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Herbal medicine: the science of the art

The Summer Meeting of the Nutrition Society, hosted by the Institute of Food Research, was held at the University of East Anglia,
Norwich on 28 June–1 July 2005
Plenary Lecture
Herbal medicine: the science of the art
Ann F. Walker
Hugh Sinclair Unit of Human Nutrition, School of Food Biosciences, University of Reading, Reading RG6 6AP, UK
In the last 50 years science has provided new perspectives on the ancient art of herbal
medicine. The present article discusses ways in which the evidence base for the professional
use of ‘Western’ herbal medicine, as therapy to treat disease, known as phytotherapy, can be
strengthened and developed. The evidence base for phytotherapy is small and lags behind that
for the nutritional sciences, mainly because phytochemicals are ingested as complex mixtures
that are incompletely characterised and have only relatively recently been subject to scientific
scrutiny. While some methodologies developed for the nutritional sciences can inform
phytotherapy research, opportunities for observational studies are more limited, although
greater use could be made of patient case notes. Randomised clinical trials of single-herb
interventions are relatively easy to undertake and increasing numbers of such studies are being
published. Indeed, enough data are available on three herbs (ginkgo (Ginkgo biloba), St John’s
wort (Hypericum perforatum) and saw palmetto (Serenoa repens)) for meta-analyses to have
been undertaken. However, phytotherapy is holistic therapy, using lifestyle advice, nutrition
and individually-prescribed mixtures of herbs aimed at reinstating homeostasis. While clinical
experience shows that this approach is applicable to a wide range of conditions, including
chronic disease, evidence of its efficacy is scarce. Strategies for investigating the full holistic
approach of phytotherapy and its main elements are discussed and illustrated through the
author’s studies at the University of Reading.
Phytotherapy: Herbal medicine: Complementary medicine: Integrated medicine
‘Western’ herbal medicine, as practised in the UK, uses
herbs not only from European origin, but from many parts
of the world. Trade between Europe and the East in
culinary spices and herbs and later European migrations to
the Americas, Africa and Australia added contributions to
the materia medica. However, most impact came from
North America (Griggs, 1997). In the 18th century English
colonists, often bereft of qualified medical attention, combined
native tradition with folklore from the ‘old country’.
Nascent botanical-based therapies arising from these
inauspicious beginnings, had, by the middle of the
19th century, achieved considerable sophistication. This
knowledge, including the use of North American herbs,
was transferred to UK herbalists in the mid-1800s, primarily
by herbal practitioner Albert Coffin, and these
herbs are still used today by herbal practitioners in the
UK. More recently, facilitated by internet communication,
further contributions to the materia medica have
come from Chinese traditional and Ayurvedic medicine
systems.
Early clinical studies from the 1950s into the therapeutic
attributes of herbal medicines were mostly conducted in
Germany and documented in German. Indeed, it is only
relatively recently that German studies on effects of medicinal
plants have been published in English or studies
undertaken in other countries. Although increasing, the
evidence base for the efficacy of herbal medicine is small
compared with that of nutrition. The present article will
describe the ways in which the evidence base might be
developed and what knowledge might be transferred from
the nutritional sciences. Since the term ‘herbal medicine’
means both the botanical materia medica and the practice
of herbal medicine, the term phytotherapy will be used to
describe the latter.
Corresponding author: Dr Ann Walker, fax 44 118 966 6930, email a.f.walker@reading.ac.uk
Proceedings of the Nutrition Society (2006), 65, 145–152 DOI:10.1079/PNS2006487
g The Author 2006
The current situation
Phytotherapy is currently practised in the UK under the
1968 Medicines Act (UK Parliament, 1977), which
replaced the 1542 Act of Parliament introduced by Henry
VIII to protect herbalists from prosecution (Griggs, 1997).
In the 1968 Medicines Act there is a provision for the
prescription and supply of herbal medicine by a herbalist,
although no professional qualifications were defined
(Griggs, 1997). To further protect the public, discussions
are currently underway between the professional bodies
that represent herbal practitioners and the Department of
Health to develop a system of statutory self-regulation of
herbal practitioners for accrediting training courses and
monitoring professional conduct.
