Edzard Ernst

MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Yesterday, BBC NEWS published the following interesting text about a BBC4 broadcast entitled ‘THE ROYAL ACTIVIST’ aired on the same day:

Prince Charles has been a well-known supporter of complementary medicine. According to a… former Labour cabinet minister, Peter Hain, it was a topic they shared an interest in.

“He had been constantly frustrated at his inability to persuade any health ministers anywhere that that was a good idea, and so he, as he once described it to me, found me unique from this point of view, in being somebody that actually agreed with him on this, and might want to deliver it.”
Mr Hain added: “When I was Secretary of State for Northern Ireland in 2005-7, he was delighted when I told him that since I was running the place I could more or less do what I wanted to do.***
“I was able to introduce a trial for complementary medicine on the NHS, and it had spectacularly good results, that people’s well-being and health was vastly improved.

“And when he learnt about this he was really enthusiastic and tried to persuade the Welsh government to do the same thing and the government in Whitehall to do the same thing for England, but not successfully,” added Mr Hain.

*** obviously there is no homeopathic remedy for megalomania (but that’s a different story)

Oh really?

A TRIAL?

SPECTACULARLY GOOD RESULTS?

NO KIDDING?

Let’s have a look at the ‘trial’ and its results. An easily accessible report provides the following details about it:

From February 2007 to February 2008, Get Well UK ran the UK’s first government-backed complementary therapy pilot. Sixteen practitioners provided treatments including acupuncture, osteopathy and aromatherapy, to more than 700 patients at two GP practices in Belfast and Derry.   

The BBC made an hour long documentary following our trials and tribulations, which was broadcast on BBC1 NI on 5 May 2008.

Following the successful completion of the pilot, the results were analysed by Social and Market Research and recommendations were made to the Health Minister

Aims and Objectives 

The aim of the project was to pilot services integrating complementary medicine into existing primary care services in Northern Ireland. Get Well UK provided this pilot project for the Department for Health, Social Services and Public Safety (DHSSPS) during 2007.

The objectives were:

  • To measure the health outcomes of the service and monitor health improvements.
  • To redress inequalities in access to complementary medicine by providing therapies through the NHS, allowing access regardless of income.
  • To contribute to best practise in the field of delivering complementary therapies through primary care.
  • To provide work for suitably skilled and qualified practitioners.
  • To increase patient satisfaction with quick access to expert care.
  • To help patients learn skills to improve and retain their health.
  • To free up GP time to work with other patients.
  • To deliver the programme for 700 patients.

Results 

The results of the pilot were analysed by Social and Market Research, who produced this report.

The findings can be summarised as follows: 

Following the pilot, 80% of patients reported an improvement in their symptoms, 64% took less time off work and 55% reduced their use of painkillers.

In the pilot, 713 patients with a range of ages and demographic backgrounds and either physical or mental health conditions were referred to various complementary and alternative medicine (CAM) therapies via nine GP practices in Belfast and Londonderry. Patients assessed their own health and wellbeing pre and post therapy and GPs and CAM practitioners also rated patients’ responses to treatment and the overall effectiveness of the scheme.

Health improvement
• 81% of patients reported an improvement in their physical health
• 79% reported an improvement in their mental health
• 84% of patients linked an improvement in their health and wellbeing directly to their CAM treatment
• In 65% of patient cases, GPs documented a health improvement, correlating closely to patient-reported improvements
• 94% of patients said they would recommend CAM to another patient with their condition
• 87% of patient indicated a desire to continue with their CAM treatment

Painkillers and medication
• Half of GPs reported prescribing less medication and all reported that patients had indicated to them that they needed less
• 62% of patients reported suffering from less pain
• 55% reported using less painkillers following treatment
• Patients using medication reduced from 75% before treatment to 61% after treatment
• 44% of those taking medication before treatment had reduced their use afterwards

Health service and social benefits
• 24% of patients who used health services prior to treatment (i.e. primary and secondary care, accident and emergency) reported using the services less after treatment
• 65% of GPs reported seeing the patient less following the CAM referral
• Half of GPs said the scheme had reduced their workload and 17% reported a financial saving for their practice
• Half of GPs said their patients were using secondary care services less.

