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

bias

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The website of this organisation is always good for a surprise. A recent announcement relates to a course of Thought Field Therapy (TFT):

As part of our ongoing programme to explore prospects for improved healthcare, the College is pleased to announce a course on TFT – a “Tapping” therapy – independently provided by Janet Thomson MSc.

In healthcare we may find ourselves exhausting the evidence-based options and still looking for ways to help our patients. So when trusted practitioners suggest simple and safe approaches that appear to have benefit we are interested.

TFT is a simple non-invasive, technique that anyone can learn, for themselves or to pass on to their patients, to help cope with negative thoughts and emotions. It was developed by Roger Callahan who discovered that tapping on certain meridian points could help counter negative emotions. Janet trained with Roger and has become an accomplished exponent of the technique.

Janet has contracted her usual two-day course into one: to get the most from this will require access to her Tapping For Life book and there will be pre-course videos demonstrating some of the key techniques.  The second consecutive day is available for advanced TFT training, to help in dealing with difficult cases, as well as how to integrate TFT with other modalities.

How much does it cost (excluding booking fee)?  Day One only – £195; Day Two only – £195 (only available if you have previously completed day one); Both Days – £375.

When is it?  Saturday & Sunday 7th-8th March – 09:30-17:30

What, you don’t know what TFT is? Let me fill you in.

According to Wiki, TFT is a fringe psychological treatment developed by an American psychologist, Roger Callahan.[2] Its proponents say that it can heal a variety of mental and physical ailments through specialized “tapping” with the fingers at meridian points on the upper body and hands. The theory behind TFT is a mixture of concepts “derived from a variety of sources. Foremost among these is the ancient Chinese philosophy of chi, which is thought to be the ‘life force’ that flows throughout the body”. Callahan also bases his theory upon applied kinesiology and physics.[3] There is no scientific evidence that TFT is effective, and the American Psychological Association has stated that it “lacks a scientific basis” and consists of pseudoscience.[2]

Other assessments are even less complimentary: Thought field therapy (TFT) is a New Age psychotherapy dressed up in the garb of traditional Chinese medicine. It was developed in 1981 by Dr. Roger Callahan, a cognitive psychologist. While treating a patient for water phobia:

He asked her to think about water, tap with two fingers on the point that connected with the stomach meridian and much to his surprise, her fear of water completely disappeared.*

Callahan attributes the cure to the tapping, which he thinks unblocked “energy” in her stomach meridian. I don’t know how Callahan got the idea that tapping on a particular point would have anything to do with relieving a phobia, but he claims he has developed taps for just about anything that ails you, including a set of taps that can cure malaria (NPR interview).

TFT allegedly “gives immediate relief for post traumatic stress disorder (PTSD ), addictions, phobias, fears, and anxieties by directly treating the blockage in the energy flow created by a disturbing thought pattern. It virtually eliminates any negative feeling previously associated with a thought.”*

The theory behind TFT is that negative emotions cause energy blockage and if the energy is unblocked then the fears will disappear. Tapping acupressure points is thought to be the means of unblocking the energy. Allegedly, it only takes five to six minutes to elicit a cure. Dr. Callahan claims an 85% success rate. He even does cures over the phone using “Voice Technology” on infants and animals; by analyzing the voice he claims he can determine what points on the body the patient should tap for treatment.

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Yes, TFT seems utterly implausible – but what about the clinical evidence?

There are quite a few positive controlled clinical trials of TFT. They all have one thing in common: they smell fishy to me! I know, that’s not a very scientific judgement. Let me rephrase it: I am not aware of a single trial that proves TFT to have effects beyond placebo (if you know one, please post the link).

And Janet Thomson, MSc (the therapist who runs the course), who is she? Her website is revealing; have a look if you are interested. If not, it might suffice to say that she modestly claims that she is an outstanding Life Coach, Therapist & Trainer.

So, considering that TFT is so very implausible and unproven, why does the ‘College of Medicine and Integrated Healthcare’ promote it in such strong terms?

I have to admit, I do not know the answer – perhaps they want at all costs to become known as the ‘College of Quack Medicine’?

