commercial interests
This ‘Manifesto of the European Committee for Homeopathy (ECH) and the European Federation of Homeopathic Patients Associations (EFHPA)‘ has just been published. It is worth considering in more detail, I think. So, I will first reproduce the document in its entirety and subsequently provide some critical assessment of it.
Homeopathy: a solution for major healthcare problems in the EU
- Helps to reduce the need of antibiotics in human and veterinary health care, thus reducing the problem of antimicrobial resistance [i],[ii]
- Increases quality of life and reduces severity of complaints in patients with chronic disease, when integrated in health care [iii],[iv],[v],[vi],[vii],[viii]
- Can reduce the use of long-term conventional prescription drugs, when integrated in health care [ix]
Homeopathy: safe and cost-effective with a high patient satisfaction
- Can lead to lower health care costs, when integrated in health care, [x],[xi],[xii],
- Is safe, with high patient satisfaction [xiii],[xiv],[xv],[xvi]
- Patients using homeopathy have better outcomes than users of conventional treatment, with similar costs [xvii]
- Quality, safety and correct labelling of homeopathic products is guaranteed by Directive 2001/83 EC
EU consumers expect and demand homeopathy as part of their health care
- Reported as the most used medical complementary medicine in Europe [xviii]
- Three out of four European citizens know about homeopathy and out of them 29% use it for their day-to day health care [xix]
Scientific evidence of the highest calibre confirms the clinical efficacy of homeopathic medicine
- Clinical effects of homeopathic medicines have been confirmed by systematic reviews and meta- analyses [xx],[xxi],[xxii],[xxiii],[xxiv],[xxv],[xxvi]
There is convincing evidence for biological efficacy of homeopathic medicine
- Irrefutable scientific evidence has been published on the positive effects of homeopathic products in laboratory settings [xxvii],[xxviii]
References
[i] Grimaldi-Bensouda L, Bégaud B, Rossignol M, et al. Management of upper respiratory tract infections by different medical practices, including homeopathy, and consumption of antibiotics in primary care: the EPI3 cohort study in France 2007-2008. PLoS One. 2014 Mar 19;9(3):e89990
[ii] Camerlink I, Ellinger L, Bakker EJ, Lantinga EA. Homeopathy as replacement to antibiotics in the case of Escherichia coli diarrhoea in neonatal piglets. Homeopathy. 2010 Jan;99(1):57-62
[iii] Witt CM, Lüdtke R, Baur R, Willich SN. Homeopathic medical practice: long-term results of a cohort study with 3981 patients. BMC Public Health 2005; 5:115
[iv] Spence DS, Thompson EA, Barron SJ. Homeopathic treatment for chronic disease: a 6-year, university-hospital outpatient observational study. J Altern Complement Med 2005; 11:793–798
[v] Mathie RT, Robinson TW. Outcomes from homeopathic prescribing in medical practice: a prospective, research-targeted, pilot study. Homeopathy 2006; 95:199–205
[vi] Thompson EA, Mathie RT, Baitson ES, et al. Towards standard setting for patient-reported outcomes in the NHS homeopathic hospitals. Homeopathy 2008; 97:114–121
[vii] Witt CM, Lüdtke R, Mengler N, Willich SN. How healthy are chronically ill patients after eight years of homeopathic treatment?–Results from a long term observational study BMC Public Health 2008;8:413
[viii] Rossi E, Endrizzi C, Panozzo MA, Bianchi A, Da Frè M. Homeopathy in the public health system: a seven-year observational study at Lucca Hospital (Italy). Homeopathy 2009; 98:142–148
[ix] Grimaldi-Bensouda L, Abenhaim L, Massol J, et al. EPI3-LA-SER group. Homeopathic medical practice for anxiety and depression in primary care: the EPI3 cohort study. BMC Complement Altern Med. 2016 May 4; 16:125
[x] Kooreman P, Baars EW. Patients whose GP knows complementary medicine tend to have lower costs and live longer. Eur J Health Econ. 2012 Dec;13(6):769-76
[xi] Baars EW, Kooreman P. A 6-year comparative economic evaluation of healthcare costs and mortality rates of Dutch patients from conventional and CAM GPs. BMJ Open. 2014 Aug 27;4(8):e005332
[xii] Colas A, Danno K, Tabar C, Ehreth J, Duru G. Economic impact of homeopathic practice in general medicine in France. Health Econ Rev. 2015;5(1):55
[xiii] Van Wassenhoven M, Galen Y. An observational study of patients receiving homeopathic treatment. Homeopathy 2004 Jan;93(1):3-11
[xiv] Marian F, Joost K, Saini KD, von Ammon K, Thurneysen A, Busato A. Patient satisfaction and side effects in primary care: An observational study comparing homeopathy and conventional medicine. BMC Complement Altern Med. 2008 Sep 18; 8:52
[xv] Witt C, Keil T, Selim D, et al. Outcome and costs of homoeopathic and conventional treatment strategies: a comparative cohort study in patients with chronic disorders. Complement Ther Med. 2005;13(2):79-86
[xvi] Marian F, Joost K, Saini KD, von Ammon K, Thurneysen A, Busato A. Patient satisfaction and side effects in primary care: An observational study comparing homeopathy and conventional medicine. BMC Complement Altern Med. 2008 Sep 18; 8:52
[xvii] Bornhöft G, Wolf U, von Ammon K, Righetti M, Maxion-Bergemann S, Baumgartner S, Thurneysen AE, Matthiessen PF. Effectiveness, safety and cost-effectiveness of homeopathy in general practice – summarized health technology assessment.Forsch Komplementmed. 2006;13 Suppl 2:19-29. Epub 2006 Jun 26. Review
[xviii] Eardley S, Bishop FL, Prescott P, Cardini F, Brinkhaus B, Santos K Ͳ Rey, Vas J, von Ammon K, Hegyi G, Dragan S, Uehleke B, Fønnebø V, Lewith G. CAM use in Europe. The patients’ perspective.Part I: A systematic literature review of CAM prevalence in the EU. 2012. Online retrieved 19-11-2019. https://cam-europe.eu/wp-content/uploads/2018/09/CAMbrella-WP4-part_1final.pdf
[xix] Report of the European Commission, 1997. Online retrieved 15-12-2019 via https://www.hri-research.org/resources/essentialevidence/use-of-homeopathy-across-the-world/
[xx] Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV, Jonas WB. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet. 1997 Sep 20;350(9081):834-4.
