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

alternative medicine

Pyruvate, a ketone and an alpha-keto acid, occurs naturally in the body when glucose is converted into energy. It is part of the Krebs cycle, the complex chain of reactions in which nutrients are metabolised to provide energy. High doses of pyruvate seem to stimulate the breakdown of fat in the body. It is therefore not surprising that pyruvate is used in all sorts of slimming aids; and if the advertising for ‘fat burners’ is to be believed, pyruvate is just the ticket for the desperate slimmer.

One such product advertisement, for instance, claims that sodium pyruvate and potassium pyruvate, which can act as a stimulant for the metabolism, adding to the thermogenesis process. Pyruvates have been found in studies to reduced the storage of fat in the body and convert the food source into calories which are then burned off in the production of heat. In one study, rats were injected with three fat burners, including pyruvates, and the rats given the pyruvates burned the greatest amount of fat by increasing the rat’s resting metabolic rate. With the elevated resting metabolic rate, the body burned more fat in individuals, which makes pyruvate an excellent source for weight maintenance.

So, maybe pyruvate works for rats – but does it really help those of us who would like to lose a few kilos? Some studies seem to say so, but others don’t. What do we conclude? There can only be one solution: we need a systematic review of the totality of the available trial evidence – and you probably guessed it: we have just published such an article.

The objective of our systematic review was to examine the efficacy of pyruvate in reducing body weight. Extensive literature searches identifies 9 RCTs of which 6 were met our inclusion criteria. All had methodological weaknesses. The meta-analysis revealed a statistically significant difference of 0.72 kg in body weight with pyruvate compared to placebo. The magnitude of the effect is small, and its clinical relevance is therefore uncertain. Adverse events included gas, bloating, diarrhoea, and increase in low-density lipoprotein cholesterol.

Our conclusion: The evidence from randomized clinical trials does not convincingly show that pyruvate is efficacious in reducing body weight. Limited evidence exists about the safety of pyruvate. Future trials involving the use of this supplement should be more rigorous and better reported.

Pyruvate supplements are popular; people who want to lose weight are misled into believing that they are effective. Bodybuilders as well as other athletes tend to take them because pyruvate is claimed to reduce body fat and enhance the ability to use energy more efficiently. None of these assumptions is based on sound evidence. Regardless of the evidence, a whole industry is exploiting the gullible and doing very well on it.

As these ‘fat burners’ are by no means cheap, I recommend a more efficient and more economical method for normalising body weight: eat a little less and move a bit more – I know it’s naff, but it works!

Preston Long’s book has featured on this blog before. It is truly an important contribution to the literature on chiropractic, and I recommend that anyone with an interest in the subject should read it. Harriet Hall wrote about it even if you think you’ve heard it all before, there are revelations here that will be new to you, that will elicit surprise, indignation, and laughter.

In a way, an even better ‘recommendation’ comes from someone who previously made numerous vile comments on my blog, Eugen Roth: In my opinion the close relationship that the author has with both Stephen Barrett and Prof Edzard Ernst makes this book just another part of the witch hunt against chiropractic which was initiated more than 50 years ago… In my opinion Prof Ernst and Dr Barrett have continued this witch hunt over many years and have now teamed up with the author to try and give credence to their misguided message. I have no ‘close relationship’ with Long, and his book is not a witch hunt; it is a factual and fascinating of chiropractic abuse, fraud and make-belief.

Chiropractors are in many ways not that different from other health care professionals. Most of them, like Preston Long, go into their profession with all the very best intentions; they study hard what is being taught at Chiropractic College; they pass their exams and set up a practice to earn a decent living. During their career, they subsequently treat thousands of patients, and many of them perceive some benefit. Those who don’t fail to return and are quickly forgotten. Over the years, chiropractors thus become convinced that their interventions are effective.

In several other ways, however, chiropractors differ from conventional health care professionals. The most fundamental differences, I think, relate to the facts that chiropractic is based on the erroneous dogma of its founding fathers, and that chiropractors fail to abide by the rules of evidence-based medicine and practice. Preston Long writes eloquently about many other rules which some chiropractors fail to abide to in addition.

D.D. Palmer, the ‘inventor’ of chiropractic, believed that all human illness was the result of ‘subluxations’ of the spine which impeded the flow of the ‘Innate’ and required correction through spinal adjustments. To his followers, this new approach to healing was the only correct one – one that could cure all health problems. When these assumptions were first formulated, more than a century ago, they might not even have appeared entirely ridiculous; today, in the face of an immense amount of new knowledge, they can easily be disclosed as pure fantasy and chiropractors who believe in Palmer’s gospel have become the laughing stock of all health care professionals.