I missed this article by Canadian vascular surgeons when it came out in 2018. It is well-argued, and I think you should read it in full, if you can get access (it’s behind a pay wall). It contains interesting details about the anti-vax attitude of doctors of integrative medicine (something we discussed before), as well as the most dubious things that go on in the ‘Cleveland Clinic’. Here is at least the abstract of the article:

Evidence-based medicine, first described in 1992, offers a clear, systematic, and scientific approach to the practice of medicine. Recently, the non-evidence-based practice of complementary and alternative medicine (CAM) has been increasing in the United States and around the world, particularly at medical institutions known for providing rigorous evidence-based care. The use of CAM may cause harm to patients through interactions with evidence-based medications or if patients choose to forego evidence-based care. CAM may also put financial strain on patients as most CAM expenditures are paid out-of-pocket. Despite these drawbacks, patients continue to use CAM due to media promotion of CAM therapies, dissatisfaction with conventional healthcare, and a desire for more holistic care. Given the increasing demand for CAM, many medical institutions now offer CAM services. Recently, there has been controversy surrounding the leaders of several CAM centres based at a highly respected academic medical institution, as they publicly expressed anti-vaccination views. These controversies demonstrate the non-evidence-based philosophies that run deep within CAM that are contrary to the evidence-based care that academic medical institutions should provide. Although there are financial incentives for institutions to provide CAM, it is important to recognize that this legitimizes CAM and may cause harm to patients. The poor regulation of CAM allows for the continued distribution of products and services that have not been rigorously tested for safety and efficacy. Governments in Australia and England have successfully improved regulation of CAM and can serve as a model to other countries.

Those who have been following this blog a little know how much I agree with these authors. In fact, in the peer-reviewed literature, I have been publishing similar arguments for almost 20 years, e.g:

The University College London Hospitals (UCLH) include the ‘Royal London Hospital for Integrated Medicine’ (RLHIM). The RLHIM offers a range of so-called alternative medicines (SCAMs), including acupuncture.

This is how they advertise traditional acupuncture to the unsuspecting public:

Acupuncture is a part of Traditional Chinese Medicine (TCM). This is a system of healing which has been practised in China and other Eastern countries for thousands of years.

Although often used as a means of pain relief, it can treat people with other illnesses. The focus is on improving the overall well-being of the patient, rather than the isolated treatment of specific symptoms.

You will be seen individually and assessed by an acupuncturist trained in TCM. They will use traditional Chinese techniques including pulse, tongue and abdominal diagnosis. They will also ask you about your medical history and lifestyle.

The TCM trained acupuncturist can stimulate the body’s own healing response and help to restore its natural balance.

The principal aim of acupuncture in treating the whole person is to create balance between your physical, emotional and spiritual needs. It can help to relax, improve mood and sleep, relieve tension and improve your sense of well-being, as well as improving symptoms.

We will assess your individual needs and discuss a treatment plan with you during your initial consultation.

The treatment may include the use of the following:

  • The use of fine acupuncture needles
  • Moxibustion (burning of the herb mugwort close to the surface of the skin)
  • Cupping therapy (to create local suction on the skin)
  • Acupressure (pressure applied to acu-points to stimulate energy flow)
  • Electro-acupuncture (a low voltage current is passed between 2 needles)

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How reliable is this information? I will try to answer this question by discussing the 6 statements that, in my view, are most questionable.

Although often used as a means of pain relief, it can treat people with other illnesses

Whether acupuncture is effective for pain relief is debatable. A recent analysis cast considerable doubt on the assumption. The notion that acupuncture ‘can treat people with other illnesses’ seems like a ‘carte blanche’ for treating virtually any condition regardless of evidence.

Improving the overall well-being of the patient

I am not aware of sound evidence that acupuncture is an effective treatment for improving overall well-being.

Traditional Chinese techniques including pulse, tongue and abdominal diagnosis

These diagnostic techniques have not been adequately validated and have no place in evidence-based healthcare.

The TCM trained acupuncturist can stimulate the body’s own healing response and help to restore its natural balance

I am not aware of sound evidence to show that acupuncture stimulates healing. The statement seems like another ‘carte blanche’ for treating anything the therapist feels like, regardless of evidence.

The principal aim of acupuncture in treating the whole person is to create balance between your physical, emotional and spiritual needs

The claim that acupuncture is a holistic treatment is based on little more than wishful thinking by acupuncturists.

It can help to relax, improve mood and sleep, relieve tension and improve your sense of well-being, as well as improving symptoms

I am not aware of sound evidence that acupuncture is effective in treating any of the named conditions. The end of the sentence (‘as well as improving symptoms’) is another ‘carte blanche’ for doing anything the acupuncturists feels like.

