MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

alternative medicine

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The use of so-called alternative medicine (SCAM) are claimed to be associated with preventive health behaviors. However, the role of SCAM use in patients’ health behaviors remains unclear.

This survey aimed to determine the extent to which patients report that SCAM use motivates them to make changes to their health behaviours. For this purpose, a secondary analysis of the 2012 National Health Interview Survey data was undertaken. It involved 10,201 SCAM users living in the US who identified up to three SCAM therapies most important to their health. Analyses assessed the extent to which participants reported that their SCAM use motivated positive health behaviour changes, specifically: eating healthier, eating more organic foods, cutting back/stopping drinking alcohol, cutting back/quitting smoking cigarettes, and/or exercising more regularly.

Overall, 45.4% of SCAM users reported being motivated by SCAM to make positive health behaviour changes, including exercising more regularly (34.9%), eating healthier (31.4%), eating more organic foods (17.2%), reducing/stopping smoking (16.6% of smokers), or reducing/stopping drinking alcohol (8.7% of drinkers). Individual SCAM therapies motivated positive health behaviour changes in 22% (massage) to 81% (special diets) of users. People were more likely to report being motivated to change health behaviours if they were:

  • aged 18-64 compared to those aged over 65 years;
  • of female gender;
  • not in a relationship;
  • of Hispanic or Black ethnicity, compared to White;
  • reporting at least college education, compared to people with less than high school education;
  • without health insurance.

The authors concluded that a sizeable proportion of respondents were motivated by their SCAM use to undertake health behavior changes. CAM practices and practitioners could help improve patients’ health behavior and have potentially significant implications for public health and preventive medicine initiatives; this warrants further research attention.

This seems like an interesting finding! SCAM might be ineffective, but it motivates people to lead a healthier life. Thus SCAM has something to show for itself after all.

Great!

Except, there is another explanation of the results, one that might be much more plausible.

What if some consumers, particularly females who are well-educated and have no health insurance, one day decide that it’s time to do something for their health. Thus they initiate several things:

  • they start using SCAM;
  • they exercise more regularly;
  • they eat more healthily;
  • they consume organic food;
  • they stop smoking;
  • they stop boozing.

The motivation common to all these changes is their determination to do something about their health. Contrary to the authors’ wishful thinking, SCAM has little or even nothing to do with it. The notion was induced by SCAM practitioners who like to think that they play a role in disease prevention, by the leading questions of the interviewer, by recall bias, or by other factors..

What did the wise man say once upon a time?

CORRELATION IS NOT CAUSATION!

 

 

Traditional Chinese Medicine (TCM) is a term created by Mao lumping together various modalities in an attempt to pretend that healthcare in the People’s Republic of China (PRC) was being provided despite the most severe shortages of conventional doctors, drugs and facilities. Since then, TCM seems to have conquered the West, and, in the PRC, the supply of conventional medicine has hugely increased. Today therefore, TCM and conventional medicine peacefully co-exist side by side in the PRC on an equal footing.

At least this is what we are being told – but is it true?

I have visited the PRC twice. The first time, in 1980, I was the doctor of a university football team playing several games in the PRC, including one against their national team. The second time, in 1991, I co-chaired a scientific meeting in Shanghai. On both occasions, I was invited to visit TCM facilities and discuss with colleagues issues related to TCM in the PRC. All the official discussions were monitored by official ‘minders’, and therefore fee speech and an uninhibited exchange of ideas are not truly how I would describe them. Yet, on both visits, there were occasions when the ‘minders’ were absent and a more liberal discussion could ensue. Whenever this was the case, I did not at all get the impression that TCM and conventional medicine were peacefully co-existing. The impression that I did get was that their co-existence resembled more a ‘shot-gun marriage’.

During my time running the SCAM research unit at Exeter, I had the opportunity to welcome several visiting researchers from the PRC. This experience seemed to confirm my impression that TCM in the PRC was less than free. As an example, I might cite one acupuncture project I was once working on with a scientist from the PRC. When it was nearing its conclusion and I mentioned that we should now think about writing it up to publish the findings, my Chinese colleague said that being a co-author was unfortunately not an option. Knowing how important publications in Western journals are for researchers from the PRC, I was most surprised by this revelation. The reason, it turned out, was that our findings failed to be favourable for TCM. My friend explained that such a paper would not advance but hinder an academic career, once back in the PRC.