Impressed? Well, in case you are, please consider this:

  • there was no control group
  • therefore it is not possible to attribute any of the outcomes to the alternative therapies offered
  • they could have been due to placebo-effects
  • or to the natural history of the disease
  • or to regression towards the mean
  • or to social desirability
  • or to many other factors which are unrelated to the alternative treatments provided
  • most outcome measures were not objectively verified
  • the patients were self-selected
  • they would all have had conventional treatments in parallel
  • this ‘trial’ was of such poor quality that its findings were never published in a peer-reviewed journal
  • this was not a ‘trial’ but a ‘pilot study’
  • pilot studies are not normally for measuring outcomes but for testing the feasibility of a proper trial
  • the research expertise of the investigators was close to zero
  • the scientific community merely had pitiful smiles for this ‘trial’ when it was published
  • neither Northern Ireland nor any other region implemented the programme despite its “spectacularly good results”.

So, is the whole ‘trial’ story an utterly irrelevant old hat?

Certainly not! Its true significance does not lie in the fact that a few amateurs are trying to push bogus treatments into the NHS via the flimsiest pseudo-research of the century. The true significance, I think, is that it shows how Prince Charles, once again, oversteps the boundaries of his constitutional role.

Arnold Relman has died aged 91. He was a great personality, served for many years as editor-in-chief of ‘The New England Journal of Medicine’ and was professor of medicine and social medicine at Harvard Medical School. He also was an brilliantly outspoken critic of alternative medicine, and I therefore believe that he deserves to be remembered here. The following excerpts are from an article he wrote in 1998 about Andrew Weil, America’s foremost guru of alternative medicine; I have taken the liberty of extracting a few paragraphs which deal with alternative medicine in general terms.

Until now, alternative medicine has generally been rejected by medical scientists and educators, and by most practicing physicians. The reasons are many, but the most important reason is the difference in mentality between the alternative practitioners and the medical establishment. The leaders of the establishment believe in the scientific method, and in the rule of evidence, and in the laws of physics, chemistry, and biology upon which the modern view of nature is based. Alternative practitioners either do not seem to care about science or explicitly reject its premises. Their methods are often based on notions totally at odds with science, common sense, and modern conceptions of the structure and the function of the human body. In advancing their claims, they do not appear to recognize the need for objective evidence, asserting that the intuitions and the personal beliefs of patients and healers are all that is needed to validate their methods. One might have expected such thinking to alienate most people in a technologically advanced society such as ours; but the alternative medicine movement, and the popularity of gurus such as Weil, are growing rapidly…

That people usually “get better,” that most relatively minor diseases heal spontaneously or seem to improve with simple common remedies, is hardly news. Every physician, indeed every grandmother, knows that. Yet before we accept Weil’s contention that serious illnesses such as “bone cancer,” “Parkinson’s disease,” or “scleroderma” are similarly curable, or respond to alternative healing methods, we need at least to have some convincing medical evidence that the patients whom he reports in these testimonials did indeed suffer from these diseases, and that they were really improved or healed. The perplexity is not that Weil is using “anecdotes” as proof, but that we don’t know whether the anecdotes are true.

Anecdotal evidence is often used in the conventional medical literature to suggest the effectiveness of treatment that has not yet been tested by formal clinical trials. In fact, much of the mainstream professional literature in medicine consists of case reports — “anecdotes,” of a kind. The crucial difference between those case reports and the testimonials that abound in Weil’s books (and throughout the literature of alternative medicine) is that the case reports in the mainstream literature are almost always meticulously documented with objective data to establish the diagnosis and to verify what happened, whereas the testimonials cited by alternative medicine practitioners usually are not. Weil almost never gives any objective data to support his claims. Almost everything is simply hearsay and personal opinion.

To the best of my knowledge, Weil himself has published nothing in the peer-reviewed medical literature to document objectively his personal experiences with allegedly cured patients or to verify his claims for the effectiveness of any of the unorthodox remedies he uses. He is not alone in this respect. Few proponents of alternative medicine have so far published clinical reports that would stand the rigorous scientific scrutiny given to studies of traditional medical treatments published in the serious medical journals. Alternative medicine is still a field rich in undocumented claims and anecdotes and relatively lacking in credible scientific reports…

… Thus Weil can believe in miraculous cures even while claiming to be rational and scientific, because he thinks that quantum theory supports his views.

Yet the leading physicists of our time do not accept such an interpretation of quantum theory. They do not believe quantum theory says anything about the role of human consciousness in the physical world. They see quantum laws as simply a useful mathematical formulation for describing subatomic phenomena that are not adequately handled by classical physical theory, although the latter remains quite satisfactory for the analysis of physical events at the macro-level. Steven Weinberg has observed that “quantum mechanics has been overwhelmingly important to physics, but I cannot find any messages for human life in quantum mechanics that are different in any important way from those of Newtonian physics.” And overriding all discussions of the meaning of quantum physics is the fundamental fact that quantum theory, like all other scientific law, is only valid to the extent that it predicts and accords with the evidence provided by observation and objective measurement. Richard Feynman said it quite simply: “Observation is the ultimate and final judge of the truth of an idea.” Feynman also pointed out that scientific observations need to be objective, reproducible, and, in a sense, public — that is, available to all interested scientists who wish to check the observations for themselves.

