Prevalence of use of complementary and alternative medicine (CAM) by physicians in the UK: A systematic review of surveys

Abstract

This systematic review aims to estimate the prevalence of use of complementary and alternative medicine (CAM) by physicians in the UK. Five databases were searched for surveys monitoring the prevalence of use of CAM, which were published between 1 January 1995 and 7 December 2011. In total, 14 papers that reported 13 separate surveys met our inclusion criteria. Most were of poor methodological quality. The average prevalence of use of CAM across all surveys was 20.6% (range 12.1-32%). The average referral rate to CAM was 39% (range 24.6-86%), and CAM was recommended by 46% of physicians (range 38-55%). The average percentage of physicians who had received training in CAM was 10.3% (range 4.8-21%). The three most commonly used methods of CAM were acupuncture, homeopathy and relaxation therapy. A sizable proportion of physicians in the UK seem to employ some type of CAM, yet many have not received any training in CAM. This raises issues related to medical ethics, professional competence and education of physicians.

Full text

© Royal College of Physicians, 2012. All rights reserved. 505
■ PROFESSIONAL ISSUES Clinical Medicine 2012, Vol 12, No 6: 505–512
ABSTRACT – This systematic review aims to estimate the
prevalence of use of complementary and alternative medicine
(CAM) by physicians in the UK. Five databases were searched
for surveys monitoring the prevalence of use of CAM, which
were published between 1 January 1995 and 7 December
2011. In total, 14 papers that reported 13 separate surveys
met our inclusion criteria. Most were of poor methodological
quality. The average prevalence of use of CAM across all sur-
veys was 20.6% (range 12.1–32%). The average referral rate to
CAM was 39% (range 24.6–86%), and CAM was recommended
by 46% of physicians (range 38–55%). The average percentage
of physicians who had received training in CAM was 10.3%
(range 4.8–21%). The three most commonly used methods of
CAM were acupuncture, homeopathy and relaxation therapy.
A sizable proportion of physicians in the UK seem to employ
some type of CAM, yet many have not received any training in
CAM. This raises issues related to medical ethics, professional
competence and education of physicians.
KEY WORDS: complementary and alternative medicine, survey,
systematic review
Introduction
Complementary and alternative medicine (CAM) has been
defined as ‘diagnosis, treatment and/or prevention which com-
plements mainstream medicine by contributing to a common
whole, satisfying a demand not met by orthodoxy, or diversifying
the conceptual framework of medicine’.1 The prevalence of use
of CAM by physicians in the UK has been reported to be high,
yet few doctors have sufficient training in this area.2 Different
surveys have generated vastly different prevalence rates; the true
level of use of CAM by physicians in the UK is therefore less than
clear. This systematic review aimed to summarise and critically
evaluate surveys monitoring the prevalence of use of CAM by
physicians in the UK during the last 15 years.
Methods
Systematic literature searches were performed for all English
language references using AMED, CINAHL, Cochrane, Embase
and Medline for surveys published between 1 January 1995 and
7 December 2011 (a previous review evaluated earlier surveys).3
Details of the search strategy are summarised in the appendix. In
addition, relevant book chapters, review articles and our own
departmental files were searched by hand for further
relevant articles.
Only surveys that reported quantitative data on prevalence of
use of CAM by physicians in the UK were included. Surveys that
reported only qualitative data were excluded. Information from
the included surveys was extracted according to predefined cri-
teria and assessed by two independent reviewers. Any disagree-
ments were settled through discussion.
The following methods were considered as CAM: acupunc-
ture/acupressure, Alexander technique, aromatherapy, autogenic
training, Ayurveda, (Bach) flower remedies, biofeedback, chela-
tion therapy, chiropractic, Feldenkrais, herbal medicine, home-
opathy, hypnotherapy, imagery, kinesiology, massage of any
form, meditation, naturopathy, neural therapy, osteopathy, qi
gong, reflexology, relaxation therapy, shiatsu, spiritual healing,
static magnets, tai chi and yoga. Non-herbal dietary supplements
and vitamins, psychotherapy, physical exercises and some physio-
therapeutic modalities such as electrotherapy and ultrasound
were not considered to be CAM and therefore were excluded
from our analyses.
Use of CAM was defined as the provision of any type of access
to CAM, including recommendations, referrals, provision of
treatment or self-administration. Where available, we calculated
the average of the percentage of responders who stated that they
recommended, referred or practised CAM.
