Edzard Ernst

MD, PhD, FMedSci, FSB, FRCP, FRCPEd

A cult can be defined not just in a religious context, but also as a” usually nonscientific method or regimen claimed by its originator to have exclusive or exceptional power in curing a particular disease.” After ~20 years of researching this area, I have come to suspect that much of alternative medicine resembles a cult – a bold statement, so I better explain.

One characteristic of a cult is the unquestioning commitment of its members to the bizarre ideas of their iconic leader. This, I think, chimes with several forms alternative medicine. Homeopaths, for instance, very rarely question the implausible doctrines of Hahnemann who, to them, is some sort of a semi-god. Similarly, few chiropractors doubt even the most ridiculous assumptions of their founding father, D D Palmer who, despite of having been a somewhat pathetic figure, is uncritically worshipped. By definition, a cult-leader is idealised and thus not accountable to anyone; he (yes, it is almost invariably a male person) cannot be proven wrong by logic arguments nor by scientific facts. He is quite simply immune to any form of scrutiny. Those who dare to disagree with his dogma are expelled, punished, defamed or all of the above.

Cults tend to brain-wash their members into unconditional submission and belief. Likewise, fanatics of alternative medicine tend to be brain-washed, i.e. systematically misinformed to the extend that reality becomes invisible. They unquestioningly believe in what they have been told, in what they have read in their cult-texts, and in what they have learnt from their cult-peers. The effects of this phenomenon can be dramatic: the powers of discrimination of the cult-member are reduced, critical questions are discouraged, and no amount of evidence can dissuade the cult-member from abandoning even the most indefensible concepts. Internal criticism is thus by definition non-existent.

Like religious cults, many forms of alternative medicine promote an elitist concept. Cult-members become convinced of their superiority, based not on rational considerations but on irrational beliefs. This phenomenon has a range of consequences. It leads to the isolation of the cult-member from the rest of the world. By definition, critics of the cult do not belong to the elite; they are viewed as not being able to comprehend the subtleties of the issues at hand and are thus ignored or not taken seriously. For cult-members, external criticism is thus non-existent or invalid.

Cult-members tend to be on a mission, and so are many enthusiasts of alternative medicine. They use any conceivable means to recruit new converts. For instance, they try to convince family, friends and acquaintances of their belief in their particular alternative therapy at every conceivable occasion. They also try to operate on a political level to popularize their cult. They cherry pick data, often argue emotionally rather than rationally, and ignore all arguments which contradict their belief system.

Cult-members, in their isolation from society, tend to be assume that there is little worthy of their consideration outside the cult. Similarly, enthusiasts of alternative medicine tend to think that their treatment is the only true method of healing. Therapies, concepts and facts which are not cult-approved are systematically defamed. An example is the notion of BIG PHARMA which is employed regularly in alternative medicine. No reasonable person assumes that the pharmaceutical industry smells of roses. However, the exaggerated and systematic denunciation of this industry and its achievements is a characteristic of virtually all branches of alternative medicine. Such behaviour usually tells us more about the accuser than the accused.

There are many other parallels between a  cult and alternative medicine, I am sure. In my view, the most striking one must be the fact that any spark of cognitive dissonance in the cult-victim is being extinguished by highly effective and incessant flow of misinformation which often amounts to a form of brain-washing.

Acupuncture is not just one single form of therapy, there are dozens of variations of this theme. For instance, acupuncture-points can, according to proponents of this form of treatment, be stimulated in a number of ways: needles, heat (moxibustion), electrical current, laser-light, ultrasound or pressure. In the latter case, the therapy is called acupressure. This therapy is popular and often recommended as a form of self-treatment, for instance, to alleviate nausea and vomiting of all causes.

Chemotherapy-induced nausea/vomiting can normally be successfully treated with standard anti-emetic drugs. Some patients, however, may not respond satisfactorily and others prefer a drug-free option such as acupressure for which there has been encouraging evidence. A brand-new study sheds new light on this issue.

