Edzard Ernst

MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Case reports of adverse effects after chiropractic spinal manipulation usually come as publications in peer-reviewed medical journals. As such they tend to documents that are factual, detached and clinical. This is an intended effect and is meant to increase objectivity; at the same time it omits all of the directness and emotions that are associated with such incidences which can, of course, be important. Here is a case report that is dramatically different. It is a story told by a sibling of the victim (both had been having manipulations for migraines regularly) on this website. As I think it is poignant, I have not changed anything except for shortening it slightly.

My youngest brother has been receiving chiro for… long, however last week he received very, very aggressive neck adjustments 3 times in a row. The last one left him feeling off and he felt like it worsened his migraine. He called me asking if I had ever had an adjustment worsen a headache and I said yes, once or twice. He then told me it was creating a different vision issue than his regular migraine aura. I told him get to emergency ASAP. He had a full stroke 15 minutes later. At the age of 29 years. Thank God he went to ER, he told me he almost went to try to sleep it off after he hung up the phone.

An MRI and CT scan showed that the stroke was NOT a clot that was already formed and agitated/released by the neck adjustment. But that the adjustment had actually caused a large tear in his vertebral artery and that it had in turn caused bleeding into his brain and consequently the stroke.

The doctor told him that had he not come in right when he did, he would most certainly have died or in the best case scenario, been a vegetable.

I realize that perhaps the chiropractor did not realize how aggressive he was being or even consider the trauma he could cause. Or maybe, he made a poor judgement call, he is only human. I have since consulted my own chiropractor, who sadly, is of the opinion that it’s just not possible for a chiropractor to cause such trauma and that it simply was an issue waiting to happen and that the adjustment just ‘helped’ it along. He stated over and over that chiro CANNOT cause a stroke. I am scared enough to not go back. I find physio to help my neck more anyway.

The other part is, the ER doctor told my brother that he has seen what he considers to be an alarming increase in chiropractic related strokes and vertebral artery tears. I realize that nowhere NEAR even 90% of all patients adjusted have this issue, but it definetely exists and it IS scary.

I expect that several apologists will now accuse me again of being alarmist, but I do wonder how often such cases happen and remain unreported. I am certainly not aware that this case has been published in a peer-reviewed journal.

Over the years, I have received so many insults, attacks and legal challenges that I could start writing blog posts only about them and the issues involved. Recently someone asked me during the discussion part of a public lecture: “How did you manage to deal with all this aggression emotionally?” My answer was meant as a joke but, in a way, it is also true: ” You only need to become a masochist, and you enjoy every minute of it.”

Today, most of these attacks make me laugh because they are so stupid and mad. They merely show that the author has run out of arguments. In other words, they signal a victory which is, I think, quite enjoyable.

Recently I found such a victory of reason over madness on this website. It is not a new post but somehow I had missed it; and it is so remarkable that I have to reproduce it here without the slightest alteration. Here it is, enjoy!

Edzard Ernst himself admitted that he tried learning homeopathy, acupuncture, herbalism and chiropractic but never completed any course on them. He had 2 months of classes and 6 months of homeopathy training in Germany. In Germany, where homeopathy is regulated, it is a prerequisite to pass an exam by a Governing Medical Council, which he did not do. He had never wrote an exam. He has zero qualifications in homeopathic medicine but still falsely claims that he has been trained as a homeopath. 

Without having a required medical qualification, he illegally practiced Homeopathy and admitted in a national newspaper (UK Guardian, 3/4/2012) that he was “….impressed with the results achieved by Homeopathy. Many of my patients seemed to improved dramatically….”.
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Edzard Ernst published two papers in favour of homeopathy
1. Phlebology
Complementary Treatment of Varicose Veins: A Randomised, Placebo-controlled, Double-blind Trial”
Edzard Ernst, T. Saradeth, K.L. Resch, 1990, 157-163.
Three doses of a popular German combination of eight homeopathic medicines were given daily for 24 days. Measures were venous filling time, leg volume, and subjective symptoms. The study found that venous filling time improved in those given the homeopathic medicines by 44%, while it deteriorated in the placebo group by 18%. Other measures also had significant differences.
Linde OR=2.6 in favour of homeopathy, Linde Quality=1
2. Journal of Clinical Gastroenterology
Homeopathy for post-operative ileus (1997)
Barnes, Edzard Ernst
6 trials, 776 patients, medicines: Opium, Arnica, Raphanus sativus, China, Pyrogenum. Two of the four studies that also measured time to first faeces reported a positive effect for homeopathy. A meta-analysis of all six included studies revealed a statistically significant effect in favour of homeopathy for time to first flatus. This effect remained even with the exclusion of the two low quality studies. A significant effect in favour of homeopathy was also found for time to first flatus when a homeopathic remedy of less than 12C potency was used. 
Conclusion: “There is some evidence to support the administration of a homeopathic remedy immediately after surgery to reduce the duration of ileus”
4 out of 6 trials are of best quality. AMSTAR score=6/11

By fraud he became a Professor of Complementary medicine in University of Exeter (an accredited University in UK) in 1993 by fooling them (How can you become a Professor of Complementary medicine when you have zero qualifications in complementary medicine?). It would be interesting to know who appointed Edzard as Professor. Did he tell porky pies to get the job?