Suspecting that the notion of a peaceful co-existence of TCM and conventional medicine in the PRC was far from true, I have always been puzzled how the myth could survive for so many years. Now, finally, it seems to crumble. This is from a recent journalistic article entitled ‘Chinese Activists Protest the Use of Traditional Treatments – They Want Medical Science’ which states that thousands of science activists in the PRC protest that the state neglects its duty to treat its citizens with evidence-based medicine (here is the scientific article this is based on):

Over a number of years, Chinese researcher Qiaoyan Zhu, who has been affiliated with the University of Copenhagen’s Department of Communication, has collected data on the many thousand science activists in China through observations in Internet forums, on social media and during physical meetings. She has also interviewed hundreds of activists. Together with Professor Maja Horst, who has specialized in research communication, she has analyzed the many data on the activists and their protests in an article that has just been published in the journal Public Understanding of Science:

“The activists are better educated and wealthier than the average Chinese population, and a large majority of them keep up-to-date with scientific developments. The protests do not reflect a broad popular movement, but the activists make an impact with their communication at several different levels,” Maja Horst explained and added: “Many of them are protesting individually by writing directly to family, friends and colleagues who have been treated with – and in some cases taken ill from – Traditional Chinese Medicine. Some have also hung posters in hospitals and other official institutions to draw attention to the dangers of traditional treatments. But most of the activism takes place online, on social media and blogs.

Activists operating in a regime like the Chinese are obviously not given the same leeway as activists in an open democratic society — there are limits to what the authorities are willing to accept in the public sphere in particular. However, there is still ample opportunity to organize and plan actions online.

“In addition to smaller groups and individual activists that have profiles on social media, larger online groups are also being formed, in some cases gaining a high degree of visibility. The card game with 52 criticisms about Traditional Chinese Medicine that a group of activists produced in 37,000 copies and distributed to family, friends and local poker clubs is a good example. Poker is a highly popular pastime in rural China so the critical deck of cards is a creative way of reaching a large audience,” Maja Horst said.

Maja Horst and Qiaoyan Zhu have also found examples of more direct action methods, where local activist groups contact school authorities to complain that traditional Chinese medicine is part of the syllabus in schools. Or that activists help patients refuse treatment if they are offered treatment with Traditional Chinese Medicine.

________________________________________________________________

I am relieved to see that, even in a system like the PRC, sound science and compelling evidence cannot be suppressed forever. It has taken a mighty long time, and the process may only be in its infancy. But there is hope – perhaps even hope that the TCM enthusiasts outside the PRC might realise that much of what came out of China has led them up the garden path!?

 

Spinal manipulation is a treatment employed by several professions, including physiotherapists and osteopaths; for chiropractors, it is the hallmark therapy.

  • They use it for (almost) every patient.
  • They use it for (almost) every condition.
  • They have developed most of the techniques.
  • Spinal manipulation is the focus of their education and training.
  • All textbooks of chiropractic focus on spinal manipulation.
  • Chiropractors are responsible for most of the research on spinal manipulation.
  • Chiropractors are responsible for most of the adverse effects of spinal manipulation.

Spinal manipulation has traditionally involved an element of targeting the technique to a level of the spine where the proposed movement dysfunction is sited. This study evaluated the effects of a targeted manipulative thrust versus a thrust applied generally to the lumbar region.

Sixty patients with low back pain were randomly allocated to two groups: one group received a targeted manipulative thrust (n=29) and the other a general manipulation thrust (GT) (n=31) to the lumbar spine. Thrust was either localised to a clinician-defined symptomatic spinal level or an equal force was applied through the whole lumbosacral region. The investigators measured pressure-pain thresholds (PPTs) using algometry and muscle activity (magnitude of stretch reflex) via surface electromyography. Numerical ratings of pain and Oswestry Disability Index scores were collected.

Repeated measures of analysis of covariance revealed no between-group differences in self-reported pain or PPT for any of the muscles studied. The authors concluded that a GT procedure—applied without any specific targeting—was as effective in reducing participants’ pain scores as targeted approaches.

The authors point out that their data are similar to findings from a study undertaken with a younger, military sample, showing no significant difference in pain response to a general versus specific rotation, manipulation technique. They furthermore discuss that, if ‘targeted’ manipulation proves to be no better than ‘general’ manipulation (when there has been further research, more studies), it would challenge the need for some current training courses that involve comprehensive manual skill training and teaching of specific techniques. If simple SM interventions could be delivered with less training, than the targeted approach currently requires, it would mean a greater proportion of the population who have back pain could access those general manipulation techniques. 

Assuming that the GT used in this trial was equivalent to a placebo control, another interpretation of these results is that the effects of spinal manipulation are largely or even entirely due to a placebo response. If this were confirmed in further studies, it would be yet one more point to argue that spinal manipulation is not a treatment of choice for back pain or any other condition.

