MD, PhD, FMedSci, FSB, FRCP, FRCPEd

risk/benefit

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In a recent PJ article, Michael Marshall from the ‘Good Thinking Society’ asked “WHY ON EARTH IS THE NHS SPENDING EVEN A SINGLE PENNY ON HOMEOPATHY?”. A jolly good question, given the overwhelmingly negative evidence, I thought  – but one that must be uncomfortable to homeopaths. Sure enough, a proponent of homeopathy, Jeanette Lindsay from Glasgow, has objected to Marshall’s arguments in a short comment which is a fairly typical defence of homeopathy; I therefore take the liberty of reproducing it here (the 12 references in her text were added by me and refer to my footnotes below):

I wonder if people such as Michael Marshall (The Pharmaceutical Journal 2016;297:101), who would refuse [1] patients the option of NHS homeopathic treatment, have considered the plight of people failed by evidence-based medicine ? [2] Where are those with chronic, disabling conditions to turn when the medicines available on the NHS do not work, or worse, are positively harmful? [3]

Take the instance of a woman with multiple drug allergies who has no means of treating her severe inflammatory arthritis and no suitable analgesia. [4] It has been demonstrated that disease states with immune system involvement are particularly susceptible to the placebo effect but how does one induce this? Current thinking precludes treatment with placebo medicines but it so happens that homeopathic remedies would appear, from the results of clinical trials [5], to be a good substitute. [6] Used properly, there is a good chance that in this case homeopathic treatment may achieve a real therapeutic effect. [7]

Patients who cannot tolerate allopathic [8] treatment do not just go away because they cannot take the prescribed medicine. [9] They suffer and surely deserve a better range of options [10] than those provided by the current obsession with evidence-based medicine. [11] The availability of homeopathic treatment is important and should not be denied until better alternatives become commonplace. [12]

[1] Michael Marshall does not ‘refuse’ homeopathy on the NHS; that is not in his power. He merely questions whether NHS funds should not be spent on treatments that demonstrably do more good than harm.

[2] I am sure he as carefully considered such patients.

[3] Depending on the exact circumstances, such patients have many options: for instance, they could change their physician, have their diagnosis re-considered, or try a non-drug treatment.

[4] An allergy to one drug is rarely (I would even say never) associated with allergies to all drugs for any given condition. Even if this were the case, there are several non-drug treatments for arthritis or other diseases.

[5] I think this is fantasy; there is no good evidence from clinical trials to show that homeopathy is efficacious for either inflammatory or degenerative arthritis.

[6] Is this an admission that homeopathic remedies are placebos?

[7] I am not aware of sound evidence to support this statement.

[8] ‘Allopathic’ is a derogatory term introduced by Hahnemann to defame conventional medicine.

[9] I have never seen a patient who could not tolerate any prescription medicine. I suspect this is fantasy again.

[10] Patients deserve the optimal therapy available for their conditions – that is a therapy that demonstrably generates more good than harm. Homeopathy is clearly not in this category.

[11] An obsession? Yes, perhaps it is an obsession for some dedicated healthcare professionals to provide the best possible treatments for their patients. But the way it is put here, it sounds as though this was something despicable. I would argue that such an ‘obsession’ would be most commendable.

[12] For practically all conditions, symptoms, illesses and diseases that afflict mankind, better alternatives than homeopathy have been available since about 150 years.

It seems to me that Jeanette Lindsay has been harshly disappointed by conventional medicine. Perhaps this is why, one day, she consulted a homeopath and received the empathy, understanding and compassion that she needed to get better. Many homeopaths excel at these qualities; and this is the main reason why their patients swear by them, even though their remedies are pure placebos.

My advice to such patients is: find a physician who has time, empathy and compassion. They do exist! Once you have found such a doctor, you can benefit from the compassion and empathy just as you may have benefitted from the homeopath’s compassion and empathy. But in addition to these benefits (and contrary to what you got from your homeopath), you will also be able to profit from the efficacy of the treatments prescribed.

