Germany has long been the ‘Promised Land’ for so-called alternative medicine (SCAM). For many years, about two-thirds of the general population has been reported to be regular SCAM users. Now, this seems about to change. A recent survey found that only one-third of Germans believe that homeopathy works as well as conventional medicine. The verdict on SCAM as a whole is similar: Only 35 percent of respondents would like SCAM to play a role in healthcare in addition to modern medicine. The results originate from an extensive representative survey commissioned by the GWUP and carried out by the KANTAR Institute to sound out attitudes toward esotericism and pseudoscience. The figure below depicts percentage figures of the belief in (from left to right) homeopathy, integrated medicine, spiritual healing, electrosmog, dowsing, clairvoyance, psychokinesis, ghosts, astrology, extra-terrestrials, none mentioned.

“It is a good sign for health care if two-thirds of the population reject dubious cures. The experience from the pandemic shows that we can only fight diseases with science and modern medicine,” stated Amardeo Sarma, chairman of GWUP. “I am pleased with the result because it also underlines the impact of our educational work. I’m convinced that we’re helping people make important decisions, removing uncertainty and, not least, preventing suffering caused by incorrect treatments.”

“As a physician, I am pleased when more and more people are concerned with their health and critically question promises of healing,” said Dr. Natalie Grams. “For me, the declining approval of homeopathy means that it is worthwhile to publicly stand by science and not be muzzled by industry interests. Fewer homeopathics mean more good medicine for patients that really works.”

This sounds like good news indeed. Yet, I think, we need to be careful and avoid jumping to conclusions because prevalence surveys are often not as reliable as they seem.

1) They frequently lack a clear definition of what is being surveyed. There is no generally accepted definition of alternative medicine, and even if the researchers address specific therapies, they run into huge problems. Take integrated medicine, for instance – some see this as alternative medicine, while others would, of course, argue that it is the integration of social and health care. Or take homeopathy – many consumers confuse it with herbal medicine.

2) The questionnaires used for such surveys are rarely validated. Essentially, this means that we cannot be sure they evaluate what we think they evaluate. We all know that the way we formulate a question can determine the answer. There are many potential sources of bias here, and they are rarely taken into consideration. It is therefore not surprising that different surveys report different prevalences. In Indonesia, for instance, an increase in SCAM use has been reported associated with the pandemic.

3) The typical survey has a low response rate; sometimes the response rate is not even provided or remains unknown even to the investigators. This means we do not know how the majority of patients/consumers who received but did not fill the questionnaire would have answered. Often there is good reason to suspect that those who have a certain attitude did respond, while those with a different opinion did not. This self-selection process is likely to produce misleading findings.

4) The typical survey has a long list of questions and reports only those results that the investigators find interesting or pleasing. Such selective reporting can introduce a significant bias that may not be detectable for the reader of the report.

I am sure the new survey is not seriously affected by any of these drawbacks. After all, it is from the GWUP, the Society of the Scientific Study of Para-Sciences. If they are not able to do good science, who is?

My most frequently cited paper was published by Angelo Izzo and myself in 2001. It has so far been cited 1612 times. Here is its abstract:

Despite the widespread use of herbal medicines, documented herb-drug interactions are sparse. We have reviewed the literature to determine the possible interactions between the seven top-selling herbal medicines (ginkgo, St John’s wort, ginseng, garlic, echinacea, saw palmetto and kava) and prescribed drugs. Literature searches were performed using the following databases: Medline (via Pubmed), Cochrane Library, Embase and phytobase (all from their inception to July 2000). All data relating to herb-drug interactions were included regardless of whether they were based on case reports, case series, clinical trials or other types of investigation in humans. In vitro experiments were excluded. Data were extracted by the first author and validated by the second author. 41 case reports or case series and 17 clinical trials were identified.