Surely almost all scientists would agree with Feynman that, regardless of what theory of nature we wish to espouse, we cannot escape the obligation to support our claims with objective evidence. All theories must conform to the facts or be discarded. So, if Weil cannot produce credible evidence to validate the miraculous cures that he claims for the healing powers of the mind, and if he does not support with objective data the claims he and others make for the effectiveness of alternative healing methods, he cannot presume to wear the mantle of science, and his appeal to quantum theory cannot help him.

Some apologists for alternative medicine have argued that since their healing methods are based on a “paradigm” different from that of traditional medicine, traditional standards of evidence do not apply. Weil sometimes seems to agree with that view, as when he talks about “stoned thinking” and the “ambivalent” nature of reality, but more recently — as he seeks to integrate alternative with allopathic medicine — he seems to acknowledge the need for objective evidence. This, at least, is how I would interpret one of his most recent and ambitious publishing ventures, the editorship of the new quarterly journal Integrative Medicine***.

Integrative Medicine describes itself as a “peer-reviewed journal … committed to gathering evidence for the safety and efficacy of all approaches to health according to the highest standards of scientific research, while remaining open to new paradigms and honoring the healing power of nature.” The Associate Editors and Editorial Board include prominent names in both alternative medicine and allopathic medicine, who presumably support that mission. Yet the first two issues will disappoint those who were looking for original clinical research based on new, objective data. Perhaps subsequent issues will be different, but in any case it is hard to understand the need for Weil’s new journal if he truly intends to hold manuscripts to accepted scientific standards: there already exist many leading peer-reviewed medical journals that will review research studies of alternative healing methods on their merits. During the past decade or so, only a few such studies have passed rigorous review and have been published in first-rate journals. Recently, more studies have been published, but very few of them report significant clinical effects. And that is pretty much where matters now stand. Despite much avowed interest in research on alternative medicine and increased investment in support of such research, the evidentiary underpinnings of unconventional healing methods are still largely lacking…

The alternative medicine movement has been around for a long time, but it was eclipsed during most of this century by the success of medical science. Now there is growing public disenchantment with the cost and the impersonality of modern medical care, as well as concern about medical mistakes and the complications and side-effects of pharmaceuticals and other forms of medical treatment. For their part, physicians have allowed the public to perceive them as uninterested in personal problems, as inaccessible to their patients except when carrying out technical procedures and surgical operations. The “doctor knows best” attitude, which dominated patient-doctor relations during most of the century, has in recent decades given way to a more activist, consumer-oriented view of the patient’s role. Moreover, many other licensed health-care professionals, such as nurse-practitioners, psychotherapists, pharmacists, and chiropractors, are providing services once exclusively reserved to allopathic physicians.

The net result of all these developments has been a weakening of the hegemony that allopathic medicine once exercised over the health care system, and a growing interest by the public in exploring other healing approaches. The authority of allopathic medicine is also being challenged by a swelling current of mysticism and anti-scientism that runs deep through our culture. Even as the number and the complexity of urgent technological and scientific issues facing contemporary society increase, there seems to be a growing public distrust of the scientific outlook and a reawakening of interest in mysticism and spiritualism.

All this obscurantism has given powerful impetus to the alternative medicine movement, with its emphasis on the power of mind over matter. And so consumer demand for alternative remedies is rising, as is public and private financial support for their study and clinical use. It is no wonder that practicing physicians, the academic medical establishment, and the National Institutes of Health are all finding reasons to pay more attention to the alternative medicine movement. Indeed, it is becoming politically incorrect for the movement’s critics to express their skepticism too strongly in public…

There is no doubt that modern medicine as it is now practiced needs to improve its relations with patients, and that some of the criticisms leveled against it by people such as Weil — and by many more within the medical establishment itself — are valid. There also can be no doubt that a few of the “natural” medicines and healing methods now being used by practitioners of alternative medicine will prove, after testing, to be safe and effective. This, after all, has been the way in which many important therapeutic agents and treatments have found their way into standard medical practice in the past. Mainstream medicine should continue to be open to the testing of selected unconventional treatments. In keeping an open mind, however, the medical establishment in this country must not lose its scientific compass or weaken its commitment to rational thought and the rule of evidence.