[xxi] Cucherat M, Haugh MC, Gooch M, Boissel JP.Evidence of clinical efficacy of homeopathy. A meta-analysis of clinical trials. HMRAG. Homeopathic Medicines Research Advisory Group. Eur J Clin Pharmacol. 2000 Apr;56(1):27-33
[xxii] Hahn RG. Homeopathy: meta-analyses of pooled clinical data. Forsch Komplementmed. 2013;20(5):376-81
[xxiii] Mathie RT, Van Wassenhoven M, Jacobs J et al. Model validity and risk of bias in randomised placebo-controlled trials of individualised homeopathic treatment. Complement Ther Med. 2016 Apr; 25:120-5
[xxiv] Mathie RT, Lloyd, SM, Legg, LA, Clausen J, Moss S, Davidson JR, Ford: Randomised placebo-controlled trials of individualised homeopathic treatment: systematic review and meta-analysis. Syst Rev 2014 Dec 6; 3:142
[xxv] Mathie RT, Clausen J. Veterinary homeopathy: systematic review of medical conditions studied by randomised placebo-controlled trials. Vet Rec. 2014 Oct 18;175(15):373-81.
[xxvi] Mathie RT, Clausen J. Veterinary homeopathy: meta-analysis of randomised placebo-controlled trials. Homeopathy. 2015 Jan;104(1):3-8.
[xxvii] Tournier A, Klein SD, Würtenberger S, Wolf U, Baumgartner S. Physicochemical Investigations of Homeopathic Preparations: A Systematic Review and Bibliometric Analysis-Part 2. J Altern Complement Med. 2019 Jul 10
[xxviii] Witt CM, Bluth M, Albrecht H, Weisshuhn TE, Baumgartner S, Willich SN. The in vitro evidence for an effect of high homeopathic potencies–a systematic review of the literature. Complement. Ther Med. 2007 Jun;15(2):128-38
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Did I state above that the manifesto is worth considering in more detail? I need to retract or modify this statement.
Here are the considerations that are relevant, in my view:
- The statements in the manifesto are based on wishful thinking and do not reflect the reality based on the best evidence available today.
- The manifesto is the result of a mixture of cherry-picking and/or misinterpreting the evidence.
- Most of the cited studies have been discussed on this blog in previous posts which disclose their flaws and/or erroneous conclusions.
So, instead of discussing all the tedious details yet again, I will present here a corrected version of the manifesto:
Homeopathy: no solution for major healthcare problems in the EU
- Does not help to reduce the need of antibiotics in human and veterinary health care, thus reducing the problem of antimicrobial resistance
- does not increases quality of life and reduces severity of complaints in patients with chronic disease, when integrated in health care
- Cannot reduce the use of long-term conventional prescription drugs, when integrated in health care
Homeopathy: neither safe nor cost-effective with a high patient satisfaction
- Cannot lead to lower health care costs, when integrated in health care
- Is unsafe
- Patients using homeopathy have no better outcomes than users of conventional treatment, but cause higher costs
- Quality and correct labelling of homeopathic products is guaranteed by Directive 2001/83 EC
Some EU consumers expect and demand homeopathy as part of their health care
- Reported as a much-used complementary medicine in Europe
- Three out of four European citizens know about homeopathy and out of them many use it for their day-to day health care
Scientific evidence of the highest calibre fails to confirm the clinical efficacy of homeopathic medicine
- Clinical effects of homeopathic medicines have been confirmed by systematic reviews and meta- analyses to be no better than placebo
There is no convincing evidence for biological efficacy of homeopathic medicine
- No irrefutable scientific evidence has been published on the positive effects of homeopathic products in laboratory settings
The objective of this analysis was to evaluate the impact of chiropractic utilization upon use of prescription opioids among patients with spinal pain. The researchers employed a retrospective cohort design for analysis of health claims data from three contiguous US states for the years 2012-2017.
They included adults aged 18-84 years enrolled in a health plan and with office visits to a primary care physician or chiropractor for spinal pain. Two cohorts of subjects were thus identified:
- patients who received both primary care and chiropractic care,
- Patients who received primary care but not chiropractic care.
The total number of subjects was 101,221. Overall, between 1.55 and 2.03 times more nonrecipients of chiropractic care filled an opioid prescription, as compared with recipients.