When Samuel Hahnemann translated Cullen’s ‘Treatise on Materia Medica’ in 1790, he learnt of Cullen’s explanation of the actions of Peruvian (or China) bark, Cinchona officinalis, a malaria treatment. Hahnemann disagreed with it and decided to conduct experiments of his own. He thus ingested high doses of Cinchona and noticed that subsequently he developed several of the symptoms that are characteristic of malaria. This is how Hahnemann later described his experience:

I took for several days, as an experiment, four drams of good china daily. My feet and finger tips, etc., at first became cold; I became languid and drowsy; my pulse became hard and quick; an intolerable anxiety and trembling (but without rigor); trembling in all limbs; then pulsation in the head, redness in the cheeks, thirst; briefly, all those symptoms which to me are typical of intermittent fever, such as the stupefaction of the senses, a kind of rigidity of all joints, but above all the numb, disagreeable sensation which seems to have its seat in the periosteum over all the bones of the body – all made their appearance. This paroxysm lasted for two or three hours every time, and recurred when I repeated the dose and not otherwise. I discontinued the medicine and I was once more in good health.

Hahnemann described what de facto was the 1st homeopathic proving. Despite the fact that Hahnemann misinterpreted the event, provings thus became the very basis of homeopathy. At Hahnemann’s time, it was highly uncommon for doctors to test their medicines in this way. So, one might wonder: where did the idea come from?  Is it his very own innovation, or did he get the idea from someone else?

In 1777, Hahnemann had studied medicine in Vienna. The medical school was at the time strongly influenced by Gerard van Swieten (1700-1772) He was the innovator of a new way of medical thinking and is honoured for this legacy to the present day in Vienna.

 

Van Swieten’s aim was to put medicine on new scientific foundations based on objective clinical observation, botanical and chemical research, and the introduction of new, powerful remedies.

One of the pupils of this school was Anton Störck (1731-1803). He became the director of Austrian public health and medical education, appointed by Empress Maria Theresia. Störck was the first medical scientist to systematically test the effects of medicines, including poisonous plants (e.g., hemlock, henbane, meadow saffron).

 

In numerous cases, Störck used himself as a subject in his experiments to determine adverse effects and tolerable dose levels. One of his pupils was Joseph Quarin who fully adopted his teacher’s concepts. He later rose to considerable prominence in the Viennese medical establishment.

 

Hahnemann’s clinical teacher at Vienna was Joseph Quarin. Hahnemann’s idea of  ‘homeopathic provings’ are thus to a significant extent influenced by Störck’s innovation.

Once upon a time, arsenic has been used widely for medicinal and other purposes. Now that we know how toxic it is, few people would voluntarily take it – except of course fans of homeopathy. In homeopathy, arsenic is an important and popular remedy.

Here is what HOMEOPATHY PLUS tell us about its therapeutic potential:

Arsenic is a toxic chemical element, historically used as a poison. It is safe to use with infants through to the elderly when prepared in homeopathic potencies. Those who need Arsenicum are prone to hypochondriasis and are intolerant of untidiness and disorder. They are anxious, critical, and restless, and dislike being alone but may be irritable with company. Restlessness may be followed by exhaustion which is out of proportion to their illness. They fear illness and disease, death, and being alone. Discharges tend to be acrid and burning. Burning pains paradoxically feel better for heat (except the headache which is better for cold applications). Thirst is for sips of warm drinks but cold drinks worsen. Symptoms worsen between midnight and 2 AM.

Colds and Hayfever

    • Red, puffy, burning eyes that feel better for hot compresses.
    • Watery, nasal discharge that burns and reddens the nostrils and lip.
    • Frequent sneezing with no relief.

Coughs

    • Worsened by cold air or cold drinks.
    • Rapid, difficult breathing, with wheezing (asthma).
    • Coughs or wheezing worse for lying down and better for sitting upright.
      Headaches
    • Burning, throbbing pain.
    • Worsened by heat and relieved by cold applications or cool air (though rest of body will be chilly and rugged up).

Skin Problems

    • Eczema with burning, itching, dry skin.

Digestive Problems

    • Thirst for frequent small sips of water.
    • Burning stomach pains eased by drinking milk.
    • Offensive, burning, scalding diarrhoea.
    • A key remedy for food poisoning or gastroenteritis.

Fever

    • Hot head and cold body.
    • Chilly and want to be rugged up.

Sleep

    • Restless and anxious – insomnia between midnight and 2 AM
    • Dreams of robbers

For Pets

    • Chilly, anxious pets.
    • Itchy, dry skin eruptions in chilly, anxious animals.

Where do I find it?

Arsenicum album (Ars.) is available from our online store as a single remedy and is also included in the following Complexes (combination remedies): Anxiety; Common Cold – Watery; Hay Fever; Insomnia; Mouth Ulcer; Panic Stop; Sinus Pain; Winter Defence.

Important

While above self-limiting or acute complaints are suitable for home treatment, see your healthcare provider if symptoms worsen or fail to improve. Chronic or persistent complaints, which may or may not be mentioned above, require a different treatment and dosage protocol so are best managed by a qualified homeopath for good results.