Over the last 10 years training in phytotherapy has
evolved into the degree-level courses now based at several
universities in the UK. The training elements comprise
those commonly encountered in a medical degree, as well
as botany, materia medica, phyto-pharmacology, phytotherapeutics
and nutrition. Registration as a herbal practitioner
requires 500 h of clinical training. As the therapeutic
approach is holistic, requiring a full medical history,
patient consultations normally take about 1 h. The therapeutic
aim is restoration of homeostasis by targeting the
underlying causes of illness through lifestyle counselling,
nutrition and individually-prescribed herbal mixtures
(typically three to six herbs; Mills & Bone, 2000). This
holistic therapy is, as required, integrated with modern
medication. Hence, the intervention is complex, which is
problematic when seeking to enhance the evidence base for
its efficacy.
A herbal practitioner most commonly prescribes herbs in
liquid form as aqueous–alcoholic tinctures (i.e. as an aqueous–
alcoholic extract of the herb; Bone, 2003). Occasionally,
tisanes (i.e. a tea made by infusion of the herb with
boiling water), powdered herb capsules or herb extract
tablets may be used. Examples of conditions that respond
well to phytotherapy are given in Table 1. An example
case history will illustrate how the intervention is applied
(Table 2). The individual, KC, was a 64-year-old man
with X-ray evidence of severe osteoarthritis in both
hips, who also complained of shoulder pain and headaches.
The consultation was in December 2004, shortly after a
hospital specialist had recommended an assessment for a
right-hip replacement in May 2005. The dietary advice was
to increase intake of dairy products, oily fish and wholegrain
cereals. Potential nutrient deficits were addressed
with a multinutrient supplement, including antioxidants,
fish oil and glucosamine, aimed at reducing inflammatory
tendency. In addition, a mixture of herbs with antiinflammatory
or diuretic properties (Mills & Bone, 2000)
Table 1. Examples of health problems which can benefit from phytotherapy
Inflammatory conditions: eczema, psoriasis, arthritis, migraine, bronchitis, catarrh, sinusitus, hayfever, inflammatory bowel disease, peripheral
neuropathy
Hormonal syndromes: menopausal, premenstrual, poly-cystic ovary
Fatigue syndromes: chronic fatigue, fibromyalgia
Digestive problems: gastritis, constipation, indigestion
Cardiovascular conditions: arrhythmia, intermittent claudication, hyperlipidaemia, hypertension
Nervous system: anxiety, low-mood or depression, panic attacks, tremor, muscle tension, insomnia
Table 2. Case study of patient KC suffering with acute osteoarthritis: progress during treatment with phytotherapy for 6 months
Patient details
Presentation at 1st
consultation Dec 2004
Nutritional advice and nutrients
and herbal medicine prescribed Outcome
Male, 64 years, non-smoker OA in both hips. Dietary advice: Mar 2005:
Diet: eats plenty of fruit and
vegetables but low
intake of dairy products and
oily fish
Prescribed medication: none
Left hip scored as severe by
specialist (7/10). To be
assessed for surgery in 5
month’s time. Some days he
cannot walk
›Dairy products
›Whole grains
›Oily fish
Nutrient supplements (as tablets
or capsules):
Times of no pain in left hip
No pain in shoulder
May 2005:
Hip ‘at its best for years’.
Slight ache occasionally in
Hip pain disturbs sleep Multinutrient left hip
Other health concerns: left
shoulder pain and headaches
Vitamins C and E
Glucosamine
Surgery postponed
No headaches
Fish oil
Herbal medicine (as a mixture of
tinctures):
Devil’s claw root
Meadowsweet herb
Guaiacum gum
Willow bark
Turmeric root
Gravel root
›, Increase intake; OA, osteoarthritis; EFA, essential fatty acids; devil’s claw, Harpagophytum procumbens D.C.; meadowsweet, Filipendula ulmaria; willow, Salix
spp.; turmeric, Curcuma longa; guaiacum, Guaiacum officinale; gravel root, Eupatorium purpureum.
146 A. F. Walker
was prescribed, including devil’s claw (Harpagophytum
procumbens), meadowsweet (Filipendula ulmaria), willow
(Salix spp.) bark, turmeric (Curcuma longa), guaiacum
(Guaiacum officinale) gum and gravel (Eupatorium
purpureum) root. By March 2005 the shoulder pain had
gone and hip pain was less. By May 2005 the hip pain was
reduced to a slight ache and KC was able to postpone
surgery.