The results indicate that St John’s wort (Hypericum perforatum) lowers blood concentrations of cyclosporin, amitriptyline, digoxin, indinavir, warfarin, phenprocoumon and theophylline; furthermore it causes intermenstrual bleeding, delirium or mild serotonin syndrome, respectively, when used concomitantly with oral contraceptives (ethinylestradiol/desogestrel), loperamide or selective serotonin-reuptake inhibitors (sertaline, paroxetine, nefazodone). Ginkgo (Ginkgo biloba) interactions include bleeding when combined with warfarin, raised blood pressure when combined with a thiazide diuretic and coma when combined with trazodone. Ginseng (Panax ginseng) lowers blood concentrations of alcohol and warfarin, and induces mania if used concomitantly with phenelzine. Garlic (Allium sativum) changes pharmacokinetic variables of paracetamol, decreases blood concentrations of warfarin and produces hypoglycaemia when taken with chlorpropamide. Kava (Piper methysticum) increases ‘off periods in Parkinson patients taking levodopa and can cause a semicomatose state when given concomitantly with alprazolam. No interactions were found for echinacea (Echinacea angustifolia, E. purpurea, E. pallida) and saw palmetto (Serenoa repens).

In conclusion, interactions between herbal medicines and synthetic drugs exist and can have serious clinical consequences. Healthcare professionals should ask their patients about the use of herbal products and consider the possibility of herb-drug interactions.

The article was so successful that the journal ‘DRUGS’ asked us to publish an update. As the journal is highly respected we obliged with pleasure; here is the abstract of the update of 2009:

The concomitant use of herbal medicines and pharmacotherapy is wide spread. We have reviewed the literature to determine the possible interactions between seven popular herbal medicines (ginkgo, St John’s wort, ginseng, garlic, echinacea, saw palmetto and kava) and conventional drugs. Literature searches were performed using MEDLINE, Cochrane Library and EMBASE and we identified 128 case reports or case series, and 80 clinical trials. Clinical trials indicate that St John’s wort (Hypericum perforatum), via cytochrome P450 (CYP) and/or P-glycoprotein induction, reduces the plasma concentrations (and/or increases the clearance) of alprazolam, amitriptyline, atorvastatin, chlorzoxazone, ciclosporin, debrisoquine, digoxin, erythromycin, fexofenadine, gliclazide, imatinib, indinavir, irinotecan, ivabradine, mephenytoin, methadone, midazolam, nifedipine, omeprazole, oral contraceptives, quazepam, simvastatin, tacrolimus, talinolol, verapamil, voriconazole and warfarin. Case reports or case series suggest interactions of St John’s wort with adrenergic vasopressors, anaesthetics, bupropion, buspirone, ciclosporin, eletriptan, loperamide, nefazodone, nevirapine, oral contraceptives, paroxetine, phenprocoumon, prednisone, sertraline, tacrolimus, theophylline, tibolone, tryptophan, venlafaxine and warfarin. Ginkgo (Ginkgo biloba) decreases the plasma concentrations of omeprazole, ritonavir and tolbutamide. Clinical cases indicate interactions of ginkgo with antiepileptics, aspirin (acetylsalicylic acid), diuretics, ibuprofen, risperidone, rofecoxib, trazodone and warfarin. Ginseng (Panax ginseng) may interact with phenelzine and warfarin. Kava (Piper methysticum) increases the clearance of chlorzoxazone (a CYP2E1 substrate) and may interact with alprazolam, levodopa and paroxetine. Garlic (Allium sativum) interacts with chlorpropamide, fluindione, ritonavir and warfarin; it also reduces plasma concentrations of chlorzoxazone (a CYP2E1 probe). Echinacea might affect the clearance of caffeine (a CYP1A2 probe) and midazolam (a CYP3A4 probe). No interactions have been reported for saw palmetto (Serenoa repens). Numerous interactions between herbal medicines and conventional drugs have been documented. While the significance of many interactions is uncertain, several interactions, particularly those with St John’s wort, may have serious clinical consequences.

Angelo Izzo is a lovely man and a highly skilled pharmacologist. He came to my department in 2000 as a guest researcher (on his own funds) and worked with us for several months. This is how the 2001 paper was created. After he returned to his native Naples, Italy, he became a professor of pharmacology with a special interest in plant pharmacology. He has published many further important papers and, together with his Italian colleagues, a most useful book entitled ‘Phytotherapy: A Quick Reference to Herbal Medicine‘. I warmly recommend it to anyone interested in herbal medicine.