Some called him a failed Homeopath. Fear of failure made him skeptic. Fate made him ‘skeptic without k’, get famous as an authority after failing as CAMventional practitioner. He co-authored a book “Trick or Treatment”.  It was full of half-truths which were exposed in a book by William Alderson titled ‘Halloween Science’.

His downfall started in 2005 when “Ernst breached the professional code of scientific behaviour by leaking under-review paper before publication” (as a reviewer of a Journal Lancet). It was deplored by the journal and the scientific community.

He was exposed in year 2007 by Alliance for Natural Health. He is considered to be The Rachel Maddow of Alternative Health

He got potentised when he was forced to put down his papers at University of Exeter as Professor of Complementary Medicine in 2011, two years ahead of his official retirement. Immediately after his retirement, a homeopathy clinic was established in the University.

He was removed from editorial board of a reputed Elsevier Journal in 2013. It was a fall from grace.

He is fighting a losing battle against Prince Charles who is going to have the last laugh.

Chris Wilkinson has dedicated a law in his name titled “Ernst First Law”. It says, “Endlessly repeat what they want to hear and the septics will keep sending me their blessings and I shall be king.”

More about him at http://safe-medicine.blogspot.co.uk/2015/09/the-contribution-of-professor-edzard.html

DID I PROMISE TOO MUCH?

The article then goes on by throwing more mud, lies and attacks at two of my friends: Simon Singh and David Colquhoun. Some might think that we should sue the author – I would disagree: we need to encourage such people to publish more of this stuff because it is not only hilarious but also such a sweet victory of reason over madness.

Over the years, I had to get used to some abominably poor research in alternative medicine, particularly homeopathy. This new paper takes the biscuit, in my fairly well-informed opinion.

The article in question reports a survey investigating the management of paediatric tonsillopharyngitis, with a focus on natural remedies. For that purpose, 138 paediatricians, general practitioners and ear-nose-throat (ENT) specialists from 7 countries were sent a self-made, non-validated questionnaire.

The results indicate that a rapid strept test (RST) to diagnose acute tonsillopharyngitis was routinely used by 41% of the respondents. The use of RST allowed 200 diagnosis/year compared with 125 diagnosis/year for clinicians who did not use this tool. Homeopathic remedies were prescribed as a supportive therapy by 62% of participants. Among different homeopathic remedies, SilAtro-5-90 was the most frequently prescribed. In the chronic setting, homeopathy was suggested as a supportive therapy by 59% of all participants, phytotherapy by 28% and vitamins/nutritional supplementation by 37%.

The authors of this paper concluded from these results that the management of tonsillopharyngitis in paediatric patients still remains empiric. Natural remedies, and homeopathy in particular, are used in the management of URTIs. An integrative approach to these infections may help reduce excessive antibiotic prescription.

No wonder that homeopathy and research into it are the laughing stock of the scientific community!

A survey of this nature is already a fairly daft idea. What could it possibly show? That health care professionals who like homeopathy answer, while the vast majority don’t!

But the pinnacle of silliness must be the conclusions drawn from such ‘research’. Let’s take them step by step:

  1. the management of tonsillopharyngitis in paediatric patients still remains empiric – this is not true nor is it borne out by the data generated.
  2. Natural remedies, and homeopathy in particular, are used in the management of URTIs – this may be true, but it has been known before; we therefore do not need to waste time and effort to re-state it.
  3. An integrative approach to these infections may help reduce excessive antibiotic prescription – this is not supported by the data and it also seems nonsensical: if it truly successful in reducing antibiotic prescribing, it is arguably no longer integrative but alternative.

So?

Say no more!

Chronic pain is a common and serious problem for many patients. Treatment often includes non-pharmacological approaches despite the mostly flimsy evidence to support them. The objective of this study was to measure the feasibility and efficacy of hypnosis (including self-hypnosis) in the management of chronic pain in older hospitalized patients.

