Use of alternative therapies in patients submitted to anorectal manometry.

BACKGROUND AND AIM: Anorectal manometry is used in the evaluation of disorders of the lower gastrointestinal tract: constipation, incontinence, anorectal pain. Most of these conditions are invalidating. Moreover, the patients do not benefit from a perfect therapy. Therefore many of them also use alternative therapies, but we still miss data on the use of alternative therapies in anorectal disorders. Therefore we looked for the use of alternative therapies in patients submitted to anorectal manometry.
MATERIAL AND METHODS: 60 consecutive patients submitted to anorectal manometry were questioned about the use of alternative therapy by a specially developed structured questionnaire. All of them accepted to answer the questionnaire after careful instruction. The questions were administered by a qualified staff and filled before the investigation.
RESULTS: The indication for anorectal manometry was: incontinence 18 cases (20%), constipation 33 cases (55%), anorectal pain 9 cases (15%). 44 out of 60 (73%) patients admitted to have used one or more alternative therapies, usually together with the observance of medical dietary or pharmacological prescriptions. These were: homeopathy 10 (17%), herbal therapy 36 (60%), acupuncture 1 (0.02%), bioenergy resonance 11 (18%). Users were mainly females with a low level of education. The use of alternative therapy was similar in all three subgroups of patients.
CONCLUSION: These data emphasizes the importance of the use of alternative therapies in patients with anorectal disorders submitted to anorectal manometry.

Introduction

In our area, there is a lack of knowledge on the use of alternative therapy [1]. Ignoring or avoiding to know the problem, does not help us managing patients with difficult conditions.

The satisfaction of the patients with the allopathic medicine depends on the quality of the doctor-patient relationship, but also on the availability of effective drugs [2]. The efficiency of therapeutic methods, especially of those based on pharmacotherapy and perceived as chemical or “unnatural”, may influence the attitude of the patients toward alternative therapies. Dissatisfaction with the results of scientific treatment methods and/or distrust of pharmacological substances, coupled with unscientific remedies tradition, led many patients to other ways considered more healthful and safe. This approach directed patients to alternative and complementary therapies.

Alternative therapy is defined as the form of therapy that avoids the administration of drugs or the use of therapeutic techniques recognized by the scientific medical community. Complementary treatments are methods applied in addition to specific medical treatments, to achieve improved health [3]. In the last decade we witness an impressive increase of the use of alternative and complementary therapies, demonstrated in both medical journals [4,5] and in wide circulation mass-media.

In Romania, there are not many data on the use of alternative treatments. In this study, we investigated the use of alternative therapies by patients examined in a tertiary medical center by anorectal manometry.

Material and methods

Group of patients

We selected patients referred to a center for anorectal manometry, considering that they suffered of significant impairment and did not benefit from the best allopathic therapy. Many of them also used anorectal biofeedback. Sixty consecutive patients were included in the study.

The composition of this group appears in Table I.

Table I

Demographic data of the subjects.

Feature	Values
Gender F/B	38/22 (number)
Age (mean+/−SD)	55+/−10 (years)
Level of education: low, medium, high	22/16/22 (number)

Questionnaire

The use of alternative medicine was investigated with a specially developed structured interview. This questionnaire included questions about using alternative therapies, type, amount, duration, indication. The questionnaire was administered after obtaining the informed consent, but before the investigation, by a qualified staff. This is a one–page questionnaire, easy to fill. All the participants accepted to fill in the questionnaire after careful instruction. In some cases it was necessary that the questions were read by the investigator (elderly patients).

Descriptive statistical analysis and comparisons were performed with the commercially available Medcalc program.

Ethical issues

The participants gave their informed consent. The study was conducted according to the Helsinki Declaration on human experimentation.

Results

All patients agreed to participate in the study, resulting in a rate of 100% responsiveness.

The indication for anorectal manometry was: incontinence 18 cases (30%), constipation 33 cases (55%), anorectal pain 9 cases (15%).

Forty-four out of 60 (73%) patients admitted to have used one or more alternative therapies, usually together with the observance of medical dietary or pharmacological prescriptions.