The authors concluded that patients with spinal pain who saw a chiropractor had half the risk of filling an opioid prescription. Among those who saw a chiropractor within 30 days of diagnosis, the reduction in risk was greater as compared with those with their first visit after the acute phase.
Similar findings have been reported before and we have discussed them on this blog (see here, here and here). As before, one has to ask: WHAT DO THEY ACTUALLY MEAN?
The short answer is NOTHING MUCH! And certainly not what many chiros make of them.
They do not suggest that chiropractic care is a substitute for opioids in the management of spinal pain.
Why?
There are several reasons. Perhaps the most important ones are that such analyses lack any clinical outcome data, and that comparing one mistake (opioid-overuse) whith what might be another (chiropractic care) is a wrong apporoach. Imagine a scenario where half to the patients had received, in addition to their usual care, the services of:
- a paranormal healer,
- a crystal therapist,
- a shaman,
- or a homeopath.
Nobody would be surprised to see a very similar result, particularly if all of these practitioners were in the habit of discouraging their patients from using conventional drugs. Or imagine a scenario where half of all patients suffering from spinal pain are entered into an environment where they receive no treatment at all. Who would not expect that this regimen does not dramatically reduce the risk of filling an opioid prescription? But would that indicate that zero treatment is a good solution for managing spinal pain?
The thing is this:
- If you want to reduce opioid use, you need to prescribe less opioids (for instance, by re-educating doctors to do as they have been told in med school and curb over-prescribing).
- If you discourage patients to use opioids (as many other healthcare professionals would), many will not use opioids.
- If you want to know whether chiropractic is effective in managing spinal pain, you need to conduct a well-designed clinical trial.
Or, to put it simply:
CORRELATION IS NOT CAUSATION!
A new appointment in the realm of so-called alternative medicine (SCAM) has just been announced:
Friends of Science in Medicine (FSM) President, Assoc Professor Ken Harvey MB BS (Melb), FRCPA, AM congratulates Professor Jon Wardle, nurse and naturopath, with postgraduate qualifications in public health, law and health economics, on being appointed to Southern Cross University’s (SCU) Maurice Blackmore Chair of Naturopathic Medicine in Lismore. Professor Wardle has also been appointed as Foundation Director of the National Centre for Naturopathic Medicine (NCNM) funded with $10 Million from the Blackmore Foundation set up to sponsor research into ‘complementary medicine’.
Vice Chancellor, Professor Adam Shoemaker BA (Hons), PhD (ANU), researcher in Indigenous literature and culture, said the benefits of basing the NCNM at Southern Cross were enormous, “Being in a region like the Northern Rivers of New South Wales means we have brilliant local networks in this field. We are also supported by a local community who, like the University, are really receptive to trying new things in order to create a healthier future”.
Professor Harvey comments, “Professor Wardle certainly has challenges ahead. The Northern Rivers region is the anti-vax capital of Australia and some naturopaths advise against vaccination. Degree courses in naturopathy such as the Torrens Bachelor of Health Science (Naturopathy) degree, include studies of homeopathy, iridology and flower essence therapy. None have scientific evidence of efficacy”.
FSM has long argued that health care should be based on scientifically sound research, published in peer-reviewed journals of accepted standing. FSM is equally concerned about medical practitioners offering unproven and often exploitative treatments as it is about complementary medicine practitioners. Professor Harvey said, “some naturopaths practicing in Lismore, associated with SCU, work at clinics that use unverified laboratory tests to make dubious diagnoses and recommend treatment programs that lack evidence of efficacy”.
Professor Harvey (and FSM) conclude that there is an urgent need for evidence-based science to be applied to naturopathy. They trust that Professor Wardle will emulate Professor Edzard Ernst, Foundation Professor of Complementary Medicine at Exeter University, by applying accepted scientific standards to the evaluation of naturopathic interventions.
The March 24 opening of the NCNM in Lismore will feature a panel discussion on the future of health care with guest speakers: Professor Kerryn Phelps AM, former President of the Australasian Integrative Medicine Association, Marcus Blackmore AM, naturopath and Executive Director of Blackmores Ltd, which markets vitamin and herbal products, and Professor Jon Wardle. FSM hopes that the panel will discuss some of the issues raised above.
Sounds exciting, but is Wardle up to the job?
Judging from his publication record, he is certainly a naturopath through and through. He has published lots of papers; as far as I can see most of them are surveys of some sort or another. Many leave me somewhat bewildered. Two examples must suffice:
Objectives: To explore the recommendations of naturopathic medicine for the management of endometriosis, dysmenorrhea, and menorrhagia, drawing on traditional and contemporary sources.
Design: Content analysis.
Setting: Australia, Canada, and the United States of America (USA).
Subjects: Contemporary sources were identified from reviewing naturopathic higher education institutions’ recommended texts, while traditional sources were identified from libraries which hold collections of naturopathic sources. Sources were included if they were published from 1800 to 2016, were in English, published in Australia, Canada, or the USA, and reported on the topic. Included sources were as follows: 37 traditional texts; 47 contemporary texts; and 83 articles from naturopathic periodicals.
Results: Across included sources, the most reported disciplines were herbal medicine, clinical nutrition, mineral medicines, homeopathy, hydrotherapy, and chemical-based medicines. Herbal medicines were extensively reported from all sources for the management of endometriosis, dysmenorrhea, and menorrhagia. Clinical nutrition was only recommended from contemporary sources for all three conditions. Mineral medicines were mentioned in both traditional and contemporary sources, but were only recommended for dysmenorrhea and menorrhagia. There were limited recommendations for homeopathy and hydrotherapy treatments in all conditions across all sources. Chemical-based medicines were only mentioned for dysmenorrhea and menorrhagia, and recommendations ceased after 1922. Recommendations for endometriosis were not present in any of the traditional sources, across all reported disciplines.