The subject of herb-drug interactions is in my view hugely important. When Angelo and I first approached it in 2001, it was woefully under-researched; in that year, there were just 37 Medline-listed papers on the subject. This has now increased very significantly; since 2011 there are about 150 articles on the topic each year. It is tempting to think that Angelo (and I) had a tiny influence on this positive development.

Acupuncture has been widely used for acute low back pain (LBP), yet there remains continued controversy regarding its efficacy. Therefore, this systematic review aimed at evaluating the evidence.

English and Chinese databases were searched for randomized controlled trials (RCTs) of acupuncture for acute LBP published up to May 2020. Data on the outcomes of pain intensity, functional status, and analgesic use were extracted. The meta-analysis was performed using the Cochrane Collaboration’s RevMan 5.3, and pooled data were expressed as mean differences (MD) with 95% confidence intervals (CIs).

Of the 13 eligible RCTs identified, 9 were from China, one each from Brazil, the United Kingdom, Australia, and South Korea. Four studies were published in English, and 9 were published in Chinese. The 13 RCTs (involving 707 patients) provided moderate-quality evidence that acupuncture has a statistically significant association with improvements in VAS (visual analog scale) score [MD: −1.75 (95% CI: −2.39, −1.12)]. Two studies indicated that acupuncture did not influence the RMDQ (Roland-Morris Disability Questionnaire) scores more than the control treatment [MD: −2.34 (95% CI: −5.34, 0.67)]. Three studies suggested that acupuncture influenced the ODI (Oswestry Disability Index) scores more than the control treatment [MD: −12.84 (95% CI: −23.94, −1.74)]. Two studies suggested that acupuncture influenced the number of pills more than the control treatment [MD: −3.19 (95% CI: −3.45, −2.92)]. Merely 2 RCTs were sham-controlled and only 4 of the 13 RCTs mentioned adverse effects.

The authors concluded that acupuncture treatment of acute LBP was associated with modest improvements in the VAS score, ODI score, and the number of pills, but not the RMDQ score. Our findings should be considered with caution due to the low power original studies. High-quality trials are needed to assess further the role of
acupuncture in the treatment of acute LBP.

I do appreciate the authors’ call for caution in interpreting the findings. Yet, I feel that much more caution than the authors advise is needed here:

  • Most studies are from China, and we have often seen that these trials cannot be trusted.
  • Only 2 RCTs are sham-controlled which means that most studies failed to control for placebo effects.
  • Most studies do not mention adverse effects, confirming the unethically low standards of these investigations.

I am afraid that this new review does not inspire me with confidence that acupuncture is an effective therapy for acute LBP.

Google Scholar is quite a fantastic tool; I recently (20/5/2021) glanced at my own profile and decided to have a closer look at the 100 of my papers that have been cited most frequently. The list below shows these ‘top 100’; in the 1st column is the reference (title of the article, authors, journal). In the MIDDLE column are the numbers of times each paper has been cited (if you click on it, you see the articles that cited the paper in question), and the far-right column tells you the year of publication.

Here we go:

