Edzard Ernst

MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Readers of this blog will know that few alternative treatments are more controversial and less plausible than homeopathy. Therefore they might be interested to read about the latest attempt of homeopathy-enthusiasts to convince the public that, despite all the clinical evidence to the contrary, homeopathy does work.

The new article was published in German by Swiss urologist and is a case-report describing a patient suffering from paralytic ileus. This condition is a typical complication of ileocystoplasty of the bladder, the operation the patient had undergone. The patient had also been suffering from a spinal cord injury which, due to a pre-existing neurogenic bowel dysfunction, increases the risk of paralytic ileus.

The paraplegic patient developed a massive paralytic ileus after ileocystoplasty and surgical revision. Conventional stimulation of bowel function was unsuccessful. But after adjunctive homeopathic treatment normalization of bowel function was achieved.

The authors conclude that adjunctive homeopathic therapy is a promising treatment option in patients with complex bowel dysfunction after abdominal surgery who do not adequately respond to conventional treatment.

YES, you did read correctly: homeopathic therapy is a promising treatment

In case anyone doubts that this is more than a trifle too optimistic, let me suggest three much more plausible reasons why the patient’s bowel function finally normalised:

  • It could have been a spontaneous recovery (in most cases, even severe ones, this is what happens).
  • It could have been all the conventional treatments aimed at stimulating bowel function.
  • It could have been a mixture of the two.

The article made me curious, and I checked whether the authors had previously published other material on homeopathy. Thus I found two further articles in a very similar vein:

Article No 2 (dated 2014):

We present the clinical course of a patient with an epididymal abscess caused by multiresistant bacteria. As the patient declined surgical intervention, a conservative approach was induced with intravenous antibiotic treatment. As the clinical findings did not ameliorate, adjunctive homeopathic treatment was used. Under combined treatment, laboratory parameters returned to normal, and the epididymal abscess was rapidly shrinking. After 1 week, merely a subcutaneous liquid structure was detected. Fine-needle aspiration revealed sterile purulent liquid, which was confirmed by microbiological testing when the subcutaneous abscess was drained. Postoperative course was uneventful.

As the risk for recurrent epididymitis is high in persons with spinal cord injury, an organ-preserving approach is justified even in severe cases. Homeopathic treatment was a valuable adjunctive treatment in the above-mentioned case. Therefore, prospective studies are needed to further elucidate the future opportunities and limitations of classical homeopathy in the treatment of urinary tract infections.

Article No 3 (dated 2012):

Recurrent urinary tract infections (UTI) in patients with spinal cord injury are a frequent clinical problem. Often, preventive measures are not successful. We present the case reports of five patients with recurrent UTI who received additional homeopathic treatment. Of these patients, three remained free of UTI, whereas UTI frequency was reduced in two patients. Our initial experience with homeopathic prevention of UTI is encouraging. For an evidence-based evaluation of this concept, prospective studies are required.

It seems clear that all of the three more plausible explanations for the patients’ recovery listed above also apply to these two cases.

One might not be far off speculating that J Pannek, the first author of all these three articles, is a fan of homeopathy (this suspicion is confirmed by a link between him and the HOMEOPATHY RESEARCH INSTITUE: Prof Jürgen Pannek on the use of homeopathy for prophylaxis of UTI’s in patients with neurogenic bladder dysfunction). If that is so, I wonder why he does not conduct a controlled trial, rather than publishing case-report after case-report of apparently successful homeopathic treatments. Does he perhaps fear that his effects might dissolve into thin air under controlled conditions?

Case-reports of this nature can, of course, be interesting and some might even deserve to be published. But it would be imperative to draw the correct conclusions. Looking at the three articles above, I get the impression that, as time goes by, the conclusions of Prof Pannek et al (no, I know nobody from this group of authors personally) are growing more and more firm on less and less safe ground.

In my view, responsible authors should have concluded much more cautiously and reasonably. In the case of the paralytic ileus, for instance, they should not have gone further than stating something like this: adjunctive homeopathic therapy might turn out to be a promising treatment option for such patients. Despite the implausibility of homeopathy, this case-report might deserve to be followed up with a controlled clinical trial. Without such evidence, firm conclusions are clearly not possible.