To put it simply: homeopaths can help patients via non-specific therapeutic effects; responsible physicians can help patients via non-specific therapeutic effects plus the specific effects of the treatments they prescribe.

 

Since several years, there has been an increasingly vociferous movement within the chiropractic profession to obtain limited prescription rights, that is the right to prescribe drugs for musculoskeletal problems. A recent article by Canadian and Swiss chiropractors is an attempt to sum up the arguments for and against this notion. Here I have tried to distil the essence of the pros and contras into short sentences.

 1) Arguments in favour of prescription rights for chiropractors

1.1 Such privileges would be in line with current evidence-based practice. Currently, most international guidelines recommend, alongside prescription medication, a course of manual therapy and/or exercise as well as education and reassurance as part of a multi-modal approach to managing various spine-related and other MSK conditions.

1.2 Limited medication prescription privileges would be consistent with chiropractors’ general experience and practice behaviour. Many clinicians tend to recommend OTC medications to their patients in practice.

1.3 A more comprehensive treatment approach offered by chiropractors could potentially lead to a reduction in healthcare costs by providing additional specialized health care options for the treatment of MSK conditions. Namely, if patients consult one central practitioner who can effectively address and provide a range of treatment modalities for MSK pain-related matters, the number of visits to providers might be reduced, thereby resulting in better resource allocation.

1.4 Limited medication prescription rights could lead to improved cultural authority for chiropractors and better integration within the healthcare system.

1.5 With these privileges, chiropractors could have a positive influence on public health. For instance, analgesics and NSAIDs are widely used and potentially misused by the general public, and users are often unaware of the potential side effects that such medication may cause.

2) Arguments against prescription rights for chiropractors

2.1 Chiropractors and their governing bodies would start reaching out to politicians and third-party payers to promote the benefits of making such changes to the existing healthcare system.

2.2 Additional research may be needed to better understand the consequences of such changes and provide leverage for discussions with healthcare stakeholders.

2.3 Existing healthcare legislation needs to be amended in order to regulate medication prescription by chiropractors.

2.4 There is a need to focus on the curriculum of chiropractors. Inadequate knowledge and competence can result in harm to patients; therefore, appropriate and robust continuing education and training would be an absolute requirement.

2.5 Another important issue to consider relates to the divisiveness around this topic within the profession. In fact, some have argued that the right to prescribe medication in chiropractic practice is the profession’s most divisive issue. Some have argued that further incorporation of prescription rights into the chiropractic scope of practice will negatively impact the distinct professional brand and identity of chiropractic.

2.6 Such privileges would increase chiropractors’ professional responsibilities. For example, if given limited prescriptive authority, chiropractors would be required to recognize and monitor medication side effects in their patients.

2.7 Prior to medication prescription rights being incorporated into the chiropractic scope of practice worldwide, further discussions need to take place around the breadth of such privileges for the chiropractic profession.

In my view, some of these arguments are clearly spurious, particularly those in favour of prescription rights. Moreover, the list of arguments against this notion seems a little incomplete. Here are a few additional ones that came to my mind:

  • Patients might be put at risk by chiropractors who are less than competent in prescribing medicines.
  • More unnecessary NAISDs would be prescribed.
  • The vast majority of the drugs in question is already available OTC.
  • Healthcare costs would increase (just as plausible as the opposite argument made above, I think).
  • Prescribing rights would give more legitimacy to a profession that arguably does not deserve it.
  • Chiropractors would then continue their lobby work and soon demand the prescription rights to be extended to other classes of drugs.

I am sure there are plenty of further arguments both pro and contra – and I would be keen to hear them; so please post yours in the comments section below.

As has been discussed on this blog many times before, the chiropractic profession seems to be in a bit of a crisis (my attempt at a British understatement). The Australian chiropractor, Bruce Walker, thinks that, with the adoption of his ten point plan, “the chiropractic profession has an opportunity to turn things around within a generation. Importantly, it has an obligation to the public and to successive generations of chiropractors ahead of it. By embracing this plan the profession can be set on a new path, a new beginning and a new direction. This plan should be known as the new chiropractic.”