Some chiropractors are therefore struggling to free themselves from the burden of Palmer’s nonsensical notions. But this struggle rarely is entirely successful. After all, chiropractors have been to Chiropractic College where they memorised so many falsehoods, were kept from numerous important truths, and failed to acquire the essential skills of being (self-) critical. As a result, most find it virtually impossible to completely recover from the ‘brain-wash’ they were submitted to at the beginning of their career. And even if some courageous innovators, one day, managed to expunge all the falsehoods, myths and bogus claims from their profession, the obvious question would still be, how would such a ‘chiropractic minus woo’ differ from physiotherapy?

Most chiropractors have very little inkling what evidence-based practice amounts to; the good intentions that once motivated them have long given way to the need to make money. They are unable to critically assess their own activities, and all the bogus claims they have been exposed to are thus endlessly and profitably perpetuated. The principles of medical ethics have remained alien to most of them. In fact, ‘evidence-based chiropractic’ is an oxymoron: either you abide by evidence – in which case you cannot possibly conceive the idea of adjusting spinal ‘subluxations’ – or you believe in the myth of ‘subluxations’ in which case your practice is not evidence-based. Long is right, I think, when he states: the most efficient way to protect against chiropractic mistreatment is to avoid chiropractors altogether.

Whenever someone dares to criticise their bizarre interventions, chiropractors react with anger, personal attacks, defamation or even libel suits. One argument that is voiced with unfailing regularity in such a context is the claim that the critic lacks the knowledge, insight and experience to be credible. External criticism is thus usually completely ignored.

Preston Long has been a chiropractor himself, and therefore his authority, inside knowledge and expertise cannot be undermined in this fashion. He knows what he is writing about and has been an eye-witness to most of the abuses he reports in his book. His comments are not criticism from the outside; they are thoughtful insights, hand-on experiences and first-hand accounts of fraud and abuse which originate from the very heart of chiropractic. It is this fact that makes this book unique.

Preston Long’s book provides a most valuable perspective on the education, training, thinking, misunderstandings, wrong-doings and unethical behaviours of chiropractors. He also gives valuable instructions on how we can protect ourselves against chiropractic abuse. It would be nice to think that Long’s outstanding and in many ways constructive criticism might contribute to a much-needed and long over-due reformation of chiropractic; but I would not hold my breath.

The very first article on chiropractic listed in ‘Medline’ was published 100 years ago in the ‘California State Journal of Medicine’ without the author’s name. It is a beauty! Here I take the liberty of re-publishing it in full.

Some people are really so terribly modest that it is a mystery how they can live, or even be willing to live, in a world so filled with pushing braggarts and rampant commercialism. For example, note the list of things that E. R. Blanchard D.C., (graduate chiropractor), intimates that he can cure:

“Adhesions, anemia, asthma, appendicitis, blood poison, bronchitis, backache, biliousness, catarrh, constipation, chills and fever, diabetes, dropsy, dizziness, drug and alcohol habits, diarrhoea, deafness, eczema, eye diseases, female diseases, gallstones, gravel, goitre, hay fever, indigestion, lumbago, locomotor ataxia, malaria, nervousness, neuralgia, paralysis, piles, pneumonia, rickets, ruptures, rheumatism, St. Vitus’ dance, suppressed or painful menstruation, scrofula, tumors, worms, bed wetting and other child’s diseases, leucorrhoea, or whites, stricture, emissions, impotence and many other diseases.”

This is almost as long a list as that compiled by the wealthy and admired Law brothers in connection with what they say they can cure with the wonderful Viavi, that prize of all fakes!

One hundred years later, it seems to me, not a lot has changed:

A review of 200 chiropractor websites and 9 chiropractic associations’ claims in Australia, Canada, New Zealand, the United Kingdom, and the United States was conducted between. The outcome measure was claims (either direct or indirect) regarding eight reviewed conditions, made in the context of chiropractic treatment. The results demonstrated that 190 (95%) chiropractor websites made unsubstantiated claims.

This article was posted a few months ago. Then it mysteriously vanished without a trace; nobody knows quite why or how. Today I found an old draft on my computer, so I post the article again. It might not be identical with the original but it is close enough, I think.

Some time ago, Andy Lewis formulated a notion which he called ‘Ernst’s law’. Initially, I felt this was a bit o.t.t., then it made me chuckle, and eventually it got me thinking: could there be some truth in it, and if so, why?

The ‘law’ stipulates that, if a scientist investigating alternative medicine is much liked by the majority of enthusiasts in this field, the scientist is not doing his/her job properly. In any other area of healthcare, such a ‘law’ would be absurd. Why then does it seem to make sense, at least to some degree, in alternative medicine? The differences between any area of conventional and alternative medicine are diverse and profound.