If you believe herbalists, the Daily Mail or similarly reliable sources, you come to the conclusion that herbal medicines are entirely safe – after all they are natural, and everything that is natural must be safe. However, there is plenty of evidence that these assumptions are not necessarily correct. In fact, herbal medicines can cause harm in diverse ways, e. g. because:

  • one or more ingredients of a plant are toxic,
  • they interact with prescribed drugs,
  • they are contaminated, for instance, with heavy metals,
  • they are adulterated with prescription drugs.

There is no shortage of evidence for any of these 4 scenarios. Here are some very recent and relevant publications:

German authors reviewed recent case reports and case series that provided evidence for herbal hepatotoxicity caused by Chinese herbal mixtures. The implicated remedies were the TCM products Ban Tu Wan, Chai Hu, Du Huo, Huang Qin, Jia Wei Xia Yao San, Jiguja, Kamishoyosan, Long Dan Xie Gan Tang, Lu Cha, Polygonum multiflorum products, Shan Chi, ‘White flood’ containing the herbal TCM Wu Zhu Yu and Qian Ceng Ta, and Xiao Chai Hu Tang. the authors concluded that stringent evaluation of the risk/benefit ratio is essential to protect traditional Chinese medicines users from health hazards including liver injury.

A recent review of Nigerian anti-diabetic herbal remedies suggested hypoglycemic effect of over 100 plants. One-third of them have been studied for their mechanism of action, while isolation of the bioactive constituent(s) has been accomplished for 23 plants. Several plants showed specific organ toxicity, mostly nephrotoxic or hepatotoxic, with direct effects on the levels of some liver function enzymes. Twenty-eight plants have been identified as in vitro modulators of P-glycoprotein and/or one or more of the cytochrome P450 enzymes, while eleven plants altered the levels of phase 2 metabolic enzymes, chiefly glutathione, with the potential to alter the pharmacokinetics of co-administered drugs

US authors published a case of a 44-year-old female who developed subacute liver injury demonstrated on a CT scan and liver biopsy within a month of using black cohosh to resolve her hot flashes. Since the patient was not taking any other drugs, they concluded that the acute liver injury was caused by the use of black cohosh. The authors concluded: we agree with the United States Pharmacopeia recommendations that a cautionary warning about hepatotoxicity should be labeled on the drug package.

Hong Kong toxicologists recently reported five cases of poisoning occurring as a result of inappropriate use of herbs in recipes or general herbal formulae acquired from books. Aconite poisoning due to overdose or inadequate processing accounted for three cases. The other two cases involved the use of herbs containing Strychnos alkaloids and Sophora alkaloids. These cases demonstrated that inappropriate use of Chinese medicine can result in major morbidity, and herbal formulae and recipes containing herbs available in general publications are not always safe.

Finally, Australian emergency doctors just published this case-report: A woman aged 34 years presented to hospital with a history of progressive shortness of breath, palpitations, decreased exercise tolerance and generalised arthralgia over the previous month. A full blood count revealed normochromic normocytic anaemia and a haemoglobin level of 66 g/L. The blood film showed basophilic stippling, prompting measurement of lead levels. Her blood lead level (BLL) was 105 µg/dL. Mercury and arsenic levels were also detected at very low levels. On further questioning, the patient reported that in the past 6 months she had ingested multiple herbal preparations supplied by an overseas Ayurvedic practitioner for enhancement of fertility. She was taking up to 12 different tablets and various pastes and powders daily. Her case was reported to public health authorities and the herbal preparations were sent for analytical testing. Analysis confirmed high levels of lead (4% w/w), mercury (12% w/w), arsenic and chromium. The lead levels were 4000 times the maximum allowable lead level in medications sold or produced in Australia. Following cessation of the herbal preparations, the patient was commenced on oral chelation therapy, iron supplementation and contraception. A 3-week course of oral DMSA (2,3-dimercaptosuccinic acid) was well tolerated; BLL was reduced to 13 µg/dL and haemoglobin increased to 99 g/L. Her symptoms improved over the subsequent 3 months and she remains hopeful about becoming pregnant.

So, how safe are herbal medicines? Unfortunately, the question is unanswerable. Some herbal medicines are quite safe, others are not. But always remember: whenever you administer a treatment you should ask yourself one absolutely crucial question: do the documented benefits outweigh the risks? There are several thousand different herbal medicines, and for less than a dozen of them can the honest answer to this question be YES.