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The UCLH are firmly committed to EBM. The RLHIM claims to be ‘a centre for evidence-based practice’. This claim is not supported by the above advertisement of acupuncture which is clearly not based on good evidence. Moreover, it has the potential to mislead vulnerable patients and thus cause considerable harm. In my view, it is high time that the UCLH address this problem.

In 2017, John Lawler died after receiving a chiropractic neck manipulation. The therapist was not just incompetent at providing first aid to her patient, her clumsy attempts to save his life might even have contributed to his death. Now the General Chiropractic Council (GCC) issued a special bulletin to all registrants setting out in detail the action they must take in relation to first aid:

… it is a requirement of our educational programmes that students are trained to deal with medical emergencies and thereafter it is important that chiropractors keep their knowledge and skills up to date.

We expect all chiropractors to consider their own first aid knowledge and skills and determine whether or not to undertake further specific first aid training.  We said that registrants should start by considering whether their first aid skills and knowledge are sufficient, appropriate and current.

Every chiropractor is likely to encounter potential traumatic and medical emergencies at some point in their professional life. Like all registered health care professionals chiropractors have a duty to their patients during emergencies.  Chiropractors therefore must recognise, assess and manage the potential for emergency medical and traumatic conditions that may be encountered in chiropractic settings.

Many providers of first aid training are available offering a range of courses delivered in a range of different ways, for example, the Royal College of Chiropractors has partnered with a training provider to provide first aid training courses for chiropractors across the UK: http://bit.ly/rccfirstaid

In September 2020, as part of registrants’ continuing professional development submission to the GCC, we expect to see information from each chiropractor on their first aid knowledge and skills, and the steps taken so they are assured of their competence to administer first aid should the need arise.

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One could read this statement as an admission that:

  • UK chiropractors are currently not adequately trained in first aid,
  • chiropractic manipulations can cause medical emergencies,
  • and possibly that Mr Lawler lost his life because his chiropractor was incompetent in first aid.

At the same time, I find that the statement comes many months too late and is neither clear nor compelling. Why not making it plain:

  • exactly which first aid qualification every UK chiropractor must have
  • by what time,
  • and state what penalty they will face, if they fail to comply?

And, if the GCC are aware that spinal manipulation can cause serious emergencies, why have they not established a proper reporting scheme for such events so that we all know of the frequency of such risks? Could it be that the son of the deceased John Lawler was correct when he said the GCC “seems to be a little self-regulatory chiropractic bubble where chiropractors regulate chiropractors?” And could it be that I was justified in suspecting that the GCC is not fit for purpose?

What do you think?

In 2011, the following leading researchers of so-called alternative medicine (SCAM) – no I was not invited – had a meeting in Italy, did a brainstorm and decided what we would need to know about SCAM by 2020 (today, in other words):

They proposed 6 core areas of research that should be investigated to achieve a robust knowledge base and to allow stakeholders to make informed decisions:

  1. Research into the prevalence of SCAM in Europe: Reviews show that we do not know enough about the circumstances in which SCAM is used by Europeans. To enable a common European strategic approach, a clear picture of current use is of the utmost importance.
  2. Research into differences regarding citizens’ attitudes and needs towards SCAM: Citizens are the driver for CAM utilization. Their needs and views on SCAM are a key priority, and their interests must be investigated and addressed in future SCAM research.
  3. Research into safety of SCAM: Safety is a key issue for European citizens. SCAM is considered safe, but reliable data is scarce although urgently needed in order to assess the risk and cost-benefit ratio of SCAM.
  4. Research into the comparative effectiveness of SCAM: Everybody needs to know in what situation SCAM is a reasonable choice. Therefore, we recommend a clear emphasis on concurrent evaluation of the overall effectiveness of SCAM as an additional or alternative treatment strategy in real-world settings.
  5. Research into effects of context and meaning: The impact of effects of context and meaning on the outcome of SCAM treatments must be investigated; it is likely that they are significant.
  6. Research into different models of SCAM health care integration: There are different models of SCAM being integrated into conventional medicine throughout Europe, each with their respective strengths and limitations. These models should be described and concurrently evaluated; innovative models of SCAM provision in health care systems should be one focus for SCAM research.

‘Look, half the work is done! All you need to do is fill in the top part so we can legally say the bottom part.’