Take neurology, for instance: here we have an organ-system, anatomy, physiology, pathophysiology, etiology and nosology all related more or less specifically to this field and all based on facts, rigorous science and substantial evidence. None of this knowledge, science and evidence is static, but each has evolved and can be predicted to do so in future. What we knew about neurology 50 years ago, for example, was dramatically different from what we know today. Scientific discovery discoveries in neurology link up with the knowledge gathered in other areas of medicine to generate a (more or less) complete bigger picture.

In alternative medicine or any single branch thereof, we have no specific organ-system, anatomy, physiology, pathophysiology, etiology or nosology to speak of. We also have few notions that are transferable from one branch of alternative medicine to another – on the contrary, the assumptions of homeopathy, for example, are in overt contradiction to those of acupuncture which, in turn, are out of sync with those of reflexology, aromatherapy and Reiki.

Instead, each branch of alternative medicine has its own axioms that are largely detached from reality or, indeed, from the axioms of other branches of alternative medicine. In acupuncture, for instance, we have concepts such as yin and yang, qi, meridians and acupuncture points, and there is hardly any development of these concepts. This renders them akin to dogmas, and there is no chance in hell that the combination of all the branches of alternative medicine would add up to provide a sensible ‘bigger picture’.

If a scientist were to instill scientific, critical, progressive thought in a field like neurology, thus overthrowing current concepts and assumptions, they would be greeted with open arms among many like-minded researchers who all pursue the aim of advancing their field and contributing to the knowledge base by overturning wrong assumptions and discovering new truths. If researchers were to spend their time trying to analyse the concepts or treatments of alternative medicine, thus overthrowing current concepts and assumptions, they would not only not be appreciated by the majority of the experts working in this field, they would be castigated for their actions.

If a scientist dedicated decades of hard work to the rigorous assessment of alternative medicine, that person would become a thorn in the flesh of believers. Instead of welcoming him with open arms, some disappointed enthusiasts of alternative treatments might even pay for defaming them.

On the other hand, if a researcher merely misused the tools of science to confirm the implausible assumptions of alternative medicine, he would quickly become the celebrated ‘heroes’ of this field.

This is the bizarre phenomenon that ‘Ernst’s law’ seems to capture quite well – and this is why I believe the ‘law’ is worth more than a laugh and a chuckle. In fact, ‘Ernst’s law’ might even describe the depressing reality of retrograde thinking in alternative medicine more accurately than most of us care to admit.

What do my readers feel? Their comments following this blog may well confirm or refute my theory.

Guest post by Dr. Richard Rawlins MB BS MBA FRCS, Consultant Orthopaedic and Trauma Surgeon

On 14th November 2013 the Daily Telegraph advised that ‘Meditation could help troops overcome the trauma of war: Troops suffering post traumatic stress should take up yoga and acupuncture to get over the horrors of war. The Royal Navy and Royal Marines Children’s Fund is urging troops to try alternative therapies to get over psychological disorders when they return from conflict zones. After receiving a Whitehall grant, the charity has written a book aimed at helping families understand and cope with the impact and stresses suffered by troops before, during and after warfare. It suggests servicemen try treatments such as massage, reflexology, reiki and meditation.’

As a former Surgeon Lieutenant Commander in the Royal Naval Reserve I treated servicemen on their return from the Falklands. As a father of a platoon commander who served with the Grenadier Guards in Helmand I support Combat Stress. As a member of the Magic Circle I am well acquainted with methods of deceit, deception and delusion. As a doctor I care and hope to see all patients treated appropriately, but alternative therapies must be considered critically.

To assist management of Post Traumatic Stress Disorder the Children’s Fund book provides details of relevant therapies, institutions providing them and knitting patterns for making dolls representing the service personnel and their families. The title Knit the Family is both a suggestion for practical help by making dolls and a metaphor for knitting families back together after deployment. All of which is highly laudable and deserving of substantial support. But…

I do not doubt yoga, meditation, relaxation and doll making can provide valuable emotional support for one of the most pernicious outcomes of combat. I do not doubt that support from an empathic caring practitioner or a conscientious counsellor is of benefit. But what is the added value of pressing on ‘zones’ in the feet? Of positioning hands around a patient and providing them with charms? Of feeling for and adjusting ‘subtle rhythms in cerebro-spinal fluid’? Of inserting needles in the skin? Unless there is evidence that such manoeuvres and modalities actually do provide benefit greater than any other method for producing placebo effects – why spend any valuable funds on such practices? Would not the charitable funds be better spent on psychotherapy, counselling, yoga and meditation? There is no need for CAM therapy. The RN & RM Children’s Fund suggests that complementary and alternative medicine can help PTSD. I know of no evidence alternatives such as reiki, reflexology, CST, acupuncture, Emotional Freedom Techniques (utilising ‘finger tapping’), Thought Field Therapy and Somatic Experiencing all of which are set out in the charity’s book, can provide any benefit. Indeed, the book admits there is no scientific evidence of such benefit. Spending time in a therapeutic relationship helps, but there is no evidence the therapies have any effect on their own account – and there is plenty of evidence they almost certainly do not. That is why they are referred to as being implausible and are termed ‘alternative medicine’.