Blinding patients in clinical trials is a key methodological procedure for minimizing bias and thus making sure that the results are reliable. In alternative medicine, blinding is not always straight forward, and many studies are therefore not patient-blinded. We all know that this can introduce bias into a trial, but how large is its effect on study outcomes?

This was the research question addressed by a recent systematic review of randomized clinical trials with one sub-study (i.e. experimental vs control) involving blinded patients and another, otherwise identical, sub-study involving non-blinded patients. Within each trial, the researchers compared the difference in effect sizes (i.e. standardized mean differences) between the two sub-studies. A difference <0 indicates that non-blinded patients generated a more optimistic effect estimate. The researchers then pooled the differences with random-effects inverse variance meta-analysis, and explored reasons for heterogeneity.

The main analysis included 12 trials with a total of 3869 patients. Ten of these RCTs were studies of acupuncture. The average difference in effect size for patient-reported outcomes was -0.56 (95% confidence interval -0.71 to -0.41), (I(2 )= 60%, P = 0.004), indicating that non-blinded patients exaggerated the effect size by an average of 0.56 standard deviation, but with considerable variation. Two of the 12 trials also used observer-reported outcomes, showing no indication of exaggerated effects due lack of patient blinding.

There was an even larger effect size difference in the 10 acupuncture trials [-0.63 (-0.77 to -0.49)], than in the two non-acupuncture trials [-0.17 (-0.41 to 0.07)]. Lack of patient blinding was also associated with increased attrition rates and the use of co-interventions: ratio of control group attrition risk 1.79 (1.18 to 2.70), and ratio of control group co-intervention risk 1.55 (0.99 to 2.43).

The authors conclude that this study provides empirical evidence of pronounced bias due to lack of patient blinding in complementary/alternative randomized clinical trials with patient-reported outcomes.

This is a timely, rigorous and important analysis. In alternative medicine, we currently see a proliferation of trials that are not patient-blinded. We always suspected that they are at a high risk of generating false-positive results – now we know that this is, in fact, the case.

What should we do with this insight? In my view, the following steps would be wise:

  1. Take the findings from the existing trials that are devoid of patient-blinding with more than just a pinch of salt.
  2. Discourage the funding of future studies that fail to include patient-blinding.
  3. If patient-blinding is truly and demonstrably impossible – which is not often the case – make sure that the trialists at least include blinding of the assessors of the primary outcome measures.

Some time ago, the NYT carried an article entitled HOW YOGA CAN WRECK YOUR BODY. While this might be just a trifle alarmist, it seems clear that injuries can occur and do occur more and more – not least because yoga has become so very popular. It seems relevant therefore to ask what the risks truly are. A recent article might be useful in this respect.

The aim of this study was to examine whether a national sample of yoga practitioners would report discontinued use of yoga due to injury from the practice, assess what injuries resulted in discontinued use, determine what injuries were most common and identify injuries requiring medical attention. The authors used a secondary data analysis of a nationally representative sample of 23,393 adults from the United States.

The results indicate that less than 1% of individuals who had ever practiced yoga (n = 2230) reported an injury from yoga that led to discontinued use. Of those reporting injury, less than one-third (n = 4) reported seeking medical attention. The most commonly reported side-effect of yoga was back pain. Approximately, half of those reporting back pain sought medical attention.

The authors concluded that injury due to yoga is an infrequent barrier to continued practice and severe injury due to yoga is rare.

So, yoga is fairly safe but, in rare cases, injuries can occur. If you are interested in preventing such harm, there are some precautions you can take to make sure you do not sustain injuries.

And one last thing: in my experience,  many yoga make quite absurd claims – so, if it sounds to be too good to be true, it probably is.

This is not a hoax! Homeopaths have jumped on the Ebola-bandwagon and are recommending we treat this infection with homeopathy.

You don’t believe it? Read for yourself; the following text is taken from a pro-homeopathy website:

Your best bet is to find a homeopath to treat yourself or your patient. With Ebola this might not be so feasible, and if you find there is no other assistance available, continue as described below.

Add a pill or two of the homeopathic remedy found to have the most similar symptoms to a plastic cup filled with water (tap or mineral water). Starting with Crotalus Horridus 30C is probably the best idea. Stir the cup with a plastic spoon until the pills dissolve. With the spoon, place some drops of the remedy on the patient’s tongue.

How often the remedy is taken depends on the severity of symptoms. If they are very severe, give the remedy every half hour until improvement is observed, then repeat it every hour. This can be reduced to once or twice a day, depending on improvement.