In studies in which percentage values for more than two
methods of CAM were provided, we ranked the top three
methods of CAM from each survey (I = most popular) and then
averaged the rank numbers across the surveys to generate an
overall ranking. We also provided the total number of surveys in
which a particular method of CAM was the most prevalent/
popular and then calculated the averages of those figures. Where
available, we calculated the average of the percentage of
responders who stated that they experienced benefit or were
satisfied with CAM, as well as those who reported adverse effects
(AEs) after using CAM and the cost of purchasing CAM.
Surveys were further classified according to the following cri-
teria: sample size, response rate and random sampling. We also
Prevalence of use of complementary and alternative medicine
(CAM) by physicians in the UK: a systematic review of surveys
Paul Posadzki, Amani Alotaibi and Edzard Ernst
Paul Posadzki, associate research fellow; Amani Alotaibi, research
associate; Edzard Ernst, professor emeritus
Complementary Medicine, Peninsula Medical School, Exeter
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Paul Posadzki, Amani Alotaibi and Edzard Ernst
506 © Royal College of Physicians, 2012. All rights reserved.
2003 was higher than in 1997 and 2000: the average physicians’
use of CAM in 1997 and 2000 was 14.5% (range 13–16%); this
percentage was 27.6% (range 21.4–32) in 2001 and 2003. Fig 3
fails to indicate any clear changes in referral rates between 1997
and 2003.
The methodological quality of most surveys was poor. Frequent
weaknesses included no mention of sampling technique, small
sample size, low response rate and lack of validated outcome
measures. The use of a random-sampling method was men-
tioned in three (23%) surveys.8,13,14 The response rates ranged
between 9% and 78.6% (average 55.3%).
Perceived effectiveness of CAM was mentioned in three (23%)
surveys.4,9,10,15 The average perceived effectiveness for these three
surveys was 24.5% (range 18–31%). The percentage of physi-
cians who reported AEs was mentioned in two (15.3%) sur-
veys,9,10,15 for which the average was 24.3% (range 14–38%). The
costs of CAM were given in four (30.7%) surveys.7,11,13,14 Based
on one survey, the median annual cost of acupuncture was
£2,008 per eight acupuncture GP practices.7
Acupuncture was the most popular type of CAM in three
surveys (second most popular in three surveys; third in no
surveys), homeopathy was the most popular in two studies
(second in one survey; third in three surveys) and relaxation
techniques were most popular in one survey (second in one
survey; third in no surveys) (Table 3). Using our ranking
method, acupuncture was the most popular form of CAM (23%
of surveys), followed by homeopathy (15.3%) and relaxation
techniques (7.6%).
Discussion
Our review suggests that physicians in the UK make ample use
of CAM. There are, however, many caveats. Most surveys were of
created a category of ‘high-quality surveys’, which had to have a
sample size >1,000 and a response rate >70% and had to employ
a random-sampling technique.
Results
The searches generated 15,781 potentially relevant titles and
abstracts, of which 15,767 were excluded (Fig 1). This resulted in
a total of 14 articles, which reported 13 separate surveys.2,4–16
Detailed characteristics of the included surveys are presented in
Tables 1 and 2. Eight surveys originated from England, three
from Scotland and three from the whole of the UK.
Seven surveys investigated the use of CAM in general terms
(see Table 1).2,5,6,10,13–15 Across these surveys, the average preva-
lence of use of CAM (within the past week) was 20.6% (range
12.1–32%). The average prevalence of referrals to CAM was 39%
(range 24.6–86%). On average, CAM was recommended by 46%
(range 38–55%) of physicians. The average percentage of physi-
cians who had received any training in CAM was 10.3% (range
4.8–21%).
In surveys with a response rate >50%, the average prevalence
of use of CAM was 21.3% (range 13–29.5%). In surveys with a
response rate <50%, the average prevalence of use of CAM was
20% (range 12.1–32%). Two surveys13,14 met all of the above
criteria for methodological quality. They reported an average
prevalence of 25.4% (range 21.4–29.5%).
Seven surveys assessed the use of two specific methods of
CAM: homeopathy4,9,12,16 and acupuncture7,8,11 (see Table 2).
The average prevalence for physicians’ use was 21.6% (range
6.5–49%) for homeopathy and 59.8% (range 13–90%) for
acupuncture.