In order service personnel and their families can give fully informed consent to any proposed treatment they will need to consider the probability that they are wasting time and scarce funds on implausible treatments. And members of the public who might wish to support the charity will need to carefully consider the use to which their funds might be put.

The National Institute for Clinical Excellence (NICE) has Guidelines for the management of Post Traumatic Stress Disorder and emphasises ‘Families and carers have a central role in supporting people with PTSD and many families may also need support for themselves …Healthcare professionals should identify the need for appropriate information about the range of emotional responses that may develop and provide practical advice on how to access appropriate services for these problems.’

Note that the NICE guidelines, quoted in Knit the Family, require that PTSD support services should be ‘appropriate’. So presumably the Fund has decided that implausible non-evidenced based modalities of treatment are appropriate. But just how did it come to such a decision? I have asked questions on this and a number of other points and await an answer.

And there is more to this matter. Knit the Family acknowledges the support it has received from Whitehall’s Army Covenant Libor Fund and also from the Barcarpel Foundation. Barcarpel’s website tells us it ‘is a particularly enthusiastic supporter of Complementary Medicine’ and ‘has made substantial donations to the Homeopathic Trust for Research & Education as well as establishing the Nelson Barcapel Teaching Fellowship at Exeter, specifically to enable medical practitioners to take the Integrated Healthcare programme.’ ‘Nelson’ not for the Admiral but for the firm which manufactures homeopathic remedies, sponsored the inaugural meeting of the ‘College of Medicine’, and whose Chairman Robert Wilson is also Chairman of Barcarpel. And ‘integrated medicine’ means the incorporation of non-evidenced based therapies with orthodox care. Which might be reasonable if there was evidence CAMs had an effect on PTSD – but there is no such evidence.

Special thanks are given to Jonathan Poston, Chair of the Craniosacral Therapy Association, for assistance with setting up the project; Liz Kalinowska, Fellow of the Craniosacral Therapy Association, for wise advice; Michael Kern, Founder/Principal of Craniosacral Therapy Educational Trust; Cathy Cremer, whose experience with the UK Forces Project has contributed to an understanding of how best to explain the benefits of CST for those suffering from PTSD; Silvana Calzavara whose experience working at Headway East London (acquired brain injury) proved invaluable at the Portsmouth CST clinic; Monica Tomkins, Eva Kretchmar, Sally Christian, Talita Harrison, Cathy Brooks and Simon Copp for their contribution in carrying the CST project forward.’

So we see that a group of enthusiasts for CST have inveigled their way into the Children’s Fund and are set on promoting the use of this implausible therapy for some of our most vulnerable patients. An insurgency if ever there was one. They have not been able to offer any evidence that ‘subtle rhythms’ can be felt in the cerebro-spinal fluid, let alone manipulative methods can influence the flow of cerebro-spinal fluid. And if they are not doing that, they are not doing CST. The care and attention provided by these practitioners can be applauded, but not the methods they purport to use. In which case, why use them? Would the Children’s Fund not do better to spend its funds on plausible evidence based therapies? How has the Fund assessed whether or not the promoters of CST and other CAMs are quacks? Or whether or not they are frauds? The public who are considering donations need to be reassured. The service personnel who so deservedly need support should be treated with honestly, integrity and probity – not metaphysics.

I have been challenged by homeopaths! Not again you might think, but this one is quite interesting.

Some time ago, I gave an interview in which I stated that, for a while, I had assumed homeopaths to be just a little over-enthusiastic but, over the years, I have come to the conclusion that many of them are lying outright (the interview is in German, and I used the term “luegen wie gedruckt”). Predictably, this has prompted fierce opposition from homeopaths who objected to my claim and demand proof of this statement.

So, here I will try to provide some evidence – only SOME because there is far too much for a short post of this nature. To get started, I quickly googled ‘homeopathy’ and, impressively, the very first site already provided me with the following quotes:

Homeopathy is extremely effective.

Homeopathy is completely safe.

Homeopathy is natural.

Homeopathy is holistic.

None of these statements is true; and if they are not true, they must be lies (defined as “an untrue or deceptive statement deliberately used to mislead“)! Yes, I don’t mean errors, I do mean deliberate lies.

In fact, if we want to find proof for my statement ‘MANY HOMEOPATHS LIE OUTRIGHT’, we are spoilt for choice. For instance, any homeopath who mis-quoted the so-called ‘Swiss report’ on homeopathy as being an official document of the Swiss government even when its true nature had been disclosed over and over again, was clearly telling lies; and Dana Ullman must be the undisputed champion in this respect.