If no improvement is observed after 24 hours, go to the next homeopathic remedy on the list above.

What to Do In Case Homeopathic Remedies are Unavailable
 …With any epidemic, such as Ebola, bird and swine flu, if you have no other recourse for treatment—no medical assistance available— there is a procedure for making a remedy at home that will keep you alive, although you may have a rough time of it. Vitamins, especially C, will be helpful.

You may think the following procedure—developed by the English homeopath Peter Chappell—is a crazy thing to do. But, if you or a loved one is sick with Ebola with the prospect of having one week to live, and no other help is available, you might consider it. Besides, Einstein said that if an idea didn’t seem crazy, it wasn’t worth anything.

This procedure is based on a form of therapy related to homeopathy called isopathy (curing a disease with the virulent agent of the same disease), which has proven successful for many ailments….

How to Make Your Own Ebola Remedy

What you need:
1. A face mask and gloves
2. Two bottles (50 ml up to 500 ml glass or plastic bottles) with caps
3. Clean water (mineral or tap water)
4. An Ebola sample: some spit or other disease product, such as blood, from a person infected with Ebola, or who is suspected sick with it. Any small quantity will do, even a pinhead.
5. An alcoholic liquid, such as whisky, brandy, rum, etc.
6. Half an hour of your time.

Procedure:
1. Fill the bottle with water, leaving about 20% space at the top.
2. Place the Ebola sample in the water in the bottle.
3. Close the top of the bottle with the cap.
4. Hold the bottle and strike it hard against a solid surface, such as a large book, 40 times.
5. Pour out the contents of the bottle.
6. Refill the bottle with water (the fluid remaining on the inside surface of the bottle will serve as the next Ebola sample).
7. Repeat steps 3 to 6 a total of 30 times.

Storage:
1. Pour the bottle solution into another bottle—your stock bottle.
2. Add 10% by volume of the alcoholic liquid (whisky, brandy, etc.) as a preservative.
3. Store in a place away from sunlight and electronic equipment.

Using this stock bottle, you can supply the Ebola remedy to as many people you want. With one drop from the stock bottle as an Ebola sample you can produce another stock bottle to give to someone else. Instead of the original Ebola sample you used above to make the original stock bottle, you use a drop from the first stock bottle. This process can be carried out ad infinitum, supplying a whole city, etc., if needed.

Taking Your Home-Made Ebola Remedy

For prevention:
1. Place a teaspoonful of your Ebola remedy from the stock bottle into a cup filled with water.
2. Stir the water five times with a disposable spoon or stick.
3. Take a sip from the cup.
4. During the epidemic, take a sip once or twice a day, stirring five times before taking the sip.
5. Refill the cup as needed after striking the stock bottle against a hard surface five times.

If you are sick with Ebola:
1. Place a teaspoonful of the Ebola remedy from your stock bottle into a cup filled with water.
2. Stir the water five times with a disposable spoon or stick.
3. Take a sip every 15 minutes, stirring five times each time until you notice improvement, then stop.
4. On improving, you can ease off and take the remedy every hour or so, again stirring five times before taking the remedy each time.
5. Refill the cup as needed after striking the stock bottle against a hard surface five times.

Another website had similar advice:

The following remedies would be considered by a homeopath for any of the viral hemorrhagic fevers that match this symptom picture.

As a preventative if an outbreak happens nearby, Crotalus horridus 30C, one dose daily, until the threat is out of the area is the method many homeopaths familiar with this disease suggest.

If a person is infected, the remedies most commonly used would be the following. One dose every hour, but as the severity of the symptoms decrease, frequency is reduced. If no improvement is seen after 6 doses, a new remedy ought to be considered.

Crotalus horridus 30C – Is to be considered for when there is difficulty swallowing due to spasms and constriction of the throat, dark purplish blood, edema with purplish, mottled skin.

Bothrops 30C – Is the remedy to think of when nervous trembling, difficulty articulating speech, sluggishness, swollen puffy face, black vomiting are present

Lachesis mutus 30C ,– when there’s delirium with trembling and confusion, hemorrhaging in any area, consider this remedy. Often, the person cannot bear tight or constricting clothing or bandages and feels better from heat and worse on the left side.

Mercurius corrosivus 30C, – For copious bleeding, better when lying on the back with the knees bent up, delirium, headache with burning cheeks, photophobia, black swollen lip, metallic, bitter or salt taste in mouth.