The researchers then added:

We also propose a methodological framework for SCAM research. We consider that a framework of mixed methodological approaches is likely to yield the most useful information. In this model, all available research strategies including comparative effectiveness research utilising quantitative and qualitative methods should be considered to enable us to secure the greatest density of knowledge possible. Stakeholders, such as citizens, patients and providers, should be involved in every stage of developing the specific and relevant research questions, study design and the assurance of real-world relevance for the research.

Furthermore, structural and sufficient financial support for research into SCAM is needed to strengthen SCAM research capacity if we wish to understand why it remains so popular within the EU. In order to consider employing SCAM as part of the solution to the health care, health creation and self-care challenges we face by 2020, it is vital to obtain a robust picture of SCAM use and reliable information about its cost, safety and effectiveness in real-world settings. We need to consider the availability, accessibility and affordability of SCAM. We need to engage in research excellence and utilise comparative effectiveness approaches and mixed methods to obtain this data.

Our recommendations are both strategic and methodological. They are presented for the consideration of researchers and funders while being designed to answer the important and implicit questions posed by EU citizens currently using SCAM in apparently increasing numbers. We propose that the EU actively supports an EU-wide strategic approach that facilitates the development of SCAM research. This could be achieved in the first instance through funding a European SCAM coordinating research office dedicated to foster systematic communication between EU governments, public, charitable and industry funders as well as researchers, citizens and other stakeholders. The aim of this office would be to coordinate research strategy developments and research funding opportunities, as well as to document and disseminate international research activities in this field.

With the aim to develop sustainability as second step, a European Centre for SCAM should be established that takes over the monitoring and further development of a coordinated research strategy for SCAM, as well as it should have funds that can be awarded to foster high quality and robust independent research with a focus on citizens health needs and pan-European collaboration.

We wish to establish a solid funding for SCAM research to adequately inform health care and health creation decision-making throughout the EU. This centre would ensure that our vision of a common, strategic and scientifically rigorous approach to SCAM research becomes our legacy and Europe’s reality. We are confident that our recommendations will serve these essential goals for EU citizens.

As I know all of the members of the panel personally, I am not surprised by the content of this document. That does not mean, however, that I do not find it remarkable. In my view, it is remarkable because of the nature of the 6 items that we allegedly need to know by 2020, and because of the fact that, even though none of them seem particularly demanding, today we have clarity or sound information on none of them. I also thought that both the research topics and the research methods were on the woolly side and, to a large degree, avoided what would be standard in conventional medicine. The ‘vision’ of the 13 researchers thus turns out to be the view of 13 partially sighted people on an array of platitudes.

Being just a bit sarcastic, the document could be seen as a plea for letting SCAM researchers:

  • continue to play on their far from level playing field,
  • use their preferred and largely inadequate methodologies,
  • pretend they do cutting edge science,
  • continue to avoid the real issues,
  • enjoy a life free of demanding challenges,
  • have pots of EU money for doing largely useless work.

In a word, I am confident that their recommendations would not have served any essential goals for EU citizens.

What should we make of a discipline whose disciples are unsure of what the discipline is?

Yes, I am talking of chiropractic!

Surely, the inventor of chiropractic has told them what it is. True, DD Palmer left them no end of definitions; here are just 4 to choose from:

  • Chiropractic is the science of healing without drugs.
  • Chiropractic is the art of adjusting by hand all subluxations of the three hundred articulations of the human skeletal frame, more especially the 52 articulations of the spinal column, for the purpose of freeing impinged nerves, as they emanate thru the intervertebral foramina, causing abnormal function, in excess or not, named disease.
  • Chiropractic is a name I originated to designate the science and art of adjusting vertebrae.
  • Chiropractic is a philosophical science; it has solved one of the most profound and perplexing problems of the age, namely, what is life?

Despite this plethora of definitions, chiropractors are still struggling to define their trade. This article, entitled ‘So What Is Chiropractic?’, marks the end of a recent series of papers published in a chiro-journal trying to make progress in this regard. They revealed deeply rooted disagreements within the chiropractic profession about what chiropractic is, and what it should be, as a profession [13, 19, 20], as well as disagreements and variation in relation to education of chiropractors [14, 15] and chiropractic clinical practice [11].