But there is more – much, much more! Homeopaths who promote their placebos as a cure of AIDS or cancer or any other serious disease are not just lying, they are endangering the health of millions. If anyone wants to read about individual homeopaths or organisations that have issued lies, I recommend reading this site which provides plenty of names and interesting links.

I think, I can stop here – but I do invite readers to post their own examples of ‘homeopathic lies’ in the comments below.

Sorry homeopaths, but you did ask for it!

Several sceptics including myself have previously commented on this GP’s bizarre promotion of bogus therapies, his use of disproven treatments, and his advocacy for quackery. An interview with Dr Michael Dixon, OBE, chair of the ‘College of Medicine’, and advisor to Prince Charles, and chair of NHS Alliance, and president of the ‘NHS Clinical Commissioners’ and, and, and…was published on 15 November. It is such a classic example of indulgence in fallacies, falsehoods and deceptions that I cannot resist adding a few words.

To make it very clear what is what: the interviewer’s questions are in bold Roman; MD’s answers are in simple Roman; and my comments are in bold italic typeface. The interview itself is reproduced without changes or cuts.

How did you take to alternative medicine?

I started trying out alternative medicine after 10 years of practising as a general physician. During this period, I found that conventional medicine was not helping too many patients. There were some (patients) with prolonged headaches, backaches and frequent infections whom I had to turn away without offering a solution. That burnt me out. I started looking for alternative solutions.

The idea of using alternative treatments because conventional ones have their limits is perhaps understandable. But which alternative therapies are effective for the conditions mentioned? Dr Dixon’s surgery offers many alternative therapies which are highly unlikely to be effective beyond placebo, e.g. ‘Thought Field Therapy’, reflexology, spiritual healing or homeopathy.

But alternative medicine has come under sharp criticism. It was even argued that it has a placebo effect?

I don’t mind what people call it as long as it is making patients better. If the help is more psychological than physiological, as they argue, all the better. There are less side-effects, less expenses and help is in your own hands.

I have posted several articles on this blog about this fundamental misunderstanding. The desire to help patients via placebo-effects is no good reason to employ bogus treatments; effective therapies also convey a placebo-response, if administered with compassion. Merely administering placebos means denying patients the specific effects of real medicine and is therefore not ethical.

Why are people unconvinced about alternative medicine?

One, there are vested interests – professional and organizational impact on it. Two, even practitioners in conventional medicine do not know much about it. And most importantly, we need to develop a scientific database for it. In conventional medicine, pharmaceutical companies have the advantage of having funds for research. Alternative medicine lacks that. Have people who say alternative medicine is rubbish ever done research on it to figure out whether it is rubbish? The best way to convince them is through the age-old saying: Seeing is believing.

1) Here we have the old fallacy which assumes that ‘the establishment’ (or ‘BIG PHARMA’ ) does not want anyone to know how effective alternative treatments are. In truth, everyone would be delighted to have more effective therapies in the tool-kit and nobody does care at all where they originate from.

2) GPs do not know much about alternative medicine, true. But that does not really explain why they are ‘unconvinced’. The evidence shows that they need more convincing evidence to be convinced.

3) Dixon himself has done almost no research into alternative medicine (I know that because the few papers he did publish were in cooperation with my team). Contrary to what Dixon says, there are mountains of evidence (for instance ~ 20 000 articles on acupuncture and ~5000 on homeopathy in Medline alone); and the most reliable of this evidence usually shows that the alternative therapy in question does not work.

4) Apologists lament the lack of research funds ad nauseam. However, there is plenty of money in alternative medicine; currently it is estimated to be a $ 100 billion per year business worldwide. If they are unable to channel even the tiniest of proportions into a productive research budget, only they are to blame.

5) Have people who say alternative medicine is rubbish ever done research on it to figure out whether it is rubbish? Yes, there is probably nobody on this planet who has done more research on alternative medicine than I have (and DM knows it very well, for about 15 years, he tried everything to be associated with my team). The question I ask myself is: have apologists like Dixon ever done rigorous research or do they even know about the research that is out there?

6) Seeing is believing??? No, no, no! I have written several posts on this fallacy. Experience is no substitute for evidence in clinical medicine.

Will alternative medicine be taught in UK universities?

US already has 16 universities teaching it. The College of Medicine, UK, is fighting hard for it. We are historically drenched in conventional medicine and to think out of the box will take time. But we are at it and hope to have it soon.

1) Yes, the US has plenty of ‘quackademia‘ – and many experts are worried about the appalling lack of academic standards in this area.

2) The College of Medicine, UK, is fighting hard for getting alternative medicine into the medical curriculum. Interesting! Now we finally know what this lobby group really stands for.