And now you are. of course, dying to hear this 10 point plan – well, here it is [heavily abbreviated, I am afraid (the footnotes [ ] and the comments referring to them are mine)]:

  1. There is a need to improve pre professional education for chiropractors.
    Universities or private colleges?
    Chiropractic education should where possible be conducted at universities [1] and this does not mean small single purpose institutions that are deemed universities in name only. Why is this recommended? Primarily because unlike some private colleges, government funded universities insist on intellectual evidence based rigour [2] in their learning and teaching and importantly require staff to be research active. Chiropractic courses need to have an underpinning pedagogy that insists that content [3] is taught in the context of the evidence [4] and that students obtain the necessary training to question and critically appraise [5]…
    Accreditation problems
    Underpinning chiropractic education is program accreditation and this is also in need of review particularly where vitalistic subluxation [6] based courses have been legitimised by the accreditation process…
    Hospital training
    Chiropractic education should also involve specifically relevant hospital access or work experience such as hospital rounds so that students can observe patients that are truly unwell and observe the signs and symptoms taught in their theory classes. Hospital rounds would also allow chiropractic students to interact with other health providers and increase the likelihood of legitimate partnership and respect between health professions [7].
    Who should teach chiropractic students?…
  2. There is a need to establish a progressive identity.
    Chiropractors need to become solely musculoskeletal practitioners with a special emphasis on spinal pain [8]. If the profession becomes the world’s experts in this area it will command the respect deserved [9]. Importantly it will not be seen as a collective of alternative medicine practitioners with a strange belief system [10]…
  3. The profession should develop a generalised special interest.
    …Chiropractic as a profession should also develop a special interest area in the health sciences that can make a worldwide contribution to other related health sciences. This could be either research based or clinically based or indeed both. Some possibilities are: the further development and refinement of evidence based practice [11], improved posture through motor control, musculoskeletal care for the aged and elderly, improving bone density or the very important area of translating research into practice via implementation science. Whatever chosen we need to develop a special interest that sets us apart as experts in a distinctive area [12].
  4. Marginalisation of the nonsensical elements within the profession.
    As professionals chiropractors should not tolerate colleagues or leadership in the profession who demonstrate aberrant ideas. If colleagues transgress the boundaries or professionalism they should be reported to authorities and this should be followed up with action by those authorities [13]…
  5. The profession and individual practitioners should be pro public health.
    It is important to speak up openly in favour of evidence-based public health measures and to join public health associations and agencies [14]…  For example, chiropractors promoting anti-vaccination views need to be countered [15]…
  6. Support legitimate organised elements of the profession.
    Practitioners should support and become involved in chiropractic organisations that are clearly ethical and evidence based [16] and add value to them…
    …Regular collective professional advertising of the benefits of chiropractic for back pain, for example, is a worthy undertaking but the advertisements or media offerings must be evidence based [17].
  7. The profession should strive to improve clinical practice.
    Chiropractors contribute to the public health by the aggregated benefit of positive outcomes to health from their clinical practices [18]… Where restrictive practice laws relating to chiropractors prescribing medication exist the profession should seek to overturn them [19]…
  8. The profession should embrace evidence based practice.
    EBP is the amalgam of best scientific evidence plus clinical expertise plus patient values and circumstances. So what could be missing from this equation? It is clear that in the opinion of a sizable minority of the profession the elements that are missing are “practitioner ideology” and “practitioner values and circumstances”. These additional self- serving and dangerous notions should not be entertained. The adoption of evidence based practice is critical to the future of chiropractic and yet there is resistance by elements within the profession. Soft resistance occurs with attempts to change the name of “Evidence-based practice” (EBP) to “Evidence-informed practice” (EIP). It is worth noting that currently there are over 13,000 articles listed in PUBMED on EBP but less than 100 listed on EIP. So why are some of our profession so keen to use this alternate and weaker term?
    Hard resistance against EBP occurs where it is stated that the best evidence is that based on practice experience and not research. This apparently is known as Practice Based Evidence (PBE) and has a band of followers [20]…
  9. The profession must support research.Research needs to become the number one aspiration of the profession. Research informs both practice and teaching. Without research the profession will not progress. Sadly, the research contribution by the chiropractic profession can only be described as seed like. Figure 1 is a comparison of articles published in the past 45 years by decade using the key words “Physiotherapy” or “Physical Therapy” versus “Chiropractic” (source PUBMED). The Y axis is the number of articles published and the X axis is the decade, the red represents physiotherapy articles, the blue chiropractic. The difference is stark and needs urgent change [21].If the profession at large ignores research whether in its conduct, administration or its results the profession will wither on the vine [22]…
  10. Individual chiropractors need to show personal leadership to effect change.
    Change within the profession will likely only occur if individual chiropractors show personal leadership….
    As part of this personal leadership it will be critical to speak out within the profession. Speak out and become a mentor to less experienced colleagues [23]…
[1] I do wonder whether the ambition to be university-based is not more the hope for recognition than anything else.