Its objective was to assess the effectiveness and cost-effectiveness of self-administered acupressure using wristbands compared with sham acupressure wristbands and standard care alone in the management of chemotherapy-induced nausea. Secondary objectives included assessment of the effectiveness and cost-effectiveness of the wristbands in relation to vomiting and quality of life and exploration of any age, gender and emetogenic risk effects. The trial was conducted in outpatient chemotherapy clinics in three regions in the UK involving 14 different cancer units/centres. Chemotherapy-naïve cancer patients were included receiving chemotherapy of low, moderate and high emetogenic risk. The intervention were acupressure wristbands pressing the P6 point (anterior surface of the forearm), sham-wrist bands providing no pressure on acupuncture-points or no wrist-bands at all; all three groups had standard care in addition. The main outcome measures were the Rhodes Index for Nausea/Vomiting, the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool and the Functional Assessment of Cancer Therapy – General (FACT-G). At baseline participants also completed measures of anxiety/depression, nausea/vomiting expectation and expectations from using the wristbands.

In total, 500 patients were randomised (166 standard care, 166 sham acupressure + standard care, and 168 acupressure + standard care). Data were available for 361 participants for the primary outcome. The primary outcome analysis (nausea in cycle 1) revealed no differences between the three arms. Women responded more favourably to the use of sham acupressure wristbands than men. No significant differences were detected in relation to vomiting outcomes, anxiety and quality of life. Some transient adverse effects were reported, including tightness in the area of the wristbands, feeling uncomfortable when wearing them and minor swelling in the wristband area.There were no statistically significant cost differences associated with the use of real acupressure bands.

In total, 26 patients took part in qualitative interviews. The qualitative data suggested that participants perceived the wristbands (both real and sham) as effective and helpful in managing their nausea during chemotherapy.

The authors concluded that there were no statistically significant differences between the three arms in terms of nausea, vomiting and quality of life.

Intriguingly, this study was published in two different journals; and the second article reporting the identical data concluded that no clear recommendations can be made about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting.

A further equally new study tested acupressure for post-operative nausea/vomiting. One hundred and thirty-four healthy, non-smoking women scheduled for breast surgery were randomised either to P6 stimulation or to sham control. Wristbands were applied and covered with a dressing before induction of anaesthesia. Follow-up was carried out three times within 24 h postoperative. Primary outcomes were postoperative nausea and/or vomiting.

One hundred and twelve patients completed the study. There were no statistically significant differences in the incidence of nausea or vomiting. Approximately, one third of the patients reported adverse-effects caused by the wristband, for example, redness, swelling and tenderness.

The authors of this trial concluded as follows: We did not find the Vital-Band effective in preventing either nausea or vomiting after operation in women undergoing breast surgery.

There has been quite a bit of previous research on acupressure. The most recent summary included 2 meta-analyses, 6 systematic reviews and 39 RCTs of acupressure for various conditions. Its authors stated that the strongest evidence was for pain (particularly dysmenorrhoea, lower back and labour), post-operative nausea and vomiting.

So, is acupressure effective in reducing nausea and vomiting or not? The evidence is contradictory to a degree that is baffling. If we look closer at the existing trials, we are likely to find that the more rigorous studies and those published by researchers who do not have an axe to grind tend to produce negative findings. I am therefore not convinced that acupressure has any effects beyond placebo.

Sorry, but I am fighting a spell of depression today.

Why? I came across this website which lists the 10 top blogs on alternative medicine. To be precise, here is what they say about their hit-list: this list includes the top 10 alternative medicine bloggers on Twitter, ranked by Klout score. Using Cision’s media database, we compiled the list based on Cision’s proprietary research, with results limited to bloggers who dedicate significant coverage to alternative medicine and therapies…

And here are the glorious top ten:

Andrew WeilDr. Andrew Weil’s Daily Health Tips

Joy McCarthyJoyous Health Blog

Johanna BjörkGoodlifer

Stacey ChillemiStay Healthy and Cure Your Conditions Naturally

Eric GreyDeepest Health

Kristi ShmyrPrana Holistic Blog

Cathy WongAlternative Medicine Blog

Renee CanadaHartford Healthy Living Examiner

Dee BraunNatural Holistic Health Blog

Geo EspinosaDr. Geo’s Natural Health Blog

All of these sites are promotional and lack even the slightest hint of critical evaluation. All of them sell or advertise products and are thus out to make money. All of them are full of quackery, in my view. Some of the most popular bloggers are world-famous quacks!