3) Of course, we are ‘drenched’ in medicine at medical school. What else should we expose students to?

4) Thinking ‘out of the box’ can be productive and it is something medicine is often very good at. This is how it has evolved during the last 150 years in a breath-taking speed. Alternative medicine, by contrast, has remained stagnant; it is largely a dogma.

What more should India do to promote integrated medicine?

India needs to be prouder of its institutions and more critical of the West. The West has made massive mistakes. It has done very little about long-term diseases and in preventing them. India needs to be more cautious as it will lead the world in some diseases like the diabetes. It should not depend on conventional medicine for everything, but take the best for the worst.

To advise that India should not look towards the ‘West’ for treating diabetes and perhaps use more of their Ayurvedic medicines or homeopathic remedies (both very popular alternatives in India) is a cynical prescription for prematurely ending the lives of millions prematurely.

Irritable bowel syndrome (IBS) is common and often difficult to treat – unless, of course, you consult a homeopath. Here is just one of virtually thousands of quotes from homeopaths available on the Internet: Homeopathic medicine can reduce Irritable Bowel Syndrome (IBS) symptoms by lowering food sensitivities and allergies. Homeopathy treats the patient as a whole and does not simply focus on the disease. Careful attention is given to the minute details about the presenting complaints, including the severity of diarrhea, constipation, pain, cramps, mucus in the stools, nausea, heartburn, emotional triggers and conventional laboratory findings. In addition, the patient’s eating habits, food preferences, thermal attributes and sleep patterns are noted. The patient’s family history and diseases, along with the patient’s emotions are discussed. Then the homeopathic practitioner will select the remedy that most closely matches the symptoms.

Such optimism might be refreshing, but is there any reason for it? Is homeopathy really an effective treatment for IBS? To answer this question, we now have a brand-new Cochrane review. The aim of this review was to assess the effectiveness and safety of homeopathic treatment for treating irritable bowel syndrome (IBS). (This type of statement always makes me a little suspicious; how on earth can anyone truly assess the safety of a treatment by looking at a few studies? This is NOT how one evaluates safety!) The authors conducted extensive literature searches to identify all RCTs, cohort and case-control studies that compared homeopathic treatment with placebo, other control treatments, or usual care in adults with IBS. The primary outcome was global improvement in IBS.

Three RCTs with a total of 213 participants were included. No cohort or case-control studies were identified. Two studies compared homeopathic remedies to placebos for constipation-predominant IBS. One study compared individualised homeopathic treatment to usual care defined as high doses of dicyclomine hydrochloride, faecal bulking agents and a high fibre diet. Due to the low quality of reporting, the risk of bias in all three studies was unclear on most criteria and high for some criteria.

A meta-analysis of two studies with a total of 129 participants with constipation-predominant IBS found a statistically significant difference in global improvement between the homeopathic ‘asafoetida’ and placebo at a short-term follow-up of two weeks. Seventy-three per cent of patients in the homeopathy group improved compared to 45% of placebo patients. There was no statistically significant difference in global improvement between the homeopathic asafoetida plus nux vomica compared to placebo. Sixty-eight per cent of patients in the homeopathy group improved compared to 52% of placebo patients.

The overall quality of the evidence was very low. There was no statistically significant difference between individualised homeopathic treatment and usual care for the outcome “feeling unwell”. None of the studies reported on adverse events (which, by the way, should be seen as a breech in research ethics on the part of the authors of the three primary studies).

The authors concluded that a pooled analysis of two small studies suggests a possible benefit for clinical homeopathy, using the remedy asafoetida, over placebo for people with constipation-predominant IBS. These results should be interpreted with caution due to the low quality of reporting in these trials, high or unknown risk of bias, short-term follow-up, and sparse data. One small study found no statistically difference between individualised homeopathy and usual care (defined as high doses of dicyclomine hydrochloride, faecal bulking agents and diet sheets advising a high fibre diet). No conclusions can be drawn from this study due to the low number of participants and the high risk of bias in this trial. In addition, it is likely that usual care has changed since this trial was conducted. Further high quality, adequately powered RCTs are required to assess the efficacy and safety of clinical and individualised homeopathy compared to placebo or usual care.

THIS REVIEW REQUIRES A FEW FURTHER COMMENTS, I THINK

Asafoetida, the remedy used in two of the studies, is a plant native to Pakistan, Iran and Afghanistan. It is used in Ayurvedic herbal medicine to treat colic, intestinal parasites and irritable bowel syndrome. In the ‘homeopathic’ trials, asafoetida was used in relatively low dilutions, one that still contains molecules. It is therefore debatable whether this was really homeopathy or whether it is more akin to herbal medicine – it was certainly not homeopathy with its typical ultra-high dilutions.