[2] The lack of ‘intellectual evidence based rigor’ in chiropractic might prevent from being accepted by universities.

[3] What content?

[4] What evidence?

[5] If one critically assesses chiropractic, it very quickly falls apart.

[6] Subluxation does not need to be reviewed, it needs to be scrapped once and for all.

[7] Again I wonder whether this ambition is about anything else than gaining acceptance and recognition.

[8] In what way would they then differ from physiotherapists?

[9] Same point as in 1 and 7.

[10] The strangest belief system must be that of chiropractic!

[11] This is almost comical! Chiropractic is clearly much further away from evidence practice than chiropractors are aware. In my view, this statement reveals an embarrassing degree of delusion.

[12] To me, this sounds embarrassingly naïve.

[13] If such transgressions were reported in all instances, there would be only very few chiropractors left with a clean slate, I fear.

[14] The profession has a very poor track when it comes to public health measures; as back pain specialists they also would not be in a key position for such a task.

[15] I fear there are far too many anti-vaccination chiros for this to be a realistic prospect.

[16] There is plenty of evidence to show that chiropractic is often neither ethical nor evidence-based.

[17] Advertising is ethically problematic; responsible physicians are extremely cautious and restricted in this respect.

[18] What is this supposed to mean? It sounds politically correct but seems to be little more than a platitude.

[19] So, the future of chiropractic lies in prescribing medicines?

[20] These ‘followers’ are people who want to introduce double standards in healthcare – hardly anything worthy of consideration, I think.

[21] To understand this figure better, we need to know that physiotherapy is, compared to most other areas of healthcare, also not a very research-active field.

[22] But that’s precisely what chiropractors have been doing for the last 100 years!

[23] If you want to know how chiropractors receive a colleague who ‘speaks out’, you only need to read some of the comments Preston Long attracted with his guest post on this blog.

Anyone you thinks that with such a strategy “the chiropractic profession has an opportunity to turn things around within a generation” is, in my view, naïve and deluded. The 10 points are not realistic and woefully incomplete. The most embarrassing omission is a clear statement that chiropractors are fully dedicated to making sure that they serve the best interest of their patients by doing more good than harm.

Wouldn’t it be nice to be able to enjoy food and drink to one’s heart content and, once the pounds are piling up, simply swallow a pill and the weight goes down to normal? There are plenty of such pills on the market, but here I advise you to avoid them – mainly for two reasons.

The first is that they do not work. On this blog, we have discussed this before. The claims made for weight loss supplements are bogus. The manufacturers promise substantial body weight reductions not because their product is effective but because they want your money. So, unless you want to donate your cash to quacks, don’t buy such rubbish.

The second reason is probably even more compelling: weight-loss supplements endanger your health. A new paper tells us more about their risks. This investigation was aimed at identifying banned and discouraged-use ingredients, such as ephedra, 1,3-dimethylamylamine, and beta-methyl-phenylethylamine, in readily available weight loss dietary supplements within a 10-mile radius of Regis University.