A single center randomized controlled trial using a two arm parallel group design (hypnosis versus massage). Inclusion criteria were chronic pain for more than 3 months with impact on daily life activities, intensity of > 4; adapted analgesic treatment; no cognitive impairment. Fifty-three patients were included. Pain intensity decreased significantly in both groups after each session. Average pain measured by the brief pain index sustained a greater decrease in the hypnosis group compared to the massage group during the hospitalization. This was confirmed by the measure of intensity of the pain before each session that decreased only in the hypnosis group over time. Depression scores improved significantly over the time only in the hypnosis group. There was no effect in either group 3 months post hospitals discharge.

The authors concluded that hypnosis represents a safe and valuable tool in chronic pain management of hospitalized older patients. In hospital interventions did not provide long-term post discharge relief.

So, hypnotherapy is better than massage therapy when administered as an adjunct to conventional pain management. As it is difficult to control for placebo effects, which might be substantial in this case, we cannot be sure whether hypnotherapy per se was effective or not.

Who cares? The main thing is to make life easier for these poor patients!

There are situations where I tend to agree with this slightly unscientific but compassionate point of view. Yes, the evidence is flimsy, but we need to help these patients. Hypnotherapy has very few risks, is relatively inexpensive and might help badly suffering individuals. In this case, does it really matter whether the benefit was mediated by a specific or a non-specific mechanism?

We all hope that serious complications after chiropractic care are rare. However, this does not mean they are unimportant. Multi-vessel cervical dissection with cortical sparing is an exceptional event in clinical practice. Such a case has just been described as a result of chiropractic upper spinal manipulation.

Neurologists from Qatar published a case report of a 55-year-old man who presented with acute-onset neck pain associated with sudden onset right-sided hemiparesis and dysphasia after chiropractic manipulation for chronic neck pain.

Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded.

The authors concluded that chiropractic cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.

Chiropractors will claim that they are highly specialised and that such events must be true rarities. Others might even deny a causal relationship altogether. Others again would claim that, relative to conventional treatments, chiropractic manipulations are extremely safe. You only need to search my blog using the search-term ‘chiropractic’ to find that there are considerable doubts about these assumptions:

  • Many chiropractors are not well trained and seem mostly in the business of making a tidy profit.
  • Some seem to have forgotten most of the factual knowledge they may have learnt at chiro-college.
  • There is no effective monitoring scheme to adequately record serious side-effects of chiropractic care.
  • Therefore the incidence figures of such catastrophic events are currently still anyone’s guess.
  • Publications by chiropractic interest groups seemingly denying this point are all fatally flawed.
  • It is not far-fetched to fear that under-reporting of serious complications is huge.
  • The reliable evidence fails to demonstrate that neck manipulations generate more good than harm.
  • Until sound evidence is available, the precautionary principle leads most critical thinkers to conclude that neck manipulations have no place in routine health care.

On this blog, I have repeatedly tried to alert consumers and patients to the risks of herbal medicine. The risks include:

A new paper throws more light on the latter issue which has been not well-studies so far.

The objective of this study was to investigate the relationship between the use of medicinal plants and medication adherence in elderly people. The authors conducted an observational, cross-sectional study of elderly residents in Cuité-PB, Northeastern Brazil, through a household survey. A stratified proportional and systematic random sample of 240 elders was interviewed in their homes and the use of pharmaceutical medicines and of medicinal plants was assessed by direct examination. The association of medication adherence with socio-demographic, clinical, medication and use of medicinal plants was analysed with multiple logistic regression.

The results showed that medication non-adherence increases with use of herbal medicines (adjusted odds ratio 2.022, 95% CI 1.059–3.862, p = 0.03), as well as with the number of different medicinal plants used (adjusted odds ratio 1.937, 95% CI 1.265–2.965, p = 0.002).

The authors concluded that this study provides first-hand evidence that the use of herbal medicines is associated with poor medication adherence. Given the high frequency of the use of herbal medicines, further research into the mechanisms of this association is justified.

This conclusion is well-put, I think. If these findings are confirmed in other populations, we are confronted with a somewhat paradoxical situation: combining herbal and synthetic medicines can reduce adherence to the synthetic drugs and, in cases where adherence is not affected, it could increase the risk of herb/drug interactions.

Natural Pharmacy Business reported that the UK homeopathic pharmacy, Helios, has just launched 5 new combination remedies. Nothing exciting about that, you might say. But wait, these products have licences from the UK regulator and are thus allowed to make therapeutic claims. A spokesperson for Helios was quoted as stating about the new products that ‘…we can actually say what they do, making it easier for customers to recommend or choose what is needed.’