There are not two kinds of medicine, one conventional and the other unconventional, that can be practiced jointly in a new kind of “integrative medicine.” Nor, as Andrew Weil and his friends also would have us believe, are there two kinds of thinking, or two ways to find out which treatments work and which do not. In the best kind of medical practice, all proposed treatments must be tested objectively. In the end, there will only be treatments that pass that test and those that do not, those that are proven worthwhile and those that are not. Can there be any reasonable “alternative”?

 

*** the journal only existed for a short period of time

Do you suffer from any of the following conditions/problems?

• Feeling of being forsaken and SEPARATION; huge despair.
• Oppression (political, family, abuse-sexual, religious, being bullied) and perceiving yourself as victim.
• States of possession.
• Children of ambitious parents who are pushed.
• Caring professions which give rise to burn out and/or brain deadness.
• Indescribable evil/darkness.
• Not showing anything: MASKS, unsmiling.
• Suspicious, uneasy, shifty eyes; cannot look you in the eye.
• Hangdog of head, beaten.
• Frequent weeping, tears just flow; sense of numbness or despair over them.
• Deep grief which cannot be accessed, unspoken, but it hangs in the air.
• Depression, sense of blackness, total isolation, aloneness, despair.
• Panic, need to escape but can’t. TERROR.
• Feel brainwashed, lack the courage to break free, unable to break from the past.
• Everything will fail; despair of recovery.
Painlessness.
• Aggression against yourself.
• Impulsivity – anything can happen.
• Aggression to others or animals (fascinated by it). Child who hangs a cat with a rope around the neck to see what happens.
• Deceit.
• Guilt, not resolvable.
• ASTHMA, crushing on chest, suffocation.
• Headache, deep crushing, congestion, bursting with depression and photophobia; gives the feeling of being cut off and isolated.
• After strokes, for parts not connected yet again.
• Temporary blindness and deafness in emotional situations.
• Stiffness of joints-swelling: ” a claw coming into it”.
• Dupuytren.
• Emptiness, a hole in the gut (ulcers).
Narcolepsia (20 hrs a day).
• Insomnia.

If so, you are, according to some homeopaths, in need of a very special homeopathic remedy: BERLIN WALL.

No, I am not joking! There are even case reports of successful treatments with this extraordinary remedy: A case of asthma, fear and depression, solved with the remedy ‘Berlin Wall’.

Homeopathy is based on the ‘like cures like’ principle. This means that anything which causes symptoms in a healthy person, can be used to treat these symptoms when they occur in a patient. ANYTHING! Even fragments from the BERLIN WALL.

Of course, the bits of the wall are not administered in their original form; this might be unhealthy and, eventually, it could even exhaust the supply of the raw material. It is ‘potentized‘ which means it is diluted and diluted and diluted and diluted and…

So, the homeopathic BERLIN WALL is as safe as a placebo – in fact, it is a placebo!

On this blog, I have repeatedly stressed that there is reasonably good evidence to show that some herbal medicines are effective. The one that is probably supported with better evidence than any other is St. John’s wort (SJW). The first systematic review of SJW was published in 1995 and concluded that SJW is an effective symptomatic treatment for various forms of depressions. Meanwhile, many more trials have become available, and the current Cochrane review concludes that the available evidence suggests that the hypericum extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; c) and have fewer side effects than standard antidepressants. 

This must be good news for many patients; particularly the fact that SJW is much safer than synthetic antidepressants seems attractive. But don’t be fooled – SJW may still cause harm. If taken on its own, it is almost as safe as placebo, but when it is combined with other drugs, it can powerfully interact and significantly lower the plasma level of a wide range of prescription medicines.

Some proponents of alternative medicine have suggested that this caution is alar@BocktheRobber mist, and they insist that, actually, the danger is minimal. Are they correct? We need data, I think, not opinion.

A new article provides new insights.

The objective of this study was to assess how often SJW is prescribed with medications that may interact dangerously with it. The researchers conducted a retrospective analysis of nationally representative data from the National Ambulatory Medical Care Survey. The study setting was U.S. non-federal outpatient physician offices. Patients who were prescribed SJW between 1993 and 2010 were the subjects. The outcome measures were medications co-prescribed with SJW.

Twenty-eight percent of SJW visits involved a drug that has potentially dangerous interaction with SJW. These included selective serotonin reuptake inhibitors, benzodiazepines, warfarin, statins, verapamil, digoxin, and oral contraceptives.