Interactions between herbal medicines and prescribed drugs. AA Izzo, E Ernst: Drugs 61 (15), 2163-2175 1608* 2001
Influence of context effects on health outcomes: a systematic review. Z Di Blasi, E Harkness, E Ernst, A Georgiou, J Kleijnen: Lancet 357 (9258), 757-762 1564 2001
Fibrinogen as a cardiovascular risk factor: a meta-analysis and review of the literature. E Ernst, KL Resch: Annals of internal medicine 118 (12), 956-963 1544 1993
The prevalence of complementary/alternative medicine in cancer: a systematic review. E Ernst, B Cassileth: Cancer: Interdisciplinary International Journal of the American Cancer 1173 1998
The desktop guide to complementary and alternative medicine: an evidence-based approach. E Ernst, MH Pittler, C Stevinson, A White 854 2001
Harmless herbs? A review of the recent literature. E Ernst: The American journal of medicine 104 (2), 170-178 852 1998
The desktop guide to complementary and alternative medicine: an evidence-based approach. E Ernst, MH Pittler, C Stevinson, A White 837 2001
Aloe vera: a systematic review of its clinical effectiveness. BK Vogler, E Ernst: British journal of general practice 49 (447), 823-828 767 1999
Leukocytes and the risk of ischemic diseases. E Ernst, DE Hammerschmidt, U Bagge, A Matrai, JA Dormandy: Jama 257 (17), 2318-2324 754 1987
The Risk–Benefit Profile of Commonly Used Herbal Therapies: Ginkgo, St. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava. E Ernst: Annals of internal medicine 136 (1), 42-53 726 2002
Prevalence of use of complementary/alternative medicine: a systematic review. E Ernst: Bulletin of the world health organization 78, 258-266 725 2000
The BBC survey of complementary medicine use in the UK. E Ernst, A White: Complementary therapies in medicine 8 (1), 32-36 646 2000
The efficacy of “distant healing”: a systematic review of randomized trials. JA Astin, E Harkness, E Ernst: Parapsychology, 433-440 633 2017
Toxic heavy metals and undeclared drugs in Asian herbal medicines. E Ernst: Trends in pharmacological sciences 23 (3), 136-139 630 2002
Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials. E Ernst, MH Pittler: British journal of anaesthesia 84 (3), 367-371 623 2000
Meta-analysis: acupuncture for low back pain. E Manheimer, A White, B Berman, K Forys, E Ernst: Annals of internal medicine 142 (8), 651-663 600 2005
Garlic for treating hypercholesterolemia: a meta-analysis of randomized clinical trials