In the opinion of the authors’ paper, it is ironic that, while chiropractic has a strong presence in large parts of the world [3], is taking on increasingly important roles in disability prevention [6, 7, 17], in the military [5] and in interprofessional care [8] as well as growing research capacity [16], discussions about fundamental values and direction of the profession are unresolved. They believe that this unresolved issue creates confusion for stakeholders and threatens to impede professionalization and cultural authority. If chiropractors are to remain relevant in today’s evidence-based healthcare environment, they argue, there is an urgent need to agree on, and further describe, what chiropractic is, what chiropractors do and importantly to provide evidence for value of these activities to patients and societies.

So, what do we make of chiropractic in view of the fact that chiropractors seem to be unsure what it is?

I let you decide.

I am currently studying DD Palmer’s TEXTBOOK OF THE SCIENCE, ART, AND PHILOSOPHY OF CHIROPRACTIC. It is a 1 000 page volume full of ignorance, repetition, allegation, pomp, overstatement and utter nonsense. I strongly advise everyone to stay well clear of it.

However, skimming through this accumulation of flimflam, I was repeatedly reminded of the origin of the anti-vax stance to which so many chiropractors still subscribe. Yes, I did mention this before: Far too many chiropractors believe that vaccinations do not have a positive effect on public health.

In his book, originally published in 1910,  Palmer tried (unsuccessfully, I fear) to explain the basic principles of chiropractic. Most chiropractors would have read at least some of this ‘textbook’. It therefore stands to reason that Palmer’s views still colour those of today’s chiropractors.

Here are a few quotes about immunisation directly from the book:

  • On May 14, 1796, Jenner first committed the crime of vaccination…
  • No person is improved by being poisoned by either smallpox or vaccination.
  • [Vaccination] is the biggest piece of quackery and criminal outrage ever foisted upon any civilized people. Medical ignorance by which criminal outrages are murdering our children all over this country…
  • Vaccination and inoculation are pathological; Chiropractic is physiological.
  • Compulsory vaccination is an outrage and a gross interference with the liberty of the people in a land of freedom.

The question is, where did Palmer get this from? What is the reason for his anti-vax attitude? Reading the book, I get the impression that it might have been based on two main pillars: 1) his amazing ignorance and blinkered view on most things and 2) his deep antipathy of conventional medicine. To show you a little of the latter, here are just two further quotes:

  • It is a pity that the medical profession are possessed of arrogance instead of liberality; that instead of encouraging and fostering advanced ideas, they stifle and discourage advancement; that they only adopt advanced ideas when they are compelled to do so by public opinion.
  • The physician believes in his prescriptions; the pharmacist in the hidden power of drugs – superstitious therapeutics.

To this, I am tempted to add: … and chiropractors believe in the drivel written by DD Palmer over 100 years ago.

Ever since the government in Bavaria has been misguided enough to agree to a research programme testing whether homeopathy has a role in curtailing the over-use of anti-biotics, the subject of homeopathics as a replacement of antibiotics has been revived.

In this paper, homeopaths describe four female cases with recurrent urinary tract infections. The patients were treated successfully with the homeopathic strategy after several conventional approaches revealed no improvement. The follow-up period was a minimum of 3 years and the frequency of episodes with urinary tract infection as well as of antibiotic treatment was documented. Additionally, the patients were asked to assess the treatment outcome retrospectively in a validated questionnaire.

The treatment resulted in a reduction of urinary tract infections and the need for antibiotics from monthly to less than 3 times a year. Three of the four women had no cystitis and related intake of antibiotics for more than 1.5 years. A relapse of symptoms could be treated efficiently with a repetition of the homeopathic remedy. All subjective outcome assessments resulted positive.

The authors concluded that this case series suggests a possible benefit of individualized homeopathic treatment for female patients with recurrent urinary tract infections. Larger observational studies and controlled investigations are warranted. 

Such articles make me quite angry! They have the potential to mislead many patients and, in extreme cases, might even cost lives.

The ‘possible benefit’ of any treatment cannot be demonstrated with such flimsy case series. It has to be shown in properly controlled clinical trials. The findings of case series are confounded by dozens of variables and tell us next to nothing about cause and effect.

Case series make sense when they explore possible new therapeutic avenues. Homeopathy does certainly not fall into this category. The notion that homeopathics might be an alternative to antibiotics has been tested many times before in different settings, in animals, in humans, it vivo and in vitro. This has never generated convincingly positive findings. To re-address it by reporting uncontrolled cases is not just a nonsense; in my view, it is an unethical attempt to mislead us.