What about impartial information for the public? What about critical review of the evidence? What about a degree of balance? What about guiding consumers to make responsible, evidence-based decisions? What about preventing harm? What about using scarce resources wisely?

I don’t see any of this on any of the sites.

You see, now I have depressed you too!

Quick, buy some herbal, natural, holistic and integrative anti-depressant! As it happens, I have some for sale….

Some people will probably think that I am obsessed with writing about the risk of chiropractic. True, I have published quite a bit on this subject, both in the peer-reviewed literature as well as on this blog – but not because I am obsessed; on this blog, I will re-visit the topic every time a relevant new piece of evidence becomes available because it is indisputably such an important subject. Writing about it might prevent harm.

So far, we know for sure that mild to moderate as well as serious complications, including deaths, do occur after chiropractic spinal manipulations, particularly those of the upper spine.  What we cannot say with absolute certainty is whether they are caused by the treatment or whether they happened coincidentally. Our knowledge in this area relies mostly on case-reports and surveys which, by their very nature, do not allow causal inferences. Therefore chiropractors have, in the past, been able to argue that a causal link remains unproven.

A brand-new blinded parallel group RCT might fill this gap in our knowledge and might reject or establish the notion of causality once and for all. The authors’ objective was to establish the frequency and severity of adverse effects from short term usual chiropractic treatment of the spine when compared to a sham treatment group. They thus conducted the first ever RCT  with the specific aim to examine the occurrence of adverse events resulting from chiropractic treatment. It was conducted across 12 chiropractic clinics in Perth, Western Australia. The participants comprised 183 adults, aged 20-85, with spinal pain. Ninety two participants received individualized care consistent with the chiropractors’ usual treatment approach; 91 participants received a sham intervention. Each participant received two treatment sessions.

Completed adverse questionnaires were returned by 94.5% of the participants after the first appointment and 91.3% after the second appointment. Thirty three per cent of the sham group and 42% of the usual care group reported at least one adverse event. Common adverse events were increased pain (sham 29%; usual care 36%), muscle stiffness (sham 29%; usual care 37%), headache (sham 17%; usual care 9%). The relative risk was not significant for either adverse event occurrence (RR = 1.24 95% CI 0.85 to 1.81); occurrence of severe adverse events (RR = 1.9; 95% CI 0.98 to 3.99); adverse event onset (RR = 0.16; 95% CI 0.02 to 1.34); or adverse event duration (RR = 1.13; 95% CI 0.59 to 2.18). No serious adverse events were reported.

The authors concluded that a substantial proportion of adverse events following chiropractic treatment may result from natural history variation and non-specific effects.

If we want to assess causality of effects, we have no better option than to conduct an RCT. It is the study design that can give us certainty, or at least near certainty – that is, if the RCT is rigorous and well-made. So, does this study reject or confirm causality? The disappointing truth is that it does neither.

Adverse events were clearly more frequent with real as compared to sham-treatment. Yet the difference failed to be statistically significant. Why? There are at least two possibilities: either there was no true difference and the numerically different percentages are a mere fluke; or there was a true difference but the sample size was too small to prove it.

My money is on the second option. The number of patients was, in my view, way too small for demonstrating differences in frequencies of adverse effects. This applies to the adverse effects noted, but also, and more importantly, to the ones not noted.

The authors state that no serious adverse effects were observed. With less that 200 patients participating, it would have been most amazing to see a case of arterial dissection or stroke. From all we currently know, such events are quite rare and occur perhaps in one of 10 000 patients or even less often. This means that one would require a trial of several hundred thousand patients to note just a few of such events, and an RCT with several million patients to see a difference between real and sham treatment. It seems likely that such an undertaking will never be affordable.