C Stevinson, MH Pittler, E Ernst: Annals of internal medicine 133 (6), 420-429

550 2000
Bringing medicinal plants into cultivation: opportunities and challenges for biotechnology. PH Canter, H Thomas, E Ernst: TRENDS in Biotechnology 23 (4), 180-185 524 2005
St John’s wort: Prozac from the plant kingdom. G Di Carlo, F Borrelli, E Ernst, AA Izzo: Trends in Pharmacological Sciences 22 (6), 292-297 500* 2001
Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. A White, S Hayhoe, A Hart, E Ernst: Bmj 323 (7311), 485-486 498 2001
Concept of true and perceived placebo effects. E Ernst, KL Resch: Bmj 311 (7004), 551-553 495 1995
A systematic review of systematic reviews of homeopathy. E Ernst: British journal of clinical pharmacology 54 (6), 577-582 482 2002
Aromatherapy: a systematic review. B Cooke, E Ernst: British journal of general practice 50 (455), 493-496 476 2000
The efficacy of ginseng. A systematic review of randomised clinical trials. BK Vogler, MH Pittler, E Ernst: European journal of clinical pharmacology 55 (8), 567-575 476 1999
Second thoughts about safety of St John’s wort. E Ernst: Lancet 354 (9195), 2014-2016 475 1999
Dietary supplements for body-weight reduction: a systematic review. MH Pittler, E Ernst: The American journal of clinical nutrition 79 (4), 529-536 473 2004
Herb–drug interactions: review and assessment of report reliability. A Fugh‐Berman, E Ernst: British journal of clinical pharmacology 52 (5), 587-595 468 2001
Acupuncture for back pain: a meta-analysis of randomized controlled trials. E Ernst, AR White: Archives of internal medicine 158 (20), 2235-2241 421 1998
Prospective studies of the safety of acupuncture: a systematic review. E Ernst, AR White: The American journal of medicine 110 (6), 481-485 411 2001
Panax ginseng, JT Coon, E Ernst: Drug safety 25 (5), 323-344 408 2002
The role of complementary and alternative medicine. E Ernst: Bmj 321 (7269), 1133 404 2000
Review of randomised controlled trials of traditional Chinese medicine. JL Tang, SY Zhan, E Ernst: Bmj 319 (7203), 160-161 388 1999
Peppermint oil for irritable bowel syndrome: a critical review and metaanalysis. MH Pittler, E Ernst: The American journal of gastroenterology 93 (7), 1131-1135 384 1998
Yohimbine for erectile dysfunction: a systematic review and meta-analysis of randomized clinical trials. E Ernst, MH Pittler: The Journal of urology 159 (2), 433-436 380 1998
Trick or treatment: The undeniable facts about alternative medicine. S Singh, E Ernst: WW Norton & Company 379* 2008
Prospective investigation of adverse effects of acupuncture in 97 733 patients. D Melchart, W Weidenhammer, A Streng, S Reitmayr, A Hoppe, E Ernst: Archives of internal medicine 164 (1), 104-105 375 2004
Adulteration of Chinese herbal medicines with synthetic drugs: a systematic review. E Ernst: Journal of internal medicine 252 (2), 107-113 374 2002
Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. HF Coelho, PH Canter, E Ernst. Educational Publishing Foundation 1 (S), 97 362 2013
Acupuncture–a critical analysis. E Ernst: J. Intern Med 259 (2), 125-137 357 2006
Acupuncture for treating acute ankle sprains in adults. TH Kim, MS Lee, KH Kim, JW Kang, TY Choi, E Ernst: Cochrane database of systematic reviews 353* 2014
Kava extract versus placebo for treating anxiety. MH Pittler, E Ernst:Cochrane Database of Systematic Reviews 352 2003
Methods for causality assessment of adverse drug reactions. TB Agbabiaka, J Savović, E Ernst: Drug safety 31 (1), 21-37 348 2008
Efficacy of kava extract for treating anxiety: systematic review and meta-analysis. MH Pittler, E Ernst: Journal of clinical psychopharmacology 20 (1), 84-89 345 2000
Horse chestnut seed extract for chronic venous insufficiency. MH Pittler, E Ernst: Cochrane database of systematic reviews 341 2012
A systematic review of randomized controlled trials of acupuncture for neck pain. AR White, E Ernst: Rheumatology (Oxford, England) 38 (2), 143-147 334 1999
Cardiovascular pharmacotherapy and herbal medicines: the risk of drug interaction. AA Izzo, G Di Carlo, F Borrelli, E Ernst: International journal of cardiology 98 (1), 1-14 333 2005
Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy. E Ernst, V Fialka: Journal of pain and symptom management 9 (1), 56-59 332 1994
Complementary medicine—a definition. E Ernst, KL Resch, S Mills, R Hill, A Mitchell, M Willoughby, A White: The British Journal of General Practice 45 (398), 506 331 1995
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. D Moher, A Liberati, J Tetzlaff, DG Altman, D Altman, G Antes, D Atkins, … Journal of Chinese Integrative Medicine 7 (9), 889-896 327 2009
Validating a new non-penetrating sham acupuncture device: two randomised controlled trials. J Park, A White, C Stevinson, E Ernst, M James: Acupuncture in Medicine 20 (4), 168-174 324 2002
Herbal medicinal products during pregnancy: are they safe? E Ernst: BJOG: An International Journal of Obstetrics & Gynaecology 109 (3), 227-235 322 2002
Adverse effects of herbal drugs in dermatology. E Ernst: British Journal of Dermatology 143 (5), 923-929 319 2000
Plasma fibrinogen—an independent cardiovascular risk factor. E Ernst: Journal of internal medicine 227 (6), 365-372 317 1990
Green tea (Camellia sinensis) for the prevention of cancer: K Boehm, F Borrelli, E Ernst, G Habacher, SK Hung, S Milazzo, … Cochrane Database of Systematic Reviews 312 2009
Andrographis paniculata in the treatment of upper respiratory tract infections: a systematic review of safety and efficacy. JT Coon, E Ernst: Planta medica 70 (04), 293-298 310 2004
Different standards for reporting ADRs to herbal remedies and conventional OTC medicines: face‐to‐face interviews with 515 users of herbal remedies: J Barnes, SY Mills, NC Abbot, M Willoughby, E Ernst: British journal of clinical pharmacology 45 (5), 496-500 308 1998
Complementary and alternative medicine use in England: results from a national survey. KJ Hunt, HF Coelho, B Wider, R Perry, SK Hung, R Terry, E Ernst: International journal of clinical practice 64 (11), 1496-1502 305 2010