The authors concluded that SJW is frequently used in potentially dangerous combinations. Physicians should be aware of these common interactions and warn patients appropriately.

There is little to add – perhaps just this: the awareness of physicians is undoubtedly desirable, but it is not enough; as SJW and other herbal medicines are usually self-prescribed, consumers’ awareness of the risks associated with herbal medicines is at least as important, I think.

‘THE HINKLEY TIMES’ is not a paper that I read often, I have to admit – but maybe I should! It was there that I found the following remarkable article:

Bosworth MP David Tredinnick has asked questions in the House of Commons about the growing problem of antibiotic resistance within hospitals, suggesting herbal remedies could be answer.

The Tory MP, who has a keen interest in alternative medicine particularly herbal curatives, asked Jeremy Hunt, Secretary of State for Health, whether the problem was being discussed at the very top level.

He said: “Does my right honourable friend agree that a critical problem that A and E units will face in the future is antibiotic resistance? Is he aware that the science and technology committee, of which I am a member, has been looking at this issue and it also interests the health committee, of which I am also a member? Can he assure me that he is talking to the Prime Minister about how to stimulate new antibiotic research, and will he also remember that nature has its own remedies, such as tea tree oil?”

In reply Mr Hunt said: “My honourable friend is right about the seriousness of the issue of antimicrobial resistance. Some 25,000 people die in Europe every year as a result of the failure of antibiotics – more than die in road traffic accidents. I raised the issue at the World Health Assembly and I have discussed it closely with the Prime Minister.”

David Tredinnick is no stranger to strange ideas. Wikipedia (yes I know, many people do not like it as a source) sums it up quite succinctly:

He is a supporter of complementary and alternative medicine (CAM). He has made supportive comments in Parliament on homeopathy, despite continued lack of evidence of its effectiveness. He has supported chiropractic and mentioned the influence of the Moon on blood clotting. In this same debate he characterised scientists as “racially prejudiced”. He has tabled several early day motions in support of homeopathy’s continued funding on the National Health Service.Tredinnick’s views continue to cause amused disbelief in some quarters and a spokesman for the Royal College of Surgeons of England said they would “laugh their heads off” at the suggestion they could not operate at the full moon.

At the 2010 general election, in addition to candidates from the two main parties, Tredinnick was opposed by New Scientist journalist Dr. Michael Brooks who objected to “Tredinnick’s outspoken promotion of complementary and alternative medicine.”During a hustings debate called by Brooks to “highlight the scientific literacy of the UK’s elected representatives” Brooks claimed that Tredinnick regarded homeopathy as a suitable treatment for Malaria and HIV, which Tredinnick did not deny. Tredinnick in turn argued that “alternative treatments are incredibly good value for money” and stated his belief that randomised controlled trials are not effective at evaluating very dilute preparations.

In March 2013 Tredinnick was ridiculed as “nonsensical” by the government’s outgoing chief scientist, Sir John Beddington, who said the MP had fallen for the “Galileo fallacy” (Galileo was laughed at but was right, therefore since I am laughed at I must be right).

In July 2013 Tredinnick sponsored an EDM congratulating a farmer on his decision to use homeopathy with what were claimed to be positive results.The motion was supported by one other MP but the British veterinary association says there is no evidence of any benefit.

Tredinnick is a supporter of astrology especially the use of it in medical practice.In November 2009, he spoke at a meeting organised by the Astrological Association of Great Britain, where he related his personal experience of astrology and illness, advocating that astrology be integrated into the NHS.

Tredinnick’s appointment to the Health committee in June 2010 was criticised in two science reports in the Guardian. Martin Robbins said his appointment was “an extremely disturbing development” even though “Tredinnick is a figure unlikely to be taken seriously by policymakers” whilst Nature‘s Adam Rutherford described Tredinnick as “misinformed about a great many things” and said that “giving [him] influence on medical policy ..is a bad move.”The Telegraph writer Ian Douglas also described it as “a problem.”

His appointment to the Science and technology committee also drew criticism. Andy McSmith in the Independent, cited his views that homeopathy could cure HIV, TB, malaria, urinary infections, diarrhoea, skin eruptions, diabetes, epilepsy, eye infections, intestinal parasites, cancer, and gangrene amongst others and quoted Imran Khan, head of the Campaign for Science and Engineering, as saying that “someone with such incredibly odd views is not helpful”. Tom Whipple in the Times said his appointment caused despair,whilst Elizabeth Gibney in the Times Higher Education quoted the Skeptical Voter website as saying that Tredinnick is “perhaps the worst example of scientific illiteracy in government”…

In 2009 Tredinnick attempted to claim the £125 cost of attending a course on “intimate relationships” through his Parliamentary expenses. He was also found to have used expenses to purchase astrology software, claiming it was for a debate on alternative medicine.