So, what does this new study tell us? In my view, it is strong evidence to suggest a causal kink between chiropractic treatment and mild to moderate adverse effects. I dose not prove it, but merely suggests it – yet I am fairly sure that chiropractors, once again, will not agree with me.

Postoperative ileus (POI), the phenomenon that after an operation the intestines tend to be inactive for a few days, can cause intense pain and thus contributes significantly to human suffering. It also prolongs hospital stay and increases the risks of post-operative complications. There is no known effective treatment for POI.

In China, POI is often treated with acupuncture, and due to this fact acupuncture became known in the West: James Reston, a journalist who accompanied Nixon on his first trip to China, had to have an appendectomy in a Beijing hospital, he subsequently suffered from POI, was treated with acupuncture and moxibustion, experienced symptom-relief, and subsequently wrote about it in the New York Times. This was the beginning of the present acupuncture-boom.

Since then, thousands of acupuncture trials have been published but, intriguingly, very few have tested the effectiveness of acupuncture for POI. Now researchers from the Sloan Kettering Cancer Center in New York have conducted a randomized, sham-controlled trial to test whether acupuncture reduces POI more effectively than sham acupuncture.

Ninety colon cancer patients undergoing elective colectomy were randomized to receive 30 min of true or sham acupuncture twice daily during their first three postoperative days. GI-3 (the later of the following two events: time that the patient first tolerated solid food, AND time that the patient first passed flatus OR a bowel movement) and GI-2 (the later of the following two events: time patient first tolerated solid food AND time patient first passed a bowel movement) were determined. Pain, nausea, vomiting, and use of pain medications were evaluated daily for the first three postoperative days. Eighty-one patients received the allocated intervention: 39 the true acupuncture and 42 the sham acupuncture. The mean time to GI-3 was 149 hours and 146 hours for the acupuncture group and the sham acupuncture group. No significant differences were found between groups for secondary endpoints.

The authors’ conclusion was clear: True acupuncture as provided in this study did not reduce POI more significantly than sham acupuncture.

So, did a mere misunderstanding start the present acupuncture boom? POI inevitably normalises with time. Did the journalist just imagine that acupuncture helped, while nature cured the condition? It would seem so, according to this study. But perhaps things are not just black or white. Almost at the same time as the New York trial, another study was emerged.

Researchers from Hong Kong conducted an RCT with 165 patients undergoing elective laparoscopic surgery for colonic and upper rectal cancer. Patients were assigned randomly to receive electroacupuncture (n = 55) or sham acupuncture (n = 55), once daily from postoperative days 1-4, or no acupuncture (n = 55). The primary outcome was time to defecation. Secondary outcomes included postoperative analgesic requirement, time to ambulation, and length of hospital stay. The results showed that patients who received electroacupuncture had a shorter time to defecation than patients who received no acupuncture (85.9 ± 36.1 vs 122.1 ± 53.5 h) and length of hospital stay (6.5 ± 2.2 vs 8.5 ± 4.8 days). Patients who received electroacupuncture also had a shorter time to defecation than patients who received sham acupuncture (85.9 ± 36.1 vs 107.5 ± 46.2 h). Electroacupuncture was more effective than no or sham acupuncture in reducing postoperative analgesic requirement and time to ambulation.

The Chinese researchers’ conclusion is equally clear: electroacupuncture reduced the duration of postoperative ileus, time to ambulation, and postoperative analgesic requirement, compared with no or sham acupuncture, after laparoscopic surgery for colorectal cancer.

The only other trial I know in this area failed to show that acupuncture shortens POI. What should we make of these data? A systematic review would be nice, of course, but, to the best of my knowledge, none is currently available.

Is this a question of everyone being able to pick and chose the evidence they like? Is it a question of who we trust, the researchers in New York or those in China? Is it a question of where the treatment was done authentically? Is it a question of critically analysing which study had the higher risks of bias? Or is it a question of simply saying that two negative studies are more than one positive trial?

Confused? Me too, a little!

Whatever answers we chose, several things seems fairly certain to me. It would be wrong to say that there is good evidence for acupuncture as a treatment of POI. And the acupuncture-boom that ensued after Reston’s article was to a very large degree built on a simple misunderstanding: POI is a condition that resolves literally into thin air whether we treat it or not.