Figures 2 and 3 estimate changes over time. From Fig 2, one
might assume that the prevalence of use of CAM in 2001 and
Total number of hits for electronic search
(n=15,780)
Additional records indentified through manual search
(n=1)
Duplicates removed
(n=7,089)
Records screened
(n=8,692)
Excluded:
Before 1995 (n=1,659)
Excluded:
Not UK (n=877)
Non-CAM (n=2,573)
Non-physicians (n=1,559)
No prevalence data (n=2,010)
Full-text articles assessed
for eligibility (n=891)
Total articles included
(n=14)
Fig 1. Study flow diagram.
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Use of complementary and alternative medicine in the UK
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poor quality and their findings are thus less than reliable. The
methods employed varied considerably and so comparisons
between surveys and trends over time must be interpreted cau-
tiously. It is obvious that the results of such surveys will depend
on the population targeted. If, for instance, members of an acu-
puncture organisation are surveyed, it is hardly surprising to
find that 90% of them use acupuncture.11 Similarly, it might be
suspected that physicians with an interest in CAM tend to reply
to such surveys, while others do not. This, in turn, would result
in erroneously high prevalence rates, particularly in surveys with
low response rates.
The relatively high percentage of physicians who reported AEs
is of concern. For example, in the survey of White et al (1997),
38% of physicians reported AEs, mostly after spinal manipula-
tion therapy (SMT).15 As several hundred severe complications
have been reported after upper spinal manipulations and the
effectiveness of SMT is not well documented (for example refer-
ences 17 and 18) many authors have questioned whether this
therapy generates more good than harm.19,20
As many doctors in the UK seem to use or recommend CAM,
one ought to ask whether this is ethical. Doctors have a duty of
care that essentially means they should treat each patient with
the optimal treatment for his or her condition. As the evidence
for most forms of CAM is far from strong,21 the use of CAM in
routine healthcare may present an ethical problem. It has been
argued that the use of homeopathy, a form of CAM that is bio-
logically implausible22 and for which clinical evidence is weak,23
conflicts with medical ethics.24.25 Similarly, one ought to investi-
gate why only 10.3% of doctors claim to have training in CAM
yet many more seem to use CAM, as our analyses reveal. This
discrepancy seems to indicate that there is an urgent need to
educate doctors about the essential facts related to this area.26 In
turn, this should be seen in the context of the current debate
about the scientific rigor of courses in CAM for healthcare pro-
fessionals.27
Our review has several limitations. Even though our searches
were extensive, we cannot be entirely sure that all relevant arti-
cles containing prevalence rates were located. Secondly, there is
no gold-standard assessment tool for surveys,28 so a formal
quality assessment was deemed implausible. In addition, the
results of our analyses should be interpreted with caution for
several reasons. First and foremost, calculating average per-
centage values may promote a positive or negative skew as sur-
veys were based on various sample sizes. Secondly, in eight
surveys4,5,7–9,11,12,16 the percentage values of the most popular
CAM modalities were not provided. This means that our top
three ranking list is based on six surveys. Thirdly, six sur-
veys4,7–9,11,16 investigated the use of single methods of CAM,
namely homeopathy and acupuncture, and did not include
other CAMs.
In conclusion, most surveys that have monitored physicians’
use of CAM in the UK are less than rigorous. The current evi-
dence suggests that the prevalence is high, which raises ethical
and competence issues. The most popular treatments are acu-
puncture, homeopathy and relaxation techniques.
Yea r
35%
30%
25%
20%
15%
10%
5%
0%
1997 2000 2001 2001 2003
Percentage of physicians (%)
Fig 2. Changes over time in physicians’ use of complementary and
alternative medicine (CAM) (only surveys of use of CAM in general).
Year
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1997 1998 2000 2001 2001 2003
Percentage of physicians (%)
Fig 3. Changes over time in physicians’ referral to complementary and
alternative medicine (CAM) (only surveys of use of CAM in general).
Table 3. Ranking scores.
Method of CAM Score*
I II III
Acupuncture 3 3 0
Chiropractic 0 1 1
Homeopathy 2 1 1
Hypnosis 0 0 1
Magnetotherapy 0 0 1
Osteopathy 0 3 1
Relaxation 1 1 0
*I = most popular; III = third most popular.
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Paul Posadzki, Amani Alotaibi and Edzard Ernst
508 © Royal College of Physicians, 2012. All rights reserved.