A list of banned and discouraged-use ingredients was compiled with the use of the Food and Drug Administration (FDA) dietary supplement website which provides information on supplement ingredients that are no longer legal or are advised against owing to adverse event reporting. Investigators visited all retail outlet stores within a 10-mile radius of Regis University in Denver, Colorado. Retail chains were not duplicated and only one of each chain was evaluated.

A total of 51 weight loss supplement products from retail stores were found with banned or discouraged-use substances listed on their labels. At least one banned ingredient was found to be listed on the product labels in 17 of the 51 studied supplements (33%). At least one discouraged-use ingredient was found in 46 of the 51 products (90%). Retail outlet stores dedicated to supplements and sports nutrition alone were found to have the greatest number of weight loss supplements that included banned and discouraged-use ingredients.

The authors of this paper draw the following conclusions: the FDA has taken action to remove some weight loss supplements from the market that contain banned ingredients. Unfortunately, based on the findings of this study, it is evident that products containing these ingredients remain on the market today.

You might think that these findings apply only to the US, however, I am afraid, you would be mistaken. People buy such bogus supplements on the Internet where national regulations can easily be circumvented. Thus the trade in weight-loss supplements is thriving regardless of what the FDA or any other regulatory agency might do about them.

The solution is simple: avoid such products!

No, I don’t want to put you off your breakfast… but you probably have seen so many pictures of attractive athletes with cupping marks and read articles about the virtues of this ancient therapy, that I feel I have to put this into perspective:

Cupping burnsI am sure you agree that this is slightly less attractive. But, undeniably, these are also cupping marks. So, if you read somewhere that this treatment is entirely harmless, take it with a pinch of salt.

Cupping has existed for centuries in most cultures, and there are several variations of the theme. We differentiate between wet and dry cupping. The above picture is of wet cupping gone wrong. What the US Olympic athletes currently seem to be so fond of is dry cupping.

The principles of both forms are similar. In dry cupping, a vacuum cup is placed over the skin which provides enough suction to create a circular bruise. Eventually the vacuum diminishes, and the cup falls off; what is left is the mark. In wet cupping, the procedure is much the same, except that the skin is injured before the cup is placed. The suction then pulls out a small amount of blood. Obviously the superficial injury can get infected, and that is what we see on the above picture.

In the homeopathic hospital where I worked ~40 years ago, we did a lot of both types of cupping. We used it mostly for musculoskeletal pain. Our patients responded well.

But why? How does cupping work?

The answer is probably more complex than you expect. It clearly has a significant placebo effect. Athletes are obviously very focussed on their body, and they are therefore the ideal placebo-responders. Evidently, my patients 40 years ago also responded to all types of placebos, even to the homeopathic placebos which they received ‘en masse’.

But there might be other mechanisms as well. A TCM practitioner will probably tell you that cupping unblocks the energy flow in our body. This might sound very attractive to athletes or consumers, and therefore could even enhance the placebo response, but it is nevertheless nonsense.

The most plausible mode of action is ‘counter-irritation’: if you have a pain somewhere, a second pain elsewhere in your body can erase the original pain. You might have a headache, for instance, and if you accidentally hit your thumb with a hammer, the headache is gone, at least for a while. Cupping too would cause mild to moderate pain, and this is a distraction from the muscular pain the athletes aim to alleviate.

When I employed cupping 40 years ago, there was no scientific evidence testing its effects. Since a few years, however, clinical trials have started appearing. Many are from China, and I should mention that TCM studies from China almost never report a negative result. According to the Chinese, TCM (including cupping) works for everything. More recently,also some trials from other parts of the world have emerged. They have in common with the Chinese studies that they tend to report positive findings and that they are of very poor quality. (One such trial has been discussed previously on this blog.) In essence, this means that we should not rely on their conclusions.

A further problem with clinical trails of cupping is that it is difficult, if not impossible, to control for the significant placebo effects that this treatment undoubtedly generates. There is no placebo that could mimic all the features of real cupping in clinical trials; and there is no easy way to blind either the patient or the therapist.