The alternative therapies used were: homeopathy 10 (17%), herbal therapy 36 (60%), acupuncture 1 (0.02%), bioenergy resonance 11 (18%). Some patients used more than one alternative method (Table II).

Table II

Alternative therapies used.

Therapy	Number (%)
Homeopathy	10 (17)
Herbal	36 (60)
Acupuncture	1 (0.02)
Bioenergy resonance	11 (18)
Other	2 (0.03)

The use of alternative therapy was similar in all three subgroups of patients (Table III, chi square).

Table III

Use of alternative therapies according to the anorectal condition.

Incontinence (n=18)	Constipation (n=33)	Pain (n=9)
13 (72%)	24 (73%)	7 (78%)
NS	NS	NS

Most alternative therapies were used by women with a low level of education. Most people used more than one alternative method, the most commonly used being herbal remedies.

Discussion

This is to our knowledge the first study in this country addressed to the use of drugs or alternative therapies in patients with lower gastrointestinal diseases. We carried out this study on subjects submitted to a center for anorectal manometry, because these patients are long-term users of medical services and have important complaints.

For this study we developed a specific questionnaire. This is a one page, structured questionnaire, to be completed by the patient. In special circumstances, the questionnaire was completed by a health professional. The questionnaire included beside questions on demographic data, a list of alternative therapies, the patient having to choose the one(s) he used, the duration and doses.

Our study reveals that a large number of patients with anorectal disorders use alternative treatments. This is an appropriate field for such an investigation, where patients turn to non-conventional treatments, induced by the chronic nature of the disease and the lack of an efficient standardized treatment effect. Indeed, many drugs used by allopathic doctors have failed to prove the exigency required by the paradigm of evidence-based medicine (EBM)[6]. This is why even some allopathic doctors recommend alternative therapies called “natural”, for more or less disinterested reasons. Their recommendations are some-times not easy to delimitate from medical quackery [7].

Our patients who used alternative medicine were mainly females of lower education. This is different from data reported for other areas. For instance, in the U.S. and other industrialized countries, the followers of alternative therapies belong to higher social classes, have a level of education above the average and often believe in paranormal facts [8]. In our setting, most frequent users of alternative therapy are less educated and prefer cheaper treatment modalities [1]. This is different from the situation in the U.S. and in Western Europe, where subjects rely on exotic treatments such as Chinese or Ayurvedic [9,10], which are not well-known or available in our area.

On the other hand, it is difficult to separate the complementary and alternative therapy from the hygienic-dietary recommendations based on changing lifestyle and behavior [11]. Normally, the difference between recommendations to change diet and lifestyle, part of medical treatment and prophylaxis, may be partially overlapping with alternative therapy [11]. The bio-psychosocial model of Engel, which is based on a psychosomatic approach, that takes into account life events, psychosocial factors, environmental factors, is an ideal field for a comprehensive approach of the patients with chronic gastrointestinal symptoms [13].

Many of our subjects present their symptoms in the frame of the irritable bowel syndrome (IBS). Psychotherapy, hypnotherapy and general psychological therapies, which are effective in IBS [14,15] are not part of alternative therapies, but a distinct way of treatment [16]. In this context it the attitude of patients who do not distinguish between alternative and allopathic treatments is understandable, and on the other hand they are embarrassed to admit to the allopathic doctor the use of other treatments, which have not been proven as healthful.

We did not include in this study those patients who followed anorectal biofeedback (n=3). Allthough anorectal biofeedback is considered an alternative therapy [17], we consider it as pat of an allopathic medical approach. On the other hand, we investigated subjects naïve to anorectal manometry and did not want to introduce a potential bias with the small group of patients with anorectal biofeedback who were not exposed first time to manometry.

It is important to know the amount and type of alternative therapies used in our country. Discovering the hidden face of the iceberg allows to control charlatans and to provide better treatment to patients with anorectal symptoms.

In conclusion, about three quarters of the patients with anorectal disorders referred to anorectal manometry use alternative therapies beside allopathic therapies (anorectal biofeedback excluded). The most popular is the use of herbs, followed by bioenergy resonance.