Table 1. Prevalence of the use of or referrals to CAM by physicians in UK since 1995.
Study Aim (quote) Population Method
Sampling
technique
Question(s)
asked (quote
where
appropriate)
Response
rate (%) Prevalence (%)
Most popular
CAMs
(% where given)
Perceived
effectiveness
Adverse
effects
reported (% of
respondents) Costs
Other
relevant
findings
Fewell
(2005)5
To investigate
‘awareness of
CTs by
healthcare
professionals
currently
employed by a
local healthcare
trust’
500 GPs in
England
Postal
questionnaire
NM ‘…indicate
whether their
practice area
currently use
CTs’
9 Currently using
CAM (12.1)
Acupuncture
Relaxation
Magnetotherapy
NM NM NM 4.8% of trust
employees
held
qualification in
CM
Grenfell
(1998)6
‘To investigate
local GPs’
provision of
and referral to
CTs’
275 GPs in
England
Postal
questionnaire
NM ‘…information
on their
provision of
and referral
to CTs…’
66 Referred
patients to
CAM (86)
Relaxation (25)
Acupuncture (16)
Osteopathy (13)
NM NM NM 68% received
requests for
CAM on
monthly basis
Lewith
(2001)2
‘To evaluate the
use of [and]
attitudes to
CAM among UK
physicians’
12,168
physicians in
UK
Postal
questionnaire
NM ‘…specific use
of, and
referral to, a
variety of
different CAM
therapies’
23 Practised CAM
(32)
Referred to
CAM (41)
Acupuncture (5.4)
Osteopathy (3.6)
Hypnotherapy
(2.7)
NM NM NM 85.3% agreed
or
strongly
agreed that
CAM
should be
subject to
more rigorous
testing
Perry
(2000)10
‘To ascertain
use of and
attitudes
towards CM,
amongst GPs…’
252 GPs in
England
Postal
questionnaire
NM ‘The
questionnaire
was based on
those
previously
used by
Wharton &
Lewith, and
White et al’
52 In one week:
• Involved in
CAM (56)
• Had treated
patients (13)
• Had referred
to CAM (31)
• Had endorsed
CAM (38)
Homeopathy (28)
Osteopathy (23)
Acupuncture (23)
Chiropractic (18)
Osteopathy
and
acupuncture
perceived as
most effective
21 NM 18% used
CAM regularly
Thomas
(2001)13
‘To describe the
scale and scope
of access to CM
via general
practice in
England’
1,226 GPs in
England
Postal
questionnaire
Multi-stage
random
sampling
‘…the
questionnaire
relating to
practice
provision or
referrals for
any of the
named CTs’
78.6 In one week:
• Referred to
CAM (24.6)
• Practised
CAM (21.4)
• Recommended
CAM to
patients (45)
Acupuncture
(21.2)
Homeopathy
(16.8)
Hypnotherapy
(8.3)
NM NM Patients
made
some
payment
for 25%
of CM
160 made
referrals to
CAM via NHS
64% offered
CAM
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Table 1. Continued.
Study Aim (quote) Population Method
Sampling
technique
Question(s)
asked (quote
where
appropriate)
Response
rate (%) Prevalence (%)
Most popular
CAMs
(% where given)
Perceived
effectiveness
Adverse
effects
reported (% of
respondents) Costs
Other
relevant
findings
Thomas
(2003)14
‘To generate
new national
estimates of
the provision of
CAMs in
NHS primary
care in
England…’
1,203 GPs in
England
Postal
questionnaire
Stratified
random
cluster
sampling
Questions
from Thomas
et al (2001)
72.3 Referred to
CAM (26.8)
Practised CAM
(29.5)
Acupuncture
(33.6)
Chiropractic or
osteopathy (23)
Homeopathy
(21.1)
NM NM Patients
made
some
payment
for 42%
of
practice-
based
provision
Current use
was reported
by:
• 11%
for patients
with cancer
• 10% for
elderly
patients
• 9% for
patients
with mental
health
conditions
• 5% for
patients
with
diabetes
• 5% for
patients
with CHD
White
(1997)15
‘…to determine
the use of, and
attitudes
towards, CM
among GPs’
461 GPs in
England
Questionnaire NM Questions
from Thomas
et al (1995)
47.4 In one week:
• referred to
CAM (25)
• Practised
CAM (16)
• Recommended
CAM (55)
Homeopathy (5.9)
Acupuncture (4.3)
Chiropractic,
acupuncture
and
osteopathy
rated as most
effective
38, most
commonly
after SMT
NM 68% were
‘active’ in
CAM
AE = adverse effect; BMAS = British Medical Acupuncture Society; CAM = complementary and alternative medicine; CHD = coronary heart disease; CM = complementary medicine; CT = complementary therapy;
FMS = fibromyalgia syndrome; GP = general practitioner; NM = not mentioned; OA = osteoarthritis; OT = occupational therapist; PCT = primary care trust; PT = physical therapist; SMT = spinal manipulative therapy.