So, we are left with an ancient treatment backed by a host of recent but flimsy studies and a growing craze for cupping fuelled by the Olympic games. What can one conclude in such a situation?

Personally, I would, whenever possible, recommend treatments that work beyond a placebo effect, because the placebo response tends to be unreliable and is usually of short duration – and I am not at all sure that cupping belongs into this category. I would also avoid wet cupping, because it can cause substantial harm. Finally, I would try to keep healthcare costs down; cupping itself is cheap but the therapist’s time might be expensive.

In a nutshell: would I recommend cupping? No, not any more than using a hammer for counter irritation! Will the Olympic athletes care a hoot about my recommendations? No, probably not!

 

Yesterday, a press-release reached me announcing that a Chinese herbal medicine, ‘Phynova Joint and Muscle Relief Tablets’, containing the active ingredient Sigesbeckia, is now on sale in the UK for the first time in Boots The Chemist: 

Sigesbeckia is the first traditional Chinese treatment granted a traditional herbal registration (THR) under the traditional herbal medicines product directive in the UK, by drug safety watchdog the Medicines and Healthcare Products Regulatory Agency (MHRA).  Oxford based Phynova which manufactures the product was granted the UK licence last year. 

Containing 500mg of the active ingredient, Phynova Joint and Muscle Relief Tablets are specially formulated for the relief of backache, arthritis, minor sports injuries, rheumatic or muscular pains and general aches and pains in muscles or joints.  Two tablets are taken each day, one in the morning and one in the evening. They have no known side effects and are non-addictive. .. 

The product, which retails at £19.99 for one month’s supply of 60 tablets, is available in 950 UK Boots outlets and online via Click and Collect from all stores.  It will be sold both Over the Counter (OTC) by pharmacist staff and off the shelf as part of Boots’ pain relief fixture… 

END OF QUOTE

What on earth is a ‘joint and muscle relief’? Personally I do not want to be relieved of my joints and muscles!!!

Yes, I know, they probably mean ‘joint and muscle pain relief’ but were not allowed to say so because this is a medical indication.

And what about the claim of ‘no side-effects’; is it possible that a pharmacological treatment has positive effects without any risks at all? This is not what they told me during my pharmacology course, if I remember correctly. And anyway, even placebos have side-effects!

I admit, I was puzzled.

The covering letter of the press-release provided more amazement: it informed me that “Phynova joint and muscle relief contains the active ingredient Sigesbeckia which has been through clinical trials and has been used for pain relief in China for hundreds of years…” It was the remark about clinical trials (PLURAL!!!) that caught my interest most.

So, I looked up ‘Sigesbeckia’ on Medline and found as good as nothing. This is mainly because the plant is spelled correctly ‘Siegesbeckia’ in honour of the famous botanist Siegesbeck.

Looking up ‘Siegesbeckia’, I found many pre-clinical studies but no clinical trials.

Next I searched for a comment from the MHRA and discovered that their account makes it very clear that a licence has been granted to this product “exclusively upon long standing use… and not upon data from clinical trials.”

So, who is right?

Are there clinical trials of this product or not? And, if there are any, where are they?

Perhaps someone from Phynova can enlighten us?

 

Some homeopaths advise parents not to vaccinate their kids and use homeopathic vaccinations or ‘homeo-prophylaxis’ instead. Despite the fact that it has long been clear that this approach is not effective and even dangerous, some homeopathic pharmacies have been selling the remedies used for that purpose. In the UK, Helios has been at the forefront of this dubious trade. But, a few days ago, they have changed their ways.

Here is a screenshot of the results of a search for the word ‘vaccine’, with the ‘remedies’ that were subsequently removed highlighted:

Helios vaccine remedies 1

Click the image to enlarge.

This is undoubtedly a step in the right direction. The question I ask myself is WHY DID HELIOS MAKE THIS CHANGE? Was it because they had to? Or was it because they saw the light and realised that the evidence did not support the remedies in question?