Conclusions: The findings of this article provide insights into the documented historical and contemporary treatments within naturopathic medicine for endometriosis, dysmenorrhea, and menorrhagia. While philosophical principles remain the core of naturopathic practice, the therapeutic armamentarium appears to have changed over time, and a number of the original naturopathic treatments appear to have been retained as key elements of treatment for these conditions. Such insights into naturopathic treatments will be of particular interest to clinicians providing care to women, educators designing and delivering naturopathic training, and researchers conducting clinical and health service naturopathic research.
Complementary and alternative medicine (CAM) is an increasingly prevalent part of contemporary health care. Whilst there have been some attempts to understand the dynamics of CAM integration in the health care system from the perspective of conventional care providers and patients, little research has examined the view of CAM practitioners. This study aims to identify the experiences of integration within a conventional healthcare system as perceived by naturopaths. Qualitative semi-structured interviews were conducted using a purposeful sample of 20 practising naturopaths in South East Queensland, Australia to discuss their experiences and perceptions of integrating with conventional medical providers. Analysis of the interviews revealed five broad challenges for the integration of CAM according to naturopaths: competing paradigms between CAM and conventional medicine; co-option of CAM by conventional medical practitioners; the preservation of separate CAM and conventional medical worlds by patients and providers due to lack of formalised relations; negative feedback and biases created through selective or limited experience or information with CAM; and indifferent, reactive and one-sided interaction between CAM and conventional medical providers. Naturopaths support the integration of health services and attempt to provide safe and appropriate care to their patients through collaborative approaches to practice. The challenges identified by naturopaths associated with integration of CAM with conventional providers may impact the quality of care of patients who choose to integrate CAM and conventional approaches to health. Given the significant role of naturopaths in contemporary health-care systems, these challenges require further research and policy attention.
So, is Jon Wardle up to the job?
The answer obviously depends on what the job is.
If it is about publishing 100 more surveys that show nothing of much value and are essentially SCAM-promotion, then he ought to be fine. If it is about rigorously testing which SCAMs generate more good than harm, then ‘Houston, we have a problem’!
As CORONAVIRUS-panicked consumers scramble to buy the last roll of toilet paper, the world is frantically looking for a remedy that is effective against viral infections. On Twitter, I was alerted to a homeopathic remedy (actually, it’s a ‘homotoxicological’ preparation; for more explanation, see here) that promises to do just that. Here is the advertisement in its full beauty:
Dr. Reckeweg R 88 Devirol
Anti-Viral Drops
Indications: Any viral type disease such as measles, mononucleosis, herpes, flu.
Mode of action of main Ingredients
Coxsackie, Diphterinum, Epstein Barr, Herpes simplex, Herpes zoster, Influencinum, Mononucleosis, Morbillinum, Poliomyelitis, V-Grippe:The above ingredients are highly dilutes so that none of the virus remains in the product but that the energy of the virus stimulates the immune system to defend against the intruders. This becomes a safe immunization formula to safely (without side effects) increase the natural defense against virus.
Caryophyllus aromaticus: Natural anti viral.
Euphrasia: Immune stimulant.
Dosage: As a natural immunization formula this anti viral formula is safe for child-ren and should be used 3 drops 3 times a day for 3 days.Every month for the first two years of life.The formula can be adminstered into the umbilicus and rubbed into the skin with the child’s hand.For use with older childern or adults 10 drops 3 times daily to counteract viral di-seases or 10 drops once a day as a preventative.
Remarks: In case of influenza use R6 ;for feverR1;Chickenpox R68;Herps zoster R68,R30;Measles R62;Mumps R1,R26;Cough R8,R9.Remove patient from animal protein and increase vitamin-C use and essential fatty acids.With bacterial involvement R87.With fungal involvement R82.For stress involvement Vita-C forte.EtiologyExposure to virus starts the infiltration leading to the disease.The immune system’s condition during the incubation stage determines the degree and extent of the proliferation of the viral disease.Preventing exposure is important but even more so is keeping a healthy immune system,which allows the virus to do its work without threat to penetrate a cell to proliferate.Virus are modified types of RNA or DNA which carry messages from organisma.In nature virus are kept in check by bacteria and fungus.This tringle of micro organisma supplies a needed balance so that neither of these three becomes dominant. Excess antibiotics upsets this balance and lets virus and fungus grow.
The add which originates from Reckeweg Pakistan even offers an explanation how homeopathy works: It is all based more or less on the theory of the atomic bomb. The bomb gets its energy from the splitting of the nuclei (central cores) of uranium or plutonium atoms. The relationship between mass and energy put forth by the great mathematician Albert Einstein explains how the fission of heavy atoms can produce energy. Similarly, in homoeopathy the drug substances, that is small atoms, are split into even smaller atoms generating more and more energy.
Speechless?
Yes, almost!
If you believe that this is true or that any homeopathic product might work against any viral disease, then you are probably also amongst the crowd who stockpile toilet paper for a disease that does not cause diarhoea.
PS
In case you want to know what Einstein thought about homeopathy, I can refer you to a previous post: “If one were to lock up 10 very clever people in a room and told them they were only allowed out once they had come up with the most stupid idea conceivable, they would soon come up with homeopathy.”
During my almost 30 years of research into so-called alternative medicine (SCAM), I have published many papers which must have been severe disappointments to those who advocate SCAM or earn their living through it. Many SCAM proponents thus reacted with open hostility. Others tried to find flaws in those articles which they found most upsetting with a view of discrediting my work. The 2012 article entitled ‘A Replication of the Study ‘Adverse Effects of Spinal Manipulation: A Systematic Review‘ by the Australian chiropractor, Peter Tuchin, seems to be an example of the latter phenomenon (used recently by Jens Behnke in an attempt to defame me).
Here is the abstract of the Tuchin paper:
Objective: To assess the significance of adverse events after spinal manipulation therapy (SMT) by replicating and critically reviewing a paper commonly cited when reviewing adverse events of SMT as reported by Ernst (J Roy Soc Med 100:330-338, 2007).
Method: Replication of a 2007 Ernst paper to compare the details recorded in this paper to the original source material. Specific items that were assessed included the time lapse between treatment and the adverse event, and the recording of other significant risk factors such as diabetes, hyperhomocysteinemia, use of oral contraceptive pill, any history of hypertension, atherosclerosis and migraine.
Results: The review of the 32 papers discussed by Ernst found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician).The original case reports often omitted to record the time lapse between treatment and the adverse event, and other significant clinical or risk factors. The country of origin of the original paper was also overlooked, which is significant as chiropractic is not legislated in many countries. In 21 of the cases reported by Ernst to be chiropractic treatment, 11 were from countries where chiropractic is not legislated.
Conclusion: The number of errors or omissions in the 2007 Ernst paper, reduce the validity of the study and the reported conclusions. The omissions of potential risk factors and the timeline between the adverse event and SMT could be significant confounding factors. Greater care is also needed to distinguish between chiropractors and other health practitioners when reviewing the application of SMT and related adverse effects.
The author of this ‘replication study’ claims to have identified several errors in my 2007 review of adverse effects of spinal manipulation. Here is the abstract of my article:
Objective: To identify adverse effects of spinal manipulation.
Design: Systematic review of papers published since 2001.
Setting: Six electronic databases.
Main outcome measures: Reports of adverse effects published between January 2001 and June 2006. There were no restrictions according to language of publication or research design of the reports.
Results: The searches identified 32 case reports, four case series, two prospective series, three case-control studies and three surveys. In case reports or case series, more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.
Conclusions: Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.
In my view, there are several things that are strange here:
- Tuchin published his paper 5 years after mine.
- He did not publish it in the same journal as my original, but in an obscure chiro journal that hardly any non-chiropractor would ever read.
- Tuchin never contacted me and never alerted me to his publication.
- The journal that Tuchin chose was not Medline-listed in 2012; consequently, I never got to know about the Tuchin article in a timely fashion. (Therefore, I did never respond to it.)
- A ‘replication study’ is a study that repeats the methodology of a previous study.
- Tuchin’s paper is therefore NOT a replication study. Firstly, mine was a review and not a study. Secondly, and crucially, Tuchin never repeated my methodology but used an entirely different one.
But arguably, these points are trivial. They should not distract from the fact that I might have made mistakes. So, let’s look at the substance of Tuchin’s claim, namely that I made errors or omissions in my review.
As to ‘omissions’, one could argue that a review such as mine will always have to omit some details in order to generate a concise summary. The only way to not omit any details is to re-publish all the primary papers in one large volume. Yet, this can hardly be the purpose of a systematic review.
As to the ‘errors’, it seems that the ages and sex of three patients were wrong (I have not checked this against the primary publications but, for the moment, I believe Tuchin). This is, of course, lamentable and – even though I have no idea whether the errors happened at the data extraction phase, during the typing, the revising, or the publishing of the paper – it is entirely my responsibility. I also seem to have mistaken a non-chiropractor for a chiropractor. This too is regrettable but, as the review was about spinal manipulation and not about chiropractic, the error is perhaps not so grave.
Be that as it may, these errors are unquestionably not good, and I can only apologise for them. If Tuchin had dealt with them in the usual way – by publishing in a timely fashion a ‘letter to the editor’ of the JRSM – I could have easily corrected them for everyone to see.
But I think there is a more important point to be made here:
Tuchin concludes his paper stating that it is unwise to make conclusions regarding causality from any case study or multiple case studies. The number of errors or omissions in the 2007 Ernst paper significantly limit any reported conclusions. I believe that both sentences are unjustified. The safety of any intervention in routine use has to be examined on the basis of published case studies. This is particularly true for chiropractic where no post-marketing surveillance similar to that for drugs exists.
The conclusions based on such evidence can, of course, never be firm, but they provide valuable signals that can prompt more rigorous investigations in the interest of patient safety. In view of such considerations, my own conclusions in my 2007 paper were, I think, correct and are NOT invalidated by my relatively trivial mistakes: spinal manipulation, particularly when performed on the upper spine, has repeatedly been associated with serious adverse events. Currently the incidence of such events is unknown. Adherence to informed consent, which currently seems less than rigorous, should therefore be mandatory to all therapists using this treatment. Considering that spinal manipulation is used mostly for self-limiting conditions and that its effectiveness is not well established, we should adopt a cautious attitude towards using it in routine health care.
And my conclusions in the abstract have now, I believe, become established wisdom. They are thus even less in jeopardy through my calamitous lapsus or Tuchin’s ‘replication study’: Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.
Functional Neurology (FN) is an approach used by some chiropractors. One website proudly proclaims that Functional Neurology, sometimes referred to as Chiropractic Neurology, is a term used to describe a variety of evidence-based treatments relating to neurological disorders. And another one informs us that Functional neurology, aka chiropractic neurology, is a healthcare discipline that utilizes neuroplasticity and contemporary clinical neuroscience to both evaluate and rehabilitate patients that suffer from a complex neurological condition or simply want to optimize their performance. A comprehensive neurological examination is performed in order to determine which area of the nervous system is not functioning appropriately. A customized therapy program is then tailored to address each person’s individualized neurological dysfunction.
The specific therapeutic claims that are being made for FN by chiropractors are impressive. The following list is a non-exhaustive attempt to document some of the conditions which functional neurologists claim to be able to treat: ADD/ADHD, Alzheimer’s, Anxiety disorders, Asperger’s Syndrome, Autism, Balance disorders, Blackouts, Blindness, Brain Aging issues, Canal stenosis, Cerebellar disorders,Chronic pain disorders, Cervical myelopathy, Coma, Complex regional pain syndromes, Concentration issues, Depression, Diplopia, Dizziness, Double vision, Dyslexia, Dystonia, Epilepsy, Fainting, Headaches, Heart arrhythmias, Irritable bowel syndrome, Learning difficulties, Memory issues, Mental Health, Migraines, Motion sickness, Movement disorders, Multiple sclerosis, Neglect syndromes, Numbness, Parkinson’s disease, Peripheral neuropathies, Radicular/nerve root conditions, Reflex sympathetic dystrophy, Sexual dysfunction, Sleep apnea, Sleep problems, Snoring, Speech problems, Spinal cord compression, Squints/skew deviations of the eyes, Strokes, Syncope, Tinnitus, Tics, Tourette’s, Tremors, Vertigo and Visual disturbances.
Is any of this backed up by evidence?
A review of FN included 9 articles. The included studies were conducted on adults or children, symptomatic or not, and investigated various interventions consisting of single or multiple stimuli, of varied nature, all primarily said to be provided to stimulate brain areas. Conditions included attention deficit disorders, attention deficit and hyperactivity disorders, autism-spectrum disorders, cortical visual impairment, traumatic brain injury, and migraine. Balance and the “blind spot” were investigated in healthy subjects. Major design and methodological issues were identified in all 9 studies; only 4 were considered as (potentially) appropriate for further scrutiny.
The authors concluded that no robust evidence could be found in relation to the effect or benefit of the tested FN interventions.
In a nutshell: FN is yet another addition to chiro-quackery.
Dr Jens Behnke has attracted my attention several times before (most recently here and here). Today I have decided to admit him into my ‘ALTERNATIVE MEDICINE HALL OF FAME’.
He finds himself in the company of giants:
John Weeks (editor of JCAM)
Deepak Chopra (US entrepreneur)
Cheryl Hawk (US chiropractor)
David Peters (osteopathy, homeopathy, UK)
Nicola Robinson (TCM, UK)
Peter Fisher (homeopathy, UK)
Simon Mills (herbal medicine, UK)
Gustav Dobos (various, Germany)
Claudia Witt (homeopathy, Germany and Switzerland)
George Lewith (acupuncture, UK)
John Licciardone (osteopathy, US)
Why does Behnke deserve this honour?
Because, 4 years ago, he made his doctorate under the supervision of Prof Harald Walach, pseudoscientist of the year 2012 and proven teller of falsehoods?
No, there are better reasons.
On Twitter, Behnke describes himself as a research consultant for homeopathy at the Karl and Veronica Carstens-Foundation: Evidence based medicine, CAM, clinical and basic research, health. The Carstens Stiftung say he is ‘programme director integrative medicine’. On facebook, he is merely ‘ ‘Referent of ‘Redaktion Natur und Medizin’. And on ‘Research Gate’ he lists 12 areas of skills and expertise:
Evidence Based Medicine
Medical & Health Profession Education
Meta-Analysis
Observational Studies
Science Communication
Social Media
Randomized Control Trials
Clinical Research
Philosophy Of Science
Complementary & Alternative Medicine
Integrative Medicine
Homeopathy
If this is not impressive, I don’t know what is! Particularly, if one knows that he is not a medical doctor at all!!!
So, let’s look at the list to decide whether he deserves the honour of becoming a member of my ‘HALL OF FAME’. Specifically, let’s check how many Medline-listed articles he has to his name in each of the above areas:
Evidence Based Medicine = 0
Medical & Health Profession Education = 0
Meta-Analysis = 0
Observational Studies = 0
Science Communication = 0
Social Media = 0
Randomized Control Trials = 0
Clinical Research = 0
Philosophy Of Science = 0
Complementary & Alternative Medicine = 0e
Integrative Medicine = 0
Homeopathy = 0
(No, you don’t need to praise me for my detailed, time-consuming research. It was not difficult and very quick: Jens Behnke, the ‘research consultant, has precisely zero Medline-listed publications).
So has Behnke ever conducted:
- a meta-analysis? No
- an observational study? I don’t think so
- a randomised trial? No
- any other clinical research? No
In the past, I tended to admit to my HALL OF FAME mainly those SCAM researchers who had published plenty of papers but had no study to their name that drew a negative conclusion. Behnke is not in that league. He is nevertheless worthy for his highly elaborate concept. Remember, he is a ‘research consultant in homeopathy’, and homeopathy obeys different rules than any other form of quackery. One of its axioms holds that LESS IS MORE. And considering this principle, Behnke surely must be THE expert! No publication, in homeopathic logic, evidently means that he is better than anyone else.
So, a warm welcome to our new member Jens Behnke: MAY YOUR UNPRODUCTIVITY AS A EXPERT IN 12 DIFFERENT FIELDS OF INQUIRY LAST FOR MANY MORE YEARS!
And congratulations also to the Carstens Stiftung who have so far spent 36 000 000 Euro on SCAM-research and pay Behnke’s salary as ‘research consultant’: I am sure you guys deserve him!
PS
In case Dr Behnke reads this: it is an internationally accepted standard of honesty and transparency that someone who has a doctor title and works in or comments on medical matters makes it clear that he/she is not medically trained or experienced, that in fact he/she is not a medical doctor. If not, one might think that this person is deliberately trying to mislead the public.
Wiki states that George Vithoulkas has been described as “the maestro of classical homeopathy” and is “widely considered to be the greatest living homeopathic theorist”. Others call him a “contemporary master of homeopathy” or credit him with the revival of the credibility of homeopathy.
A few days ago, THE MAESTRO has given an interview about the coronavirus which, I believe, is too hilarious to miss:
Q. What is your opinion of coronavirus, what homeopathy can do ?
A. Unless we have selected the real symptoms of the different stages of this influenza from the clinicians who are dealing at this moment with the infected cases, we cannot do anything substantial.
We should know the symptomatology of the beginning stages -before the pneumonia- and propose remedies for this stage in order to reduce the victims of going to the second stage. Also we should know the symptomatology of the later stage of pneumonia or diarrhea to propose different remedies for this advanced stage.
But the symptomatology has to be taken by an experienced homeopath in order to be reliable.
I think the best would be to establish contact with the clinicians in order to give us a fist hand information.
To give at random remedies as a prophylaxis and to make people think that they are protected it is irresponsible.
Q. What do you think about those homeopaths who advertise that are treating cancer cases using homeopathic remedies while at the same time the patients are treated with allopathic drugs?
Advertising that cancer cases can be cured by homeopathy in spite of the fact patients are treated with conventional drugs is an unethical act that should be avoided at all costs by any honest homeopath.
The reasons are simple.
A. The homeopathic remedy will act if it is prescribed according to the symptoms of the case. But in such a situation where the patient is under chemotherapy, the symptoms are suppressed by the allopathic drugs. Therefore the prescriptions at best are not prescribed according to the law of similars but are given in an arbitrary way, therefore instead of the similimum, several remedies are prescribed at random. Actually in this way, the case becomes more and more confused and the organism is more and more disorganised.
B. The homeopathic remedy acts on the energy level -on the vital force- inciting the organism to increase its response (initial aggravation) so the two treatments are antagonistic, the one suppresses the defense mechanism, the other strengthens it.
C. Out of such a confusion within the organism, no one can say what actually has happened in such a patient.
Of course each doctor is free to apply any treatment that according to his understanding will benefit the patient, but to claim publicly that homeopathy can cure cancer under such conditions is totally immoral.
Obviously patients will flock around such physicians in the beginning and can make them rich but in the end the disappointments will be for both parties, the doctors and the patients but mostly on the part of doctors.
Q. Perhaps because of the guilt for all the lies and false hopes?
Homeopathy is an amazing therapeutic system, that can make doctors and patients extremely happy but has limits and the doctors should not transgress these boundaries for material gain.
It is a great pity that homeopathy will be reduced to a routine massive therapy with meagre results by those who are advertising polypharmacy with such mongrel practices like the ones with prearranged therapeutic protocols or mixopathy.
If such practices prevail, finally the real classical homeopathy, that can have such amazing results, if it is learned and practiced correctly, will die out amidst an aggressive and competitive society.
So, essentially the great Vithoulkas seems to be saying that treating even the most serious diseases with homeopathy is fine, as long as homeopaths use no treatments other than homeopathy and as long as they do exactly what Vithoulkas proclaims or – even better – Vithoulkas does it himself.
I know, this is very similar to what Hahnemann, the creator of this cult, stated about 200 years ago … but it is nevertheless totally bonkers.
It seems that some people are pushing the notion that Boiron’s homeopathic product
Oscillococcinum®
might be helpful for the prevention and/or treatment of the Corona virus infection. To get an idea how implausible this assumption is, read my previous post on the subject.
The website of Boiron, the producer of the product, seems undeterred by plausibility and states the following:
Clinical studies show Boiron Oscillococcinum (Oscillo®) reduces the duration and severity of flu-like symptoms when taken at the onset of symptoms.1-2 Oscillo does not cause drowsiness and has no known or reported drug interactions.
Uses*
- Temporarily relieves flu-like symptoms such as body aches, headache, fever, chills and fatigue
- Non-drowsy; no drug interactions
- Easy-to-take, quick-dissolving pellets
- For everyone 2 years of age and older
- Make sure your patients always have Oscillococcinum on hand—it works best when taken at the first sign of symptoms. Help your patients feel better before they feel worse.
While this text does not state that Oscillococcinum works for the coronavirus, one could easily read it as implying it, particularly if one also considers this tweet:
Oscillococcinum USA
@OscilloUSA
Getting sick when travelling can ruin the best of vacations. Take non-drowsy Oscillococcinum the moment you feel body aches, headache, fever, chills or fatigue coming on. http://bit.ly/2BGCmCz
________________________________________________________________________________
On the Internet we find many much more direct claims. Take this website, for instance:
The commonly indicated Homeopathic remedies for Coronavirus are: –
• OSCILLOCOCCINUM
• Arsenic Album
• INFLUENZINUM
**However, for best results contact a Qualified Homeopathic doctor so that correct medicines can be prescribed.
And even some politicians promote such irresponsible nonsense.
________________________________________________________________________________
All the claims about Oscillococcinum have one thing in common: they are not evidence based! Any notion that it might work against the coronavirus is pure fantasy. And the above statement by Boiron is based on two cherry-picked studies. The totality of the evidence, however, does not show that Oscillococcinum is effective. The current Cochrane review says about its effectiveness: There is insufficient good evidence to enable robust conclusions to be made about Oscillococcinum(®) in the prevention or treatment of influenza and influenza-like illness. Our findings do not rule out the possibility that Oscillococcinum(®) could have a clinically useful treatment effect but, given the low quality of the eligible studies, the evidence is not compelling. There was no evidence of clinically important harms due to Oscillococcinum(®).
The reason, I guess, why this conclusion is not more forthright stating THERE IS NO GOOD EVIDENCE THAT OSCILLOCOCCINUM HAS ANY EFFECT can be found in the list of conflicts of interest of the paper’s authors:
All three review authors are research‐active in the field of homeopathy. They were members of the International Scientific Committee for Homeopathic Investigations (ISCHI), whose membership also included two employees of Boiron (the manufacturers of Oscillococcinum®), and whose committee activities ceased in July 2013. Progress with the Cochrane Review on Oscillococcinum® was presented briefly at ISCHI meetings in 2010 and 2011. The drafting of this Cochrane Review was carried out independently of those communications and of the authors’ other ongoing research activity. ISCHI has not run or sponsored any research on Oscillococcinum®.
Robert T Mathie: Dr Mathie is Research Development Adviser, British Homeopathic Association. He was a member of the International Scientific Committee on Homeopathic Investigations, which ceased its committee activities in July 2013. Joyce Frye: Part of Dr Frye’s salary was supported by a research grant from the Standard Homeopathic Company, paid to her employer, the Center for Integrative Medicine, Department of Family Medicine, University of Maryland, USA. Support ended in June 2013 when Dr Frye resigned from the University of Maryland. Standard Homeopathic Company does not manufacture Oscillococcinum or any similar product, and had no interest in the outcome of the review. Dr Frye received honoraria from the International Scientific Committee on Homeopathic Investigations, which was dissolved in July 2013. Peter Fisher: I am Expert Adviser on Complementary and Alternative Medicine to the National Institute for Health and Clinical Excellence (NICE), which may take an interest in the evidence in this review. I am Editor in Chief of an international, peer‐reviewed journal dedicated to homeopathy. All payments and reimbursements for lectures have been from universities or professional or learned societies. None of these lectures has been dedicated to the subject of this review. Some meetings have been supported by grants from commercial interests, including the manufacturer of the product that is the subject of the review.
So, to be clear: oscillococcinum does not help against the corona or any other virus. Those who claim otherwise are either mistaken, or have a commercial interest, or both.
Deep venous thrombosis (DVT) is usually a blood clot in a deep vein of a leg. It is a potentially life-threatening condition, because the clot can detach itself and end up in the lungs thus causing a pulmonary embolism which can be fatal. A DVT therefore is a medical emergency which is typically managed by immobilising the patient and putting him/her on anticoagulants.
Yet, homeopaths seem to have discovered another approach. Indian homeopaths just published a case report of a DVT in an old patient totally cured exclusively by the non-invasive method of treatment with micro doses of potentized homeopathic drugs selected on the basis of the totality of symptoms and individualization of the case. The authors concluded that, since this report is based on a single case of recovery, results of more such cases are warranted to strengthen the outcome of the present study. 
The patient was advised by his doctor to have surgery which he refused. Instead, he consulted a homeopath who treated him homoeopathically. No conventional treatments were given. The patient recovered, yet his recovery is almost certainly unrelated to the homeopathics he received. Spontaneous recovery after DVT is not uncommon, and it is almost certain that it is this what the case report describes.
It is simply not plausible, nor is there evidence that homeopathy can alter the natural history of a DVT. This means that what the Indian homeopaths have described in their paper is nothing less than a case of gross negligence. Had the patient died of a pulmonary embolism due to an untreated DVT, it could have put them behind bars.
While it is, of course, most laudable that homeopaths have taken to publishing even their most serious errors, it would be more reassuring, if they developed some sort of insight into their mistakes. Instead, they seem naively confident and stupidly ignorant of the danger they pose to the public: homeopathy can play significant therapeutic roles in very serious diseases like DVT, provided the drugs are needs to be carefully selected on the basis of i) individualization of cases, ii) the totality of symptoms and personalized data, and iii) taking into consideration the pathogenicity level and proper diagnosis of the disease. Further, homeopathy may also be safely used in patients with conventional drug allergy (antibiotics) or other physical conditions preventing intake of conventional medicines.
My conclusion and recommendation: stay away from homeopaths, folks!