A closer look at the Helios website reveals more details. The 5 remedies are described as follows:

1) Helios Injury 30c – Arnica, Rhus tox and Ruta grav are combined to form a homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of pains and minor trauma associated with minor injuries, bruises, strains and sprains as well as minor emotional trauma associated with the above. The remedy comes in lactose free, organic sucrose pills in our easy to use single dose dispenser in 30c potency.

2) Helios Sleep 30c – Avena sativa, Coffea, Passiflora and Valarian are combined to form a homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of temporary sleep disturbances wherever you are. The remedy comes in lactose free, organic sucrose pills in our easy to use single dose dispenser in 30c potency. This product is not recommended for children under 18, please call us for advice for use in children.

3) Helios ABC 30c  – Aconite, Belladonna and Chamomilla are combined to form a homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of minor feverish illness and/or minor earache in children up to 12 years and for symptoms associated with teething in infants or toddlers. The remedy comes in lactose free, organic sucrose pills in our easy to use single dose dispenser in 30c potency. Remedies for babies may be dissolved in half a teaspoon of previously boiled, cooled water.

4) Helios Stress Relief 30c –  Aconite, Arg nit and Arsenicum are combined to form a homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of symptoms associated with mild stress. The remedy comes in lactose free, organic sucrose pills in our easy to use 4gm single dose dispenser in 30c potency. This product is not recommended for children under 18, please call us for advice for use in children.

5) Helios Hay Fever 30c –  Allium cepa, Euphrasia and Sabadilla are combined to form a homeopathic medicinal product used within the homeopathic tradition for the symptomatic relief of Hay Fever. The remedy comes in lactose free, organic sucrose pills in our easy to use single dose dispenser in 30c potency.

So, now they are entitled to tell us what these remedies actually do!!!

Interesting!

Interesting, because what they do tell us is actually not true. If you look critically at the evidence, you are inevitably going to arrive at entirely different verdicts about the effectiveness of these remedies: THEY ACTUALLY DO NOTHING!

(No, buying them does something to you bank balance, but that’s all)

Consumers are being seriously ripped off and misled here to believe that these homeopathics might actually be needed in cases of illness: THE TRUTH IS THAT THERE IS NO CONDITION FOR WHICH THEY HAVE BEEN PROVEN TO BE EFFECTIVE!

Why did the regulator grant them a licence and allow them to make such claims?

Perhaps someone from the MHRA has the kindness to enlighten us.

I didn’t think that I would post something today.

Why?

Because it’s my birthday!

After opening the packages, reading the cards and having a very relaxed start of the day, I looked into my emails and found a lot of nice messages. More congratulations emerged on twitter and facebook. But the nicest note came from someone called Shirley; almost certainly not knowing it was my birthday, she sent me the following email:

From: shirley
Subject: your work

Message Body:
I’ve just come across your website and can’t believe you actually have set up a whole site devoted to trolling alternative medicine, which may not be your area of expertise but helps millions of people every day. why is it so hard for you to acknowledge that illness and pain most often has an underlying emotional cause.? could you be suffering from some unresolved trauma of your own?
either way, you’re a dickhead.

And why do I find this nice?

Simple, because it confirms that my work here is important, that I am doing the right thing, and that I am making progress. Thank you Shirley for this unexpected gift; you made my day!

As I said before: AD HOMINEM ATTACKS ARE NOTHING BUT A VICTORY OF REASON OVER UNREASON

 

PS

Let me use this occasion to thank everyone else who send me birthday messages.

When given the diagnosis ‘CANCER’, most people go into some sort of shock. Once they have recovered, they are likely to learn that they now face many months of very aggressive treatments which will reduce their quality of life to almost zero. This, they are told, is no guarantee but will merely increase their chances to survive the cancer.

Understandably, before they make what might be the most important decision of their lives, patients are desperate and tempted to look elsewhere to find out for themselves what their options are. It would be foolish to simply accept what their team of health care professionals have been saying. With decisions as important as this one, it is wise to listen to second and possibly third opinions. Who could argue with this logic?

Most cancer patients then go on the Internet and have a look at what alternatives are on offer. Here they find virtually millions of sites offering information. A person with pancreatic cancer might thus be unfortunate enough to stumble over a site called What Alternative Medicine works best against Pancreatic Cancer? If she does, her life is at risk.

You think I am exaggerating? In this case, let me quote from this website (I made no changes whatsoever, not even corrections of the spelling mistakes):

Just to remind you this particular thread is concerned with alternative treatments for cancer. People here are seeking information about alternative medicine. Now we all know that immunotherapy represents potentially a great leap forward in the treatment of cancer in the mainstream medical community although the stats are still pretty low for repsonse most of which have been done on melanoma patients. Nonetheless impresive compared to the useless toxic treatments peddled by the drug industry over the last 30 years. Interferon being one of the worst treatments inflicted on many a poor cancer patient along with chemo and radiation for which many cancers have little or no response and are extremely toxic. I make no false claims about the work of Dr Kelley or Dr Gonzalez for that matter. For those willing to dig a little and research their work they will find a body of good evidence for their protocol.

You might say that this is an extreme exception of irresponsible, life-threatening misinformation. But I disagree. The Internet is full with sites of this nature. They promote treatments for which there is no good evidence; what is worse, they encourage patients to forego conventional treatments which might save their lives. If anyone then dares to point this out, he will be attacked for being in the pocket of ‘Big Pharma’.

I know, a little insignificant post like mine will change very little, but I also feel strongly that, if I do not keep banging on about this issue, who else will warn patients that misinformation from the Internet and other sources can kill?

In 2009, we published a systematic review of studies testing acupuncture as a treatment of menopausal hot flushes. We searched the literature using 17 databases from inception to October 10, 2008, without language restrictions. We only included randomized clinical trials (RCTs) of acupuncture versus sham acupuncture. Their methodological quality was assessed using the modified Jadad score. In total, six RCTs could be included. Four RCTs compared the effects of acupuncture with penetrating sham acupuncture on non-acupuncture points. All of these trials failed to show specific effects on menopausal hot flush frequency, severity or index. One RCT found no effects of acupuncture on hot flush frequency and severity compared with penetrating sham acupuncture on acupuncture points that are not relevant for the treatment of hot flushes. The remaining RCT tested acupuncture against non-penetrating acupuncture on non-acupuncture points. Its results suggested favourable effects of acupuncture on menopausal hot flush severity. However, this study was too small to generate reliable findings. At the time, we concluded that sham-controlled RCTs fail to show specific effects of acupuncture for control of menopausal hot flushes. We also argued that more rigorous research is warranted.

It seems that such research has just become available.

The aim of a brand-new study – a stratified, blind (participants, outcome assessors, and investigators, but not treating acupuncturists were blinded to treatment allocation), parallel, randomized, sham-controlled trial with equal allocation – was to assess the efficacy of Chinese medicine acupuncture against sham acupuncture for menopausal hot flushes (HFs). It was funded by the Australian National Health and Medical Research Council.

Women older than 40 years were recruited; they had to be in the late menopausal transition or postmenopause with at least 7 moderate HFs daily, meeting criteria for Chinese medicine diagnosis of kidney yin deficiency. These patients received 10 treatments over 8 weeks of either standardized Chinese medicine needle acupuncture designed to treat ‘kidney yin deficiency’ or they got the same amount of non-insertive sham acupuncture. The primary outcome was HF score at the end of treatment. Secondary outcomes included quality of life, anxiety, depression, and adverse events. Participants were assessed at 4 weeks, the end of treatment, and then 3 and 6 months after the end of treatment. Intention-to-treat analysis was conducted with linear mixed-effects models.

In total, 327 women were randomly assigned to acupuncture (n = 163) or sham acupuncture (n = 164). At the end of treatment, 16% of participants in the acupuncture group and 13% in the sham group were lost to follow-up. Mean HF scores at the end of treatment period were 15.36 in the acupuncture group and 15.04 in the sham group. No serious adverse events were reported.

The authors concluded that Chinese medicine acupuncture was not superior to non-insertive sham acupuncture for women with moderately severe menopausal HFs.

The trial has several strengths: it includes a large sample size and the patients were adequately blinded to eliminate the effects of expectations. It was published in a top journal, and we can therefore assume that it was properly peer-reviewed. Combined with the evidence from our previous systematic review, this indicates that acupuncture has no effect beyond placebo.

In other words: ACUPUNCTURE IS NOTHING BUT A THEATRICAL PLACEBO.

One does not need to be a clairvoyant to predict that acupuncturists will now find what they perceive as a flaw in the new study and claim that its results were false-negative. Subsequently they will probably conduct their own trial which, because it is wide open to bias, will generate the finding they were hoping for.

This sequence of poor quality positive and high quality negative studies could go on ad infinitum.

This begs the question: how can such wasteful pseudo-research be stopped?

In theory, applications to ethics committees for research that is not aimed at answering open and important questions should get rejected. In practice, however, this is unlikely to happen. In my experience, the main reason preventing such actions is that, when it comes to alternative medicine, ethics committees tend to be too lenient (attempting to be ‘politically correct’), too uninterested (thinking that alternative medicine is not really a serious area of research) and too uninformed (failing to insist on a rigorous assessment of the already available evidence).

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