Body pain	-.51
General health	-.33
General vitality	-.45
Social functioning	-.54
Emotional role performance	-.52
Mental health	-.48

The picture of which conditions responded better or worse to complementary therapies is rather more complex, since changes for different conditions tended to show change on different dimensions of the SF36 scale. Also, the small numbers of patients suffering from specific conditions meant that little analysis could be undertaken at this level: even when grouped by broad category of problem, the relatively small numbers in the ‘emotional’ and ‘other problem’ groups were too small for significant tests to be very sensitively run. The only highly significant result to show up was in relation to physical functioning, with patients reporting that their main problem related to joints and bones (musculo-skeletal problems) reporting significantly higher levels of improvement in this scale than patients with other types of problem (Table 22). This group also reported higher levels of change in relation to physical role performance.

In contrast to this, patients who reported that their main problem related to emotional difficulties reported higher levels of improvement on the dimensions of mental health and social functioning, while patients with ‘other’ problems reported higher levels of improvement in relation to general health and social functioning, although the difference between these two groups and the rest of the referrals was not significant.

Table 22  Change by type of problem

Dimension on SF36 scale	Mean change all referrals	Patients with joint problems	Patient with emotional problems	Patients with other problems
Physical functioning	6.1	7.5*	3.5	3.4
Physical role performance	16.9	17.6	11.7	17.3
Body pain	12.7	12.6	12.8	10.2
General health	1.3	.3	1.5	3.2
Vitality	4.2	4.4	5.2	2.8
Emotional role performance	8.1	7.2	9.4	10.8
Social functioning	6.5	5.2	15.7	1.4
Mental health	4.9	4.1	9.7	8.3
Total questionnaires	-	140	42	26

* There are overlaps between these three groups, since some patients indicated that they had more than one health problem
** The difference in the level of change between these two groups was significant at .05


3.2  Demographic differences

Generally speaking, women assessed themselves as having a greater level of change following treatment than men, although this result did not show up very clearly in variations in SF36 results, apart from a slightly higher level of change for women on the dimensions of vitality and emotional role performance (not significant).

There were, however, more marked differences between patients of different age groups: those in older age groups appeared to respond better to complementary medicine than those in younger age groups, except in relation to general vitality and mental health (Table 23). Again, this was not generally a significant difference, except in relation to body pain, and for patients older than 50, in relation to a lower mean change level. This is perhaps surprising, since levels of chronic illness were somewhat higher in the older age groups.

Table 23  Change by age

Dimension of SF36 scale	40 or over	Under 40
Physical functioning	7.2	4.5
Physical role performance	20.6	15.1
Body pain	18.6	7.6*
General health	-.3	3.4
Vitality	2.6	2.8
Emotional role performance	12.2	3.1
Social functioning	12.2	3.1
Mental health	3.5	5.1*
Total questionnaires	62	52

* The difference in the level of change between these two groups was significant at .05


3.3  Experience of complementary medicine and attitude to health

At the start of the project, there was some speculation about whether patients with experience of complementary therapies, or who asked to be referred to such therapies, would be more likely to respond than those who did not. One hypothesis put forward was that there was a difference in response between patients who were ‘amenable’ to complementary therapies - that is, they have a strong motivation and willingness to take charge of their own health, and those who took a very passive approach to their health.

Comparison of SF36 scores between these different groups showed some interesting results. Patients who had considerable experience of complementary therapies prior to referral had a mean level of change slightly higher than patients who had not previously used complementary therapies, but this was not significant. On the other hand, patients who asked for complementary therapies had a lower level of change (significant on several dimensions) than those who had not specified what kind of treatment they wanted (Table 24). This may have been because of the higher rate of chronic health problems amongst patients requesting complementary medicine.

Table 24  Change by who initiated referral

Dimension of SF36 scale	Patient asked for complementary medicine	Patient did not ask for complementary medicine
Physical functioning	3	9
Physical role performance	9.9	23.6
Body pain	10.5	14.8
General health	3.3	-.4**
Vitality	1	7.1**
Emotional role performance	6.4	9.6
Social functioning	4.2	8.7
Mental health	4.8	5
Total questionnaires	80	88

* The difference in the level of change between these two groups was significant at .05


To assess the overall ‘attitude’ of patients towards their health, referrals were asked on their initial questionnaire to complete a set of questions to measure their ‘Health locus of control’ (Walleston et al 1978). In the Multidimensional Health Locus of Control Scale (MHLC), three dimensions are identified:  the Internal Locus Of Health Control (people strongly internally motivated in relation to their own health), Powerful Others Locus Of Control (health seen to be influenced by significant others) and the Chance Locus Of Control (health believed to be largely the result of chance).

There did appear to be some relationship between patients’ attitude to health and level of change following treatment, although the significance of this was generally rather weak. However, overall, all the correlations between level of SF36 change and an internal locus of control were positive ones (ie. the higher the score on this dimension, the stronger their internal motivation and the greater the level of change as recorded in SF36 scores), with the correlation between change in body pain, vitality and mental health being significant at the .05 level (Table 25). In contrast to this, many of the correlations between the other two dimensions were negative ones, (ie. the higher they scored, the stronger their belief that health is influenced by chance, or by significant others, and the less change following treatment recorded by SF36 scores) but none of these were significant.

Table 25  Correlations between level of change and score of locus of control scale

Dimension of SF36	Internal locus of control	Powerful others locus of control	Chance locus of control
Physical	.03	-.01	-.08
Physical role	.12	.09	-.09
Body pain	.12*	-.08	.04
General health	.04	.05	.01
Vitality	.17*	-.04	-.03
Social functioning	.04	-.01	-.09
Emotional role	.03	-.05	-.09
Mental health	.15*	-.06	-.03

* The correlation between the local of control scores and level of change on SF36 scores was significant at .05

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