About 85% of German children are treated with herbal remedies. Yet, little is known about the effects of such interventions. A new study might tell us more.

This analysis accessed 2063 datasets from the paediatric population in the PhytoVIS data base, screening for information on indication, gender, treatment, co-medication and tolerability. The results suggest that the majority of patients was treated with herbal medicine for the following conditions:

  • common cold,
  • fever,
  • digestive complaints,
  • skin diseases,
  • sleep disturbances
  • anxiety.

The perceived effect of the therapy was rated in 84% of the patients as very good or good without adverse events.

The authors concluded that the results confirm the good clinical effects and safety of herbal medicinal products in this patient population and show that they are widely used in Germany.

If you are a fan of herbal medicine, you will be jubilant. If, on the other hand, you are a critical thinker or a responsible healthcare professional, you might wonder what this database is, why it was set up and how exactly these findings were produced. Here are some details:

The data were collected by means of a retrospective, anonymous, one-off survey consisting of 20 questions on the user’s experience with herbal remedies. The questions included complaints/ disease, information on drug use, concomitant factors/diseases as well as basic patient data. Trained interviewers performed the interviews in pharmacies and doctor’s offices. Data were collected in the Western Part of Germany between April 2014 and December 2016. The only inclusion criterion was the intake of herbal drugs in the last 8 weeks before the individual interview. The primary endpoint was the effect and tolerability of the products according to the user.

And who participated in this survey? If I understand it correctly, the survey is based on a convenience sample of parents using herbal remedies. This means that those parents who had a positive experience tended to volunteer, while those with a negative experience were absent or tended to refuse. (Thus the survey is not far from the scenario I often use where people in a hamburger restaurant are questioned whether they like hamburgers.)

So, there are two very obvious factors other than the effectiveness of herbal remedies determining the results:

  1. selection bias,
  2. lack of objective outcome measure.

This means that conclusions about the clinical effects of herbal remedies in paediatric patients are quite simply not possible on the basis of this survey. So, why do the authors nevertheless draw such conclusions (without a critical discussion of the limitations of their survey)?

Could it have something to do with the sponsor of the research?

The PhytoVIS study was funded by the Kooperation Phytopharmaka GbR Bonn, Germany.

Or could it have something to do with the affiliations of the paper’s authors:

1 Institute of Pharmacy, University of Leipzig, Brüderstr. 34, 04103, Leipzig, Germny. nieberkaren@gmx.de.

2 Kooperation Phytopharmaka GbR, Plittersdorfer Str. 218, 573, Bonn, Germany. nieberkaren@gmx.de.

3 Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.

4 ClinNovis GmbH, Genter Str. 7, 50672, Cologne, Germany.

5 Bayer Consumer Health, Research & Development, Phytomedicines Supply and Development Center, Steigerwald Arzneimittelwerk GmbH, Havelstr. 5, 64295, Darmstadt, Germany.

6 Kooperation Phytopharmaka GbR, Plittersdorfer Str. 218, 53173, Bonn, Germany.

7 Institute of Pharmaceutical Biology, Goethe University Frankfurt, Max-von-Laue-Str. 9, 60438, Frankfurt, Germany.

8 Chair of Naturopathy, University Medicine Rostock, Ernst-Heydemann Str. 6, 18057, Rostock, Germany.

WHAT DO YOU THINK?

An enthusiast of homeopathy recently posted an overview of systematic reviews of homeopathy concluding that the data we do have point towards homeopathy as having an effect greater than that of placebo:

In recent decades, homeopathy has been examined via a number of clinical trials, the number of which now allow meta-analysis. As we can see from the study findings, the type of homeopathy research (ie, individualized vs non-individualized, placebo-controlled vs non-placebo-controlled) can have a strong influence on the results, although trial quality also has a strong effect.

All meta-analyses performed in at least a somewhat open and rigorous manner have found statistically significant effects. This suggests that homeopathy has a greater-than-placebo effect, or at least a strong trend in that direction, when using data from the totality of homeopathy research, or from individualized, placebo-controlled trials. The meta-analyses with questionable methodology, one of which is undergoing government investigation for academic irregularities, have produced negative results, which have been demonstrated to be a direct result of their exclusion of vast swathes of the homeopathic clinical trial literature (based on arbitrary and unexplained criteria), as well as of their failure to differentiate – as Mathie has done – different types of homeopathic research.