On this blog, we have repeatedly discussed the serious adverse effects of Spinal Manipulative Therapies (SMT) as frequently administered by chiropractors, osteopaths and physiotherapists. These events mostly relate to vascular accidents involving vertebral or carotid arterial dissections after SMT of the upper spine. Lower down, the spine is anatomically far less vulnerable which, however, does not mean that injuries in this region after SMT are impossible. They have been reported repeatedly but, to the best of my knowledge, there is no up-to-date review of such events – that is until recently.

Australian researchers have just filled this gap by publishing a systematic review aimed at systematically reviewing all reports of serious adverse events following lumbo-pelvic SMT. They conducted electronic searches in MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 12, 2012. Article-selection was performed by two independent reviewers using predefined criteria. Cases were included involving individuals 18 years or older who experienced a serious adverse event following SMT applied to the lumbar spine or pelvis by any type of provider (chiropractic, medical, physical therapy, osteopathic, layperson). A serious adverse event was defined as an untoward occurrence that resulted in death or was life threatening, required hospital admission, or resulted in significant or permanent disability. Reports published in English, German, Dutch, and Swedish were included.

The searches identified a total of 2046 papers, and 41 articles reporting a total of 77 cases were included in the review. Important case details were frequently missing in these reports, such as descriptions of SMT technique, the pre-SMT presentation of the patient, the specific details of the adverse event, time from SMT to the adverse event, factors contributing to the adverse event, and clinical outcome.

The 77 adverse events consisted of cauda equina syndrome (29 cases); lumbar disk herniation (23 cases); fracture (7 cases); haematoma or haemorrhagic cyst (6 cases); and12 cases of neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and oesophageal rupture.

The authors’ conclusion was that this systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbo-pelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review.

This review is timely and sound. Yet several factors need consideration:

1) The search strategy was thorough but it is unlikely that all relevant articles were retrieved because these papers are often well-hidden in obscure and not electronically listed journals.

2) It is laudable that the authors included languages other than English but it would have been preferable to impose no language restrictions at all.

3) Under-reporting of adverse events is a huge problem, and it is anyone’s guess how large it really is [we have shown that, in our research it was precisely 100%]

4) This means that the 77 cases, which seem like a minute number, could in reality be 770 or 7700 or 77000; nobody can tell.

Cauda equina (horse tail) syndrome was the most frequent and most serious adverse event reported. This condition is caused by nerve injury at the lower end of the spinal canal. Symptoms can include leg pain along the sciatic nerve, severe back pain, altered or loss of sensation over the area around the genitals, anus and inner thighs as well as urine retention or incontinence and faecal incontinence. The condition must be treated as an emergency and usually requires surgical decompression of the injured nerves.

Disk herniation, the second most frequent adverse event, is an interesting complication of SMT. Most therapists using SMT would probably claim (no, I have no reference for that speculation!) that they can effectively treat herniated disks with SMT. The evidence for this claim is, as far as I know, non-existent. In view of the fact that SMT can actually cause a disk to herniate, I wonder whether SMT should not be contra-indicated for this condition. I am sure there will be some discussion about this question following this post.

The authors make a strong point about the fact that case reports never allow causal inference. One can only agree with this notion. However, the precautionary principle in medicine also means that, if case reports provide reasonable suspicion that an intervention might led to adverse-effects, we need to be careful and should warn patients of this possibility. It also means that it is up to the users of SMT to demonstrate beyond reasonable doubt that SMT is safe.

A recent post of mine seems to have stimulated a lively discussion about the question IS THERE ANY GOOD EVIDENCE AT ALL FOR OSTEOPATHIC TREATMENTS? By and large, osteopaths commented that they are well aware that their signature interventions for their most frequently treated condition (back pain) lack evidential support and that more research is needed. At the same time, many osteopaths seemed to see little wrong in making unsubstantiated therapeutic claims. I thought this was remarkable and feel encouraged to write another post about a similar topic.