If it was the latter motivation, we will soon know – because, in that case, they will surely do the same with the entire rest of their remedies.

Why?

BECAUSE THERE IS NOT GOOD EVIDENCE THAT ANY HIGHLY DILUTED HOMEOPATHIC REMEDY IS MORE THAN A PLACEBO.

AROMATHERAPY is one of the most popular alternative therapies. The experience is usually pleasant enough, but what are the risks? None!!! At least this is what the therapists would claim. But is this true? Perhaps not. According to a recent press-release, the risks might be considerable.

Officials with the Tennessee Poison Control Center (TPC) are warning that they are seeing an increasing number of toxic exposures, mostly involving children, to essential oils used in aromatherapy. The TPC says the number of essential oil exposures doubled between 2011 and 2015, and 80 percent of those cases involved children. The primary route of poisoning is by ingestion, but also occurs with excessive or inappropriate application to the skin. Children are at risk because their skin easily absorbs oils and because they may try to ingest essential oils from the container.

“Tea tree oil is commonly cited, and most of those cases are accidental ingestions by children.” said Justin Loden, PharmD, certified specialist in Poison Information (CSPI) at TPC. Most essential oils have a pleasant smell but bitter taste, so children easily choke on them and aspirate the oil to their lungs, Loden said.

Several essential oils such as camphor, clove, lavender, eucalyptus, thyme, tea tree, and wintergreen oils are highly toxic. All of the oils produce oral and throat irritation, nausea, and vomiting when ingested. Most essential oils either produce central nervous system (CNS) stimulation, which results in agitation, hallucinations, delirium, and seizures or CNS depression, which results in lethargy and coma. Other toxic effects include painless chemical burns, hypotension, acute respiratory distress syndrome, acute liver failure, severe metabolic acidosis, and cerebral edema depending on which essential oil is in question.

Tennessee Poison Center Tips for using essential oils

  • Safely using and storing essential oils is extremely important
  • Use essential oil products ONLY for their intended purpose.
  • Use only the amount stated on the label/guide.
  • Do not swallow an essential oil unless the label says to do so.
  • Do not use a product on the skin unless the label says to do so.
  • Do not leave the product out (i.e. as a pesticide) unless the label says to do so.
  • If you have bottles of essential oils at home, keep them locked up, out of sight and reach of children and pet at all times. Children act fast, so do poisons.

Many will think that this is alarmist – but I don’t. In fact, in 2012, I published a systematic review aimed at critically evaluating the evidence regarding the adverse effects associated with aromatherapy. No, it was not funded by ‘BIG PHARMA’ but by THE ROYAL COLLEGE OF PHYSICIANS, LONDON.

Five electronic databases were searched to identify all relevant case reports and case series. Forty two primary reports met our inclusion criteria. In total, 71 patients experienced adverse effects of aromatherapy. Adverse effects ranged from mild to severe and included one fatality. The most common adverse effect was dermatitis. Lavender, peppermint, tea tree oil and ylang-ylang were the most common essential oils responsible for adverse effects.

At the time, we concluded that aromatherapy has the potential to cause adverse effects some of which are serious. Their frequency remains unknown. Lack of sufficiently convincing evidence regarding the effectiveness of aromatherapy combined with its potential to cause adverse effects questions the usefulness of this modality in any condition.

I might add – before the therapists start making comments – that, yes, aromatherapy is still dimensions safer than many conventional treatments. But remember: the value of a therapy is not determined by its safety but by the risk/benefit balance! And what are the proven benefits of aromatherapy, I ask you.

I get comments of this nature all the time, sometimes by the dozen per day. As the argument is so very common, let me ONCE AGAIN explain what is wrong with it. Here are 10 very simple points for those who find it hard to understand the issue.