Compared to some of theses bizarre activities, the notion that herbal remedies might provide the solution for antibiotic resistance seems almost reasonable and clever.

ALMOST!!!

Tredinnick does not seem to know that:

  • many antibiotics originate from plants or other natural substances,
  • several large pharmaceutical companies are feverishly looking for more such substances from plants,
  • most plants do actually contain substances which have antibiotic activity,
  • however, most cannot be used as medicines, for instance, because they are far too toxic (tea tree oil is a good example for this),
  • once a pure compound has been isolated from a plant and is used therapeutically, it ceases to be herbal medicine (which is defined as the use of full plant extracts),
  • it is thus unlikely that full plant extracts, i. e. herbal medicine, will ever provide a solution to antibiotic resistance.

I have little doubt that Tredinnick will continue to mislead parliament and the public with his nonsensical views about alternative medicine. And even if it might have no effect whatsoever, I will continue to point out just how nonsensical they are.

Some time ago, I published a post entitled HOW TO BECOME A CHARLATAN. This prompted ‘THE NORWEGIAN ACADEMY OF SCIENCE AND LETTERS’ to invite me to give a lecture on the subject, a great honour, I am sure. Consequently, I have thought about this somewhat unusual subject quite a lot.

Obviously, my thoughts come from the perspective of someone who has researched alternative medicine for many years. Pseudoscientists seem to love alternative medicine and proponents of alternative medicine love pseudoscience. As a result, alternative medicine is densely populated by pseudoscientists.

But what is the characteristic of pseudoscience? Reflecting on this question, I found not one but several hallmarks (and for each of them, there are many posts on this blog which provide further explanations):

Based on these 12 hallmarks, one could create a simple score which indicates the likelihood of the presence of pseudoscience. In other words, it might be useful to consider pseudoscience in terms of a sliding scale. Some things in alternative medicine can be just a bit pseudoscientific, others quite a lot, while others again are hopelessly so.

The issue of pseudoscience is by no means just academic; it is very real problem and has many important, practical implications. The most important one probably is that, in health care (and other areas as well), pseudoscience can be harmful, even to the point that it costs lives of vulnerable patients who believe that everything masquerading as science can be relied upon.

Many readers of this blog will be agree that the founder of homeopathy invented placebo-therapy. However, few might know that he did this not once but twice (albeit in entirely different circumstances).

Samuel Hahnemann (1755-1843) was the first physician who administrated placebos to his patient on a systematic and regular basis – at least, this is the thesis that a medical historian with a special interest in homeopathy, R Juette, recently published. His study is based upon unpublished documents (e.g. patients’ letters) kept in the Archives of the Institute for the History of Medicine of the Robert Bosch Foundation in Stuttgart. It also profited from the critical examination of Hahnemann’s case journals and the editorial comments which have also been published in this series.

Hahnemann differentiated clearly between homeopathic drugs and pharmaceutical substances which he considered as sham medicine and called ‘allopathic medicine’. Juette’s analysis of Hahnemann’s case journals revealed that the percentage of Hahnemann’s placebo prescriptions was very high - between 54 and 85 percent. In most instances, Hahnemann marked placebos with the paragraph symbol (§). The rationale behind this practice was that Hahnemann encountered many patients who were used to taking medicine on a daily basis as it was typical for the age of ‘heroic medicine’. His main reason for giving placebos intentionally was therefore to please the impatient patient who was used to the regimen of frequent medications of ‘allopathic’ medicine.

Being a proponent of homeopathy, Juette does not mention Hahnemann’s second invention of placebo therapy: in the shape of his very own, highly diluted homeopathic remedies. Hahnemann was, of course, convinced that they differed from placebo. Two hundred years ago, this attitude was perhaps forgivable. Today, we know that a typical homeopathic medicine contains no substance that could have any meaningful health effects, and that the best evidence fails to show that homeopathic remedies produce effects that differ from placebos. In a word, they are placebos.

It follows that Hahnemann invented the routine use of placebo twice over: 1) intentionally to satisfy the demand for medication of patients who, according to his judgement, needed none, and 2) unintentionally in the form of homeopathic remedies which he thought were effective but are, as we know today, pure placebos.

