Mary is a 74-year-old grandmother who has had an active lifestyle looking after her grandchildren, playing bowls and participating in 5km walks with her walking group. However, over recent years she has been diagnosed with osteoarthritis. The pain is becoming progressively worse, affecting her ability to get around and continue with her activities. She has slightly raised blood pressure. To help manage the pain from her knee osteoarthritis she has tried several pain medications however she has experienced some side effects. Her doctor has advised her that a knee replacement may be an option in the future.
Defining your situation clarifies the overall context of your decision. What are the key facts, important information, and concerns that are relevant to your decision? What questions do you have about your situation?
Mary is worried about letting her daughter down by being unable to look after the grandchildren. She is considering what other options are available to her, and she doesn't want to have knee replacement surgery. Mary has been inundated with advice from her family and friends. She is also reading some articles about how to manage osteoarthritis pain naturally.
Sometimes you have specific options to consider or you may have different options to choose from. At other times, you may want to explore what your choices could be based on your own goals. Think about the alternatives, strategies and options relating to what you could do. Start to gather information you will need to evaluate your choices. At this stage it is useful to consider:
- What do you already know about your healthcare choices?
- What questions do you have about your healthcare choices?
One of your options is to consider continue with your pain medications, and the side effects from the treatment. You do not have to use complementary medicine.
What are Mary's choices?
From Mary's readings and advice from family and friends she knows she has several choices. Mary thinks that acupuncture and herbal gels may be good for her situation.
When making decisions about complementary medicine, it is important to understand what you hope to achieve by using each therapy.
Key questions to ask when clarifying your objectives:
- Why do you want to use complementary medicine?
- What outcome are you hoping to achieve? For example, improving your quality of life, reducing pain.
- What is the objective of your choice at this point in time?
To make sure your objectives are clear, consider using SMART to develop them.
- Specific: make them precise. What exactly does it look like?
- Measureable: how would you know you achieved your goal?
- Attainable: is your goal realistic and possible?
- Relevant: is this an important issue for you to focus on?
- Timebound: give your objective a timeframe
Mary has two specific objectives for using complementary medicine.
- Minimise pain.
- Improve her ability to remain active.
People around you like family, friends and health professionals can help you:
- Find or provide additional information about your healthcare choices.
- Discuss your options and goals.
- Support you in making your decision.
What are their roles and responsibilities? Think about whether:
- They should just be informed of your decision or if you want their support in implementing your decision.
- You want their input when analysing the choices, but not in making the decision.
- You want particular individuals to be involved in the decision you are currently facing.
Who are Mary's people that will be involved with Mary's decision-making?
- General practitioner
- Close friends
How well does each choice you are considering achieve your objectives? Asking the following questions will help:
- What is the current evidence and is this relevant to me?
- Is it safe and are there side effects?
- Will it interact with any medication that I am taking right now?
- What are my values, beliefs and hopes around this choice?
Evaluation pros and cons
When investigating the pros and cons of a treatment consider the following:
- Your overall goal, the potential benefits and risks, and what is known about the treatment
- The impact of your quality of life, relationships and overall health
- Your personal values and goals
- Your ability to commit to a treatment
- Time, cost and energy involved with the treatment
Evaluating evidence to help your decision
Because there can be complex, contradictory or missing information, evidence about the effectiveness and safety can assist your decision-making.
Scenario 1: it works and it is safe
- You have discussed the information with your general practitioner (GP) for your particular situation
- There is some credible evidence the complementary medicine therapy might work for your goal, and that it is likely that it is safe to use.
- If it seems okay for your situation, you can consider using it.
- Inform your healthcare provider of use, and monitor its effects on you.
- It can be helpful to make a plan together with your healthcare provider on how to monitor for side effects, and to discuss the safety of the information. Your healthcare provider is the best person to provide advice that is tailored just for you as they know your full medical history.
Scenario 2: it may not work, but it is safe
- There is some credible evidence that the complementary medicine therapy is safe to use in your situation.
- There is conflicting information or little information about whether the therapy works in your situation.
- Based on the discussion with your health care provider, you may consider using it.
- If you use it, you should be clear about possible side effects that could occur, and you should work with your healthcare provider to monitor all effects on you.
Scenario 3: it works, but it may not be safe
- There is some credible evidence that the complementary medicine therapy might work in your situation.
- There is conflicting information or little information about the safety of the therapy in your situation.
- Based on the discussion with your healthcare provider, you may choose to consider using it, but make sure you are aware of the possible side effects and monitor your response closely with your healthcare provider.
Scenario 4: it may not work and it may not be safe
- There is conflicting information or little information that the complementary medicine therapy may work and is safe in your situation.
- Because this therapy may harm you and there is nothing to suggest it will help you, it is not recommended you try this therapy.
- Talk with your healthcare provider about complementary medicine (or conventional medicine) options with better evidence that fits with your complementary medicine goals. It may be a good time to review all your options. For example, if pain management is not adequate, your healthcare provider may recommend other options.