Acupuncture for smoking cessation. AR White, H Rampes, E Ernst: Cochrane Database of Systematic Reviews 304* 2002
A review of stroke rehabilitation and physiotherapy. E Ernst: Stroke 21 (7), 1081-1085 298 1990
Ginkgo biloba extract for the treatment of intermittent claudication: a meta-analysis of randomized trials. MH Pittler, E Ernst: The American journal of medicine 108 (4), 276-281 295 2000
Adverse effects of spinal manipulation: a systematic review. E Ernst: Journal of the royal society of medicine 100 (7), 330-338 290 2007
The safety of massage therapy. E Ernst: Rheumatology 42 (9), 1101-1106 282 2003
Life-threatening adverse reactions after acupuncture? A systematic review. E Ernst, A White: Pain 71 (2), 123-126 282 1997
Herbal medicines for treatment of bacterial infections: a review of controlled clinical trials. KW Martin, E Ernst: Journal of Antimicrobial Chemotherapy 51 (2), 241-246 280 2003
Alternative and complementary therapies for the menopause. Borrelli, E Ernst: Maturitas 66 (4), 333-343 278 2010
Valerian for insomnia: a systematic review of randomized clinical trials. C Stevinson, E Ernst: Sleep medicine 1 (2), 91-99 271 2000
Adverse effects profile of the herbal antidepressant St. John’s wort (Hypericum perforatum L.). E Ernst, JI Rand, J Barnes, C Stevinson: European journal of clinical pharmacology 54 (8), 589-594 271 1998
The possible role of hemorheology in atherothrombogenesis. W Koenig, E Ernst: Atherosclerosis 94 (2-3), 93-107 269 1992
Red ginseng for treating erectile dysfunction: a systematic review. DJ Jang, MS Lee, BC Shin, YC Lee, E Ernst: British journal of clinical pharmacology 66 (4), 444-450 263 2008
Complementary therapies for depression: an overview. E Ernst, JI Rand, C Stevinson: Archives of general psychiatry 55 (11), 1026-1032 260 1998
Quality of herbal medicines: challenges and solutions. J Zhang, B Wider, H Shang, X Li, E Ernst: Complementary therapies in medicine 20 (1-2), 100-106 257 2012
Heavy metals in traditional Indian remedies. E Ernst: European journal of clinical pharmacology 57 (12), 891-896 253 2002
Heavy metals in traditional Chinese medicines: a systematic review. E Ernst, JT Coon: Clinical Pharmacology & Therapeutics 70 (6), 497-504 251 2001
Vitex agnus castus. C Daniele, JT Coon, MH Pittler, E Ernst: Drug safety 28 (4), 319-332 245 2005
Acupuncture for peripheral joint osteoarthritis: a systematic review and meta-analysis. YD Kwon, MH Pittler, E Ernst: Rheumatology 45 (11), 1331-1337 242 2006
The efficacy of herbal medicine–an overview. E Ernst: Fundamental & clinical pharmacology 19 (4), 405-409 242 2005
Herb–drug interactions: an overview of systematic reviews. P Posadzki, L Watson, E Ernst. British journal of clinical pharmacology 75 (3), 603-618 241 2013
Adverse events of herbal food supplements for body weight reduction: systematic review. MH Pittler, K Schmidt, E Ernst: obesity reviews 6 (2), 93-111 240 2005
Randomized, double-blind trial of chitosan for body weight reduction. MH Pittler, NC Abbot, EF Harkness, E Ernst: European Journal of Clinical Nutrition 53 (5), 379-381 237 1999
Massage therapy for low back pain: a systematic review. E Ernst: Journal of pain and symptom management 17 (1), 65-69 236 1999
Feverfew for preventing migraine. MH Pittler, E Ernst: Cochrane database of systematic reviews 235 2004
Intermittent claudication, exercise, and blood rheology. EE Ernst, A Matrai: Circulation 76 (5), 1110-1114 235 1987
Adverse effects of herbal medicines: an overview of systematic reviews. P Posadzki, LK Watson, E Ernst: Clinical medicine 13 (1), 7 233 2013
Horse-chestnut seed extract for chronic venous insufficiency: a criteria-based systematic review. MH Pittler, E Ernst: Archives of Dermatology 134 (11), 1356-1360 232 1998
The effectiveness of acupuncture in treating acute dental pain: a systematic review. E Ernst, MH Pittler: British dental journal 184 (9), 443-447 231 1998
 Complementary therapies for asthma: what patients use. E Ernst: Journal of Asthma 35 (8), 667-671 230 1998
87.   Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. E Ernst, MS Lee, TY Choi: PAIN 152 (4), 755-764 229 2011
The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. JA Astin, E Ernst: Cephalalgia 22 (8), 617-623 228 2002
Hawthorn extract for treating chronic heart failure: meta-analysis of randomized trials. MH Pittler, K Schmidt, E Ernst: The American journal of medicine 114 (8), 665-674 227 2003
Complementary medicine: what physicians think of it: a meta-analysis. E Ernst, KL Resch, AR White: Archives of internal medicine 155 (22), 2405-2408 226 1995
A brief history of acupuncture. A White, E Ernst: Rheumatology 43 (5), 662-663 225 2004
Hawthorn extract for treating chronic heart failure. R Guo, MH Pittler, E Ernst: Cochrane Database of Systematic Reviews 221 2008
Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys. P Posadzki, LK Watson, A Alotaibi, E Ernst: Clinical medicine 13 (2), 126 220 2013
Herbal medicines for asthma: a systematic review. A Huntley, E Ernst: Thorax 55 (11), 925-929 218 2000
 Plasma viscosity and the risk of coronary heart disease: results from the MONICA-Augsburg Cohort Study, 1984 to 1992. W Koenig, M Sund, B Filipiak, A Doring, H Lowel, E Ernst: Arteriosclerosis, thrombosis, and vascular biology 18 (5), 768-772 215 1998
Alternative therapy bias. E Ernst, MH Pittler: Nature 385 (6616), 480-480 214 1997
 Systematic review: hepatotoxic events associated with herbal medicinal products. MH Pittler, E Ernst: Aliment Pharmacol & Therapeutics 18 (5), 451-471 212 2003
Anthocyanosides of Vaccinium myrtillus (bilberry) for night vision—a systematic review of placebo-controlled trials. PH Canter, E Ernst: Survey of ophthalmology 49 (1), 38-50 210 2004
Prevalence of complementary/alternative medicine for children: a systematic review. E Ernst: European journal of pediatrics 158 (1), 7-11 210 1999
Homeopathy for postoperative ileus?: a meta-analysis. J Barnes, KL Resch, E Ernst: Journal of Clinical Gastroenterology 25 (4), 628-633