*Average estimate.
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Paul Posadzki, Amani Alotaibi and Edzard Ernst
510 © Royal College of Physicians, 2012. All rights reserved.
Table 2. Prevalence of use of specific methods of CAM by physicians in UK since 1995.
Study Aim (quote) Population Method
Sampling
technique
Question(s) asked
(quote where
appropriate)
Response
rate (%)
Prevalence of
use (%)
Most
popular
CAMs
Perceived
effectiveness (%)
Adverse
effects (% of
respondents) Costs
Other relevant
findings
Ekins-
Daukes
(2004)4
‘To investigate the
extent of
homoeopathic
prescribing in
primary care for
childhood
diseases…’
161 GPs in
Scotland
equestionnaire NM ‘…to determine
reasons for or
against prescribing
homoeopathic
medicines to
children…’
75 Prescribed
homeopathic
medicines (22)
Homeopathy Frequent
prescribers
strongly agreed
homeopathy was
efficacious (18)
NM NM 94% of GPs
perceived
homeopathy as
safe
Johnson
(2008)7
‘ …to test the
feasibility of
surveying national
data on referrals
and prescribing’
3 PCTs including
orthopaedic,
pain,
physiotherapy
and
rheumatology
practice
managers in
England
equestionnaire Non-
random
sampling
‘…whether any
member of the
primary care team
offered
acupuncture, and if
so how many
appointments per
week’
65* Provided
acupuncture
(13)
Acupuncture NM NM Median of
£2,008
annually
Considerable
variation in
acupuncture
provision
between different
PCTs
Orpen
(2004)8
‘…to establish
whether
acupuncture
services are
provided…’
Nurses, medical
staff,
physiotherapists
and
pharmacists in 42
hospitals in UK
Postal
questionnaire
Random
sampling
‘…to supply
information on the
number of staff
who performed
acupuncture…’
71 Provided
acupuncture
(76.6)
Acupuncture NM NM NM Average waiting
time for first
acupuncture
treatment was
18.5 weeks
Perry
(2000)9
‘…to ascertain the
use of and
attitudes towards
homeopathy
amongst GPs…’
252 GPs in
England
Postal
questionnaire
NM ‘The questionnaire
was based on those
previously used by
Wharton and
Lewith, and White
et al’
52 Used
homeopathy
(6.5)
Homeopathy 31 14 NM 23% of GPs
considered
homeopathy to
have valid basis
Price
(2004)11
‘To assess the
usage of
acupuncture by
members of
BMAS…’
2,312 GPs,
doctors, other
health
professionals
in UK
Postal
questionnaire
NM ‘…whether they
currently treated
patients with
acupuncture’
48 Respondents
provided
acupuncture
(90)
Acupuncture NM NM 61% of
acupuncture
treatments
given free
within NHS
More than one
million
acupuncture
treatments each
year provided by
members of BMAS
Ross
(2006)12
‘To investigate the
current levels of
homoeopathic
and herbal
prescribing in
Scottish
general practice’
323 GPs in
Scotland
Descriptive survey NM NM NM Prescribed
homeopathic
(32)
Prescribed
herbal
remedies (49)
Homeopathy
Herbal
medicine
NM NM NM 60% of GPs
prescribed
homoeopathic or
herbal medicines
Wyllie
(1998)16
‘ …to assess the
attitude of GPs in
Lothian, Scotland,
to homoeopathy’
540 GPs in
Scotland
Postal
questionnaire
NM ‘Have you received
any training in
complementary
medicine?’
56.3% Prescribed
homeopathy
(9)
Homeopathy NM NM NM 69% of GPs had
referred patients
for homeopathy
BMAS = British Medical Acupuncture Society; NM = not mentioned; PCT = primary care trust.