Secale cornutum 30c,– For thin, slow, painless oozing dark hemorrhage with offensive odor, cold skin and tingling in the limbs. The individual wants to be uncovered and feels WORSE from motion.

Echinacea 30C – For when there’s sepsis or blood poisoning, fetid smelling discharges and enlarged lymph nodes.

Homeopathy is an ideal medical stratagem for survivalists, homesteaders and anyone wanting to be self-reliant in any situation.

I felt quite sick after reading these texts - sick and frightened. If some homeopaths really believe this nonsense, we should, I think, all be frightened of them.

There must be well over 10 000 clinical trials of acupuncture; Medline lists ~5 000, and many more are hidden in the non-Medline listed literature. That should be good news! Sadly, it isn’t.

It should mean that we now have a pretty good idea for what conditions acupuncture is effective and for which illnesses it does not work. But we don’t! Sceptics say it works for nothing, while acupuncturists claim it is a panacea. The main reason for this continued controversy is that the quality of the vast majority of these 10 000 studies is not just poor, it is lousy.

“Where is the evidence for this outraging statement???” – I hear the acupuncture-enthusiasts shout. Well, how about my own experience as editor-in-chief of FACT? No? Far too anecdotal?

How about looking at Cochrane reviews then; they are considered to be the most independent and reliable evidence in existence? There are many such reviews (most, if not all [co-]authored by acupuncturists) and they all agree that the scientific rigor of the primary studies is fairly awful. Here are the crucial bits of just the last three; feel free to look for more:

All of the studies had a high risk of bias

All included trials had a high risk of bias…

The studies were not judged to be free from bias…

Or how about providing an example? Good idea! Here is a new trial which could stand for numerous others:

This study was performed to compare the efficacy of acupuncture versus corticosteroid injection for the treatment of Quervain’s tendosynovitis (no, you do not need to look up what condition this is for understanding this post). Thirty patients were treated in two groups. The acupuncture group received 5 acupuncture sessions of 30 minutes duration. The injection group received one methylprednisolone acetate injection in the first dorsal compartment of the wrist. The degree of disability and pain was evaluated by using the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) scale and the Visual Analogue Scale (VAS) at baseline and at 2 weeks and 6 weeks after the start of treatment. The baseline means of the Q-DASH and the VAS scores were 62.8 and 6.9, respectively. At the last follow-up, the mean Q-DASH scores were 9.8 versus 6.2 in the acupuncture and injection groups, respectively, and the mean VAS scores were 2 versus 1.2. Thus there were short-term improvements of pain and function in both groups.

The authors drew the following conclusions: Although the success rate was somewhat higher with corticosteroid injection, acupuncture can be considered as an alternative option for treatment of De Quervain’s tenosynovitis.

The flaws of this study are exemplary and numerous:

  • This should have been a study that compares two treatments – the technical term is ‘equivalence trial – and such studies need to be much larger to produce a meaningful result. Small sample sizes in equivalent trials will always make the two treatments look similarly effective, even if one is a pure placebo.
  • There is no gold standard treatment for this condition. This means that a comparative trial makes no sense at all. In such a situation, one ought to conduct a placebo-controlled trial.
  • There was no blinding of patients; therefore their expectation might have distorted the results.
  • The acupuncture group received more treatments than the injection group; therefore the additional attention might have distorted the findings.
  • Even if the results were entirely correct, one cannot conclude from them that acupuncture was effective; the notion that it was similarly ineffective as the injections is just as warranted.

These are just some of the most fatal flaws of this study. The sad thing is that similar criticisms can be made for most of the 10 000 trials of acupuncture. But the point here is not to nit-pick nor to quack-bust. My point is a different and more serious one: fatally flawed research is not just a ‘poor show’, it is unethical because it is a waste of scarce resources and, even more importantly, an abuse of patients for meaningless pseudo-science. All it does is it misleads the public into believing that acupuncture might be good for this or that condition and consequently make wrong therapeutic decisions.

In acupuncture (and indeed in most alternative medicine) research, the problem is so extremely wide-spread that it is high time to do something about it. Journal editors, peer-reviewers, ethics committees, universities, funding agencies and all others concerned with such research have to work together so that such flagrant abuse is stopped once and for all.