If you are pregnant, a ‘breech presentation’ is not good news. It occurs when the fetus presents ‘bottom-down’ in the uterus. There are three types:

  • Breech with extended legs (frank) – 85% of cases
  • Breech with fully flexed legs (complete)
  • Footling (incomplete) with one or both thighs extended

The significance of breech presentation is its association with higher perinatal mortality and morbidity when compared to cephalic presentations. This is due both to pre-existing congenital malformation, increased incidence of breech in premature deliveries and increased risk of intrapartum trauma or asphyxia. Caesarean section has been adopted as the ‘normal’ mode of delivery for term breech presentations in Europe and the USA, as the consensus is that this reduces the risk of birth-related complications.

But Caesarian section is also not a desirable procedure. Something far less invasive would be much more preferable, of course. This is where the TCM-practitioners come in. They claim they have the solution: moxibustion, i.e. the stimulation of acupuncture points by heat. But does it really work? Can it turn the fetus into the correct position?

This new study aimed to assess the efficacy of moxibustion (heating of the acupuncture needle with an igniting charcoal moxa stick) with acupuncture for version of breech presentations to reduce their rate at 37 weeks of gestation and at delivery. It was a randomized, placebo-controlled, single-blind trial including 328 pregnant women recruited in a university hospital center between 33 4/7 and 35 4/7 weeks of gestation. Moxibustion with acupuncture or inactivated laser (placebo) treatment was applied to point BL 67 for 6 sessions. The principal endpoint was the percentage of fetuses in breech presentation at 37 2/7 weeks of gestation.

The results show that the percentage of fetuses in breech presentation at 37 2/7 weeks of gestation was not significantly different in both groups (72.0 in the moxibustion with acupuncture group compared with 63.4% in the placebo group).

The authors concluded that treatment by moxibustion with acupuncture was not effective in correcting breech presentation in the third trimester of pregnancy.

You might well ask why on earth anyone expected that stimulating an acupuncture point would turn a fetus in the mother’s uterus into the optimal position that carries the least risk during the process of giving birth. This is what proponents of this technique say about this approach:

During a TCM consultation to turn a breech baby the practitioner will take a comprehensive case history, make a diagnosis and apply the appropriate acupuncture treatment.  They will assess if moxibustion might be helpful. Practitioners will then instruct women on how to locate the appropriate acupuncture points and demonstrate how to safely apply moxa at home. The acupuncture point UB 67 is the primary point selected for use because it is the most dynamic point to activate the uterus.  Its forte is in turning malpositioned babies.  It is located on the outer, lower edge of both little toenails. According to TCM theory, moxa has a tonifying and warming effect which promotes movement and activity.  The nature of heat is also rising.  This warming and raising effect is utilised to encourage the baby to become more active and lift its bottom up in order to gain adequate momentum to summersault into the head down position. This technique can also be used to reposition transverse presentation, a situation where the baby’s has its shoulder or back pointing down, or is lying sideways across the abdomen.

Not convinced? I can’t say I blame you!

Clearly, we need to know what the totality of the most reliable evidence shows; and what better than a Cochrane review to inform us about it? Here is what it tells us:

Moxibustion was not found to reduce the number of non-cephalic presentations at birth compared with no treatment (P = 0.45). Moxibustion resulted in decreased use of oxytocin before or during labour for women who had vaginal deliveries compared with no treatment (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.13 to 0.60). Moxibustion was found to result in fewer non-cephalic presentations at birth compared with acupuncture (RR 0.25, 95% CI 0.09 to 0.72). When combined with acupuncture, moxibustion resulted in fewer non-cephalic presentations at birth (RR 0.73, 95% CI 0.57 to 0.94), and fewer births by caesarean section (RR 0.79, 95% CI 0.64 to 0.98) compared with no treatment. When combined with a postural technique, moxibustion was found to result in fewer non-cephalic presentations at birth compared with the postural technique alone (RR 0.26, 95% CI 0.12 to 0.56).

In other words, there is indeed some encouraging albeit not convincing evidence! How can this be? There is no plausible explanation why this treatment should work!

But there is a highly plausible explanation why the results of many of the relevant trials are false-positive thus rendering a meta-analysis false-positive as well. I have repeatedly pointed out on this blog that practically all Chinese TCM-studies report (false) positive results; and many of the studies included in this review were done in China. The Cochrane review provides a strong hint about the lack of rigor in its ‘plain language summary’:

The included trials were of moderate methodological quality, sample sizes in some of the studies were small, how the treatment was applied differed and reporting was limited. While the results were combined they should be interpreted with caution due to the differences in the included studies. More evidence is needed concerning the benefits and safety of moxibustion.