Most osteopaths treat children for a wide range of conditions and claim that their interventions are helpful. They believe that children are prone to structural problems which can be corrected by their interventions. Here is an example from just one of the numerous promotional websites on this topic:

STRUCTURAL  PROBLEMS, such as those affecting the proper mobility and function of the  body’s framework, can lead to a range of problems. These may include:

  • Postural – such as scoliosis
  • Respiratory  – such as asthma
  • Manifestations of brain  injury – such as cerebral palsy and spasticity
  • Developmental  – with delayed physical or intellectual progress, perhaps triggering learning  behaviour difficulties
  • Infections – such  as ear and throat infections or urinary disturbances, which may be recurrent.

OSTEOPATHY can assist in the prevention of health problems, helping children to make a smooth  transition into normal, healthy adult life.

As children cannot give informed consent, this is even more tricky than treating adults with therapies of questionable value. It is therefore important, I think, to ask whether osteopathic treatments of children is based on evidence or just on wishful thinking or the need to maximise income. As it happens, my team just published an article about these issues in one of the highest-ranking paediatrics journal.

The objective of our systematic review was to critically evaluate the effectiveness of osteopathic manipulative treatment (OMT) as a treatment of paediatric conditions. Eleven databases were searched from their respective inceptions to November 2012. Only randomized clinical trials (RCTs) were included, if they tested OMT against any type of control intervention in paediatric patients. The quality of all included RCTs was assessed using the Cochrane criteria.

Seventeen trials met our inclusion criteria. Only 5 RCTs were of high methodological quality. Of those, 1 favoured OMT, whereas 4 revealed no effect compared with various control interventions. Replications by independent researchers were available for two conditions only, and both failed to confirm the findings of the previous studies. Seven RCTs suggested that OMT leads to a significantly greater reduction in the symptoms of asthma, congenital nasolacrimal duct obstruction, daily weight gain and length of hospital stay, dysfunctional voiding, infantile colic, otitis media, or postural asymmetry compared with various control interventions. Seven RCTs indicated that OMT had no effect on the symptoms of asthma, cerebral palsy, idiopathic scoliosis, obstructive apnoea, otitis media, or temporo-mandibular disorders compared with various control interventions. Three RCTs did not report between-group comparisons. The majority of the included RCTs did not report the incidence rates of adverse-effects.

Our conclusion is likely to again dissatisfy many osteopaths: The evidence of the effectiveness of OMT for paediatric conditions remains unproven due to the paucity and low methodological quality of the primary studies.

So, what does this tell us? I am sure osteopaths will disagree, but I think it shows that for no paediatric condition do we have sufficient evidence to show that OMT is effective. The existing RCTs are mostly of low quality. There is a lack of independent replication of the few studies that suggested a positive outcome. And to make matters even worse, osteopaths seem to be violating the most basic rule of medical research by not reporting adverse-effects in their clinical trials.

I rest my case – at least for the moment.

A new condition, the Knighthood Starvation Syndrome (KSS), might soon be included in our systems of disease classification. Sporadic cases have been noted as far back as the 1950s, but recent decades have seen an alarming proliferation of incidents. The epidemiology of the KSS is most peculiar: it is endemic in the British Isles, particularly in large centres and seems to affect almost exclusively alpha males in their 60ies who have climbed up to dizzy heights on the career ladder and who think of themselves very highly.

The KSS tends to remain unrecognised for many years; early signs of dormant KSS include name dropping, pomposity, and a general alignment with the views of the establishment. Later stages are characterised by a sudden and often surprising change of opinion on several professional matters, an abnormal need for political correctness, an insatiable hunger for favourable mentions in the national press, a phobia related to rocking boats or blowing whistles, an urge to get involved in charitable work and/or high-profile committees of any type, and an increasing ruthlessness in pursuing ones personal goals under the guise of a professional purpose. Some of the features of the KSS are reminiscent of a classical degenerative disease, say experts who have studied the syndrome in much detail.