  1. My expertise is in alternative medicine and not in pharmacology. I know many pharmacologists who are competent to criticise aspects of pharmacotherapy and do so regularly. I do NOT consider myself competent to comment on pharmacotherapy.
  2. The fact that some things are not perfect in one area of health care (e. g. pharmacotherapy) does certainly not mean that one is not allowed to criticise shortcomings in other areas (e. g. homeopathy).
  3. As far as I can tell, it is not pharmaceuticals that ‘kill 100k a year’, but the issue is more complex: a sizable proportion of this tragic total is due to medical errors, for instance.
  4. The 100k figure seems to refer to the US where the vast majority of the population take pharmaceuticals but only about 2% of the population ever try homeopathy.
  5. Nobody seems to dispute that pharmaceuticals have beneficial effects beyond placebo; the general consensus regarding highly diluted homeopathics is that they have no effects beyond placebo.
  6. To judge the value of a therapy, it is naïve and dangerously misleading to consider just its risks. If we did that, aromatherapy would be preferable to surgery, reflexology would be better than chemotherapy and OF COURSE homeopathy would be better than pharmacotherapy. And if we then implemented this ‘wisdom’ into routine practice, we would hasten the deaths of millions.
  7. Any reasonable judgement of the value of any therapy must account for its documented risks in relation to its documented benefits. In other words, we must always try to weigh the two against each other and do a risk/benefit analysis.
  8. If a therapy is associated with finite risks and no benefits, its risk/benefit balance cannot possibly be positive. Where the benefit is non-existent or doubtful, even relatively small risks will inevitably tilt this balance in to the negative.
  9. This is precisely the situation that applies to homeopathy: its benefits beyond placebo are doubtful and its risks are fairly well documented.
  10. This means that homeopathy cannot be considered to be a therapy that is fit for purpose.

Cervical spine manipulation (CSM) is a popular manipulative therapy employed by chiropractors, osteopaths, physiotherapists and other healthcare professionals. It remains controversial because its benefits are in doubt and its safety is questionable. CSM carries the risk of serious neurovascular complications, primarily due to vertebral artery dissection (VAD) and subsequent vertebrobasilar stroke.

Chinese physicians recently reported a rare case of a ‘locked-in syndrome’ (LIS) due to bi-lateral VAD after CSM treated by arterial embolectomy. A 36-year-old right-handed man was admitted to our hospital with numbness and weakness of limbs after receiving treatment with CSM. Although the patient remained conscious, he could not speak but could communicate with the surrounding by blinking or moving his eyes, and turned to complete quadriplegia, complete facial and bulbar palsy, dyspnoea at 4 hours after admission. He was diagnosed with LIS. Cervical and brain computed tomography angiography revealed bi-lateral VADs. Aorto-cranial digital subtraction angiography showed a vertebro-basilar thrombosis which was blocking the left vertebral artery, and a stenosis of right vertebral artery. The patient underwent emergency arterial embolectomy; subsequently he was treated with antiplatelet therapy and supportive therapy in an intensive care unit and later in a general ward. After 27 days, the patient’s physical function gradually improved. At discharge, he still had a neurological deficit with muscle strength grade 3/5 and hyperreflexia of the limbs.

The authors concluded that CSM might have potential severe side-effect like LIS due to bilaterial VAD, and arterial embolectomy is an important treatment choice. The practitioner must be aware of this complication and should give the patients informed consent to CSM, although not all stroke cases temporally related to CSM have pre-existing craniocervical artery dissection.

Informed consent is an ethical imperative with any treatment. There is good evidence to suggest that few clinicians using CSM obtain informed consent from their patients before starting their treatment. This is undoubtedly a serious violation of medical ethics.

So, why do they not obtain informed consent?

To answer this question, we need to consider what informed consent would mean. It would mean, I think, conveying the following points to the patient in a way that he or she can understand them:

  1. the treatment I am suggesting can, in rare cases, cause very serious problems,
  2. there is little good evidence to suggest that it will ease your condition,
  3. there are other therapies that might be more effective.

Who would give his or her consent after receiving such information?

I suspect it would be very few patients indeed!

AND THAT’S THE REASON, I FEAR, WHY MANY CLINICIANS USING CSM PREFER TO BEHAVE UNETHICALLY AND FORGET ABOUT INFORMED CONSENT.

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