A herbal medicine does not exert its physiological action
through a single mechanism, as do many modern drugs. On
the contrary, the action of any herb is multifaceted,
reflecting compositional plurality (Williamson, 2003). As
with foods, botanical medicines are consumed according to
tradition of use; there being no legal requirements for
toxicological testing. Following the implementation of the
EC Directive 2004/24/EC on traditional herbal medicinal
products (European Commission, 2004) from November
2005, documented evidence of traditional use in the EC
and safety data are required before registration of a herbal
product, but not evidence of efficacy. However, a stronger
evidence base is required to elevate the current status
of botanical medicines in society. Only in this way can
phytotherapy take its place as an important partner in
integrative medicine.
Evolution of a phytotherapy science base: lessons from
nutritional science
Over the last century nutritional science has developed a
strong and evolving evidence base, some of the methodologies
of which can be used to inform those researching
into herbal medicine. The earliest nutritional studies were
focused on the identification of the finite number of nutrients
required to sustain life. Epidemiology developed in
earnest from the 1970s and has been important in giving
direction to potential associations between diet and disease
to be confirmed by experimental methods. It is now
accepted that, although epidemiology cannot definitively
prove a connection between diet and disease, it can
emphasise links to explore further through experiment. In
contrast, herbal medicine offers less opportunity for
observational studies as, unlike food, the general population
are not commonly consuming herbs on a regular basis.
Several surveys of herbal use have been undertaken (for
example, see Nicolaou & Johnston, 2004), but none have
linked intake to any disease condition and, so far, little use
has been made of treatment outcome from patient records.
By the 1970s clinical studies were well established in
nutritional science, and many focused on single-nutrient
interventions, relatively easy to blind, with specified outcomes
such as physiological biomarkers. These studies
provided, and continue to provide, the opportunity to
elucidate the mechanisms of action, as required for scientific
integrity and progress. More recently, however, wellconducted
dietary studies with patient-orientated outcomes,
such as the Dietary Approaches to Stop Hypertension
Study (Sacks et al. 1999) have been introduced. These
studies can have more immediate relevance to patient
care than single-nutrient studies, even though they generate
little information on mechanisms. There is clearly a place
for both lines of enquiry in nutrition and this multifaceted
approach to research provides a model to develop the
evidence base for phytotherapy.
In contrast to nutrition, the basis of herbal medicine
depends exclusively on the action of non-essential nutrients,
the phytochemicals. The complexity and multitude of
these compounds found in plant tissues means that component
identification has been relatively recent (depending
on modern developments in instrumentation) and is still far
from complete. The traditional interventions of phytotherapy
are crude extracts of plants as tisanes, decoctions
(made by boiling dense herbal materials, such as roots,
with water) or tinctures. Although a considerable science
base exists on the physiological effects of isolated phytochemicals
(mostly derived from animal studies), these
data have limited application to an evidence base for
phytotherapy, because each plant has several (or many)
physiologically-active components and synergism between
them should be anticipated (Williamson, 2001).
Meta-analyses on single herbal extracts
Numerous randomised double-blind clinical studies have
been undertaken on single-herb extracts since the 1980s,
mostly in Germany (European Scientific Cooperative on
Phytotherapy, 2003). Indeed, for ginkgo (Ginkgo biloba),
St John’s wort (Hypericum perforatum) and saw palmetto
(Serenoa repens) data have been sufficient to undertake
meta-analyses.
Ginkgo-leaf extract was developed from the 1950s as a
herbal medicine in Germany to treat memory loss. This
relatively modern use is well supported by pharmacological
evidence as well as clinical trials, and beneficial effects
on the circulatory system have been shown (European
Scientific Cooperative on Phytotherapy, 2003). The extract
is unusual among herbal extracts in that it is a ‘narrowspectrum’
crude extract produced commercially by selective
solvent extraction to achieve a 50:1 extract (fifty parts
by weight of dried leaf being equivalent to one part by
weight of extract), high in ginkgolides and bilobalide, the
active compounds. Concluding their meta-analysis of trials
of ginkgo-extract intervention for memory loss, Birks et al.
(2002) stated ‘. . . there is promising evidence of improvement
in cognition and function . . .’.