The above title was used for a Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

I have taken the liberty to quote its abstract in full:

Purpose—Cervical artery dissections (CDs) are among the most common causes of stroke in young and middle-aged adults. The aim of this scientific statement is to review the current state of evidence on the diagnosis and management of CDs and their statistical association with cervical manipulative therapy (CMT). In some forms of CMT, a high or low amplitude thrust is applied to the cervical spine by a healthcare professional.

Methods—Members of the writing group were appointed by the American Heart Association Stroke Council’s Scientific Statements Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge.

Results—Patients with CD may present with unilateral headaches, posterior cervical pain, or cerebral or retinal ischemia (transient ischemic or strokes) attributable mainly to artery–artery embolism, CD cranial nerve palsies, oculosympathetic palsy, or pulsatile tinnitus. Diagnosis of CD depends on a thorough history, physical examination, and targeted ancillary investigations. Although the role of trivial trauma is debatable, mechanical forces can lead to intimal injuries of the vertebral arteries and internal carotid arteries and result in CD. Disability levels vary among CD patients with many having good outcomes, but serious neurological sequelae can occur. No evidence-based guidelines are currently available to endorse best management strategies for CDs. Antiplatelet and anticoagulant treatments are both used for prevention of local thrombus and secondary embolism. Case-control and other articles have suggested an epidemiologic association between CD, particularly vertebral artery dissection, and CMT. It is unclear whether this is due to lack of recognition of preexisting CD in these patients or due to trauma caused by CMT. Ultrasonography, computed tomographic angiography, and magnetic resonance imaging with magnetic resonance angiography are useful in the diagnosis of CD. Follow-up neuroimaging is preferentially done with noninvasive modalities, but we suggest that no single test should be seen as the gold standard.

Conclusions—CD is an important cause of ischemic stroke in young and middle-aged patients. CD is most prevalent in the upper cervical spine and can involve the internal carotid artery or vertebral artery. Although current biomechanical evidence is insufficient to establish the claim that CMT causes CD, clinical reports suggest that mechanical forces play a role in a considerable number of CDs and most population controlled studies have found an association between CMT and VAD stroke in young patients. Although the incidence of CMT-associated CD in patients who have previously received CMT is not well established, and probably low, practitioners should strongly consider the possibility of CD as a presenting symptom, and patients should be informed of the statistical association between CD and CMT prior to undergoing manipulation of the cervical spine.

In my view, this is an important statement to which I have little to add – however, I hope that the readers of this post will have comments, criticisms, observations, opinions, etc.

We all know, I think, that chronic low back pain (CLBP) is common and causes significant suffering in individuals as well as cost to society. Many treatments are on offer but, as we have seen repeatedly on this blog, not one is convincingly effective and some, like chiropractic, is associated with considerable risks.

Enthusiasts claim that hypnotherapy works well, but too little is known about the minimum dose needed to produce meaningful benefits, the roles of home practice and hypnotizability on outcome, or the maintenance of treatment benefits beyond 3 months. A new trial was aimed at addressing these issues.

One hundred veterans with CLBP participated in a randomized, four parallel group study. The groups were (1) an eight-session self-hypnosis training intervention without audio recordings for home practice; (2) an eight-session self-hypnosis training intervention with recordings; (3) a two-session self-hypnosis training intervention with recordings and brief weekly reminder telephone calls; and (4) an eight-session active (biofeedback) control intervention.

Participants in all four groups reported significant pre- to post-treatment improvements in pain intensity, pain interference and sleep quality. The three hypnotherapy groups combined reported significantly more pain intensity reduction than the control group. There was no significant difference among the three hypnotherapy groups. Over half of the participants who received hypnotherapy reported clinically meaningful (≥30%) reductions in pain intensity, and they maintained these benefits for at least 6 months after treatment. Neither hypnotizability nor amount of home practice was associated significantly with treatment outcome.

The authors conclude that two sessions of self-hypnosis training with audio recordings for home practice may be as effective as eight sessions of hypnosis treatment. If replicated in other patient samples, the findings have important implications for the application of hypnosis treatment for chronic pain management.

Even though this trial has several important limitations, I do agree with the authors: these results would be worth an independent replication – not least because self-hypnosis is cheap and does not carry great risks. What would be interesting, in my view, are studies that compare several alternative LBP therapies (e.g. chiropractic, osteopathy, acupuncture, massage, various form of exercise and hypnotherapy) in terms of cost, risks, long-term effectiveness and patients’ preference. I somehow feel that the results of such comparative trials might overturn the often issued recommendations for spinal manipulation, i.e. chiropractic or osteopathy.