Opinions are divided as to the root causes of the KSS. Some psychiatrists claim it is due to early childhood mal-adaptation or bad potty-training, while sexologist are convinced that it caused by a chronically unfulfilled sex-life, and psychologists tend to believe it is a delayed mid-life crisis that was not allowed to blossom in a timely fashion. Endocrinologists have identifies various abnormalities regarding the levels of stress and sex hormones, nutritionists are discussing a lack of vitamin D in combination with an excess of red meat and fast food, and ENT surgeons speculate that it is caused by the absence of tonsillectomy during adolescence.

Unsurprisingly, alternative practitioners have developed their own theories most of which are, however, frowned upon by mainstream medics. Chiropractors view the KSS as the result of subluxation at the atlas level and advocate spinal adjustments followed by life-long maintenance therapy. TCM-practitioners are suggesting that a blocked kidney-chi has led to a pathological dominance of yin-energy, a minor aberration which could easily be corrected by acupuncture along the appropriate meridian. Bach Flower enthusiasts speak of vibrations being out of tune and recommend an intensive cure with Rescue Remedy. And finally, homeopaths see the KSS as the final poof of their theory of miasma where the bad air of the executive floor and caused serious damage which can only be neutralised by an in-depth homeopathic history and prolonged, individualised treatment.

Despite these and other attempts of altering the natural history of the syndrome, it tends to progress gradually in predisposed individuals, and symptoms are likely to worsen significantly over time, often to the point that the poor victim becomes a public menace. So far, the only known, evidence-based remedy is rather heroic and sadly not often available: the award of a knighthood. This intervention usually leads to a swift and uneventful recovery. In some tragic cases, however, the KSS subsequently degenerates into the HoLS-Syndrome, the even more vicious House of Lords Starvation Syndrome.

I have mentioned it before, I know, but it seems important, so please bear with me as I revisit the subject: there is no other area of health care that is more plagued by surveys than alternative medicine. They are usually conducted on a small convenience sample of consumers and try to tell us that many of them use and like alternative medicine (or a specific alternative treatment). And why is this important? Because this information is subsequently employed to convince us, politicians, journalists, heirs to the throne etc. that thousands of consumers cannot be wrong and that alternative medicine must therefore be a good thing.
Sceptics know, of course, that this argumentum ad populum is a classical fallacy. Recently, we published an article which provides fairly hard evidence to substantiate this fact.

The main aim of our systematic review was to estimate the prevalence of use of alternative medicine (AM) in the UK. Five databases were searched for peer-reviewed surveys published between 1 January 2000 and 7 October 2011. In addition, relevant book chapters and files from our own departmental records were searched by hand. Eighty-nine surveys were included, with a total of 97,222 participants. Surely, fact that this large amount of UK surveys had emerged in only about one decade, speaks for itself.

Most studies turned out to be of poor methodological quality. Across all surveys, the average one-year prevalence of AM-use was 41.1%, and the average lifetime prevalence was 51.8%. However, many of these investigations were flimsy. According to methodologically sound surveys, the equivalent rates were 26.3% and 44%, respectively. In surveys with response rates >70%, the average one-year prevalence was nearly threefold lower than in surveys with response rates below 50%. Herbal medicine was the most popular CAM, followed by homeopathy, aromatherapy, massage and reflexology.

To the best of my knowledge, this is the first time that four crucial points about such surveys have been clearly documented:

1) The amount of surveys in AM is staggering.

2) They contribute very little worthwhile knowledge and mostly seem to be exercises in AM-promotion.

3) Their methodological quality is usually low.

4) The poor quality surveys systematically over-estimate the prevalence of AM-use.

I think it is time that AM investigators focus on real research answering important questions which advance out knowledge, that AM-journal editors stop publishing meaningless nonsense, and that decision-makers understand the difference between promotion dressed up as science and real research.

 

 

Tai Chi, as we know it in the West, is said to promote the smooth flow of “energy” throughout the body by performing postures, slow meditative movements and controlled breathing. Tai Chi is also supposed to help increasing flexibility, suppleness, balance and coordination. According to enthusiasts, the smooth, gentle movements of Tai Chi aid relaxation and help to keep the mind calm and focused.