St John’s wort is a herb of European origin that has
been used since antiquity. Although its actions include
modulation of immune function and anti-inflammatory and
antiviral effects, modern research has focused on its antidepressant
properties. The research has been carried out on
‘full-spectrum’ extracts of approximately 5:1 (five parts by
weight of dried leaf being equivalent to one part by weight
of extract), with guaranteed (standardised) amounts of
hypericin, a key active compound. Two meta-analyses
have been reported. Kasper & Dienel (2002) found that the
herb ‘. . . . reduced the symptoms of depression more
effectively than placebo’, while Linde et al. (2005) concluded
that ‘compared with standard anti-depressants
Hypericum extracts had similar effects’. Based on the
clinical trial evidence over-the-counter preparations of St
John’s wort are sold for their mood-enhancing properties,
although herbal practitioners use the herb for a wider range
Plenary Lecture 147
of conditions, including chronic fatigue syndrome and viral
infections. Although the antiviral effects are well supported
by pharmaceutical studies, the immune-enhancing effects
experienced in the clinical setting have yet to be researched.
Saw palmetto is native to the eastern seaboard of North
America. The berry is the source of b-sitosterol, which has,
as a single compound, been shown to improve urinary
symptoms and flow in benign prostatic hyperplasia
according to a systematic review by Wilt et al. (2000).
Both nettle (Urtica dioica) root and saw palmetto have
been shown to reduce symptoms of benign prostatic
hyperplasia in clinical trials and both are rich sources of
b-sitosterol. More than nine double-blind clinical trials
have been conducted on saw palmetto, which show a
positive effect of a daily dose (9:1 extract (nine parts by
weight of the dried herb (or berry) being equivalent to one
part by weight of extract); 320 mg/d) for 3 months on
symptoms of benign prostatic hyperplasia, equivalent to
that obtained with finasteride (the generic drug prescribed).
In a meta-analysis Boyle et al. (2004) have concluded
that men with benign prostatic hyperplasia randomised
to take saw palmetto extract ‘. . . showed a significant
improvement in peak flow rate and reduction in nocturia
above placebo . . .’.
A clinical study on hawthorn
Studies on single-herb intervention have included the
effects of hawthorn (Crataegus laevigata) on hypertension.
Traditionally used for the treatment of hypertension,
atherosclerosis, poor circulation and heart disease, the
actions of hawthorn are focused on the cardiovascular
system. The active constituents are mostly flavonoids, on
which the extracts are standardised. The physiological
actions that have been demonstrated in preclinical studies
show antioxidant, smooth muscle relaxant, vasodilatory
and hypertensive properties. Although interactions with
modern drugs prescribed for cardiac insufficiency have
been speculated, none have been reported. Indeed, Tankanow
et al. (2003) have shown no interaction between
digoxin and hawthorn.
In a pilot study of thirty-six healthy volunteers with
mildly-raised blood pressure, who were taking no prescribed
medication, a non-significant lowering of resting
diastolic blood pressure after administration of a daily dose
of 500 mg hawthorn extract (leaves and flowers) for 10
weeks has been reported (Walker et al. 2002). In a followup
study seventy-nine subjects with mild hypertension and
type 2 diabetes with or without prescribed drug treatment
were recruited (Walker et al. 2006). The subjects, 71% of
whom were taking hypotensive drugs, were randomised to
take 1200 mg hawthorn extract daily or placebo for 16
weeks. Those subjects on hawthorn (n 39) were found to
have a small but significant reduction (P = 0.035) in mean
diastolic blood pressure (mmHg; from 85.6 (95% CI 83.3,
87.9) at baseline to 83.0 (95% CI 80.5, 85.5) at outcome)
compared with the placebo intervention (n 40; 84.5 (95%
CI 82.0, 87.0) and 85.0 (CI 82.2, 87.7) respectively; see
Fig. 1). No herb–drug interactions were found, there were
no effects on liver or kidney function and a similar number
of minor side-effects were experienced in both groups.
There were no withdrawals because of adverse reactions
in the group receiving hawthorn. These data support the
evidence base for the safety of hawthorn.
For a subset of the study group (AF Walker, G Marakis,
E Simpson, JL Hope, PA Robinson, R Bundy and HCR
Simpson, unpublished results) plasma triacylglycerols
were found to have decreased significantly (P = 0.015)
in response to the hawthorn intervention (n 21; mean
(mmol/l) at: baseline, 1.62; outcome, 1.38) compared with
the placebo (n 19; mean (mmol/l) at: baseline, 1.58; outcome,
1.88; Fig. 2). A similar response comparison for
plasma HDL-cholesterol shows a non-significant increase
for the hawthorn subgroup (P = 0.068) compared with
the placebo. However, for HDL a significant difference
(P = 0.015) was found at outcome (mean value of
1.29 mmol/l) compared with baseline (mean value of
−4·0
−3·5
−3·0
−2·5
−2·0
−1·5
−1·0
−0·5
0
0·5
1·0
Change in blood pressure (mmHg)
Placebo Hawthorn
*
Fig. 1. Change in blood pressure from baseline for seventy-nine
subjects with type 2 diabetes after 16 weeks of daily hawthorn
(Crataegus laevigata) supplementation compared with placebo.