So, would I recommend moxibustion for breech conversion? I don’t think so!

Dr. Oz, famous through his TV show promoting all types of quackery, recently testified before a US Senate subcommittee hearing on protecting consumers from false and deceptive advertising of weight loss products. This event turned out to be less than flattering for Dr Oz. One journalist commented that he “might as well be a cowardly lion — sent home with his tail between his legs after being accused at a congressional hearing of lying on his show about weight-loss claims.”

“I don’t get why you need to say this stuff, because you know it’s not true,” said Senator Claire McCaskill, who led the commerce subcommittee hearing. “The scientific community is almost monolithically against you in terms of the efficacy of the products you called ‘miracles,’ ” the Democratic senator from Missouri told Oz. “It’s a major problem when people are spending more and more money and they’re gaining more and more weight,” said Senator Amy Klobuchar.“Either you don’t talk about these things at all, or you’re going to have to be more specific because right now . . . this is not working.”

A source close to Dr Oz said he was perplexed: “We were invited down to Washington to testify at a hearing about scams and instead it became all about how much we hate your show.” Oz himself testified that he “heard the message…I do personally believe in the items that I talk about.”

“I intensively study them. I have given my family these products. . . . If you can lose a pound a week more than you would have lost by using them, it jump-starts you and gets you going. I think it makes sense.” “I’m surprised you’re defending this,” McCaskill replied. “It’s something that gives people false hope. I don’t see why you need to go there.”

Another journalist commented that the Senators repeatedly placed him on the defense over his weight loss products: “I know you know how much power you have. I know you know that. You are very powerful and [with] power comes a great deal of responsibility,” Senator Claire McCaskill , who led the Senate’s consumer protection hearing titled “Protecting Consumers from False and Deceptive Advertising of Weight-Loss Products…You are being made an example of today because of the power you have in this space…We didn’t call this hearing to beat up on you but we did call this hearing to talk about a real crisis in consumer protection. You can either be part of the police here or you can be part of the problem.”

Oz insisted he was no huckster but admitted the products promoted on his show don’t always have “the scientific muster” to present their benefits as “fact…I actually do personally believe in the items that I talk about in the show. I passionately studied them. I recognize that oftentimes they don’t have the scientific muster to present as fact but nevertheless I would give my audience the advice I give my family all the time. And I have given my family these products,” he said.

Dr Oz also said that some alternative treatments, such as prayer, cannot be tested scientifically. “I don’t think this ought to be a referendum on the use of alternative medical therapies. Because if that’s the case, listen, I’ve been criticized for having folks coming on my show talking about the power of prayer,” he said. “I can’t prove that prayer helps people survive an illness.”

No, Dr Oz! I know you are mistaken! I have done the research – both on alternative slimming aids and on spiritual healing. The results quite clearly show that these methods are not more effective than a placebo.

Many proponents of chiropractic claim that chiropractic spinal manipulation therapy (SMT) for chronic low back pain (LBP) might save health care cost. As LBP is a hugely expensive condition, this is a mighty important question. The evidence on this issue is, however, flimsy to say the least. Most experts seem to conclude that more reliable data are needed. On this background, it seems relevant to note that a new relevant study has just become available.

The purpose of this analysis was to report the incremental costs and benefits of different doses of SMT in patients with LBP.

The researchers randomized 400 patients with chronic LBP to receive doses of 0, 6, 12, or 18 sessions of SMT. Patients were scheduled for 18 visits for 6 weeks and received SMT or light massage control from a chiropractor. Societal costs in the year after study enrollment were estimated using patient reports of health care use and lost productivity. The main health outcomes were the number of pain-free days and disability-free days.

The results show that costs for treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were greater age, greater disability, lower quality-adjusted life year scores, and higher costs in the period preceding enrolment. Pain-free and disability-free days were greater for all SMT doses compared with control, but only SMT 12 yielded a statistically significant benefit of 22.9 pain-free days and 19.8 disability-free days. No statistically significant group differences in quality-adjusted life years were noted.

The authors drew the following conclusions from these data: a dose of 12 SMT sessions yielded a modest benefit in pain-free and disability-free days. Care of chronic LBP with SMT did not increase the costs of treatment plus lost productivity.

So, is chiropractic SMT for LBP cost-effective? I leave it to my readers to answer this question.

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