Niacin – also known as vitamin B3 or nicotinic acid - is a natural compound (formula C
6
H
5
NO
2
) and an essential nutrient for humans. It is water-soluble, which means it is not stored in the body. Excess amounts of the vitamin leave the body through the urine. That means we need a continuous supply of niacin in your diet.

Niacin is found in variety of foods, including liver, chicken, beef, fish, cereal, peanuts and legumes. It can also be synthesized from tryptophan, an essential amino acid found in protein. Niacin has long been an accepted treatment for high cholesterol. It is well-documented to increase the levels of high-density cholesterol (HDL or “good cholesterol”) and to decrease the levels of low-density cholesterol (LDL or “bad cholesterol”).

But what do these effects really mean? Do they translate into true health benefits? A brand-new study casts doubt on the value of niacin therapy:

After a pre-randomization run-in phase to standardize the background statin-based LDL cholesterol-lowering therapy and to establish participants’ ability to take extended-release niacin without clinically significant adverse effects, the researchers randomly assigned 25,673 adults with vascular disease to receive 2 g of extended-release niacin and 40 mg of laropiprant or a matching placebo daily. The primary outcome was the first major vascular event (non-fatal myocardial infarction, death from coronary causes, stroke, or arterial revascularization).

During a median follow-up period of 3.9 years, participants who were assigned to extended-release niacin-laropiprant had an LDL cholesterol level that was 10 mg per deciliter (0.25 mmol/l) lower and an HDL cholesterol level that was 6 mg per deciliter (0.16 mmol/l) higher than the levels in those assigned to placebo. Thus the lipid-effects of previous studies were confirmed.

However, assignment to niacin-laropiprant, as compared with assignment to placebo, had no significant effect on the incidence of major vascular events Niacin-laropiprant was associated with an increased incidence of disturbances in diabetes control that were considered to be serious and with an increased incidence of diabetes diagnoses as well as increases in serious adverse events associated with the gastrointestinal system, the musculoskeletal system, the skin and infections and bleeding.

Based of these data, the authors arrived at the following conclusion: among participants with atherosclerotic vascular disease, the addition of extended-release niacin-laropiprant to statin-based LDL cholesterol-lowering therapy did not significantly reduce the risk of major vascular events but did increase the risk of serious adverse events.

This extremely well-done trial is a poignant reminder of the fact that, in health care, we must never take our assumptions for granted. Here the underlying assumption was that the Niacin-induced lipid changes lead to a reduction of cardiovascular risks. Not only it proved to be erroneous but, through serious adverse effects, Niacin actually decreased patients’ health status.

The lessons from all this are straight forward, I think:

  • ‘Natural’ does not necessarily mean safe.
  • Long-established does not necessarily mean efficacious.
  • Assumptions are merely assumptions, nothing more; if we want to make sure that they hold, we need to test them.
  • When we finally do test assumptions, we better do it rigorously.

One alternative therapy that I have so far almost entirely neglected is Ayurveda. It is said to be one of the fastest growing system within this sector. Ayurvedic healing includes herbs, nutrition, panchakarma cleansing, acupressure massage, Yoga, Sanskrit, and Jyotish (Vedic astrology). The website of the ‘Choppra Center’ explains: Recognizing that human beings are part of nature, Ayurveda describes three fundamental energies that govern our inner and outer environments: movement, transformation, and structure. Known in Sanskrit as Vata (Wind), Pitta (Fire), and Kapha (Earth), these primary forces are responsible for the characteristics of our mind and body. Each of us has a unique proportion of these three forces that shapes our nature. If Vata is dominant in our system, we tend to be thin, light, enthusiastic, energetic, and changeable. If Pitta predominates in our nature, we tend to be intense, intelligent, and goal-oriented and we have a strong appetite for life. When Kapha prevails, we tend to be easy-going, methodical, and nurturing. Although each of us has all three forces, most people have one or two elements that predominate.

However, the evidence for its effectiveness is not overwhelming. In 2007, we published a systematic review of Ayurvedic treatments for rheumatoid arthritis (RA). Seven studies met our inclusion criteria. Trials tested either Ayurvedic medicine against placebo or other Ayurvedic medicines. Of 3 placebo-controlled RCTs, one high-quality trial did not show benefit of the active treatment against placebo, while another incompletely reported study indicated beneficial effects of an Ayurvedic medicine. A further incompletely reported study showed no significant difference. The remaining 4 trials were difficult to interpret because they tested an Ayurvedic medicine against other Ayurvedic medicines whose effects were not proven. We concluded that there is a paucity of RCTs of Ayurvedic medicines for RA. The existing RCTs fail to show convincingly that such treatments are effective therapeutic options for RA.

Because of this paucity of reliable evidence, any new assessments are welcome.

The aim of this article was to review and meta-analyze the effectiveness and safety of different Ayurvedic interventions in patients with osteoarthritis (OA). 138 electronic databases were searched through August 2013. Randomized controlled trials, randomized crossover studies, cluster-randomized trials, and non-randomized controlled clinical trials were eligible. Adults with pre-diagnosed OA were included as participants.

Interventions were included as Ayurvedic, if they were explicitly labeled as such. The main outcome measures were pain, physical function, and global improvement. Risk of bias was assessed using the Cochrane risk of bias tool.

19 randomized and 14 non-randomized controlled trials on 12 different drugs and 3 non-pharmaceutical interventions with a total of 2,952 patients were included. For the compound preparation, Rumalaya, large and apparently unbiased effects beyond placebo were found for pain (standardized mean difference [SMD] -3.73; 95 % confidence interval [CI] -4.97, -2.50; P < 0.01) and global improvement (risk ratio 12.20; 95 % CI 5.83, 25.54; P < 0.01).

There was also some evidence that effects of the herbal compound preparation Shunti-Guduchi are comparable to those of glucosamine for pain (SMD 0.08; 95 % CI -0.20, 0.36; P = 0.56) and function (SMD 0.15; 95 % CI -0.12, 0.36; P = 0.41).

Based on single trials, positive effects were found for the compound preparations RA-11, Reosto, and Siriraj Wattana. For Boswellia serrata, Lepidium Sativum, a Boswellia serrata containing multicomponent formulation and the compounds Nirgundi Taila, Panchatikta Ghrita Guggulu, and Rhumayog, and for non-pharmacological interventions like Ayurvedic massage, steam therapy, and enema, no evidence for significant effects against potential methodological bias was found.

No severe adverse events were observed in any of the trials.

The authors concluded that the drugs Rumalaya and Shunti-Guduchi seem to be safe and effective drugs for treatment of OA-patients, based on these data. However, several limitations relate to clinical research on Ayurveda. Well-planned, well-conducted and well-published trials are warranted to improve the evidence for Ayurvedic interventions.

I am, of course, pleased that other too have noticed the paucity of good evidence and recommend more and better research into this area. There are, however, several things that worry me about this systematic review:

  • How can there be a total absence of adverse effects? Even placebos would generate some.
  • The conclusion that Rumalaya and Shunti-Guduchi are safe does not seem justified on the basis of just a few trials.
  • My own review found quite encouraging effects for Boswellia serrate.
  • 138 electronic databases? I did not even know that so many existed!
  • I am also concerned by the way the treatments found to be ‘safe and effective’ are being promoted on the internet:

Rumalaya is a phytopharmaceutical formulation that relieves joint and bone ache associated with various orthopedic ailments. Its natural ingredients possess potent anti-inflammatory properties that alleviate pain. As an immunomodulator, Rumalaya modulates both the humoral and cell-mediated immune response to aches and pain. The medicine has strong anti-arthritic properties that work to combat arthritis.

Indications:

  • Rheumatic arthritis
  • Rheumatoid arthritis
  • Cervical and lumbar spondylosis
  • Osteoarthritis
  • Arthralgia
  • Gout
  • Frozen shoulder
  • Traumatic inflammatory conditions like fibrositis, bursitis, synovitis, capsulitis, tenosynovitis, myositis and sciatica.

I fail to see good evidence to support most of these claims.

Lastly, I find that the authors fail to warn the public in sufficiently strong terms of some of the drawbacks of Ayurvedic medicines. Many of them seem not to be safe. One of several problems is that they have been shown to be often contaminated/adulterated with toxic substances such as heavy metals.

My conclusion about the value of Ayurvedic medicines is therefore not so optimistic: EFFICACY IS USUALLY MORE THAN DOUBTFUL, WHILE RISKS ARE WELL-DOCUMENTED.

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