(\\\\\), Diastolic blood pressure; ( ), systolic blood pressure. Mean
value for the change in diastolic blood pressure was significantly
different from that for the placebo: *P = 0.035.
Placebo Hawthorn
−0·3
−0·2
−0·1
0
0·1
0·2
0·3
0·4
Plasma lipid concentration (mmol/l)
*
Fig. 2. Changes in plasma lipaemic variables from baseline for a
study subset (n 40) of subjects with type 2 diabetes after 16 weeks
of daily hawthorn (Crataegus laevigata) supplementation compared
with placebo. (\\\\\), Total cholesterol; ( ), HDL-cholesterol; (&)
triacylglycerols. Mean value for triacylglycerols was significantly
different from that for the placebo: *P = 0.015.
148 A. F. Walker
1.24 mmol/l), not matched in the placebo group. Favourable
lipaemic effects of hawthorn have been suggested
previously from a human study (Rigelsky & Sweet, 2002).
As for blood pressure, the lipaemic effects of hawthorn are
small, as often found for biomarkers in natural-medicine
intervention studies. However, in phytotherapy the mild
effects of several herbs are amplified in the clinical
situation by the traditional use of herbal combinations.
As far as glycaemic control is concerned fasting blood
glucose levels were not found to be affected significantly
by intervention. However, the outcome response of mean
plasma insulin concentration of the hawthorn subset shows
a significant increase (P = 0.020) compared with the placebo
group (Fig. 3). For the hawthorn subset (n 21) the
mean values (pmol/l) were 63.1 at baseline and 73.5 at
outcome, while for the placebo subset (n 20) mean values
were 72.0 and 66.6 respectively. These findings are surprising
and unexpected, although they do concur with
results from a study on rats with streptozotocin-induced
diabetes, which show potent anti-hyperglycaemic activity
of hawthorn (Jouad et al. 2003). This extent of support for
pancreatic function in type 2 diabetes is substantial and
clearly warrants further study.
Developing an evidence base for phytotherapy
Studies on single herbal extracts can support the traditional
use of herbs, but these studies paint only a partial picture
of the traditional use of herbs, administered as mixtures, in
phytotherapy. While there is considerable and growing
evidence on patient-orientated outcomes of diets such as
the Dietary Approaches to Stop Hypertension diet to help
inform public health authorities in nutrition, there is no
such evidence to support the practice of ‘Western’ phytotherapy.
Although herbal medicine as used in traditional
Chinese medicine is better supported by randomised studies,
this evidence does not contribute to an evidence base
for Western phytotherapy because of the differences in
therapeutic approach; Chinese herbal medicine is based on
restoration of energy balance (yin–yang) rather than
restoration of homeostasis.
Collation of patient case notes
Collation of patient case notes can be carried out with
minimal funding to provide observational evidence to
support phytotherapy, as the following example shows. In
a retrospective audit of treatment of chronic fatigue syndrome
data from on-going clinic case notes of female
patients meeting the Centers for Disease Control 1994
classification criteria for chronic fatigue syndrome (Fukuda
et al. 1994) at first consultation have been collated (AF
Walker, unpublished results). Hence, the main inclusion
criterion was persistent or relapsing fatigue for >6 months,
not alleviated by rest and preventing normal activities. To
comply with the Centers for Disease Control classification
subjects also had to have experienced at least four of the
following: loss of memory or concentration, sore throat,
tender lymph nodes, muscle pain, joint pain, headaches,
unrefreshing sleep or post-exercise malaise. Eight patients
met these criteria and Table 3 shows their details.
Dietary advice was given to increase intake of fruit and
vegetables (seven of the eight patients), oily fish (seven of
the eight patients) and dairy products (two of the eight
patients) and to replace high-n-6 PUFA seed oils with olive
oil (two of the eight patients). All women were advised to
take a multinutrient supplement. Based on the first consultation,
in which a non-validated mini-food-frequency
questionnaire was completed and health complaints recorded,
the following additional supplements were advised:
vitamin C (six of the eight patients), n-3 PUFA (six of the
eight patients), Ca Mg (six of the eight patients), Mg (five
of the eight patients), vitamin E (two of the eight patients)
and Cr (one of the eight patients). The most commonlyprescribed
herbs used among the eight women in the audit
were: St John’s wort (all eight patients); echinacea (Echinacea
purpurea; five of the eight patients); chaste berry
(Vitex agnus-castus; five of the eight patients); astragalus
(Astragalus membranaceus; five of the eight patients);
ashwanganda (Withania somnifera; four of the eight
patients); schizandra (Schisandra chinensis; four of the
eight patients); vervain (Verbena officinalis; three of the
eight patients). A further twenty-six herbs were prescribed
for only one or two women.
The main outcome of the audit was the response to cold
viruses. Clinical experience has revealed a distinct change
in response to cold viruses by patients suffering chronic
fatigue syndrome, whose cycles of remitting and relapsing
fatigue can occur as often as every 2 weeks. As relapse
often coincides with the occurrence of colds among other
family members, it is likely to be related to viral infection.
However, patients with chronic fatigue syndrome normally
experience few respiratory symptoms, only exacerbation of
fatigue. Indeed, it is common to hear patients with chronic
fatigue syndrome say ‘I have not had a cold for years’. As
the patient’s health improves, fatigue diminishes and this
outcome usually coincides with the appearance of a ‘head
cold’. Patients may then go through a phase of very frequent
head colds, which gradually settle down to one or
two per year (as for healthy individuals) as vitality is
regained. A search of the literature has revealed no reference
to this phenomenon, which is likely to relate to
immune competence, although many practitioners are
Placebo Hawthorn
−10
−5
0
5
10
15
20
Plasma insulin (pmol/l)
*
Fig. 3. Changes in plasma insulin concentration from baseline for a
study subset (n 40) of subjects with type 2 diabetes after 16 weeks
of daily hawthorn (Crataegus laevigata) supplementation compared
with placebo. Mean value was significantly different from that for the
placebo: *P = 0.020.
Plenary Lecture 149
aware of it. Table 3 shows the time from first consultation
to the ‘first’ head cold among the women in the audit.
Audits of case notes, such as this one, may allow practitioner
experience to become available to a wider audience,
may inspire further clinical studies and could be
carried out prospectively for greater rigour.
Clinical trials of phytotherapy
Any clinical investigation into the therapeutic potential of
the complexity of phytotherapy intervention is fraught with
difficulties. Fortunately, Bensoussan et al. (1998) have
provided a modus operandi; they have investigated the
effects of Chinese herbal medicine in a randomised
double-blind trial on 116 patients who fulfilled the Rome
criteria of irritable bowel syndrome (Drossman et al.
1994). Patients were randomly allocated to one of three
treatment groups: individualised Chinese herbal prescriptions
(n 38); a standard Chinese herbal formulation (n 43);
placebo (n 35). Patients received treatment as powdered
herb capsules (five capsules three times daily) for 16 weeks
and were evaluated by both a traditional Chinese herbalist
and a gastroenterologist at baseline and outcome. Volunteers
were seen on five occasions in consultation with a
Chinese herbalist, when progress was assessed and herbal
medicine prescribed from a formulary of eighty-one herbs.
Practitioners were blinded to the randomisation coding. A
dispenser, privy to the coding, fulfilled herbal prescriptions
only for those randomised to individualised treatment;
other patients received placebo or the standard herbal formula.
Compared with patients in the placebo group, those
patients in both active treatment groups were found to
show improvement in irritable bowel syndrome scores.
Although the effects of individualised and standard treatments
were found to be equivalent at outcome, at followup
14 weeks after the completion of treatment only the
individualised treatment group maintained the improvement.