The clinical data are flawed. Issues with methodology used in homeopathy RCTs, combined with a lack of research funding, have produced a lack of high-quality trials and data. However, the data we do have point towards homeopathy as having an effect greater than that of placebo.

There can be no argument with this conclusion, aside from possible new data emerging. Anyone who disputes this is going against the existing set of the highest-quality evidence on homeopathy.

His overview is based on the following publications:

Kleijnen, 19911 All types of homeopathy (eg, single remedy vs combination). Methodological quality assessed; 105 trials. Results: Positive trend, regardless of type of homeopathy; 81 trials were positive, 24 showed no effect.
Linde, 19972 All types of homeopathy. Out of 185 trials, 119 met inclusion criteria; 89 of these had extractable data. Results: OR = 2.45 (95% CI 2.05-2.93).
Ernst, 19983 Individualized homeopathy; 5 trials determined to be high-quality. Results: OR = 0.
Linde, 19985 Individualized homeopathy; 32 trials, 19 of which had extractable data. Results: OR = 1.62 for all trials (95% CI 1.17-2.23). Only high-quality trials produced no significant trend.
Cucherat, 20009 All types of homeopathy; 118 trials, 16 of which met inclusion criteria. Used unusual method of combining p values. Results: All trials = p< 0.000036. Less than 10% dropouts: p<0.084; less than 5% dropouts (higher standards than most trials considered reliable): p<0.08 (non-significant).
Shang, 200511 All types of homeopathy; only 8 trials selected from 21 high-quality trials of 110 selected with unusual criteria. Results: OR = 0.88 (0.65-1.19). Result strongly disputed by statisticians.
Mathie, 201413 Individualized homeopathy; of the analysis pooled data from 22 higher-quality, individualized, double-blind RCTs. Results: OR = 1.53 (1.22-1.91) for all trials pooled; OR = 1.93 (1.16-3.38) for the 3 reliable trials.
NHMRC, 201516 Out of 176 studies, 171 were excluded, leaving only 5 for the study. Investigators used unprecedented methods, did not combine data, and are currently under investigation for outcome shopping. Results: Negative results.
Mathie, 201720 Non-individualized homeopathy; very few higher-quality trials. Results: For 54 trials with extractable data, SMD = -0.33 (-0.44, -0.21). When these were adjusted for publication bias, SMD = -0.16 (-0.46,-0.09). The 3 high-quality trials had non-significant results: SMD = -0.18 (-0.46, +0.09).
Mathie, 201821 Individualized, other-than-placebo-controlled trials; 11 trials found, 8 with extractable data. Results: 4 heterogeneous comparative trials showed a non-significant difference. One trial in this group was positive. Three heterogeneous trials with additive homeopathy showed a statistically significant SMD. No definitive conclusion possible due to trial heterogeneity, poor quality, and low number of trials.
Mathie, 201922 Non-individualized, other-than-placebo-controlled trials; 17 RCTs found, 14 with high risk of bias. Results: Significant heterogeneity prevented much comparison; 3 comparable trials showed a non-significant SMD.

Apart from getting the wrong end of the stick when interpreting the results of these papers (see for instance here, and here), there are other rather embarrassing flaws in this overview:

  1. Many older systematic reviews were omitted (including about 10 of my own papers). This is relevant because the author of the above review went beck until 1991 to find the reviews he included.
  2. Several new papers were missing as well. This is relevant because the author evidently included reviews up to 2019. Here are the key passages from the conclusions of some of them:

homoeopathy as a whole may be considered as a placebo treatment.

We tested whether p-curve accurately rejects the evidential value of significant results obtained in placebo-controlled clinical trials of homeopathic ultramolecular dilutions. Our results suggest that p-curve can accurately detect when sets of statistically significant results lack evidential value.

We found no evidence to support the efficacy of homeopathic medicinal products

no firm conclusions regarding the effectiveness and safety of homeopathy for the treatment of IBS can be drawn.

Due to both qualitative and quantitative inadequacies, proofs supporting individualized homeopathy remained inconclusive.

… the use of homeopathy currently cannot claim to have sufficient prognostic validity where efficacy is concerned.

I am, of course, not saying that this overview amounts to anything like a systematic review. It merely gives you a flavour how trustworthy proponents of homeopathy are when they pretend to provide us with an objective evaluation of the best available evidence.

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