Dosage Instructions

For acute and self-limiting complaints, take one pill or five drops of the remedy every 30 minutes to 4 hours (30 minutes for intense symptoms, 4 hours for milder ones). Once an improvement is noticed, stop dosing and repeat the remedy only if symptoms return. If there is no improvement at all by three doses, choose a different remedy or seek professional guidance. Chronic symptoms or complaints require a course of professional treatment to manage the changes in potencies and remedies that will be required.

So, arsenic is safe to use with infants through to the elderly when prepared in homeopathic potencies!

True of false?

We recently discussed a case of homeopathic arsenic poisoning from India. Now a similar one has been reported from Switzerland. A Swiss doctor published a case report of chronic arsenic poisoning associated with the intake of a homeopathic remedy.

For about 4 years the patient had taken globules of a freely purchasable homeopathic remedy containing inorganic arsenic (iAs) diluted to D6 (average arsenic content per single globule: 0.85 ± 0.08 ng). She took the remedy because it was advertised for gastrointestinal confort. In the previous 7 months, she had taken 20 to 50 globules daily (average 30 ng arsenic daily).

She complained of nausea, stomach and abdominal cramps, diarrhoea and flatulence, headache, dizziness, anxiety, difficulty concentrating, insomnia, snoring, leg cramps and fatigue, loss of appetite, increased thirst and sweating, reduced diuresis, weight gain, paleness and coolness of both hands with a furry feeling of the hands, eczema of the hands, arms and legs, conjunctivitis and irregular menstruation.

The physical and laboratory examinations showed a body mass index of 30 kg/m2, acne vulgaris, bilateral spotted leukonychia, eczema of hands, arms and legs, non-pitting oedema of the legs, elevated plasma alkaline phosphatase activity, folate deficiency and severe vitamin D3 insufficiency. The arsenic concentration in her blood was <0.013 µmol/l, and arsenic was undetectable in her scalp hair. The total iAs concentration was 116 nmol/l in the morning urine and 47 nmol/l in the afternoon urine.

The urinary arsenic concentration decreased and the patient’s complaints improved upon interruption of the arsenic globules, vitamin D3, thiamine and folic acid supplementation, and symptomatic therapy.

The author concluded that an avoidable toxicant such as inorganic arsenic, for which no scientific safe dose threshold exists, should be avoided and not be found in over-the-counter medications.

The author rightly states that causality of this association cannot be proven. However, he also stresses that a causal link between chronic iAs exposure and the patient’s nonspecific systemic symptoms is nevertheless suggested by circumstantial evidence pointing to the disappearance of CAsI signs and symptoms after therapy including interruption of the exposure. In his (and my) view, this renders causality most likely.

 

Acupuncture is often recommended for relieving symptoms of fibromyalgia syndrome (FMS). The aim of this systematic review was to ascertain whether verum acupuncture is more effective than sham acupuncture in FMS.

Ten RCTs with a total of 690 participants were eligible, and 8 RCTs were eventually included in the meta-analysis. Its results showed a sizable effect of verum acupuncture compared with sham acupuncture on pain relief, improving sleep quality and reforming general status. Its effect on fatigue was insignificant. When compared with a combination of simulation and improper location of needling, the effect of verum acupuncture for pain relief was the most obvious.

The authors concluded that verum acupuncture is more effective than sham acupuncture for pain relief, improving sleep quality, and reforming general status in FMS posttreatment. However, evidence that it reduces fatigue was not found.

I have a much more plausible conclusion for these findings: in (de-randomised) trials comparing real and sham acupuncture, patients are regularly de-blinded and therapists are invariably not blind. The resulting bias and not the alleged effectiveness of acupuncture explains the outcome.

And why do I think that this conclusion is much more plausible?

Firstly, because of Occam’s Razor.

Secondly, because this is roughly what my own systematic review of the subject found (The notion that acupuncture is an effective symptomatic treatment for fibromyaligia is not supported by the results from rigorous clinical trials. On the basis of this evidence, acupuncture cannot be recommended for fibromyalgia). This view is also shared by other critical reviews of the evidence (Current literature does not support the routine use of acupuncture for improving pain or quality of life in FM). Perhaps more crucially, the current Cochrane review seems to concur: There is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia. There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being. EA is probably better than MA for pain and stiffness reduction and improvement of global well-being, sleep and fatigue. The effect lasts up to one month, but is not maintained at six months follow-up. MA probably does not improve pain or physical functioning. Acupuncture appears safe. People with fibromyalgia may consider using EA alone or with exercise and medication. The small sample size, scarcity of studies for each comparison, lack of an ideal sham acupuncture weaken the level of evidence and its clinical implications. Larger studies are warranted.

I have met many acupuncturists who think that homeopathy is bunk. Similarly, I have met many homeopaths who are convinced that acupuncture is a placebo therapy. And, I have met some (not many) practitioners of so-called alternative medicine (SCAM) who think so highly of both SCAMs that they combine the two into one handy treatment: HOMEOPUNCTURE.

I had almost forgotten (or is supressed the correct verb?) but, to be entirely truthful, a long time ago (in the mid 1970s), I even experimented with this odd therapy myself. When I worked as a junior doctor in a homeopathic hospital, several of my collegues practised homeopuncture and taught me how to do it. Essentially, you inject homeopathic remedies into acupuncture points. My colleagues told me that this approach is more powerful than each method alone. I tried it several times but remained unconvinced.

Recently, a German Heilpraktiker (Andreas Maier), reminded me of all this. Here is what he states on his website about homeopuncture:

In traditional Chinese medicine, acupuncture in addition to the herb medicine as well as certain movement therapies (eg. B. Gong Qi) constituting an important element in the treatment of diseases.

By stimulating energy points with the help of fine needles will then attempts to harmonize the flow of vital energy. a disruption of vital energy because (also called Qi), is considered in Chinese medicine as a cause of any disease.

Only when the energy flows freely through all the tissues and organs of the body, the organism can develop normally and is healthy. A similar approach is also the Homeopathy, which originated at the other end of the world, namely in Germany.

Samuel Hahnemann (1755 – 1843), the discoverer of this method of healing, also saw a failure of the life force as a pathogenic factor.

By smallest stimuli the homeopath tries to eliminate these disease-causing disorder and bring about healing. Unlike in the acupuncture reduced drug doses to be used strictly in accordance with the  principle of similarity  are selected.

Mid-19th century was the German physician Dr. August consecration firmly (1840- 1896) that disease with painful spots may accompany the body.

These pain points are often far from the actual disease process. The phenomenon was known to the Chinese for thousands of years in Europe, however, no one had yet busy. Dr. Weihe, himself a keen homeopath, was in the treatment of his patients finally see that by the suitably chosen homeopathic healed not only the disease, but also disappeared the painfulness of the points.

It was surprising that certain homeopathic remedies appear to be well-defined points had a direct bearing on the body.

A few years later, the Chinese medicine and acupuncture also reached the European continent, they took Weihe discoveries closer look. A comparison of the so-called consecration points with acupuncture points showed significant matches.

The more than 300 known Weihe points are also used therapeutically since both diagnosis. Because they can provide information on the pathological processes in the body and on the displayed homeopathic. thus the Homöopunktur brings together the findings from Chinese medicine and homeopathy. The treatment can be done differently.

On the one hand the consecration points can be traditionally stimulated with fine needles, concomitant administration of homeopathic medicine. With the help of injection preparations, means may also be injected directly to the point.

________________________________________________________________

(sorry about my friend’s poor English; I hope you could make sense of it)

I don’t think I need to tell you what the evidence tells us about homeopuncture. Yes, you guessed it: nothing! But the idea of combining SCAMs is fascinating nevertheless. So, let me suggest a few further SCAM combinations that might be attractive:

  • acupuncture + massage (sorry, that already exists under the name of shiatsu)
  • colonic irrigation + coffea (that to is already taken by the Gerson guys)
  • art therapy + homeopathy (too late: this one too already exists; painting homeopathy on the body surface)
  • detox + meditation (no, the health retreat/wellness entrepreneurs might get upset)

I am clearly not very successful at finding viable SCAM combinations. Let’s look for something innovative, something that nobody has yet thought of. How about:

  • homeo-laugh (homeopathy followed by an explanation what homeopathy is resulting in laughter; not sure that this would sell all that well)
  • kinesiology colour taping (instead of using random colours for kinesiology tape, this approach uses the wisdom of coulourtherapists to match the patient’s individual colour requirements; this means the therapists needs dual qualifications and can thus charge double – I think that might be attractive!)
  • autologous slapping therapy (this combination of slapping and autologous blood therapy (ABT) means the therapist has to hit so hard that the patient develops sizable haematomas which are the ABT part of the intervention; perhaps a bit risky, as some patients might call the police)
  • effective reverse energy transfer counselling, ERETC (the patients is counselled that his money can, with the help of the therapist, be converted into pure healing energy; to make it work, the patient needs to transfer it to the account of the therapist – the more the better)

I think I like ERECT best; in fact, I will start work on it straight away. It still needs to be perfected, but once it’s up and running, it will be just great and, as the name already makes clear, effective – not for the patient, but for the therapist!

I live (most of my time) in the UK, a country where the media interest in so-called alternative medicine (SCAM) is considerable. Years ago, the UK press used to be very much in favour of SCAM. In 2000, we showed that the level of interest was huge and the reporting was biased. Here is our short BMJ paper on the subject:

The media strongly influences the public’s view of medical matters. Thus, we sought to determine the frequency and tone of reporting on medical topics in daily newspapers in the United Kingdom and Germany. The following eight newspapers were scanned for medical articles on eight randomly chosen working days in the summer of 1999: the Times, the Independent, the Daily Telegraph, and the Guardian in the United Kingdom, and Frankfurter Allgemeine Zeitung, Süddeutsche Zeitung, Frankfurter Rundschau, and Die Welt in Germany. All articles relating to medical topics were extracted and categorised according to subject, length, and tone of article (critical, positive, or neutral).

A total of 256 newspaper articles were evaluated. The results of our analysis are summarised in the table. We identified 80 articles in the German newspapers and 176 in the British; thus, British newspapers seem to report on medical topics more than twice as often as German broadsheets. Articles in German papers are on average considerably longer and take a positive attitude more often than British ones. Drug treatment was the medical topic most frequently discussed in both countries (51 articles (64%) in German newspapers and 97 (55%) in British). Surgery was the second most commonly discussed medical topic in the UK newspapers (32 articles; 18%). In Germany professional politics was the second most commonly discussed topic (11 articles; 14%); this category included articles about the standing of the medical profession, health care, and social and economic systems—that is, issues not strictly about treating patients.

Because our particular interest is in complementary medicine, we also calculated the number of articles on this subject. We identified four articles in the German newspapers and 26 in the UK newspapers. In the United Kingdom the tone of these articles was unanimously positive (100%) whereas most (3; 75%) of the German articles on complementary medicine were critical.

This analysis is, of course, limited by its small sample size, the short observation period, and the subjectivity of some of the end points. Yet it does suggest that, compared with German newspapers, British newspapers report more frequently on medical matters and generally have a more critical attitude (table). German newspapers frequently discuss medical professional politics, a subject that is almost totally absent from newspapers in the United Kingdom.

The proportion of articles about complementary medicine seems to be considerably larger in the United Kingdom (15% v 5%), and, in contrast to articles on medical matters in general, reporting on complementary medicine in the United Kingdom is overwhelmingly positive. In view of the fact that both healthcare professionals and the general public gain their knowledge of complementary medicine predominantly from the media, these findings may be important.2,3

Table

Reporting on medical topics by daily newspapers in the United Kingdom and Germany, 1999

Country

United Kingdom (n=176) Germany (n=80)
Mean No articles/day 5.5 2.5
Mean (SD) No words/article 130 (26) 325 (41)
Ratio of positive articles to critical articles* 1.0 3.2

Even though I have no new data on this, my impression is that things have since changed. It seems that the UK press has become more objective and are now reporting more critical comments on SCAM. While this is most welcome, of course, one feature is still deplorable, in my view: journalists’ obsession with ‘balance’.

A recent example might explain this best. The ‘i’ newspaper published an article about homeopathy which was well-written and thoroughly researched. It explained the current best evidence on the subject and made it quite clear why homeopathy is not a reasonable therapy for any condition. But then, towards the end of the article, the journalist added this section:

Dr Lise Hansen, a veterinary homeopath based in London and author of a forthcoming book, The Complete Book of Cat and Dog Health, argues that scientists have shown how homeopathy works. She cites a paper by Luc Montagnier, the French virologist who won a Nobel Prize in 2008 for his role in discovering HIV. The following year, he published evidence of his discovery of “electromagnet signals that are produced by nanostructures derived from bacterial DNA at high aqueous dilutions”. “Mainstream medicine is about chemistry, homeopathy is physics and scientists have only recently begun to study these nanostructures,” Hansen says.

Basically, the reader is left with the impression that homeopathy might be fine after all, and that science will soon be able to catch up with it. In the interest of balance, the journalist thus confused her readers and misled the public.

Why?

Journalists are obviously taught to always cover ‘both sides’ of their stories, and they adhere to this dogma no matter what. In most instances, this works out well, because in most cases there are two sides.

But not always!

When there is a strong consensus supported by facts, science and reproducible findings, the other side ceases to have a reasonable point. There simply is no reasonable ‘other side’ when we consider global warming, evolution, the Holocaust, and many other subjects. Of course, one can always find some loon who claims the earth is flat, or that cancer is a Jewish plot against public health. But these arguments lack reason and integrity – to dish them out without anything remotely resembling a ‘fact check’ is not just annoying but harmful.

Journalists should, in my view, be more responsible, check the facts, and avoid false balance. I know this will often entail much more work, but they owe it to their readers and to the reputation of their profession.

I am not usually a vulgar person, and I do apologise for the title of this post. But, in view of todays’ subject, some vulgarity seems almost unavoidable. This post is about homeopathic provings. In my book, I explain them in some detail:

The term ‘proving’ is a mis-translation of Hahnemann’s term ‘Pruefung’ which means ‘a test’. The English term wrongly implies that some fact is being proven. According to the International Dictionary of Homeopathy, provings (also known as ‘homeopathic pathogenetic trials’ or ‘Arzneimittelpruefung’ as Hahnemann called them), are defined as the process of determining the medicinal properties of a substance; testing in material dose, mother tincture or potency, by administration to healthy volunteers, to elicit effects from which the therapeutic potential, or material medica of the substance may be derived.

In order to individualise their treatment according to the ‘like cures like’ principle, homeopaths need to know what symptoms, or ‘artificial disease’, can be caused by the substances they prescribe. If they treat a patient who suffers from running eyes and nose, for instance, they would be looking for a substance that causes runny eyes and nose in healthy individuals. This is why remedies based on onion might be used to treat conditions like the common cold or hay fever.

But most patients’ complaints are usually a lot more complex. For instance, a person might suffer from frequently runny eyes and nose together with a whole host of other symptoms, many of which might seem trivial or irrelevant to conventional doctors but, for a homeopath, all complaints and patient characteristics are potentially important.

The first proving in the history of homeopathy was Hahnemann’s quinine experiment, which convinced him that he had discovered that this malaria cure causes the symptoms of malaria when taken by a healthy individual. From this observation he deduced that any substance causing symptoms in a healthy person could be used to cure these same symptoms when they occur in a patient.

Provings are normally conducted by administering a mother tincture or a low potency to healthy volunteers who subsequently note in minute detail all sensations, symptoms, emotions and thoughts that occur to them while taking it. These are then carefully registered and eventually form the ‘drug picture’ of that substance.

As a day goes by, we all experience, of course, all sorts of sensations without apparent reason, whether we have taken a medicine or not. Therefore, simple provings are not reliable and might not describe the specific symptoms caused by the substance in question. Realising this problem, most homeopaths now advocate conducting provings in a placebo-controlled manner hoping that this method might generate only symptoms which are specific to the tested substance.

Today thousands of provings have been carried out; most of them are of very low methodological quality. Their results have been published in reference books called ‘repertories’. Homeopaths, once they have noted the full range of characteristics of a patient, can look up the optimal remedy for each individual case. To ease this process even further, sophisticated computer programs are available.

So, essentially, homeopathic provings are experiments where homeopaths give a (often highly diluted/potentised) substance to healthy volunteers and ask them to monitor all sensations that follow. These symptoms are then recorded and eventually form the ‘drug picture’ of a homeopathic remedy. When prescribing a remedy, homeopaths essentially try to match the patient’s symptoms with the drug picture. This is why provings and drug pictures are so very important to classical homeopaths.

Now, imagine that you have just swallowed a substance and start paying attention to all the sensations you feel. As I am writing these lines, I would note all of the following:

  • mild mental irritation,
  • impatience,
  • neck pain,
  • back pain,
  • heavy feet,
  • hot feet,
  • slight ringing in right ear,
  • pressure on abdomen,
  • tickling nose,
  • sweaty hands,
  • acid taste in mouth,
  • need to pass urine,
  • feeling of need to wash hands,
  • itchy scalp,
  • acidity in stomach,
  • itch over right eyebrow.

These are just some of the sensations that come and go with everyday life; they are devoid of any medical meaning or importance. In homeopathy, however, they are elevated to something of fundamental relevance. As I have just had a cup of coffee, the above list could even be seen as a proving of coffea and a contribution to its drug picture. In turn, this would then determine how homeopaths prescribe homeopathic coffea. If others generated similar symptoms after coffee, some of the symptoms listed above might become the part of the accepted drug picture of coffea.

Many of the homeopathic provings are indeed based on little more than that. Modern provings are often conducted a little more rigorously, but there are tens of thousands of different remedies and the drug pictures of many are hardly different from my above-described proving of coffea. If you find this hard to believe, see what two homeopaths noted during a homeopathic proving of another remedy:

Domination and abuse are so intense that they lead to total suppression of oneself. The person develops intense hatred towards  the dominant person, as though they are being tortured. The intensity of the suppressed emotions produces other emotional, mental and physical symptoms: suicidal thoughts, aversion to company, panic attacks with lot of anxiety, low self confidence, arrested mental development, heart palpitations with anxiety, indisposed to talk, aversion to work, compulsive disorder of work, etc.

Low self-esteem and low self-confidence are associated with dependency and fear of failure.There is intense fear of failure and inadequacy, which leads to complete helplessness. This remedy also has aversion to self and a low self image. In this remedy, there are dreams/ thoughts of toilets.