Regardless of this detail, the Cochrane review does hardly provide sound evidence for homeopathy’s efficacy. On the contrary, my reading of its findings is that the ‘possible benefit’ is NOT real but a false positive result caused by the serious limitations of the original studies. The authors stress that the apparently positive result ‘should be interpreted with caution’; that is certainly correct.

So, if you are a proponent of homeopathy, as the authors of the review seem to be, you will claim that homeopathy offers ‘possible benefits’ for IBS-sufferers. But if you are not convinced of the merits of homeopathy, you might suggest that the evidence is insufficient to recommend homeopathy. I imagine that IBS-sufferers might get as frustrated with such confusion as most scientists will be. Yet there is hope; the answer could be imminent: apparently, a new trial is to report its results within this year.

IS THIS NEW TRIAL GOING TO CONTRIBUTE MEANINGFULLY TO OUR KNOWLEDGE?

It is a three-armed study (same 1st author as in the Cochrane review) which, according to its authors, seeks to explore the effectiveness of individualised homeopathic treatment plus usual care compared to both an attention control plus usual care and usual care alone, for patients with IBS. (Why “explore” and not “determine”, I ask myself.) Patients are randomly selected to be offered, 5 sessions of homeopathic treatment plus usual care, 5 sessions of supportive listening plus usual care or usual care alone. (“To be offered” looks odd to me; does that mean patients are not blinded to the interventions? Yes, indeed it does.) The primary clinical outcome is the IBS Symptom Severity at 26 weeks. Analysis will be by intention to treat and will compare homeopathic treatment with usual care at 26 weeks as the primary analysis, and homeopathic treatment with supportive listening as an additional analysis.

Hold on…the primary analysis “will compare homeopathic treatment with usual care“. Are they pulling my leg? They just told me that patients will be “offered, 5 sessions of homeopathic treatment plus usual care… or usual care alone“.

Oh, I see! We are again dealing with an A+B versus B design, on top of it without patient- or therapist-blinding. This type of analysis cannot ever produce a negative result, even if the experimental treatment is a pure placebo: placebo + usual care is always more than usual care alone. IBS-patients will certainly experience benefit from having the homeopaths’ time, empathy and compassion – never mind the remedies they get from them. And for the secondary analyses, things do not seem to be much more rigorous either.

Do we really need more trials of this nature? The Cochrane review shows that we currently have three studies which are too flimsy to be interpretable. What difference will a further flimsy trial make in this situation? When will we stop wasting time and money on such useless ‘research’? All it can possibly achieve is that apologists of homeopathy will misinterpret the results and suggest that they demonstrate efficacy.

Obviously, I have not seen the data (they have not yet been published) but I think I can nevertheless predict the conclusions of the primary analysis of this trial; they will read something like this: HOMEOPATHY PROVED TO BE SIGNIFICANTLY MORE EFFECTIVE THAN USUAL CARE. I have asked the question before and I do it again: when does this sort of ‘research’ cross the line into the realm of scientific misconduct?

Alternative medicine thrives in the realm of common chronic conditions which conventional medicine cannot cure and which respond well to treatment with placebos. Irritable bowel syndrome (IBS) is such a condition, and IBS-sufferers who are often frustrated with the symptomatic relief conventional medicine has to offer are only too keen to try any therapy that promises help. There is hardly an alternative therapy which does not claim to be the solution to IBS-symptoms: herbal medicine, mind-body interventions, homeopathy (the subject of my next post), acupuncture, even ‘MOXIBUSTION‘.

Moxibustion is a derivative of acupuncture; instead of needles, this method employs heat to stimulate acupuncture points. Proponents believe that the effects of moxibustion are roughly equivalent to those of acupuncture but many acupuncturists feel that they are less powerful. One website explains: Moxibustion is a traditional Chinese medicine technique that involves the burning of mugwort, a small, spongy herb, to facilitate healing. Moxibustion has been used throughout Asia for thousands of years; in fact, the actual Chinese character for acupuncture, translated literally, means “acupuncture-moxibustion.” The purpose of moxibustion, as with most forms of traditional Chinese medicine, is to strengthen the blood, stimulate the flow of qi, and maintain general health.

Many proponents of moxibustion claim that their treatment works for IBS. The evidence is, however, far less clear. Two recent meta-analyses might tell us more.

The first systematic review and meta-analysis was published by Korean researchers and aimed at critically evaluating the current evidence on moxibustion for improving global symptoms of IBS. The authors conducted extensive searches and found a total of 20 RCTs to be included in their analyses. The risk of bias in these studies was generally high. Compared with pharmacological medications, moxibustion significantly alleviated overall IBS symptoms but there was a moderate inconsistency among the 7 RCTs. Moxibustion combined with acupuncture was more effective than pharmacological therapy but a moderate inconsistency among the 4 studies was found. When moxibustion was added to pharmacological medications or herbal medicine, no additive benefit of moxibustion was shown compared with pharmacological medications or herbal medicine alone. One small sham-controlled trial found no difference between moxibustion and sham control in symptom severity. Moxibustion appeared to be associated with few adverse events but the evidence is limited due to poor reporting.