Tai Chi has become popular in Western countries and is being considered for a surprisingly wide range of conditions. The patient/consumer is taught to perform postures, slow meditative movements and controlled breathing. The concepts underlying Tai Chi are strange, but that does not necessarily mean that the treatment is not effective for certain illnesses or symptoms.

There has been a surprising amount of research in this area, and some studies have generated encouraging results. A recent study which is unfortunately not available electronically ( Wu, WF; Muheremu, A; Chen, CH; Liu, WG; Sun, L. Effectiveness of Tai Chi Practice for Non-Specific Chronic Low Back Pain on Retired Athletes: A Randomized Controlled Study. JOURNAL OF MUSCULOSKELETAL PAIN 2013, 21:1, p.37-45) tested the effectiveness of Tai Chi for chronic back pain. Specifically, the researchers wanted to determine whether regular Tai Chi practice is superior to other means of sports rehabilitation in relieving non-specific chronic low back pain [LBP] in a younger population. They randomized 320 former athletes suffering from chronic LBP into a treatment [tai chi practice] and several control groups [regular sessions with swimming, backward walking or jogging, or no such interventions]. At the beginning, middle, and end of a six-month intervention, patients from all groups completed questionnaires assessing the intensity of LBP; in addition, a physical examination was conducted.

After 3 and 6 months, no statistically significant difference in the intensity of LBP was demonstrated between the Tai Chi and swimming. However, significant differences were demonstrated between the Tai Chi and backward walking, jogging, and no exercise groups.

The authors’ concluded that “Tai chi has better efficacy than certain other sports on the treatment of non-specific chronic LBP.”

This is only the second RCT of Tai chi for back pain. The first such study consisted of 160 volunteers between ages 18 and 70 years with persistent nonspecific low back pain. The experimental group (n = 80) had 18 Tai Chi sessions over a 10-week period. The waitlist control group continued with their usual health care. Bothersomeness of symptoms was the primary outcome, and secondary outcomes included pain intensity and pain-related disability. Tai Chi reduced bothersomeness of back symptoms by 1.7 points on a 0-10 scale, reduced pain intensity by 1.3 points on a 0-10 scale, and improved self-report disability by 2.6 points on the 0-24 Roland-Morris Disability Questionnaire scale. The authors of this RCT concluded that a 10-week Tai Chi program improved pain and disability outcomes and can be considered a safe and effective intervention for those experiencing long-term low back pain symptoms.

My own team have conducted their fair share of Tai Chi research. Specifically,we have published several systematic reviews of Tai Chi as an adjunctive or supportive treatment of various conditions, and the conclusions (in italics) have been mixed.

DIABETES: The existing evidence does not suggest that tai chi is an effective therapy for type 2 diabetes.

HYPERTENSION: The evidence for tai chi in reducing blood pressure in the elderly individuals is limited.

BREAST CANCER: the existing trial evidence does not show convincingly that tai chi is effective for supportive breast cancer care.

IMPROVEMENT OF AEROBIC EXCERCISE CAPACITY: the existing evidence does not suggest that regular tai chi is an effective way of increasing aerobic capacity.

PARKINSON’S DISEASE: the evidence is insufficient to suggest tai chi is an effective intervention for Parkinson’s Disease.

OSTEOPOROSIS: The evidence for tai chi in the prevention or treatment of osteoporosis is not convincing.

OSTEOARTHRITIS: there is some encouraging evidence suggesting that tai chi may be effective for pain control in patients with knee OA.

RHEUMATOID ARTHRITIS: Collectively this evidence is not convincing enough to suggest that tai chi is an effective treatment for RA.

Finally, an overview over all systematic reviews of Tai Chi suggested that the only area where the evidence is convincing is the prevention of falls in the elderly.

I think, this indicates that we should not pin our hopes too high as to the therapeutic value of Tai Chi. In particular, for back pain, the evidence might be optimistically judged as encouraging, but it is by no means convincing; the effect size seems to be small and two studies are not enough to issue general recommendations. On the other hand, considering that there is so little to offer to back pain patients, I concede that this is an area that should be studied further. Meanwhile, one could argue that Tai Chi can be fun and is devoid of risks – so, why not give it a try?

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories