placebo
It is already 7 years ago that I listed several ‘official verdicts on homeopathy‘, i.e. conclusions drawn by independent, reputable bodies evaluationg the evidence for or against homeopathy:
“The principles of homeopathy contradict known chemical, physical and biological laws and persuasive scientific trials proving its effectiveness are not available”
Russian Academy of Sciences, Russia
“Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness.”
National Health and Medical Research Council, Australia
“These products are not supported by scientific evidence.”
Health Canada, Canada
“Homeopathic remedies don’t meet the criteria of evidence based medicine.”
Hungarian Academy of Sciences, Hungary
“The incorporation of anthroposophical and homeopathic products in the Swedish directive on medicinal products would run counter to several of the fundamental principles regarding medicinal products and evidence-based medicine.”
Swedish Academy of Sciences, Sweden
“We recommend parents and caregivers not give homeopathic teething tablets and gels to children and seek advice from their health care professional for safe alternatives.”
Food and Drug Administration, USA
“There is little evidence to support homeopathy as an effective treatment for any specific condition”
National Centre for Complementary and Integrative Health, USA
“There is no good-quality evidence that homeopathy is effective as a treatment for any health condition”
National Health Service, UK
“Homeopathic remedies perform no better than placebos, and that the principles on which homeopathy is based are “scientifically implausible””
House of Commons Science and Technology Committee, UK
Since then, there have been many more statements from similar organisations (does someone know of a complete list? if so, please let me know). One such statement is from French veterinarians: Avis 2021- 3 sur l’Homéopathie vétérinaire. Aloow me to translate the crucial passages for you:
Opinion 2021- 3 on Veterinary Homeopathy. The Report of a Working Group on Veterinary Homeopathy, an Opinion on Veterinary Homeopathy adopted in the academic session on May 6, 2021. The report ecommends that :
no medical discipline or practice claiming to be a medical discipline should be exempt from the ethical duty of testing its claims;
in this respect, clinical studies on the individual, reconciling scientific rigor and practical constraints, be explored, and in particular the N of 1 trials described in human medicine;
veterinary medicine be defined as evidence-based medicine, and not as allopathic medicine;
it is reaffirmed that veterinary medicine must above all be holistic, and that consequently the label of holistic veterinary medicine cannot be monopolized by particular practices;
homeopathy in veterinary medicine, as in human medicine, is not currently recognized nor can it be claimed as an exclusive veterinary medical activity;
institutional communication provides ongoing information on the scientific approach, evidence-based medicine and complementary medicine, tailored respectively to veterinarians, the general public and, in particular, animal keepers;
veterinary surgeons who, in the absence of recognized scientific proof of the efficacy of homeopathy in particular, wish to pursue this activity, particularly as a complementary medicine, should be fully aware of their increased responsibilities due to the current lack of scientific confirmation of efficacy;
it is possible to use homeopathic preparations, insofar as the medical decision to use a complementary and non-alternative therapy systematically requires informed consent, and does not result in a loss of opportunity by delaying the diagnostic procedure and/or the establishment of a recognized effective treatment;
that, in order to provide the information needed to obtain informed consent, a prescription for a homeopathic preparation should be accompanied, on any suitable medium, by a statement to the effect that, in the current state of knowledge, veterinary homeopathy has a contextual effect;
that the term “homeopathic medicine” be eventually replaced by “homeopathic preparation” in national and European legislation, that labelling state that “the efficacy of the preparation has not been demonstrated in accordance with current standards”, and that homeopathic preparations cannot claim the properties of vaccines or replace them, without incurring criminal sanctions;
in veterinary medicine, no university diploma in homeopathy be awarded by schools and other public establishments, and that training in homeopathy only take place within the framework of training that takes into account the realities of the scientific approach;
as part of their initial training, veterinary schools are places for debate and training in critical thinking, by offering interdisciplinary seminars on non-conventional approaches;
_____________________________
So, the next time someone claims “homeopathy has been proven to work in animals”, let’s show them what the experts think of this notion.
This update of a systematic review evaluated the effectiveness of spinal manipulations as a treatment for migraine headaches.
Amed, Embase, MEDLINE, CINAHL, Mantis, Index to Chiropractic Literature, and Cochrane Central were searched from inception to September 2023. Randomized clinical trials (RCTs) investigating spinal manipulations (performed by various healthcare professionals including physiotherapists, osteopaths, and chiropractors) for treating migraine headaches in human subjects were considered. Other types of manipulative therapy, i.e., cranial, visceral, and soft tissue were excluded. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the certainty of evidence.
Three more RCTs were published since our first review; amounting to a total of 6 studies with 645 migraineurs meeting the inclusion criteria. Meta-analysis of six trials showed that, compared with various controls (placebo, drug therapy, usual care), SMT (with or without usual care) has no superior effect on migraine intensity/severity measured with a range of instruments (standardized mean difference [SMD] − 0.22, 95% confidence intervals [CI] − 0.65 to 0.21, very low certainty evidence), migraine duration (SMD − 0.10; 95% CI − 0.33 to 0.12, 4 trials, low certainty evidence), or emotional quality of life (SMD − 14.47; 95% CI − 31.59 to 2.66, 2 trials, low certainty evidence) at post-intervention. A meta-analysis of two trials showed that compared with various controls, SMT (with or without usual care) increased the risk of adverse effects (risk ratio [RR] 2.06; 95% CI 1.24 to 3.41, numbers needed to harm = 6; very low certainty evidence). The main reasons for downgrading the evidence were study limitations (studies judged to be at an unclear or high risk of bias), inconsistency (for pain intensity/severity), imprecision (small sizes and wide confidence intervals around effect estimates) and indirectness (methodological and clinical heterogeneity of populations, interventions, and comparators).
We cocluded that the effectiveness of SMT for the treatment of migraines remains unproven. Future, larger, more rigorous, and independently conducted studies might reduce the existing uncertainties.
The only people who might be surprised by these conclusions are chiropractors who continue to advertise and use SMT to treat migraines. Here are a few texts by chiropractors (many including impressive imagery) that I copied from ‘X’ just now (within less that 5 minutes) to back up this last statement:
- So many people are suffering with Dizziness and migraines and do not know what to do. Upper Cervical Care is excellent at realigning the upper neck to restore proper blood flow and nerve function to get you feeling better!
- Headache & Migraine Relief! Occipital Lift Chiropractic Adjustment
- Are migraines affecting your quality of life? Discover effective chiropractic migraine relief at…
- Neck Pain, Migraine & Headache Relief Chiropractic Cracks
- Migraine Miracle: Watch How Chiropractic Magic Erases Shoulder Pain! Y-Strap Adjustments Unveiled
- Tired of letting migraines control your life? By addressing underlying issues and promoting spinal health, chiropractors can help reduce the frequency and severity of migraines. Ready to experience the benefits of chiropractic for migraine relief?
- Did you know these conditions can be treated by a chiropractor? Subluxation, Back Pain, Chronic Pain, Herniated Disc, Migraine Headaches, Neck Pain, Sciatica, and Sports Injuries.
- When a migraine comes on, there is not much you can do to stop it except wait it out. However, here are some holistic and non-invasive tips and tricks to prevent onset. Check out that last one! In addition to the other tips, chiropractic care may prevent migraines in your future!
Evidence-based chiropractic?
MY FOOT!
THE TIMES recently published an interview with (my ex-friend) Michael Dixon, a person who has featured regularly on this blog. Here is a short passage relevant to our many discussions about homeopathy:
“Can I say on the record I’ve never studied homeopathy,” he says. “I’ve never even offered homeopathy. What I have done is said that if patients feel they’ve benefited from homeopathy, what’s the problem?”
The problem, scientists would argue, is that homeopathy undermines trust in real, evidence-based medicine. Homeopathic remedies are made by diluting active ingredients in water, often so that none of the original substance remains. Homeopathy has been banned on the NHS since 2017, because it is “at best a placebo”.
For Dixon, however, this “trench warfare” divide between alternative and conventional medicine is too binary. Even if something is scientifically impossible, as long as it helps his patients that is all that matters, Dixon says. “Many years ago, a Christian faith healer started seeing some of my patients. She made a lot of them better. I didn’t care a damn if it’s placebo — they got better,” he says.
While he thinks homeopathy can serve a purpose on the NHS, he draws a line at the “madness of some of the more wayward complementary practitioners” who will argue for using homeopathy to vaccinate children. “I would always advocate against anyone going for complementary medicine if there’s good evidence-based conventional medicine.”
Apart from
- the hilarious implication that a faith healer is NOT a “wayward practitioner”,
- the fact that, as far as I know, nobody ever claimed that Dixon studied homeopathy,
- the fact that Dixon does not understand what, according to scientists, the problems with homeopathy are,
his statements seem very empathetic at first glance.
Dixon’s key argument – if patients feel they’ve benefited from homeopathy, why not prescribe it – is an often-voiced notion. But that does not make it correct!
A physician’s duty is not primarily to please the patient. His/her duty foremost is to behave responsibly and to treat patients in the most effective way. And this includes, in a case where the patient feels to have benefitted from a useless or dangerous treatment, to inform the patient about the current best evidence. To me, this is obvious, to others, including Dixon, it seems not. Let me therefore ask you, the reader of these lines: what is the right way to act as a GP?
SCENARIO DIXON
Patient wants a treatment that is far from optimal and claims to have experienced benefit from it. The GP feels this is enough reason to prescribe it, despite plenty of evidence that shows the treatment in question has at best a placebo effect. Thus the doctor agrees to his/her patient taking homeopathy.
SCENARIO ERNST
Patient wants a treatment that is far from optimal and claims to have experienced benefit from it. The doctor takes some time to explain the the therapy is not effective and that, for the patient’s condition, there are treatments that would be better suited. The patient reluctantly agrees and the doctor prescribes a therapy that is backed by sound evidence (in case the patient resists, he/she is invited to see another doctor).
I admit that risking to lose a patient to another colleague is not an attractive prospect, particularly if the patient happens to be your King. But nobody ever said that medicine was easy – and it certainly is not a supermarket were customers can pick and choose as they please.
What do you think?
Dry needling (DN) is a treatment used by various healthcare practitioners, including physical therapists, physicians, and chiropractors. It involves the use of either solid filiform needles or hollow-core hypodermic needles for therapy of muscle pain, including pain related to myofascial pain syndrome. DN is mainly used to treat myofascial trigger points, but it is also used to target connective tissue, neural ailments, and muscular ailments. There is conflicting evidence regarding the effectiveness of DN for any condition.
Orofacial pain (OFP) typically has a musculoskeletal, dental, neural, or sinogenic origin. Our systematic review was aimed at evaluating the evidence base for the effectiveness of DN for OFP.
We searched Medline, Cochrane Central, and Web of Science (from their respective inceptions to February 2024) for RCTs evaluating the effectiveness of DN in patients with OFP. Studies with patients suffering from cervicogenic or tension type headaches as well as observational studies were excluded. Primary outcomes were pain intensity and severity; secondary outcomes were disability, quality of life, and adverse effects (AEs). The review adhered to the methods described by in the Cochrane Handbook.
Twenty-four RCTs with a total of 1,318 patients suffering from OFP could be included. Most had an unclear or high risk of bias, and the quality of the evidence ranged from very low to low for all comparisons and outcomes. A meta-analysis suggested that, compared with usual care alone, DN + usual care had no effect on pain intensity (visual analogue scale) (standardized mean difference = −1.89, 95% confidence intervals −5.81 to 2.02, very low certainty evidence) at follow-ups of up to 6 weeks. Only 6 RCTs (25%) mentioned AEs, and none of them reported that AEs had occurred. The remaining 18 (75%) studies failed to report AEs.
We concluded that DN cannot be considered as an effective treatment option for OFP. This is due to the uncertainties of the available evidence. We believe that larger, rigorous, and better reported trials with more homogeneous comparators might potentially reduce the current uncertainties. Such trials should strictly adhere to the classifications provided by the International Headache Society and published in the International Classification of Orofacial Pain.
Yet again, I need to stress that the vast majority od RCTs failed to mention AEs. When will the last (pseudo-) researcher have learnt that the non-reporting of AEs is a violation of research ethics?
The ‘WORLD JOURNAL OF PHARMACEUTICAL RESEARCH‘ just published a paper entitled RESEARCH TRIAL TO EVALUATE THE EFFICACY OF HOMEOPATHIC MEDICINES IN ACUTE PHARYNGITIS- AN OBSERVATIONAL STUDY. It is remarkable, in my view; please let me show you its abstract:
This observational study aims to evaluate the efficacy of homeopathic medicines in the management of acute pharyngitis. Acute pharyngitis, commonly caused by viral or bacterial infections, presents with symptoms such as sore throat, fever, and difficulty swallowing, significantly affecting patient quality of life. Despite the widespread use of conventional treatments, there is a growing interest in homeopathic remedies as a potential alternative. This trial involved a cohort of patients diagnosed with acute pharyngitis who received individualized homeopathic treatments based on their specific symptoms and constitutional type. Clinical outcomes were assessed using standardized symptom severity scales at baseline and follow-up visits. Data analysis focused on symptom resolution, patient-reported outcomes, and overall satisfaction with treatment. Preliminary results indicate a significant reduction in symptom severity and improvement in quality of life among participants receiving homeopathic interventions compared to standard care. These findings suggest that homeopathic medicines may offer a viable complementary approach to the management of acute pharyngitis, warranting further research to establish definitive therapeutic protocols and validate these observations.
Yes, you are right:
- This study cannot possibly assess the ‘efficacy of homeopathic medicines’. Its design does simply not allow this.
- The results are to be expected due to the natural history of the condition and say nothing about the ‘efficacy’ of the interventions.
Despite these obvious caveats, the authors reinforce their wrong message many times in the article; here are a few further quotes:
- According to the study, there was significant improvement in 61.67% of cases.
- Overall, our study emphasizes Homoeopathy as an effective treatment for acute pharyngitis and suggests its wider consideration in clinical practice.
- Homoeopathy provides a holistic, individualized, and safe approach to treating acute pharyngitis, with benefits such as minimal side effects, long-term health improvements, and enhanced patient empowerment, establishing it as a valuable therapeutic option for managing this common condition.
Who publishes such nonsense?
Surely not professionals with a higher degree!
Wrong! In fact, the authors are three professors:
- M.D. (Hom.), Phd, Assistant Professor- Department of Community Medicine State
Government Homoeopathic Medical College, Aligarh, Uttar Pradesh. - MD (Hom.), PhD, Associate Professor- Department of Pathology, G.C. Homoeopathic
Medical College, Lucknow, Uttar Pradesh. - M.D. (Hom.), PhD, Professor- PG Department of Homoeopathic Pharmacy S.S. Agrawal
Homoeopathic Medical College, Navsari, Gujarat.
And what does the ‘WORLD JOURNAL OF PHARMACEUTICAL RESEARCH‘ think they are doing when publishing such scientific misconduct? They think they serve Science & Mankind at the highest levels of Professional Ethical Conduct.
No, I am not kidding; here is a quote from their website:
“The Journal particularly aims to foster the dissemination of scientific information by publishing manuscripts related to current Pharmaceutical Drug Delivery and related fields. We started with a Mission to encourage contribution to Research in Sciences & Technology for achieving better future lives for all. We serve Science & Mankind at the highest levels of Professional Ethical Conduct.”
This study seeked to examine and compare the respective impacts of warm foot baths and foot reflexology on depression in patients undergoing radiotherapy.
A randomized clinical trial was conducted at Mashhad University of Medical Sciences in Iran in 2019, following CONSORT guidelines. Participants included non-metastatic cancer patients aged 18-60 undergoing a 28-day radiotherapy course. Patients were randomly assigned to receive either warm footbaths or foot reflexology as interventions, performed daily for 20 min over 21 days. The data were analyzed using appropriate statistical tests.
Statistical analysis indicated no significant differences in demographic attributes between the two groups. Both interventions led to a significant reduction in depression scores post-treatment compared to pre-treatment assessments. Foot reflexology showed a greater reduction in depression scores compared to footbaths with warm water.
The authors concluded that both warm footbaths and foot reflexology are effective in alleviating depression in patients undergoing radiotherapy, with foot reflexology showing a greater impact on improving depression levels. The study recommends foot reflexology as a preferred intervention for managing depression in these patients if conditions and facilities permit.
Proponents of reflexology suggest that manipulating specific points on the sole of the foot influences the physiological responses of corresponding organs. By exerting pressure on these reflex areas, numerous nerve endings in the soles are claimed to get activated, triggering the release of endorphins. This process helps block the transmission of pain signals, promotes comfort, reduces tension, and fosters a sense of tranquility. These assumptions fly in the face of science, of course. Yet, they impress many patients. By contrast, a footbath is just a footbath. Nobody makes any hocucpocus claimes about it.
What I am trying to explain is this: the placebo effect associated with a footbath is bound to be smaller than that of reflexology. And the minimal difference in outcomes (9.5 versus 8.9 on a scale ranging from 0 to 63) observed in this study are likely to be unrelated to reflexology itself – most probably, they are due to placebo responses.
So, what would you prefer, a footbath that is straight forwardly agreeable, or a treatment like reflexology that generates slightly better effects due to placebo and expectation but indoctrinates you with all sorts of pseudoscientific nonsense that undermines rational thinking about your health?
I was recently invited to give a lecture to the local medical association in Graz Austria. It was a pleasure to be in Austria again and a delight to visit the beautiful town of Graz. They had given me the following subject:
Mythen in der sogenannten Alternativmedizin [Myths of so-called alternative medicine (SCAM)]
In my lecture, I thought it prudent to relate to the situation of SCAM in Austria which is rather special:
- The seem to Austrians love the SAM; the 1-year prevalence of use is 36%!
- In Austria, SCAM is only allowed to be practised by doctors.
- Often SCAM is paid for by patients out of their own pocket.
- For many, SCAM is a question of belief.
- SCAM is being promoted by VIPs and loved by journalists; one politician even sells his own brand of dietary supplements!
- In Austria, SCAM is heavily promoted by the Austrian Medical Association who currently runs courses and issues several SCAM diplomas.
The Austrian newspaper DER STANDARD then decided to interview me on these issues. The interview has been published today, and I thought I might take the liberty of translating the central part for you:
Q: In Austria, the Medical Association offers diplomas in various alternative methods. Why is this problematic?
A: I am aware of no less than 11 such diplomas offered by the Austrian Medical Association. While in England, France or Germany, for example, homeopathy has been considerably restricted by the medical profession due to the largely negative evidence, in Austria it continues to be promoted by the medical associations. This makes Austrian medicine the laughing stock of the rest of the world. More importantly, it violates the principles of evidence-based medicine. And even more importantly, it seems to me that the Austrian Medical Association is neglecting its ethical duty towards patients for purely pecuniary reasons.
Q: But the Medical Association is only complying with the regulations.
A: The Medical Association boasts that the quality of medical care and patient safety are at the centre of its work. In view of these diplomas, this mission almost sounds like a bad joke. They claim that the diplomas comply with the regulations. But firstly, this is a question of interpretation and secondly, regulations can – I would say must – be changed if they run counter to the quality of medical care. Finally, according to its own statements, the Association is obliged to adapt the Austrian healthcare system to changing conditions. This means nothing other than that it must take account of changing evidence – for example in the field of homeopathy.
Q: And what do the many doctors who use homeopathy say?
A: They often claim that they are only following the wishes of their patients when they prescribe homeopathic remedies. This may be true, but it is certainly not a valid argument. It ignores the fact that it is a doctor’s damned duty to provide patients with evidence-based information and to treat them accordingly. After all, medicine is not a supermarket where customers can simply choose whatever they happen to like.
It should also be emphasised that the practitioners of homeopathy also earn a good living from it. The fact that there is resistance from them when it comes to prioritising evidence rather than earnings in this area is thus hardly surprising.
But of course there are also a few doctors who use homeopathy primarily because they are fully convinced of its effectiveness. I think that these colleagues should consider self-critically whether they are not violating their ethical duty to be at the cutting edge of current knowledge and to act accordingly.
Perhaps unsurprisingly, my lecture prompted a lively discussion. Those doctors in the audience who spoke were unanimously in favour of my arguments. I was later told that many of those people who are responsible for the 11 diplomas were in the audience. Sadly, none of them felt like discussing any of the issues with me.
Perhaps the interview succeeds in starting a critical discussion about SCAM in Austria?
This pragmatic, randomised controlled trial was conducted between September 2018 and February 2021 and compared the difference between primary homoeopathic and conventional paediatric care in treating acute illnesses in children in their first 24 months of life. It was conducted at the Central Council for Research in Homoeopathy (CCRH) Collaborative Outpatient Department of the Jeeyar Integrated Medical Services (JIMS) Hospital in Telangana, India, a tertiary-care hospital that provides integrated patient-centric care, using homoeopathy and Ayurveda alongside conventional medicine.
One hundred eight Indian singleton newborns delivered at 37 to 42 weeks gestation were randomised at birth (1:1) to receive either homoeopathic or conventional primary care for any acute illness over the study period. In the homoeopathic group, conventional medical treatment was added when medically indicated. Clinicians and parents were unblinded.
The study’s primary outcome was a comparison of the number of sick days due to an acute illness experienced during the first 24 months of life by children receiving homoeopathic vs. conventional treatment. Sick days were defined as days with any acute illness (febrile or afebrile) reported by the parent and confirmed by the physician. Febrile illness was recorded when body temperature, measured via the ear canal, exceeded 37.5 °C.
The secondary outcomes compared were as follows:
- The number of sickness episodes, defined as illness events (febrile or afebrile), reported by the parent and confirmed by the physician.
- Number of respiratory illness episodes and days during the 24 months. Respiratory illnesses included infections in any part of the respiratory tract (nose, middle ear, pharynx, larynx, trachea, bronchi, bronchioles, and lungs) .
- Number of diarrhoeal episodes and days during the 24 months. Diarrhoea was defined as three or more episodes of watery stool/day, with or without vomiting, with indications of dehydration, weight loss, or defective weight gain.
- Anthropometric data included weight (measured by electronic scales to the nearest 5 g), height (measured in triplicate to the nearest 0.2 cm using a rigid-length board), head circumference (HC), and mid-upper arm circumference (MUAC) (measured with a standard measuring tape to the nearest 0.2 cm every 3 months until the 24th month).
- Developmental status was evaluated according to the Developmental Assessment Scales for Indian Infants (DASII) every 6 months from the age of 6 to 24 months.
- Direct cost of treatment for illnesses during the 24 months, including cost of medications, inpatient admissions, investigations, supplements, and treatment outside the hospital facility or study site (consultation and/or medicines).
- Use of antibiotics during the 24 months, defined as the number of antibiotic episodes during the study.
- Mortality: death due to any acute illness episode.
The results show that children in the homoeopathic group experienced significantly fewer sick days than those in the conventional group (RR: 0.37, 95% CI: 0.24-0.58; p < 0.001), with correspondingly fewer sickness episodes (RR: 0.53, 95% CI: 0.32-0.87; p = .013), as well as fewer respiratory illnesses over the 24-month period. They were taller (F (1, 97) = 8.92, p = .004, partial eta squared = 0.84) but not heavier than their conventionally treated counterparts. They required fewer antibiotics, and their treatment cost was lower.
The authors concluded that homoeopathy, using conventional medicine as a safety backdrop, was more effective than conventional treatment in preventing sick days, sickness episodes, and respiratory illnesses in the first 24 months of life. It necessitated fewer antibiotics and its overall cost was lower. This study supports homoeopathy, using conventional medicine as a safety backdrop, as a safe and cost-effective primary care modality during the first 2 years of life.
Here we have another study designed in such a way that a positive result was inevitable. Both groups of children received the necessary conventional care and treatment. The verum group received homeopathy in addition. There were no placebo controls and everyone knew which child belonged to which group. Thus the verum group benefitted from a poweful placebo effect, while the control group experience disappointment over not receiving the extra attention and medication. One might argue that newborn babies cannot experience a placebo response nor disappointment. Yet, one would be wrong and in need of reading up about placebo effects by proxy.
A+B is always more than B alone
To boldy entitle the paper ‘Homoeopathy vs. conventional primary care in children during the first 24 months of life’ and state that the trial aimed to “compared the difference between primary homoeopathic and conventional paediatric care in treating acute illnesses in children in their first 24 months of life”, is as close to scientific misconduct as one can get, in my view!
Yet again, I might ask: what do we call a study that is designed in such a way that a positive result was inevitable?
- misleading?
- waste of resources?
- unethical?
- fraud?
And again, I let you decide.
PS
I feel disappointed that a decent journal published this paper without even a critical comment!
Chiropractic is a complementary medicine that has been growing increasingly in different countries over recent decades. It addresses the prevention, diagnosis and treatment of the neuromusculoskeletal system disorders and their effects on the whole body health.
This review aimed to evaluate the effectiveness of chiropractic in the treatment of different diseases. To gather data, scientific electronic databases, such as Cochrane, Medline, Google Scholar, and Scirus were searched and all systematic reviews in the field of chiropractic were obtained. Reviews were included if they were specifically concerned with the effectiveness of chiropractic treatment, included evidence from at least one clinical trial, included randomized studies and focused on a specific disease. The articles were excluded if:
- – they were concerned with a combination of chiropractic and other treatments (not specifically chiropractic treatment);
- – they lacked at least one clinical trial;
- – they lacked at least one randomized study;
- – and they studied chiropractic in the treatment of multiple diseases.
The research data including the article’s first author’s name, type of disease, intervention type, number and types of research used, meta-analysis, number of participants, and overall results of the study, were extracted, studied and analyzed.
Totally, 23 chiropractic systematic reviews were found, and 11 articles met the defined criteria. The results showed the influence of chiropractic on improvement of neck pain, shoulder and neck trigger points, and sport injuries. In the cases of asthma, infant colic, autism spectrum disorder, gastrointestinal problems, fibromyalgia, back pain and carpal tunnel syndrome, there was no conclusive scientific evidence. There is heterogeneity in some of the studies and also limited number of clinical trials in the assessed systematic reviews. Thus, conducting comprehensive studies based on more reliable study designs are highly recommended.
The authors stressed that three points should be emphasized. Firstly, there is a discrepancy between the development of chiropractic in different countries of the world and the quality and quantity of studies regarding the effectiveness and safety of chiropractic in treatment of diseases. Secondly, some of the systematic reviews regarding the effectiveness of chiropractic in treatment of diseases had a minimum quality of research methodology and were not useful for evaluation. Some of the excluded articles are examples of this problem. Finally, a limited number of studies (11 systematic review articles and 10 diseases) had the required criteria and were assessed in the study.
Assessment and analysis of the studies showed the impact of chiropractic on improvement of some upper extremity conditions including shoulder and neck trigger points, neck pain and sport injuries. In the case of asthma, infant colic and other studied diseases, further clinical trials with larger sample sizes and high quality research methodology are recommended.
So, is chiroprctic of proven effectiveness for any disease?
The conditions for which there is tentatively positive evidence (btw: most rely on my research!!!) are arguably not diseases but symptoms of undelying conditions. Therefore, the answer to my question above is:
NO.
Cupping is a from of so-called alternative medicine (SCAM) that has featured already many times on this blog, e.g.:
- Wet cupping in the management of cervical spondylosis? No!
- The effectiveness of cupping therapy for low back pain
- Cupping: “the propagation of ancient, scientifically unsound techniques that may cause more harm than benefit”
- Cupping therapy for non-specific chronic low back pain
- Cupping for Olympic swimmers. Or: why breaking your shoulder is not necessarily good for writing a successful book
- Wet cupping and dry humour
- Cupping for athletes: rubbish trials, rubbish review, rubbish journal
- The future of cupping: it’s bright, profitable and vacuous
Now a new and interesting paper has been published on the subject
This review aimed to investigate the effectiveness of cupping therapy on low back pain (LBP). Medline, Embase, Scopus and WANFANG databases were searched for relevant cupping RCTs on low back pain articles up to 2023. A complementary search was manually made on 27 September for update screening. Full-text English and Chinese articles on all ethnic adults with LBP of cupping management were included in this study. Studies looking at acute low back pain only were excluded. Two independent reviewers screened and extracted data, with any disagreement resolved through consensus by a third reviewer. The methodological quality of the included studies was evaluated independently by two reviewers using an adapted tool. Change-from-baseline outcomes were treated as continuous variables and calculated according to the Cochrane Handbook. Data were extracted and pooled into the meta-analysis by Review Manager software (version 5.4, Nordic Cochrane Centre).
Eleven trials involving 921 participants were included (6 on dry and 5 on wet cupping). Five studies were assessed as being at low risk of bias, and six studies were of acceptable quality. High-quality evidence demonstrated cupping significantly improves pain at 2-8 weeks endpoint intervention (d=1.09, 95% CI: [0.35-1.83], p = 0.004). There was no continuous pain improvement observed at one month (d=0.11, 95% CI: [-1.02-1.23], p = 0.85) and 3-6 months (d=0.39, 95% CI: [-0.09-0.87], p = 0.11). Dry cupping did not improve pain (d=1.06, 95% CI: [-0.34, 2.45], p = 0.14) compared with wet cupping (d=1.5, 95% CI: [0.39-2.6], p = 0.008) at the endpoint intervention. There was no evidence indicating the association between pain reduction and different types of cupping (p = 0.2). Moderate- to low-quality evidence showed that cupping did not reduce chronic low back pain (d=0.74, 95% CI: [-0.67-2.15], p = 0.30) and non-specific chronic low back pain (d=0.27, 95% CI: [-1.69-2.24], p = 0.78) at the endpoint intervention. Cupping on acupoints showed a significant improvement in pain (d=1.29, 95% CI: [0.63-1.94], p < 0.01) compared with the lower back area (d=0.35, 95% CI: [-0.29-0.99], p = 0.29). A potential association between pain reduction and different cupping locations (p = 0.05) was found. Meta-analysis showed a significant effect on pain improvement compared to medication therapy (n = 8; d=1.8 [95% CI: 1.22 – 2.39], p < 0.001) and usual care (n = 5; d=1.07 [95% CI: 0.21- 1.93], p = 0.01). Two studies demonstrated that cupping significantly mediated sensory and emotional pain immediately, after 24 h, and 2 weeks post-intervention (d= 5.49, 95% CI [4.13-6.84], p < 0.001). Moderate evidence suggested that cupping improved disability at the 1-6 months follow-up (d=0.67, 95% CI: [0.06-1.28], p = 0.03). There was no immediate effect observed at the 2-8 weeks endpoint (d=0.40, 95% CI: [-0.51-1.30], p = 0.39). A high degree of heterogeneity was noted in the subgroup analysis (I2 >50%).
The authors concluded that high- to moderate-quality evidence indicates that cupping significantly improves pain and disability. The effectiveness of cupping for LBP varies based on treatment durations, cupping types, treatment locations, and LBP classifications. Cupping demonstrated a superior and sustained effect on pain reduction compared with medication and usual care. The notable heterogeneity among studies raises concerns about the certainty of these findings. Further research should be designed with a standardized cupping manipulation that specifies treatment sessions, frequency, cupping types, and treatment locations. The actual therapeutic effects of cupping could be confirmed by using objective pain assessments. Studies with at least six- to twelve-month follow-ups are needed to investigate the long-term efficacy of cupping in managing LBP.
A crucial point here is that only 3 of the included studies were ‘patient-blind’, i.e. tried to control for placebo effects by using a sham procedure:
- The first of these used leaking vaccum cups that failed to create sucction. This would therefore not have resulted in the typical circular hematoma. In other words, patients were easily de-blinded.
- The second trial compared two different wet cupping techniques which involved different procedures. This would have been easily identifiable by the patients. In other words, patients were easily de-blinded.
- The third (which showed no effectiveness of cupping) supposedly patient-blind study used a similar method as the first. In other words, patients were easily de-blinded.
In addition, we ought to remember that in no study was it possible to blind the therapists. Thus there is a danger of verbal or non-verbal communications impacting on the outcomes.
In my view, it follows that the effectiveness of cupping is far lass certain than the authors of this paper try to make us believe.