The authors concluded that moxibustion may provide benefit to IBS patients although the risk of bias in the included studies is relatively high. Future studies are necessary to confirm whether this finding is reproducible in carefully-designed and conducted trials and to firmly establish the place of moxibustion in current practice.

The way I see it, these conclusions are far too optimistic. There was only one RCT that controlled for placebo-effects, and the results of that study were negative. Thus I would conclude that some studies report effectiveness of moxibustion for IBS, yet the effects seem not to be caused by the treatment per se but are most likely due to a placebo-effect.

The second systematic review and meta-analysis was published by Chinese researchers and aimed at evaluating the clinical efficacy and safety of moxibustion and acupuncture in treatment of IBS. The authors included randomized and quasi-randomized clinical trials in their analyses and were able to include 11 trials. Their meta analysis suggests that the effectiveness of the combined methods of acupuncture and moxibustion is superior to conventional western medication treatment. The authors concluded that acupuncture-moxibustion for IBS is better than the conventional western medication treatment.

While the first meta-analysis was at least technically sound, the second seems to have too many flaws to mention: the search methodology was flimsy, many available studies were not included, their risk of bias was not assessed critically, the conclusions are based more on wishful thinking than on the available data, etc.

If we consider that moxibustion is a method of stimulating acupoints, we have to assume that it can at best be as effective as acupuncture, quite possibly slightly less. Thus it is relevant to see what the evidence tells us about acupuncture for IBS. The current Cochrane review of acupuncture for IBS shows that sham-controlled RCTs have found no benefits of acupuncture relative to a credible sham acupuncture control for IBS symptom severity or IBS-related quality of life.

I think I rest my case.

If we ask how effective spinal manipulation is as a treatment of back pain, we get all sorts of answers. Therapists who earn their money with it – mostly chiropractors, osteopaths and physiotherapists – are obviously convinced that it is effective. But if we consult more objective sources, the picture changes dramatically. The current Cochrane review, for instance, arrives at this conclusion: SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.

Such reviews tend to pool all studies together regardless of the nature of the practitioner. But perhaps one type of clinician is better than the next? Certainly many chiropractors are on record claiming that they are the best at spinal manipulations. Yet it is conceivable that physiotherapists who do manipulations without being guided by the myth of ‘adjusting subluxations’ have an advantage over chiropractors. Three very recent systematic reviews might go some way to answer these questions.

The purpose of the first systematic review was to examine the effectiveness of spinal manipulations performed by physiotherapists for the treatment of patients with low back pain. The authors found 6 RCTs that met their inclusion criteria. The most commonly used outcomes were pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favouring spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported significantly less medication use, health care utilization, and lost work time. The authors concluded that there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.

The second systematic Review was of osteopathic intervention for chronic, non-specific low back pain (CNSLBP). Only two trials met the authors’ inclusion criteria. They had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up. The authors drew the following conclusions: There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP. One trial concluded that the osteopathic intervention was similar in effect to a sham intervention, and the other suggests similarity of effect between osteopathic intervention, exercise and physiotherapy. Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice.

The third systematic review sought to determine the benefits of chiropractic treatment and care for back pain on well-being, and aimed to explore to what extent chiropractic treatment and care improve quality of life. The authors identified 6 studies (4 RCTs and two observational studies) of varying quality. There was a high degree of inconsistency and lack of standardisation in measurement instruments and outcome measures. Three studies reported reduced use of other/extra treatments as a positive outcome; two studies reported a positive effect of chiropractic intervention on pain, and two studies reported a positive effect on disability. The authors concluded that it is difficult to defend any conclusion about the impact of chiropractic intervention on the quality of life, lifestyle, health and economic impact on chiropractic patients presenting with back pain.

Yes, yes, yes, I know: the three reviews are not exactly comparable; so we cannot draw firm conclusions from comparing them. Five points seem to emerge nevertheless:

  1. The evidence for spinal manipulation as a treatment for back pain is generally not brilliant, regardless of the type of therapist.
  2. There seem to be considerable differences according to the nature of the therapist.
  3. Physiotherapists seem to have relatively sound evidence to justify their manipulations.
  4. Chiropractors and osteopaths are not backed by evidence which is as reliable as they so often try to make us believe.
  5. Considering that the vast majority of serious complications after spinal manipulation has occurred with chiropractors, it would seem that chiropractors are the profession with the worst track record regarding manipulation for back pain.
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