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1 An?esthetist$ OR Anatomist$ OR andrologist$ OR Audiologist$ OR Chiropodist$ OR Cytogeneticist$ OR Dermatologist$ OR Embryologist$ OR
Endocrinologist$ OR Gastroenterologist$ OR geneticist$ OR Geriatrician$ OR Gynaecologist$ OR Haematologist$ OR Histopathologist$ OR Hospitalist$
OR Immunologist$ OR Microbiologist$ OR Nephrologist$ OR Neurologist$ OR Neurophysiologist$ OR Neurosurgeon$ OR Obstetrician$ OR
Oncologist$ OR Ophthalmologist$ OR Optometrist$ OR Orthotist$ OR Otolaryngologist$ OR P?ediatrician$ OR Pathologist$ OR Perfusionist$ OR
Phlebotomist$ OR physiologist$ OR Physiotherapist$ OR Podiatrist$ OR Prosthetist$ OR Radiologist$ OR Respirologist$ OR Rheumatologist$ OR
Urologist$ .ti,ab
2 Clinical ADJ3 (assistant$ OR research$).ti,ab
3 Staff ADJ3 (associate$ OR grade$).ti,ab
4 GP$.ti,ab
5 Physician$.ti,ab
6 doctor$.ti,ab
7 surgeon$.ti,ab
8 house officer$.ti,ab
9 therapist$ ADJ3 (Cardi$ OR Hearing OR Occupational OR Physical OR Radiation OR Respiratory OR sport OR exercise).ti,ab
10 Practitioner$ ADJ3 (Associate OR Critical Care OR Endoscopy OR General OR registrar$ OR hospital OR Infection Control OR Operating OR
Perioperative OR special$ OR Respiratory OR medical).ti,ab
11 specialist$.ti,ab
12 Consultant$.ti,ab
13 Registrar$ ADJ3 (Hospital OR Special$).ti,ab
14 trust grade$.ti,ab
15 locum$.ti,ab
16 MD$.ti,ab
17 Exp Physician
18 Alternative ADJ3 (heal$ OR medic$ OR remed$ OR therap$ OR treatment$).ti,ab Complementary ADJ3 (heal$ OR medic$ OR remed$ OR therap$ OR
treatment$).ti,ab
19 integrat$ ADJ3 (heal$ OR medic$ OR remed$ OR therap$ OR treatment$).ti,ab CAM.ti,ab
20 exp Complementary Therapies/
21 Prevalen$.ti,ab.
22 Focus group$ OR Interview$ OR Question$ OR Survey$).ti,ab
23 exp health surveys/ or exp health care surveys/ or exp interviews as topic/ or exp questionnaires/
24 1 OR 2 OR 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11 OR 12 OR 13 OR 14 OR 15 OR 16 OR 17
25 18 OR 19 OR 20 OR 21 OR 22 OR 23
26 24 AND 25
Appendix 1. Detailed search strategy for Medline.
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10 Perry R, Dowrick CF. Complementary medicine and general practice:
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11 Price J, White A. The use of acupuncture and attitudes to regulation
among doctors in the UK – a survey. Acupunct Med 2004;22:72–4.
12 Ross S, Simpson CR, Mclay JS. Homoeopathic and herbal prescribing
in general practice in Scotland. Br J Clin Pharmacol 2006;62:647–52.
13 Thomas KJ, Fall M. Access to complementary medicine via general
practice. Br J Gen Pract 2001;51:25–30.
14 Thomas KJ, Coleman P, Nicholl JP. Trends in access to complemen-
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15 White AR, Resch KL, Ernst E. Complementary medicine: use and atti-
tudes among GPs. Fam Pract 1997;14:302–6.
16 Wyllie M, Hannaford P. Attitudes to complementary therapies and
referral for homoeopathic treatment. Br Homeopath J 1998;87:13–6.
17 Ernst E. Manipulation of the cervical spine: a systematic review of case
reports of serious adverse events, 1995–2001. Med J Aust 2002;176:376–
80.
18 Terrett AGJ. Current concepts in vertebrobasilar complications following
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Address for correspondence: Dr P Posadzki,
Complementary Medicine, Peninsula Medical School, Veysey
Building, Exeter, EX2 4SG.
Email: Paul.Posadzki@pcmd.ac.uk
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