Evaluation of Mary's choices
Remember the choices Mary was considering for her pain from her osteoarthritis? She has completed research on acupuncture and herbal ointments. We will use these as examples of evaluating the process.
What is the evidence about acupuncture?
What is acupuncture?
The term "acupuncture" describes a family of procedures involving the stimulation of points on the body using a variety of techniques. The acupuncture technique that has been most often studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. Practised in China and other Asian countries for thousands of years, acupuncture is one of the key components of traditional Chinese medicine.11
Does acupuncture work?
- People who had acupuncture had reduced pain compared to a placebo.12, 13
- In 100 people: 30 improve on their own, six improve due to acupuncture and 64 don't.12
Is acupuncture safe?
Acupuncture can cause some bruising, but it is considered a very safe treatment with serious side effects being very rare.14 Mary also has to consider that acupuncture involves seeing a practitioner regularly and she will be paying for these treatments.
What is the evidence about arnica gel?
What is arnica gel?
Arnica gel is a herbal medicine. Herbal medicines are defined as finished, labelled medicinal products that contain as active ingredients aerial or underground parts of plants, other plant material, or combinations thereof, whether in the crude state or as plant preparations (for example oils, tinctures).15
Does arnica gel work?
Arnica gel probably improves pain and function as well as non-steroidal anti-inflammatory drugs do.16
Is arnica gel safe?
A greater proportion of people who applied arnica reported side effects than those who applied ibuprofen (a type of non-steroidal anti-inflammatory drug (NSAID)). Arnica is POSSIBLY SAFE when used in the amounts commonly found in food or when applied to unbroken skin short-term. Arnica is associated with allergies and can cause increased heart rate and blood pressure.16, 17
Mary's evaluation of the evidence
Mary summarises the evidence and her objectives to reduce pain and remain active in the following way. There is evidence that acupuncture can reduce pain and improve function and appears to be safe.12, 13, 14 There is some evidence that arnica can reduce pain and improve function but may not be safe for Mary due to increased blood pressure.15, 16, 17
How each person balances the evidence gathered with their personal situation, values and beliefs and objectives is unique. This process may change over the course of an illness. What is important to an individual when first diagnosed may change over time.
Each person also needs to consider how much time, money and energy they are able to commit to their treatment choices.
Some individuals may approach their complementary medicine therapy decision in a very scientific and rational manner, while others may feel more comfortable with a gut feeling.
Given the evidence about effectiveness and safety, Mary decides to use acupuncture. Mary decides against arnica because of the risk of increasing her blood pressure. Mary will inform her general practitioner about her decision to use acupuncture. She will explore other options for managing pain if it is needed. Mary will monitor her pain relief to help decide if the treatment is working for her. For example, Mary decides to rate her pain out of 10 before starting treatment, and based on the advice of her acupuncturist and general practitioner, she will re-rate her pain out of 10 at the end of an eight-week course of treatment.
Recap: How will you decide?
Working with people you trust, use a careful process that helps you evaluate:
- The evidence you found.
- Your comfort with what is known and not known about a therapy.
- The safety of each choice.
- Your priorities.
- Your beliefs and personal values.
- Your ability to access and use a therapy, including whether you have the resources to support your need.
Moving forward with your decision
Once you have decided on which choices you would like to use, it is time to take action
- Create a plan to make it happen:
- Outline what you need to do to put your choice into action.
- Follow up with any people whose help you will need to take action on your decision .
- How much time will you need for your choice?
- Think of barriers and make plans to manage them.
- Monitor your progress.
- Notify the people who need to know about your decision.
This module has presented a step wise process of evaluating all factors that are involved in making a decision, including evidence (finding it, as per Module Three) along with your personal objectives goals and beliefs.
- National Center for Complementary and Integrative Health. Acupuncture (opens in a new window)
- Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DAWM, Berman BM, Bouter LM. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic 27 Reviews 2010, Issue 1. Art. No.: CD001977. DOI:10.1002/14651858.CD001977.pub2
- White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: asystematic review. Rheumatology. 2007;46(3):384-90.
- White AR. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupuncture in Medicine. 2004;22(3):122-133
- World Health Organization (WHO) Expert Committee on Specifications for Pharmaceutical Preparations - WHO Technical Report Series, No. 863, Annex 11 (Guidelines for the Assessment of Herbal Medicines) - Thirty-fourth Report (1996; 8 pages).
- Cameron M, Chrubasik S. Topical herbal therapies for treating osteoarthritis. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD010538. DOI: 10.1002/14651858. CD010538
- Dattner AM. Herbal and complementary medicine in dermatology. Dermatologic Clinics. 2004;22:325–332
- British Acupuncture Council (opens in a new window)
- Cochrane (opens in a new window)
- Arnica gel (opens in a new window)