Using the model of Bensoussan et al. (1998) a randomised
pilot study has been undertaken to investigate the
effects of practitioner-prescribed phytotherapy in the
treatment of osteoarthritis (L Hamblin, A Laird and AF
Walker, unpublished results). Twenty adults, previously
confirmed by X-ray images as suffering from osteoarthritis
of the knee, were recruited from two inner London general
practitioner practices, fourteen of whom completed the
study per protocol. Subjects continued on any conventional
medication, received healthy-eating advice and were given
a standard nutrient supplement. In addition, each subject
Table 3. Progress of eight women with chronic fatigue syndrome treated with phytotherapy and assessed in April 2003
Patient . . . SC HS AV KS JK TY AT JH
Age (years) 19 20 27 34 36 48 63 67
Date of 1st consultation
(month and year)
01/2002 09/2000 07/2000 02/2001 02/2001 12/2000 09/2002 11/1999
BMI (kg/m2) 21 18 20 24 24 20 22 20
Occupation at 1st
consultation
U U U A MR H R R
Time from 1st
consultation to ‘first’
head cold (months)
5 22 20 20 11 20 4 15
Occupation in April
2003
US U A A MR H R R
Practitioner’s
assessment of
patient’s recovery in
April 2003 (%)
100 85 90 90 85 100 100 95
Comments from
patients on wellbeing
and/or lifestyle
in April 2003
Enjoying
university
and coping
well
Keen to start
university
course
Coping well
with a new
life
I look happy
and people
notice
Life’s a
struggle,
overworking
Enjoying life
and
playing
tennis
again
Never felt
better
More robust
and
singing in
a choir
U, unemployed; US, university student; A, administrative post; MR, medical representative; H, Housewife; R, retired.
0
10
20
30
40
50
60
70
80
90
100
Meadowsweet
Dandelion root
Turmeric
Black cohosh
Celery seed
White willow
Devil's claw
Licorice
Wild yam
Bogbean
Ginger
Herbs (g per subject)
Fig. 4. Average amount of herbs (as dried-herb equivalents) per
subject prescribed for the active treatment group (n 9) during
10 weeks of a pilot study of phytotherapy for osteoarthritis.
Meadowsweet, Filipendula ulmaria; dandelion, Taraxacum officinale
Weber s.l.; turmeric, Curcuma longa; black cohosh, Cimicifuga
racemosa (L.) Nutt.; celery, Apium graveolens; white willow, Salix
spp.; devil’s claw, Harpagophytum procumbens D.C.; licorice, Glycyrrhiza
glabra; wild yam, Dioscorea villosa; bogbean, Menyanthes
trifoliata; ginger, Zingiber officinale Roscoe.
150 A. F. Walker
was randomly assigned to receive daily for 10 weeks either
individualised herbal medicine, prescribed by a herbal
practitioner from a limited formulary of eleven herbs, or
placebo in the manner of Bensoussan et al. (1998). At
baseline and outcome subjects completed the WOMACTM
knee health (Bellamy et al. 1988) and the ‘measure your
medical outcome profile’ (Paterson, 1996) questionnaires;
for the latter, patients defined two symptoms of main
concern to them.
Fig. 4 shows the average weight of herbs (g dried herb)
prescribed per subject in the herbal treatment group during
the study. While no response difference was observed
between the two groups compared with baseline, mean
knee health (n 9) was found to indicate a promising
(P = 0.060) improvement in the WOMACTM stiffness subscore
at outcome (Fig. 5). Clinically-important improvements
(>20%; Tubach et al. 2005) in the mean
WOMACTM total score and all subscores were observed
for the active treatment group at outcome compared with
baseline, while comparable values for the placebo group
(n 5) suggest a clinically-important improvement only in
the stiffness subscore. The mean ‘measure your medical
outcome profile’ symptom 2 subscore (Fig. 6), mostly
related to osteoarthritis, indicates significant improvement
at outcome (P = 0.008, respectively) compared with baseline
for those taking herbal medicine but not for those
taking placebo. Larger adequately-powered studies based
on this model could provide a way forward for investigating
patient-orientated outcome of complex holistic therapeutics.
Conclusions
The art of herbal medicine (phytotherapy) involves a
complex therapeutic intervention in which the mild effects
of single natural interventions are built into an effective
individualised therapeutic regimen. Clinical experience
shows that this approach is applicable for a wide range of
disease conditions, but it remains to be proven through
scientific enquiry. Although an increasing science base
supports the efficacy of individual herbs and defined herbal
combinations as treatment for various conditions, evidence
for the efficacy of individually-prescribed herbal combinations,
as used in Western phytotherapy is scarce. The
present paper describes several lines of enquiry through
which the evidence base for the efficacy of phytotherapy
could be strengthened.
Acknowledgements
My grateful thanks to co-researchers: Rafe Bundy, Hugh
Simpson, Eleanor Simpson, George Marakis, Louise
Hamblin and Alex Laird.
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152 A. F. Walker


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