Other symptoms include:

  • Ailments from sexual abuse and rape
  • Mind; colors; charmed by; golden/ colors; desires; golden
  • Delusion or image that body parts/ arms/ legs are smaller, and shortened
  • Dreams lascivious/ seduction/ necked people/ prostitution/ violent sex; Dreams; lascivious, voluptuous; partner, frequent change of/ voluptuous; perverse; girls, about little)
  • Dreams of dogs/ cats, felines
  • Fastidious; appearance, about; personal
  • Music; desires; drums

Believe it or not, the above text is taken from a published proving of excrementum canium – yes: dog shit!

This leads me to conclude that homeopathic provings (and, as provings are the basis for all homeopathy, with it the entire field of homeopathy) are BS.

Controlled clinical trials are methods for testing whether a treatment works better than whatever the control group is treated with (placebo, a standard therapy, or nothing at all). In order to minimise bias, they ought to be randomised. This means that the allocation of patients to the experimental and the control group must not be by choice but by chance. In the simplest case, a coin might be thrown – heads would signal one, tails the other group.

In so-called alternative medicine (SCAM) where preferences and expectations tend to be powerful, randomisation is particularly important. Without randomisation, the preference of patients for one or the other group would have considerable influence on the result. An ineffective therapy might thus appear to be effective in a biased study. The randomised clinical trial (RCT) is therefore seen as a ‘gold standard’ test of effectiveness, and most researchers of SCAM have realised that they ought to produce such evidence, if they want to be taken seriously.

But, knowingly or not, they often fool the system. There are many ways to conduct RCTs that are only seemingly rigorous but, in fact, are mere tricks to make an ineffective SCAM look effective. On this blog, I have often mentioned the A+B versus B study design which can achieve exactly that. Today, I want to discuss another way in which SCAM researchers can fool us (and even themselves) with seemingly rigorous studies: the de-randomised clinical trial (dRCT).

The trick is to use random allocation to the two study groups as described above; this means the researcher can proudly and honestly present his study as an RCT with all the kudos these three letters seem to afford. And subsequent to this randomisation process, the SCAM researcher simply de-randomises the two groups.

To understand how this is done, we need first to be clear about the purpose of randomisation. If done well, it generates two groups of patients that are similar in all factors that might impact on the results of the study. Perhaps the most obvious factor is disease severity; one could easily use other methods to make sure that both groups of an RCT are equally severely ill. But there are many other factors which we cannot always quantify or even know about. By using randomisation, we make sure that there is an similar distribution of ALL of them in the two study groups, even those factors we are not even aware of.

De-randomisation is thus a process whereby the two previously similar groups are made to differ in terms of any factor that impacts on the results of the trial. In SCAM, this is often surprisingly simple.

Let’s use a concrete example. For our study of spiritual healing, the 5 healers had opted during the planning period of the study to treat both the experimental group and the control group. In the experimental group, they wanted to use their full healing power, while in the control group they would not employ it (switch it off, so to speak). It was clear to me that this was likely to lead to de-randomisation: the healers would have (inadvertently or deliberately) behaved differently towards the two groups of patients. Before and during the therapy, they would have raised the expectation of the verum group (via verbal and non-verbal communication), while sending out the opposite signals to the control group. Thus the two previously equal groups would have become unequal in terms of their expectation. And who can deny that expectation is a major determinant of the outcome? Or who can deny that experienced clinicians can manipulate their patients’ expectation?

For our healing study, we therefore chose a different design and did all we could to keep the two groups comparable. Its findings thus turned out to show that healing is not more effective than placebo (It was concluded that a specific effect of face-to-face or distant healing on chronic pain could not be demonstrated over eight treatment sessions in these patients.). Had we not taken these precautions, I am sure the results would have been very different.

In RCTs of some SCAMs, this de-randomisation is difficult to avoid. Think of acupuncture, for instance. Even when using sham needles that do not penetrate the skin, the therapist is aware of the group allocation. Hoping to prove that his beloved acupuncture can be proven to work, acupuncturists will almost automatically de-randomise their patients before and during the therapy in the way described above. This is, I think, the main reason why some of the acupuncture RCTs using non-penetrating sham devices or similar sham-acupuncture methods suggest that acupuncture is more than a placebo therapy. Similar arguments also apply to many other SCAMs, including for instance chiropractic.

There are several ways of minimising this de-randomisation phenomenon. But the only sure way to avoid this de-randomisation is to blind not just the patient but also the therapists (and to check whether both remained blind throughout the study). And that is often not possible or exceedingly difficult in trials of SCAM. Therefore, I suggest we should always keep de-randomisation in mind. Whenever we are confronted with an RCT that suggest a result that is less than plausible, de-randomisation might be a possible explanation.

 

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