The NHMRC report on homeopathy is the most thorough, independent and reliable investigation into the value of homeopathy ever. As its conclusions are devastatingly negative about the value of homeopathy, it is hardly surprising that homeopaths tried everything and anything to undermine it. This new article gives what I believe to be a fair account of the allegations and their validity:
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Since the NHMRC declared homeopathy to be ineffective in treating any health condition, a number of disputes have been made by major organisations in favour of homeopathy. Australia’s two peak industry organisations, Complementary Medicines Australia (CMA) and the AHA, both argue in their letters to the NHRMC that the position was prejudiced based on a draft position statement leaked in 2012 stating it is unethical for health practitioners to treat patients using homeopathy, for the reason that homeopathy (as a medicine or procedure) has been shown not to be efficacious [19,20]. Furthermore, both the CMA and AHA highlight serious concerns regarding the prelude to and instigation of the work of the NHMRC’s HWC as well as the conduct of the review itself to finalise their conclusion on the use of homeopathy. Several grave issues were raised in both letters with five common key flaws cited: (1) no explanation was provided as to why level 1 evidence including randomised control trials were excluded from the review; (2) the database search used was not broad enough to capture complementary medicine and homeopathic specific content, and excluded non-human and non-English studies; (3) no homeopathic expert was appointed in the NHMRC Review Panel; (4) prior to publication, the concerns raised over the methodology and selective use of data by research contractor(s) engaged for the HWC review were abandoned for unknown reasons; and (5) no justification was provided as to why only systematic reviews were used [19,20]. Other serious accusations made by the AHA in their response letter to the NHMRC involved the blatant bias of the NHMRC evident by: the leakage of their draft position statement in April 2011 and early release of the HWC Draft Review regarding homeopathy to the media; no discussion of prophylactic homeopathy i.e. preventative healthcare; and no reference to the cost-effectiveness, safety, and quality of homeopathic medicines .
Despite the NHMRC findings being strongly disputed, they are further supported by positions taken by a number of large and respected organisations. For example, in 2009, the World Health Organization (WHO) advised against the use of homeopathic medicines for various serious diseases following significant concerns being raised by major health authorities, pharmaceutical industries, and consumers regarding its safety and quality . They reported the clinical effects were compatible with placebo effects . Similarly, in Australia, the Australian Medical Association (AMA) further supports the NHMRC findings by stating in their position statement released in 2012 that there is limited efficacy evidence regarding most complementary medicines, thereby posing a risk to patient health . More recently, in May 2015, the Royal College of General Practitioners (RACGPs) strongly advocated in their position statement against general practitioners prescribing homeopathic medicines, and pharmacists against supporting or recommending it, given the lack of evidence regarding its efficacy . This is particularly pertinent to conventional vaccines given the recent case between the Australian Competition and Consumer Commission (ACCC) vs. Homeopathy Plus! Australia Pty Ltd. The Federal Court found Homeopathy Plus! Australia Pty Ltd guilty of contravening the Australian Consumer Law by engaging in misleading and deceptive conduct through claiming that homeopathic remedies were a proven, safe, and effective alternative to the conventional vaccine against whooping cough .
The positions of the NHMRC, WHO, AMA, and the RACGPs regarding homeopathy is further supported by Cochrane reviews, which provide high-quality evidence with minimal bias . Of the twelve homeopathy Cochrane reviews available in the database, only seven address homeopathic remedies directly and were related to the following conditions: irritable bowel syndrome , attention deficit/hyperactivity disorder or hyperkinetic disorder , chronic asthma , dementia , induction of labour , cancer , and influenza . Given most of these reviews were authored by homeopaths, bias against homeopathy is unlikely [26-32]. The overarching conclusions from these reviews fail to reveal compelling evidence regarding the efficacy of homeopathic remedies [26-32]. For example, Mathie, Frye and Fisher show that there is â€œno significant difference between the effects of homeopathic Oscillococcinum® and placebo in prevention of influenza-like illness: risk ratio (RR) = 0.48, 95% confidence interval (CI) 0.17-1.34, p-value = 0.16 . The key reasons given for this failure to provide compelling evidence relate to low quality or unclear data, and lack of replicability, suggesting homeopathic remedies are unlikely to have clinical effects beyond placebo [26-32].
Sadly, the ACCC vs. Homeopathy Plus! Australia Pty Ltd is not the only case that has made headlines in Australia in recent years. An article in the Journal of Law and Medicine coincided with the NHMRC report regarding the number of deaths attributable to favouring homeopathy over conventional medical treatment in recent years . One such case was that of Jessica Ainscough, who passed away earlier this year after losing her battle with a rare form of cancer “epithelioid sarcoma“ after rejecting conventional treatment in favour of alternative therapies . Although doctors recognise Ms. Ainscough’s right to choose her own cancer treatments and understand why she refused the disfiguring surgery to save her life, they fear her message may influence others to reject conventional treatments that could ultimately save their lives . Another near death case was that of an eight-month-old boy whose mother was charged with â€œreckless grievous bodily harm and failure to provide for a child causing danger to deathâ€ after ceasing conventional medical and dermatological treatment for her son’s eczema as advised by her naturopath (an umbrella term that includes homeopathy) . The all-liquid treatment plan left the boy severely malnourished and consequently, he now suffers from developmental issues . This case is rather similar to that of R vs. Sam in 2009, where the parents of a nine-month-old girl were convicted of manslaughter by criminal negligence after favouring homeopathic treatment over conventional medical treatment for their daughter’s eczema. The girl died from septicaemia after her eczema became infected [36,37].[references are provided in the original document]
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The NHMRC report stated that
Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments.
Few other reports have previously expressed our concerns about homeopathy so clearly – little wonder then that the world of homeopathy was (and still is) up in arms.
The last time something similar happened was during the Third Reich when homeopathy had been evaluated thoroughly by leading scientists and the conclusions turned out to be just as devastatingly negative. At the time, German homeopaths allegedly made the report disappear, and all we have today about this comprehensive research programme is a very detailed eye witness report of a homeopath who had been intimately involved in the research.
Today, it is thankfully no longer possible to make major research documents disappear. So, homeopaths have to think of other strategies to defend their trade. In the case of the NHMRC report, they act like all cults tend to do and resort to misleading statements and slanderous allegations. This, I feel, is unsurprising and will inevitably turn out to be unsuccessful.
The current volume of the ‘Allgemeinen Homöopathischen Zeitung’ contains all the abstracts of the ‘Homeopathic World Congress 2017’ which will be hosted in Leipzig, 14-17 July this year by the ‘Deutschen Zentralvereins Homöopathischer Ärzte’ under the patronage of the German Health Secretary, Annette Widmann-Mauz. As not many readers of this blog are likely to be regular readers of this important journal, I have copied six of the more amusing abstracts below:
A male patient with bilateral solid renal mass was investigated and given an individualized homeopathic remedy. Antimonium crudum in 50000 potency was selected after proper case taking and evaluation. Investigations were done before and after treatment. Follow ups took place monthly. Results The patient had symptomatic relief from pain in flanks, acute retention and hematuria. The ultrasonography suggests a reduction in size of both lesions over a period of two years. A small number of lymph nodes of the para-aortic group are still visible. There is a normal level of urea and creatinine, no anemia or hypertention. The patient is surviving since 2014. Conclusion In the present day when malignancies are treated with surgeries, chemo and radiotherapies, homeopathy has a significant role to play as seen in the above case. This case with bilateral solid renal mass, probably a renal cell carcinoma, received an individualized homeopathic remedy-treatment compliant with the totality of symptoms, and permitted the patient to live longer without anemia, hypertension, anorexia or weight loss. The quality of life was maintained without the side effects of surgery, radiotherapy and chemotherapy. Acute retentions, which he used to suffer also remained absent, thereafter. The result of this case suggests to take up further studies on individualized homeopathic treatment in malignant diseases.
Urinary tract infections (UTI) are often a complaint in the homeopathic practice, mainly as uncomplicated infections in the form of a one time event. Some patients, however, have a tendency to develop recurrent or complicated urinary tract infections. Methods It is shown on the basis of case documentation that UTI should be treated homeopathic, variably. The issue of prophylaxis will be discussed. Results If there is a tendency to complicated UTI, chronic treatment after case taking of the symptom-totality of the affected must take place during a free interval. In contrast, the chronically recurring and flaming up of UTI, as well as the uniquely occurring of uncomplicated UTI, are handled as an acute illness. The treatment is based on the striking, characteristic symptoms of the infected. Conclusion The homeopathic treatment of UTI in the acute case of uncomplicated forms is usually very successful, The chronic treatment of complicated UTI shows certain difficulties. A safe homeopathic prophylaxis, in terms of conventional medicine, is problematical.
The homeopathic clinic of the Municipal Public Servant Hospital of São Paulo (HSPM – Brazil) has among patient records some cases of thyroid gland diseases (hypothyroidism or hyperthyroidism), which were treated whith the systemic homeopathic method of Carillo. This study evaluates patients with diseases of thyroid gland, analyzing improvements using a Iodium-like equalizer, adjacent to the systemic medication. The reviewed 21 cases using Iodium equalizer for the disease, adjacent to the systemic medication, in the homeopathic clinic of the HSPM, from 2000 to 2013. In four cases, it was possible to reduce the dose of allopathic medicine and finally terminate it due to normalization of the thyroid gland function. There was one case of hyperthyroidism and it was possible to terminate the use of methimazole. There were four cases, in which the function of the thyroid gland was normalized without the associated use of hormone. In three cases it was possible to reduce the dose of hormone. There were nine cases, in which it was not possible to reduce the dose of the hormone. In cases where there was an improvement applying homeopathic treatment, TSH and free T4 returned to the normal reference value. In cases that were not effective, TSH and free T4 had not normalized. Therefore, the effectiveness of Iodium depends on the ability and stability of the gland thyroid to increase or decrease hormone production, in addition to the treatment of a chronic disease, that affects the thyroid gland.
Cystitis composes infections in the urinary system, especially bladder and urethra. It has multiple causes, but the most common is infection due to microorganisms such as E. coli, streptococcus, staphylococcus etc. If the system is attacked by pathogenetic agents, the defense must include more powerful noxious agents which can fight and destroy the attacking organisms, here is the role of nosodes. Nosodes are the potentised remedies made up from dangerous noxious materials. The use of nosodes in cystitis is based on the aphorism 26– Therapeutic Law of Nature: A weaker one is always distinguished by the stronger one! Colibacillinum, streptococcinum, staphylococcinum, lyssinum, medorrhinum, psorinum and tuberculinum are useful in handling cystitis relating to the organism involved [as found in urine test] and symptom similarity. Method An observational prospective study on a group of 30 people proves the immediate, stronger defensive action of nosodes. Result Amazing! Nosodes given in low potency provided instant relief to patients. Repetition of the same, over several months offered immunity for further attacks of cystitis, as Hering had already testified nosodes have prophylactic action. Conclusion According to law of similia – as per the pathology, as per the defense! By inducing a strong artificial disease, homeopathy can eliminate the natural disease from the body. Usually nosodes are used as intercurrent drugs which play the role of catalysts, on the journey to recovery, but they are also very effective in cystitis as an acute remedy. Acute cystitis is a very troublesome state for the patients, to cure it homeopathy has an arsenal of nosodes.
In 1991, no antiretroviral therapy (ART) treatment was available. The Central Council for Research in Homeopathy had established a clinical research unit at Mumbai for undertaking investigations in HIV/AIDS. So far 2502 cases have been enrolled for homeopathic treatment and three studies have been published since then. In this paper we will highlight the impact of long term homeopathic management of cases, which have been followed up for more than 15 years. Method The HIV positive cases enrolled in different studies are continuously being managed in this unit and even after study conclusion. All the cases are being treated solely with individualised homeopathy. The cases are assessed clinically (body weight, opportunistic infections, etc.) as well as in respect to CD4 counts and CD4/CD8 ratio. Results The CD4 count was maintained in all patients, except in one case. Three patients had the CD4 level in the range of 500–1200, four in the range of 300–500, one had a 272 CD4 count. There has been a decline of CD4/ CD8 ratio since baseline, but the patients have maintained their body weights and remained free from major HIV related illnesses and opportunistic infections. The frequently indicated remedies were pulsatilla pratensis, lycopodium clavatum, nux vomica,tuberculinum bovinum, natrum muriaticum, rhus toxicodendron, medorrhinum, arsenicum album, mercurius solubilis, thuja occidentalis, nitic acid, sulphur, bryonia alba and hepar sulph. Conclusion In the emergent scenario of drug resistance and adverse reactions of ART in HIV infections, there may be a possibility of employing homeopathy as an adjuvant therapy to existing standard ART treatment. Further studies are desirable.
In the last 20 years we have treated in the Clinica St. Croce many patients with cancer. We often deal with palliative states and we aim at pain relief and improvement of life-quality, and if possible a prolongation of life. Is this possible by prescribing a homeopathic therapy? Methodology The exact application and the knowledge of the responses to the Q-potencies often give indications for the correct choice of remedy. Acute conditions of pain often need a more frequent repetition of the C-potencies needed for pain relief. Results Even with severe pain or in so-called final stages homeopathy can offer great assistance. On the basis of case reports from Clinica St. Croce, the procedure for the homeopathic treatment of cancer, and the treatment of pain and final states will be illustrated and clarified. In addition, some clinically proven homeopathic remedies will be presented for the optimal palliation in the treatment of end-states and accompanying the dying. Conclusions With the precise application and knowledge of the responses to the Q- and C-potencies, the homeopathic doctor is given a wonderful helper to treat even the most serious palliative states and can accomplish, sometimes, a miraculous healing.
MY BRIEF COMMENT
These abstracts are truly hilarious and show how totally unaware some homeopaths are of the scientific method. I say ‘some’, but perhaps it is most or even all? How can a scientific committee reviewing these abstracts let them pass and allow the material to be presented at the ‘World Congress’? How can a Health Secretary accept the patronage of such a farce?
These abstracts are therefore not just hilarious but also truly depressing. If we had needed proof that homeopathy has no place in real healthcare of today, these abstracts would go a long way in providing it. To realise that politicians, physicians, patients, consumers, journalists etc. take such infantile nonsense seriously is not just depressing but at the same time worrying, I find.
The Rubicon Group (TRG) is a collaboration of chiropractic educational institutions, emerging educational efforts and interested parties. The seven institutional members include Barcelona College of Chiropractic (Barcelona, Spain); the Chiropraktik Akademie (Dresden, Germany); Life Chiropractic College West (San Francisco, California, USA); Life University (Atlanta, Georgia, USA); McTimoney College of Chiropractic (Abingdon, Oxfordshire, UK); New Zealand College of Chiropractic (Auckland, New Zealand); and Sherman College of Chiropractic (Spartanburg, South Carolina, USA).
TRG has issued the following statement:
The term ‘subluxation’ has been used by the chiropractic profession for over a century.1, 2 It is an important element of chiropractic practice, embedded in legislation and regulation, and its clinical implications have been, and continue to be, scientifically explored.2, 3
The term subluxation, as used by chiropractors, is a researchable concept that is important to health and health care delivery.1, 2, 4 The need to properly define this entity has been widely recognized as a high priority within the profession, as evidenced by the number of groups and organizations who have offered definitions of subluxation.1, 2, 5-10
Many of the past definitions do not provide a testable definition of chiropractic subluxation.11
Some do not reflect the current research that supports a neurologically-centered model of subluxation. 2 The Rubicon Group (TRG) has utilized the current available scientific evidence to define the chiropractic subluxation. Contemporary neurophysiological language and concepts, based on current scientific publications on the topic, have been used. As this definition is subject to ongoing scientific exploration that is likely to lead to new findings and understandings, modifications may be anticipated. However, this definition reflects what is currently known, and it is congruent with current neurophysiological scientific understanding.
“We currently define a chiropractic subluxation as a self-perpetuating, central segmental motor control problem that involves a joint, such as a vertebral motion segment, that is not moving appropriately, resulting in ongoing maladaptive neural plastic changes that interfere with the central nervous system’s ability to self-regulate, self-organize, adapt, repair and heal.”
(The Rubicon Group, May 2017.)
There are three key elements, namely:
A chiropractic subluxation often relates to the spine and its connecting structures. 1 Chiropractic subluxation assessment generally involves evaluating the pathophysiological consequences of the central segmental motor control problem; 4, 12 these may include pain, asymmetry, biomechanical or postural changes (such as changes in relative range of intervertebral motion), changes in tissue temperature, texture and/or tone, and other findings that can be identified using special tests. 12 Once identified, subluxations are corrected using a variety of techniques including high velocity low amplitude chiropractic adjustments, instrument assisted adjustments, and lower force manual techniques and approaches.13
A growing body of scientific evidence has demonstrated that spinal function impacts central neural function in multiple ways,3, 4, 14-19 and that improving spinal function has an impact on clinical outcomes.20-24 Scientists have known for several decades that neurons continuously adapt in structure and function in response to our ever-changing environment.25-27 This ability to adapt is known as ‘neural plasticity’,27 and it is now well understood that the central nervous system can reorganize in response to altered input.28-35 Examples of increased sensory input that can lead to neural plastic changes include repetitive muscular activity 29, 36-41, such as typing or playing the piano, or repeated tactile sensory input such as occurs with blind Braille readers.42 Similar central nervous system change or reorganization may take place due to a decrease in behavior or activity.+ 32, 43-49 Thus the concept, that alterations in paraspinal muscle function due to abnormal spinal movement patterns are capable of changing central neural function, is totally congruent with current neuroscience understanding, as well as current scientific findings.3, 4, 14-19
[references can be found in the original]
Subluxation is not so much a ‘self-perpetuating motor control problem’ as a self-perpetuating money-maker for chiropractors, it seems to me. The history of the use of this term shows that chiropractors have changed its meaning each time they were unable to deny its nonsensicality. To throw subluxation over board is not an option because chiropractic is at its hear a subluxation cult.
Yet, we have repeatedly been told that chiropractors have all but given up the concept of ‘subluxation’. This is clearly not the case. The above statement of TRG speaks for itself, and so does a recent study showing that “the majority of [North American chiropractic] students would like to see an emphasis on correction of vertebral subluxation”. It is the correction of the non-existent subluxation that stimulates the cash flow of chiropractors, a fact known even to the novices of the cult.
The new definition, it seems to me, is little more than self-serving nonsense. Wikipedia – I know, it’s not always the most reliable source, but in this case it is miles better that TRG – has this to say about subluxation: “In chiropractic, vertebral subluxation is a supposed misalignment of the spinal column leading to a set of signs and symptoms sometimes termed vertebral subluxation complex. It has no biomedical basis and is categorized as pseudoscientific by leading authorities. Traditionally, the “specific focus of chiropractic practice” is the chiropractic subluxation and historical chiropractic practice assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body’s function and its innate intelligence, as promulgated by D. D. Palmer, the inventor of chiropractic.”
Wikipedia furthermore mentions that “in 2015, 8 internationally accredited chiropractic colleges: AECC, WIOC, IFEC-Paris, IFEC-Toulouse, USD-Odense, UZ-Zurich, UJ-Johannesburg and Durban University of Technology made an open statement which included: “The teaching of the vertebral subluxation complex as a vitalistic construct that claims that it is the cause of disease is unsupported by evidence. Its inclusion in a modern chiropractic curriculum in anything other than an historic context is therefore inappropriate and unnecessary”.”
Subluxation currently divides the chiropractic profession as we have seen here, for instance. But it is certainly not a concept that most chiropractors have been wise enough to declare obsolete.
The US ‘FEDERAL TRADE COMMISSION’ has issued an important statement about homeopathic products. The full text with references can be found here; below are a few quotes which I thought were crucial:
“…Homeopathy, which dates back to the late-eighteenth century, is based on the view that disease symptoms can be treated by minute doses of substances that produce similar symptoms when provided in larger doses to healthy people. Many homeopathic products are diluted to such an extent that they no longer contain detectable levels of the initial substance. In general, homeopathic product claims are not based on modern scientific methods and are not accepted by modern medical experts, but homeopathy nevertheless has many adherents…
Efficacy and safety claims for homeopathic drugs are held to the same standards as similar claims for non-homeopathic drugs. As articulated in the Advertising Substantiation Policy Statement, advertisers must have “at least the advertised level of substantiation.” Absent express or implied reference to a particular level of support, the Commission, in evaluating the types of evidence necessary to substantiate a claim, considers “the type of claim, the product, the consequences of a false claim, the benefits of a truthful claim, the cost of developing substantiation for the claim, and the amount of substantiation experts believe is reasonable.” For health, safety, or efficacy claims, the FTC has generally required that advertisers possess “competent and reliable scientific evidence,” defined as “tests, analyses, research, or studies that have been conducted and evaluated in an objective manner by qualified persons and [that] are generally accepted in the profession to yield accurate and reliable results.” In general, for health benefit claims, particularly claims that a product can treat or prevent a disease or its symptoms, the substantiation required has been well-designed human clinical testing.
For the vast majority of OTC homeopathic drugs, the case for efficacy is based solely on traditional homeopathic theories and there are no valid studies using current scientific methods showing the product’s efficacy. Accordingly, marketing claims that such homeopathic products have a therapeutic effect lack a reasonable basis and are likely misleading in violation of Sections 5 and 12 of the FTC Act. However, the FTC has long recognized that marketing claims may include additional explanatory information in order to prevent the claims from being misleading. Accordingly, the promotion of an OTC homeopathic product for an indication that is not substantiated by competent and reliable scientific evidence may not be deceptive if that promotion effectively communicates to consumers that: (1) there is no scientific evidence that the product works and (2) the product’s claims are based only on theories of homeopathy from the 1700s that are not accepted by most modern medical experts. To be non-misleading, the product and the claims must also comply with requirements for homeopathic products and traditional homeopathic principles. Of course, adequately substantiated claims for homeopathic products would not require additional explanation.
Perfunctory disclaimers are unlikely to successfully communicate the information necessary to make claims for OTC homeopathic drugs non-misleading. The Commission notes:
• Any disclosure should stand out and be in close proximity to the efficacy message; to be effective, it may actually need to be incorporated into the efficacy message.
• Marketers should not undercut such qualifications with additional positive statements or consumer endorsements reinforcing a product’s efficacy.
• In light of the inherent contradiction in asserting that a product is effective and also disclosing that there is no scientific evidence for such an assertion, it is possible that depending on how they are presented many of these disclosures will be insufficient to prevent consumer deception. Marketers are advised to develop extrinsic evidence, such as consumer surveys, to determine the net impressions communicated by their marketing materials.
• The Commission will carefully scrutinize the net impression of OTC homeopathic advertising or other marketing employing disclosures to ensure that it adequately conveys the extremely limited nature of the health claim being asserted. If, despite a marketer’s disclosures, an ad conveys more substantiation than the marketer has, the marketer will be in violation of the FTC Act.
In summary, there is no basis under the FTC Act to treat OTC homeopathic drugs differently than other health products. Accordingly, unqualified disease claims made for homeopathic drugs must be substantiated by competent and reliable scientific evidence. Nevertheless, truthful, nonmisleading, effective disclosure of the basis for an efficacy claim may be possible. The approach outlined in this Policy Statement is therefore consistent with the First Amendment, and neither limits consumer access to OTC homeopathic products nor conflicts with the FDA’s regulatory scheme. It would allow a marketer to include an indication for use that is not supported by scientific evidence so long as the marketer effectively communicates the limited basis for the claim in the manner discussed above.”
The new guidelines by the American College of Physicians entitled ‘Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians’ have already been the subject of the previous post. Today, I want to have a closer look at a small section of these guidelines which, I think, is crucial. It is entitled ‘HARMS OF NONPHARMACOLOGIC THERAPIES’. I have taken the liberty of copying it below:
“Evidence on adverse events from the included RCTs and systematic reviews was limited, and the quality of evidence for all available harms data is low. Harms were poorly reported (if they were reported at all) for most of the interventions.
Low-quality evidence showed no reported harms or serious adverse events associated with tai chi, psychological interventions, multidisciplinary rehabilitation, ultrasound, acupuncture, lumbar support, or traction (9,95,150,170–174). Low-quality evidence showed that when harms were reported for exercise, they were often related to muscle soreness and increased pain, and no serious harms were reported. All reported harms associated with yoga were mild to moderate (119). Low-quality evidence showed that none of the RCTs reported any serious adverse events with massage, although 2 RCTs reported soreness during or after massage therapy (175,176). Adverse events associated with spinal manipulation included muscle soreness or transient increases in pain (134). There were few adverse events reported and no clear differences between MCE and controls. Transcutaneous electrical nerve stimulation was associated with an increased risk for skin site reaction but not serious adverse events (177). Two RCTs (178,179) showed an increased risk for skin flushing with heat compared with no heat or placebo, and no serious adverse events were reported. There were no data on cold therapy. Evidence was insufficient to determine harms of electrical muscle stimulation, LLLT, percutaneous electrical nerve stimulation, interferential therapy, short-wave diathermy, and taping.”
The first thing that strikes me is the brevity of the section. Surely, guidelines of this nature must include a full discussion of the risks of the treatments in question!
The second thing that is noteworthy is the fact that the authors confirm the fact I have been banging on about for years: clinical trials of alternative therapies far too often fail to mention adverse effects. I have often pointed out that the failure to report adverse effects in clinical trials is an unacceptable violation of medical ethics. By contrast, the guideline authors seem not to feel strongly about this omission.
The third thing that is noteworthy is that the guidelines evaluate the harms of the treatments purely on the basis of the adverse effects reported in the clinical trials and systematic reviews included in their efficacy assessments. This is nonsensical for at least two reasons:
- The guideline authors themselves are aware that the trials very often fail to mention adverse effects.
- For any assessment of harm, one has to go far beyond the evidence of clinical trials, because trials tend to be too small to pick up rare adverse effects, and because they are always conducted under optimally controlled conditions where adverse effects are less likely to occur than in real life.
Together, these features of the assessment of harms explain why the guideline authors arrive at conclusions which are oddly misguided; I would even feel that they resemble a white-wash. Here are two of the most overt misjudgements:
- no harms associated with acupuncture,
- only trivial harm associated with spinal manipulations.
The best evidence we have today shows that acupuncture leads to mild adverse effects in about 10% of all cases and is also associated with very severe complications (e.g. pneumothorax, cardiac tamponade, infections, deaths) in an unknown number of patients. More details can be found for instance here, here, here and here.
And the best evidence available shows that spinal manipulation leads to moderately severe adverse effects in ~50% of all cases. In addition, we know of hundreds of cases of very severe complications resulting in stroke, permanent neurological deficits or deaths. More details can be found for instance here, here, here and here.
In the introduction, I stated that this small section of the guidelines is crucial.
The reason is simple: any responsible therapeutic decision has to be based not just on the efficacy of the treatment in question but on its risk/benefit balance. The evidence shows that the risks of some alternative therapies can be considerable, a fact that is almost totally neglected in the guidelines. Therefore, the recommendations of the new guidelines by the American College of Physicians entitled ‘Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians’ are in several aspects not entirely correct and need to be reconsidered.
Concerned about the new ACP guidelines on ‘Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians’, Andrea MacGregor asked me to publish her ‘open letter’:
I am a student about to graduate and register as a massage therapist in Canada, and I am writing to express my concern with your recommendation of the use of acupuncture in your new guideline for low-back pain management.
Leading medical and health research experts from around the world, including many who are highly familiar with the use of complementary and alternative therapies, have contributed to a highly informed commentary (attached) assembled by the Friends of Science in Medicine association (Aus.), which supports a strong conclusion that acupuncture is not effective for any specific condition, and that the evidence for it being an effective intervention for low-back pain is not convincing. Another review of acupuncture by FSM concluding that there is a lack of evidence of a therapeutic effect has been endorsed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Respected American medical science writers also maintain that claims of acupuncture’s efficacy are not science-based (examples here and here).
Additionally, previous acupuncture recommendations are being reconsidered by prominent institutions in other parts of the world. The National Institute for Health and Care Excellence guideline for NHS patients in the United Kingdom now recommends against the use of acupuncture for low-back pain, following a high-quality review that critically examined the existing evidence regarding the use of acupuncture and found it to be no more effective than a placebo. The Toronto Hospital for Sick Children has also recently removed references on their website that suggested the efficacy of acupuncture in managing specific chronic pain conditions. The World Health Organization has done the same, no longer suggesting that acupuncture is effective for low-back pain and sciatica.
As someone about to enter a field that is frequently associated with, or considered a part of, complementary healthcare, I know how tempting it can be for us, as professionals and as researchers, to exaggerate claims of efficacy and pin some very high hopes on “new possibilities” in physical therapies.
I also know first-hand how misguided and overblown some of these claims and hopes can be. Many of my own peers and instructors are proponents of acupuncture, and it is common for Canadian massage therapists to become licensed acupuncturists (a similar connection between massage and acupuncture communities, of course, also exists in the United States). I have often seen my own mentors and comrades pushing for the use of acupuncture treatments for many chronic and serious conditions for which there is no basis of evidence at all of acupuncture’s efficacy, including systemic, neurological, and developmental conditions. When questioned, they will usually refer to authorities perceived as “legitimate”, including the American College of Physicians, to say that claims of acupuncture “working” are backed by experts— whether their claims are even pain-related or not.
We see a similar situation with advertisers and media using the guise of “expert-backed” legitimization to recommend acupuncture in misleading ways, often to vulnerable people who could be making better-informed and more effective treatment and management choices for their conditions. Many of these advertising and media entities specifically mention the American College of Physicians as lending credence to their claims, sometimes somewhat out of context.
As someone with a chronic neurological disorder, I find it troubling to see untrue or exaggerated claims of benefit for incurable or serious conditions when we could be focusing on more accurate ideas and having more honest, realistic discussions of our options. This is also important when it comes to deciding how to best allocate our limited health funding resources. Quite a lot of our insurance and out-of-pocket funds are spent on alternative therapies, and it’s important to see things going to use in a way that’s proportionate and appropriate to the evidence we have.
I hope that you will reconsider your recommendation of a practice that is simply not supported by the majority of the research evidence that exists to date. Patients with complex conditions, including low-back pain, deserve accurate and realistic information regarding their treatment options, especially from such trusted and reputable sources as the American College of Physicians. Thank you for your time and attention.
Below are informed conclusions on acupuncture from 28 international experts from 10 countries, including Australia, Canada, Denmark, France, Greece, Italy, Netherlands, New Zealand, United Kingdom and United States of America.
– Sir Richard John Roberts, English biochemist and molecular biologist, 1993 Nobel Prize in Physiology or Medicine – Prof Nikolai Bogduk AM, Emeritus Professor of Pain Medicine, University of Newcastle, Australia – Prof Timothy Caulfield, LLM, FRSC, FCAHS, Canada Research Chair in Health Law & Policy, Trudeau Fellow & Professor, Faculty of Law and School of Public Health, Research Director, Health Law Institute, University of Alberta, Canada – Prof. Assimakis Kanellopoulos, PhD MSc.Prof. Applied Physiotherapy, TEI Lamia, Greece – Prof Lesley Campbell AM, MBBS, FRACP FRCP(UK), Senior Endocrinologist, Diabetes Services, St Vincent’s Hospital, Professor of Medicine, UNSW. Laboratory Co-Head, Clinical Diabetes, Appetite and Metabolism, Garvan Institute of Medical Research, SVH, NSW, Australia – Emeritus Prof Donald M. Marcus, MD, Professor of Medicine and Immunology, Emeritus, Baylor College of Medicine, Houston, United States of America (USA) – Dr Michael Vagg, MBBS(Hons) FAFRM(RACP) FFPMANZCA, Consultant in Rehabilitation and Pain Medicine, Barwon Health. Clinical Senior Lecturer, Deakin University School of Medicine. Fellow, Institute for Science in Medicine, Victoria, Australia – Prof Bernie Garrett, The University of British Columbia, School of Nursing, Vancouver, BC, Canada – A/Prof David H Gorski, MD PhD FACS, surgical oncologist, Barbara Ann Karmanos Cancer Institute, Team Leader, Breast Cancer Multidisciplinary Team, Co-Leader, Breast Cancer Biology Program, Co-Director, Alexander J Walt Comprehensive Breast Center, Chief, Section of Breast Surgery, A/Professor, Surgery, Wayne State University School of Medicine, , and Professor (Honorary) Hanoi Medical University, USA – Prof Carl Bartecchi, MD, MACP, Distinguished Professor of Clinical Medicine, University of Colorado School of Medicine, USA – Prof David Colquhoun, FRS, Dept of Pharmacology, UCL United Kingdom (UK) – Prof Edzard Ernst, MD PhD FMEdSci FSB FRCP FRCP(Edin), Complementary Medicine, Peninsula Medical School, UK – Prof Marcello Costa FAAS. Matthew Flinders Distinguished Professor and Professor of Neurophysiology (2012), Professor of Neurophysiology, Flinders University, Australia. – Emeritus Prof Alastair H MacLennan AO MB CHb MD FRCOG FRANZCOG. The Robinson Research Institute, The University of Adelaide, Australia – Prof John M Dwyer AO PhD FRACP FRCPI Doc Uni(Hon) ACU. Emeritus Professor of Medicine, University of New South Wales. Founder of the Australian Health Care Reform Alliance. Clinical consultant to the NSW Government’s Inter-Agency committee on Health Care Fraud, Australia – A/Prof Steven M Novella, clinical neurologist Yale University School of Medicine, Connecticut, USA – Prof William M London, EdD, MPH, Department of Public Health, California State University, Los Angeles, USA – Dr Steven Barrett, MD, retired psychiatrist, author, co-founder of the National Council Against Health Fraud (NCAHF), USA – Prof. Steven L. Salzberg, Ph.D., Bloomberg Distinguished Professor of Biomedical Engineering, Computer Science, and Biostatistics, Johns Hopkins University School of Medicine, USA – Prof Christopher C French, Head of the Anomalistic Psychology Research Unit, Department of Psychology, Goldsmiths, University of London, UK – Dr Cees Renckens MD PhD, gynaecologist, past president of the Dutch Society against Quackery, Netherlands – Dr Alain Braillon. MD PhD. Senior consultant. University hospital, France – Dr John McLennan, MBBS FRACP, Paediatrician, Vic – Prof Shaun Holt, BPharm(hons), MBChB(hons), Medical Researcher, Victoria University of Wellington, New Zealand – Dr Lloyd B Oppel, MD, MHSc, Canada – Professor Asbjørn Hróbjartsson, Centre for Evidence-Based Medicine, University of Southern Denmark & Odense University Hospital, Denmark – Prof Maurizio Pandolfi MD, Florence, former Professor of Clinical Ophthalmology, The University of Lund, Sweden, Italy – Professor Mark Baker, Centre for Clinical Practice Director, National Institute for Health and Care Excellence (NICE), UK
According to Sir Richard: “From everything I have read about acupuncture I have to conclude that the evidence for efficacy is just not there. I can believe it has a very strong and effective placebo effect, but if it really worked as advertised why are the numbers of successful outcomes so small when compared to treatments such as drugs that really do work. As a scientist, who likes to see proper experiments carried out so that the results can be judged with a rational analysis, the experiments I have read about just don’t meet even a low bar of acceptability. I certainly do not believe it should be endorsed as an effective treatment by any professional scientific or medical body that values its reputation.”
According to Professor Bogduk: “Although studies have shown that acupuncture “works”, the definition of “works” is generous. Most studies show minimal to no effect greater than that of sham therapy. Needles do not need to be placed at specific points; so, learning about meridians is not required. Effectiveness is marginally greater in those patients who believe in acupuncture or expect it to work. However, no studies have shown that acupuncture stops pain, while also restoring normal function and removing the need for other health care.”
According to Professor Caulfield: “In popular culture, acupuncture is often portrayed as being effective for a range of conditions. It is held up as an alternative medicine success story. In fact, the relevant data are, at best, equivocal. The most rigorous studies, such as those that are well controlled and use sham comparators, have found that in most situations acupuncture is little better than placebo. More importantly, the supernatural foundations of the practice – that illness can be attributed to an imbalance in a life force energy – has absolutely no scientific basis. Given this reality, public representations of acupuncture that present it as science-based and effective can be deeply misleading. Policies are needed to counter this noise, including, inter alia, the more aggressive deployment of truth-in-advertising regulations, the enforcement of a conceptually consistent science-based informed consent standard, and the oversight of healthcare professionals by the relevant regulatory entities.”
According to Professor Kanellopoulos: “According to the systematic reviews in the field of acupuncture, the benefits of the method, if any, are nothing more than a temporary placebo effect. From a scientific point of view, acupuncture is based on a theory, which has nothing to do with modern physiology and medicine. From a researcher’s point of view, any presented acupuncture effectiveness is due to methodological errors, data manipulation, statistical artefacts and (purposely?) poorly designed clinical trials in general. Finally, regarding the patient, any symptom’s relief comes from despair and post hoc fallacy. After decades of research and over 3000 clinical trials, any continuation of practicing, advertising, and research in the field of acupuncture is a waste of resources and puts the patients at risk, raising ethical issues for both science and society.”
According to Professor Campbell: “Acupuncture holds great theatrical appeal through its dramatic and historical aspects, particularly to those who feel that conventional medicine has failed to offer pain relief or sufficient improvement in symptoms. However an extensive body of data now exists from rigorous approaches to testing the validity of its claims of benefit actually related to the placement of the needles and not to placebo effect. For example, most recently the beneficial effect achieved in relieving fatigue in Parkinsons Disease (and there was one) was identical in a randomised controlled trial to that of placebo.”
According to Professor Donald M. Marcus: “When trials of acupuncture for relief of pain of osteoarthritis of the knee or back pain include a sham acupuncture control, there is no clinically relevant difference in efficacy between the conventional and sham procedures. A number of sham procedures have been used, including toothpicks in a plastic guide tube in a study of back pain. It’s evident that relief of pain, and probably other complaints, by acupuncture is mediated by a placebo mechanism. Since there is no scientific evidence supporting its efficacy, medical insurance should not pay for acupuncture treatments. Moreover, it is unethical to deceive patients by providing a placebo treatment without disclosure.”
According to pain specialist Dr Vagg: “Due to the lack of a scientifically plausible mechanism, and the poor quality of the bulk of the research concerning acupuncture in its many and varied forms, no credible body of pain medicine researchers or clinicians has endorsed any type of acupuncture as a recommended treatment for any identifiable group of patients with persistent pain. Moreover, there is no reason to suppose that further research of high quality will change this conclusion, given that high-quality, randomized and double-blinded studies have uniformly shown that any form of acupuncture is indistinguishable from placebo, making further research unwarranted.”
According to Professor Garrett: “Current levels of evidence on acupuncture as a therapeutic intervention for any condition is very poor. Most studies reported are of very poor quality and are not reliable. Unfortunately, there is a strong element of propaganda in the dissemination of support for acupuncture in China, as it is a part of the Traditional Chinese Medicine supported by the government there. As such, much research has been demonstrated to involve data fabrication and extreme levels of confirmation bias. There are also strong ethical concerns about research involving acupuncture in China for anesthesia or other conditions where there is no established clinical theoretical basis for its use, and far better established therapeutics are available. Overall the current state of evidence on acupuncture is that the effectiveness of acupuncture as a treatment of any health condition remains unproven, and the only good quality trials have identified it has no better outcomes than placebo. Therefore, any claims of efficacy made against specific medical conditions are deceptive.”
According to Professor Gorski: “Acupuncture seems to garner more belief because it seems more plausible. The reason is that, unlike many other alternative therapies, acupuncture actually involves a physical act, namely inserting needles into the skin. However, it is also the case that the more acupuncture has been studied, the more it has become clear that it is, as David Colquhoun and Steve Novella put it, nothing more than a theatrical placebo. Indeed, as acupuncture is more rigorously studied in randomized clinical trials with proper controls and proper blinding, the more its seeming effects disappear, so that it becomes indistinguishable from placebo. Nor is it without risk, either. Recommending acupuncture to treat any condition is, from an ethical and scientific view, indefensible.”
According to Professor Bartecchi: “Acupuncture has no medical value other than that of a placebo. Acupuncture as viewed by many of us in academic medicine is merely an elaborate, theatrical placebo, a pre-scientific superstition which lacks a plausible mechanism. It really fits the bill as an alternative medicine hoax.”
According to Professor Colquhoun: “After over 3000 trials, some of them very well designed, there is still argument about the effectiveness of acupuncture. If that were the case for a new drug, it would long since have been abandoned. The literature suggests that acupuncture has only a small and variable placebo effect: too small to be of noticeable benefit to patients. Most of its apparent effects result from a statistical artefact, regression to the mean. The continued use of acupuncture probably arises from the lack of effective treatments for conditions like non-specific low back pain. That cannot be justified, Neither is it worth spending yet more money on further research. The research has been done and it failed to produce convincing evidence.”
According to Professor Ernst: “The current evidence on acupuncture is mixed. Many trials are less than rigorous and thus not reliable. Much of the research comes from China where data fabrication has been disclosed to be at epidemic levels; it would therefore be a mistake to rely on studies from China which almost invariably report positive results. If we account for such caveats and critically review the literature, we arrive at the following conclusions: – Acupuncture is clearly not free of risks, some of which are serious; – The effectiveness of acupuncture as a treatment of any condition remains unproven, and – The current research in this area is mostly pseudo-research aimed at promoting rather than testing acupuncture”.
According to Professor Costa: “Acupuncture as a part of Traditional Chinese Medicine is not based on science simply because, as for all pre-scientific medicines, whether Greco-Roman-European, Indian or any other, none are founded on any evidence. As a Neuroscientist, I teach medical and non medical students the very foundations of how the nervous system works and how sensory stimulation affects the brain. There simply is no evidence that twigging the skin with needles or, for that matter with toothpicks, does any more than create an expectation to feel better. This is the well-known placebo effect. Selling placebos under the disguise of medicine is totally unethical.”
According to Professor MacLennan: “Acupuncture is elaborate quackery and like many placebos sold by those without responsibility for or knowledge of the wide range of health disorders and disease it can be dangerous. Dangerous because acupuncture may delay correct diagnosis and therapy, dangerous because it may delay possible evidence-based therapies and allow progression of disorders present and dangerous because it sucks limited health resources from the community. Acupuncturists derive their income from elaborate subterfuge, taking advantage of the gullible unwell who are desperate, uneducated and seek a magic cure. If there is a placebo effect it is usually temporary, and eventually disappointment from lack of long term effect may lead to secondary depression in the patient. According to Professor Dwyer: “Modern understanding of human anatomy and the distribution and function of the components of the human nervous system make a nonsense of theories that suggest there are invisible meridians criss-crossing the body wherein there are trigger spots which, when stimulated, can produce an array of benefits remote from that site. Scientists however, while dismissing the prescientific explanations offered by traditional Chinese medicine, have sought other reasons why acupuncture might provide clinical benefits particularly the relief of pain. Numerous theories have been addressed by numerous studies with many being conducted using disciplined scientific methods. The conclusions leave us with no doubt that acupuncture provides the scenario for a superb theatrical placebo; no more.”
According to Dr Novella: “Pain is a big problem. If you read about pain management centers, you might think it had been solved. It has not. And when no effective treatment exists for a medical problem, it leads to a tendency to clutch at straws. Research has shown that acupuncture is little more than such a straw. It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions. After thousands of trials of acupuncture and hundreds of systematic reviews, arguments continue unabated. In 2011, Pain published an editorial that summed up the present situation well.”
According to Professor London & Dr Barrett: “The optimistic article by Vickers et al did not consider an important point. Research studies may not reflect what takes place in most acupuncturist offices. Most acupuncturists are graduates of “oriental medical schools,” where they learn about 5element theory, “energy” flow through meridians, and other fanciful traditional Chinese medicine (TCM) concepts that do not correspond with scientific knowledge of anatomy, physiology, or pathology. Practitioners of TCM typically rely on inappropriate diagnostic procedures (pulse and tongue diagnosis) and prescribe herbal mixtures that have not been sufficiently studied. Diagnoses based on TCM such as “Qi stagnation,” “blood stagnation,” “kidney Qi deficiency,” and “yin deficiency” may not jeopardize patients who are treated in an academic setting, where they have received a medical diagnosed before entering the study. But what about people with conditions that TCM-trained acupuncturists are not qualified or inclined to diagnose? Real-world evaluations of acupuncture should also consider the cost of unnecessary treatment.”
According to Professor Salzberg: “Acupuncture is a pre-scientific practice that persists only because of relentless and often very clever marketing by its proponents. The claimed mechanisms by which acupuncture works are clearly and obviously false: modern physiology, neurology, cell biology, and other scientific disciplines explain how pain signals are transmitted in the body, and none of them support the supposed “qi” or energy fields flowing along “meridians,” as acupuncturists describe them. Hundreds of scientific studies have shown that acupuncture doesn’t work for any medical condition. Acupuncture proponents ignore the evidence and persist, primarily because they profit from their practices. There are also documented risks of complications from acupuncture, ranging from infections to punctured lungs. For these and other reasons, recommending acupuncture for any patient is simply unethical. Acupuncturists make profits by putting patients at risk.”
According to Professor French: “Acupuncture has been extensively evaluated with respect to its possible therapeutic effectiveness for a wide range of disorders. The overall conclusion from meta-analyses of such studies is that any beneficial effects reported are small in terms of effect size and probably best accounted for in terms of statistical artefacts and placebo effects, etc. In general, the higher the quality of the study, the less likely are any beneficial effects to be reported. In light of this, it would be unwise and unethical to recommend acupuncture as the treatment of choice for any condition.”
According to Dr Renckens: “In 1683 the Dutch physician Willem ten Rhijne published the first book in the western world in which the word ‘acupuncture’ was mentioned, which referred to – as the Dutch title of the book was – ‘The Chinese and Japanese way of curing all diseases and especially the podagra by burning moxa and stabbing the Golden Needle’. This exotic treatment did not gain any popularity in the Netherlands and was mainly ridiculed. This heavenly situation remained unchanged until Nixon’s trip to China (1972) and the ‘successful’ acupuncture-treatment of the journalist James Reston of the New York Times. His story in that influential newspaper caused worldwide interest in acupunctures possible benefits. Also in the Netherlands and as early as 1989 a series of systematic reviews on the efficacy of acupuncture in a number of diseases was published in the Huisarts & Wetenschap, a journal of GP’s in the Dutch language (Ter Riet et al. H&W,1989;32:308-312).Their final conclusion was: ‘the main achievement of Chinese acupuncture is to have discovered a number of spots on the human body into which needles can be safely inserted’. The huge amount of scientific research into acupuncture has since been unable to undermine this right conclusion.”
According to Dr Braillon: “No discrimination! The US Federal Trade Commission announced that homeopathic drugs should “be held to the same truthin-advertising standards as other products claiming health benefits”; very soon, homeopathic products will include statements indicating: “There is no scientific evidence backing homeopathic health claims” and “Homeopathic claims are based only on theories from the 1700s that are not accepted by modern medical experts.” In Australia, the Royal Australian College of General Practitioners formally recommended GPs to ban homeopathic products from their prescriptions and pharmacists to ban them from their shelves. The same should be required for acupuncture.”
According to Dr McLennon: “Despite claims for effectiveness, there have been very few studies of acupuncture on children that have confirmed significant benefits. Conditions such as headache, abdominal pain, bed wetting and fibromyalgia and behaviour problems such as ADHD have been investigated. More trials with better structure have universally been recommended. A double blinded trial on the treatment of headaches with laser acupuncture illustrates the problems. The number of patients was quite small (21 in each arm), the diagnoses were reasonable medically but required rediagnosis to fit Traditional Chinese Medicine criteria and treatments were individualised based on these diagnoses. It was not made clear whether the patients were completely blinded i.e. unaware they received active treatment or placebo. Until blinding can be guaranteed, trials of acupuncture will remain inconclusive.”
According to Professor Holt: “Unlike some alternative therapies, acupuncture has been extensively studied for many medical conditions and a summary would be that the higher the quality of the study, the less likely it is that a benefit other than a placebo effect is found. Studies have shown conclusively that a key aspect of acupuncture, putting needles into energy lines for medical benefits, is not true, and the same effect is elicited wherever the needles are placed. Acupuncture is not a science-based practice, can cause side effects and is not recommended for any medical condition.”
According to Dr Oppel: “It is extremely concerning that there remains no plausible rationale for a mechanism of action of acupuncture. It is noteworthy that different schools of acupuncture offer contradictory patterns of treatment. It should not go without notice that acupuncture has been so well-researched that there are hundreds , if not thousands, of clinical trials now available Unfortunately, although there is no compelling evidence of effectiveness for any of the myriad of conditions where acupuncture is claimed to be of benefit, poor quality unreplicated trials continue to be put forward by proponents as proof of acupuncture’s effectiveness. Critical thinkers will also take note that while the large majority of acupuncture trials are positive, the vast majority of properly controlled trials are not. We are in a situation now where we have excellent evidence that acupuncture is not effective.”
According to Professor Hróbjartsson: “While there have been many trials done with acupuncture, most of them are small pilot studies and large scale high quality trials are rare. Some studies have reported measurable effects, but the mechanism is not yet understood, the size of the effect is small and it is possible that a large part of the effect or all of the effect is placebo. It is obvious that you would see a physiological effect when you stick a needle into your body, the question is whether that has a measurable clinical effect. There is insufficient evidence to say that electro acupuncture is any more or any less effective.”
According to Professor Pandolfi: “With a rationale completely disconnected from the basic principles of science acupuncture cannot be considered as belonging to modern evidence–based medicine.”
According to Professor Baker: “Millions of people are affected every year by these often debilitating and distressing conditions. For most their symptoms improve in days or weeks. However for some, the pain can be distressing and persist for a long time. Regrettably there is a lack of convincing evidence of effectiveness for some widely used treatments. For example acupuncture is no longer recommended for managing low back pain with or without sciatica. This is because there is not enough evidence to show that it is more effective than sham treatment.”
The website of the HOMEOPATHY HUB gives us intriguing access to the brain of a homeopath. It tells us that “protecting patient choice is at the heart of everything we do. Homeopathy, which is the second largest system of medicine in the world, is a form of treatment which plays a vital role in the lives of hundreds of thousands of people across the UK. There is, however, a movement to try and withdraw homeopathy from the public and make homeopathic medicines difficult to secure. Our intention is to be a central “hub” for accurate information on current campaigns to retain access to homeopathy and details on how you can get involved and make your voice heard. Without public and patient support we will not be successful.”
Here are a few of the above statements that I find doubtful:
- protecting patient choice – choice requires reliable information; as we will see, this is not provided here;
- second largest system of medicine in the world – really?
- plays a vital role – where is the evidence for that claim?
- movement to try and withdraw homeopathy from the public and make homeopathic medicines difficult to secure – nobody works towards this aim, some people are trying to stop wasting public funds on useless therapies, but that’s quite different, I find;
The HOMEOPATHY HUB recently alerted its readers to the fact that the Charity Commission (CC) is currently conducting a public consultation on whether organisations promoting the use of complementary and alternative medicines (CAM) should have charitable status (https://www.gov.uk/government/consultations/consultation-on-complementary-and-alternative-medicines) and urged its readers to defend homeopathy by responding to the CC offering a “few helpful points” to raise. These 7 points give, I think, a good insight into the thinking of homeopaths. I therefore copy them here and add a few of my own comments below:
- there are many types of evidence that should be considered when evaluating the effectiveness of a therapy. These include scientific studies, patient feedback and the clinical experience of doctors who have trained in a CAM discipline. Within Homeopathy there is considerable evidence which can be found (https://www.hri-research.org)
- many conventional therapies and drugs have inconclusive evidence or prove to be useful in only some cases, for example SSRIs (anti-depressants). Inconsistent evidence is often the result of the complexity of both the medical condition being treated and the therapy being used. It is not indicative of a therapy that doesn’t work
- removing all therapies or interventions that have inconsistent or inconclusive evidence would seriously limit the public and the medical profession’s ability to help treat and ease patients suffering.
- all over the world there are doctors, nurses, midwives, vets and other healthcare professional who integrate CAM therapies into their daily practice because they see effectiveness. They would not use these therapies if they did not see their patients benefitting from them. For example in the UK, within the NHS hospital setting, outcome studies demonstrate effectiveness of homeopathy. (http://www.britishhomeopathic.org/evidence/results-from-the-homeopathic-hospitals/)
- practitioners of many CAM therapies belong to registering bodies which expect their members to comply to the highest professional standards in regards to training and practice
- In the UK the producers and suppliers of CAM treatments (homeopathy, herbal medicine etc) are strictly regulated
- as well as providing valuable information to the growing number of people seeking to use CAM as part of their healthcare, CAM charities frequently fund treatment for those people, particularly the elderly and those on a low income, whose health has benefitted from these therapies but who cannot afford them. This meets the charity’s criterion of providing a public benefit.
- “Patient feedback and the clinical experience of doctors” may be important but is not what can be considered evidence of therapeutic effectiveness.
- Yes, in medicine evidence is often inconsistent; this is why we need to rely on proper assessments of the totality of the reliable data. If that fails to be positive (as is the case for homeopathy and several other forms of alternative medicine), we are well advised not to employ the treatment in question in routine healthcare.
- Removing all treatments for which the best evidence fails to show effectiveness – such as homeopathy – would greatly improve healthcare and reduces cost. It is one of the aims of EBM and an ethical imperative.
- Yes, some healthcare professionals do use useless therapies. They urgently need to be educated in the principles of EBM. Outcome studies have normally no control groups and therefore are no adequate tools for testing the effectiveness of medical interventions.
- The highest professional standards in regards to training and practice of nonsense will still result in nonsense.
- The proper regulation of nonsense can only generate proper nonsense.
- Yes, CAM charities frequently fund bogus treatments; hopefully (and with the help of readers of this blog), the CC will put an end to this soon.
I think these 7 points by the HOMEOPATHY HUB are a very poor defence of homeopathy. In fact, they are so bad that it is not worth analysing more closely than I did above. Yet, they do provide us with an insight into the homeopathic mind-set and show how illogical, misguided and wrong the arguments of homeopathy enthusiasts really are.
I do encourage you to give your response to the CC – it wound be hard to use better arguments than the homeopaths!!!
We have discussed this notorious problem before: numerous charities (such as one that treats HIV and malaria with homeopathy in Botswana, or the one claiming that homeopathy can reverse cancer) are a clear danger to public health. I have previously chosen the example of ‘YES TO LIFE’ and explained that they promote unproven and disproven alternative therapies as cures for cancer (and if you want to get really sickened, look who act as their supporters and advisors). It is clear to me that such behaviour can hasten the death of many vulnerable patients.
Yet, many such charities get tax and reputational benefits by being registered charities in the UK. The question is CAN THIS SITUATION BE JUSTIFIED?
Currently, the UK Charity commission want to answer it. Specifically, they are asking you the following question:
- Question 1: What level and nature of evidence should the Commission require to establish the beneficial impact of CAM therapies?
- Question 2: Can the benefit of the use or promotion of CAM therapies be established by general acceptance or recognition, without the need for further evidence of beneficial impact? If so, what level of recognition, and by whom, should the Commission consider as evidence?
- Question 3: How should the Commission consider conflicting or inconsistent evidence of beneficial impact regarding CAM therapies?
- Question 4: How, if at all, should the Commission’s approach be different in respect of CAM organisations which only use or promote therapies which are complementary, rather than alternative, to conventional treatments?
- Question 5: Is it appropriate to require a lesser degree of evidence of beneficial impact for CAM therapies which are claimed to relieve symptoms rather than to cure or diagnose conditions?
- Question 6: Do you have any other comments about the Commission’s approach to registering CAM organisations as charities?
I am sure that most readers of this blog have something to say about these questions. So, please carefully study the full document, go on the commission’s website, and email your response to: email@example.com . Don’t delay it; do it now!
The aim of this paper was to systematically review surveys of 12-month prevalence of homeopathy use by the general population worldwide. Studies were identified via database searches to October 2015. Study quality was assessed using a six-item tool. All estimates were in the context of a survey which also reported prevalence of any complementary and alternative medicine use. A total of 36 surveys were included. Of these, 67% met four of six quality criteria.
Twelve-month prevalence of treatment by a homeopath was reported in 24 surveys of adults (median 1.5%, range 0.2–8.2%). Estimates for children were similar to those for adults. Rates in the USA, UK, Australia and Canada all ranged from 0.2% to 2.9% and remained stable over the years surveyed (1986–2012). Twelve-month prevalence of all use of homeopathy (purchase of over-the-counter homeopathic medicines and treatment by a homeopath) was reported in 10 surveys of adults (median 3.9%, range 0.7–9.8%) while a further 11 surveys which did not define the type of homeopathy use reported similar data. Rates in the USA and Australia ranged from 1.7% to 4.4% and remained stable over the years surveyed. The highest use was reported by a survey in Switzerland where homeopathy is covered by mandatory health insurance.
The authors concluded that each year a small but significant percentage of these general populations use homeopathy. This includes visits to homeopaths as well as purchase of over-the-counter homeopathic medicines.
These data thus indicate that the percentage of the adult general population using homeopathy over the previous 12 months was in the range of 0.7–9.8%, with a median estimate of 3.9%, and the percentage accessing treatment by a homeopath over the previous 12 months was in the range of 0.2–8.2%, with a median estimate of 1.5%. The data also suggest that, over the last few decades, use of homeopathy has remained fairly stable. These facts are in sharp contrast to the claims by homeopaths that:
- Homeopathy is hugely popular.
- Homeopathy is being used by more and more people across the globe.
- Homeopathy is the medicine of the future.
The well-documented and undeniable unpopularity of homeopathy begs the question, I think, why so many people seem to get so excited about homeopathy. The level of usage is nothing to write home about! Therefore, why don’t we just put it down to an aberration like believing the earth is flat? Why don’t we just concede that some minor, harmless stupidity will always exist in some people’s minds?
Here are some reasons why:
- It is not about the amount of people using homeopathy, but about the principle that any of the increasingly scarce public funds for healthcare are wasted on something as irrational and useless as homeopathy.
- Homeopathy makes a mockery of EBM.
- Homeopathy and homeopaths are by no means harmless.
- Homeopaths tell too many lies to be allowed to get away with them.
- Homeopathy and its followers systematically undermine rational thought.
CBC news (Canada) reported yesterday that, more than a decade ago, the Manitoba Chiropractic Health Care Commission had been tasked to review the cost effectiveness of chiropractic services. It therefore prepared a report in 2004 for the Manitoba province and the Manitoba Chiropractors Association. Since then, this report has been kept secret. The report makes 37 recommendations, including:
- Manitoba Health should limit its funding to “chiropractic treatment of acute lower back pain.”
- Manitoba Health should provide “limited coverage of the treatment of neck pain.” The report called the literature around the efficacy of chiropractic care for neck pain “ambiguous or at best weakly supportive” and noted such treatment carried a “not insignificant safety risk.”
- Manitoba Health should not fund chiropractic treatment anyone under 18 “as the literature does not unequivocally justify” the “efficacy or safety” of such treatment.
A Manitoba Ombudsman’s Office report from 2012 might shed some light on why the Manitoba Chiropractic Health Care Commission’s report was never made public. Someone had attempted to get a copy of the report, but large parts of it were redacted. “Access to this record was refused on the basis that disclosure would be harmful to a third party’s business interest,” the ombudsman report notes, “and harm the economic or financial interests or negotiating position of a public body.”
The report also challenged claims that chiropractic treatments can be address a wide variety of medical conditions. It stated that there was not enough evidence to conclude chiropractic treatments are effective in treating muscle tension, migraines, HIV, carpal tunnel syndrome, gastrointestinal problems, infertility or cancer, or as a preventive care treatment. It also said there was not enough evidence to conclude chiropractic treatments are effective for children.
The report urged Manitoba Health to establish a monitoring system to keep a closer eye on “the advertising practices of the Manitoba Chiropractors Association and its members to ensure claims regarding treatments are restricted to those for which proof of efficacy and safety exist.” It suggested the government should have regulatory powers over chiropractic ads.
A recent CBC I-Team investigation found Manitoba chiropractors advertising treatment for a wide range of conditions including Alzheimer’s, autism and pediatric services. The commission report contained sharp criticisms of previous reports that suggested funding chiropractic care could save the health-care system money. Dr. Pranlal Manga authored two widely cited reports which claim that by offering publicly funded chiropractic care, provinces can cut health-care costs. “The Manga study on Manitoba must be rejected as a guide to public policy,” the commission report states, “because its assumptions, methodology and costing of recommendations are all deeply flawed.” The reports states, “What limited evidence the Commission has suggests he [Manga] grossly exaggerates possible medical savings.” Dr. Manga did not respond to CBC’s repeated attempts to contact him.
The commission report also made recommendations around the use of X-ray machines by chiropractors. It suggested chiropractors not own and operate X-ray machines “Given the restrictive conditions under which X-rays are advisable, their poor correlation with low-back problems, their apparent limitation as a guide to appropriate treatment …[and] the apparent complete lack of monitoring [of] the use of X-ray by chiropractors.” Instead, it recommended consulting with radiologists when imaging is deemed necessary. “The Commission is of the view that the public interest, and even chiropractic itself, would be better served if chiropractors had access to radiologists for this service, rather than perform it themselves,” the report said.
All three report authors declined comment. Calls to Dave Chomiak, who was health minister at the time the report was prepared, were not returned. In an email to CBC, Manitoba Chiropractors Association president Perry Taylor said, “I personally have never seen this 13-year-old document and [it] pre-dates my time as President. As such I have no comment on this.” The CBC I-Team offered to go through the report with Taylor but he did not respond.
This report seems to confirm much of what we have discussed repeatedly on this blog: Chiropractic is not nearly as effective and safe as chiropractors try to make us believe. To hide this fact is certainly dishonest and unethical, but it is in some ways understandable: this knowledge would directly threaten the income of most chiropractors.
Yesterday I commented on another post: “the conflict of interest seems obvious: if homeopaths speak the truth, they are out of business. therefore, they are taught untruths from the first day of their training and eventually end up believing them. there is only one solution, as far as I can see: regulators must prevent them from making false claims. if not, this will go on for another 200 years and damage many patients’ health”. In the light of the above report, I will now re-phrase this: the conflict of interest seems obvious: if chiropractors allowed the truth to be known, they would soon be out of business. Therefore, they are taught untruths from the first day of their training and many end up believing them. There is only one solution, as far as I can see: regulators must prevent chiropractors from making false claims. If not, this abuse will go on for another 120 years and damage many patients’ health.