What my analysis of these data suggests is the following:

  1. Only relatively few articles (n=8) are in the ‘top 100’ that I published before I took up the Exeter post starting full-time research into so-called alternative medicine (SCAM).
  2. Despite the fact that in any such analysis older papers are at a significant advantage over newer articles, the vast majority of these 100 papers are relatively recent.
  3. Very few of our clinical trials are in the ‘top 100’, even though I did publish well over 50 during my career.
  4. Systematic reviews dominate by far and amount to 49 of the ‘top 100’.
  5. Even some of my ‘letters to the editor’ did make it into the ‘top 100’.
  6. Six of the 100 papers are surveys.
  7. As to the SCAM topics, most articles are on herbal medicine (n=39), followed by acupuncture (13), manual therapies (4), and homeopathy (2).
  8. A total of 21 of the papers have their main focus on safety issues.
  9. The vast majority of the papers are co-authored by more than one member of my team.
  10. A total of 22 articles were produced in collaboration with researchers who were not members of my team.
  11. Seventeen papers were single-author papers by myself.
  12. Even though I certainly did publish a lot in journals specialized in so-called alternative medicine (SCAM), only very few of these articles made it into this list.

There are many things that I find interesting in all this. Perhaps just a few points:

  • The two SCAM areas in which I have published many articles and do get a lot of flack for what I have written are homeopathy and chiropractic. Surprisingly, not many of these papers are in the ‘top 100’. I am not sure whether this is meaningful and if so how I should interpret this.
  • The fact that hardly any papers published in SCAM journals made the ‘top 100’ is interesting but not surprising. It means that researchers who want to see their work cited – and who doesn’t? – should avoid such journals (there are, of course, other reasons as well for avoiding such journals).
  • The fact that even ‘letters to the editors’ can get cited so frequently seems unexpected but I find it encouraging.
  • Collaboration with researchers who are not from one’s own team can be, in my experience, cumbersome but it is worth it and often fruitful.
  • If you asked me, is there a correlation between the quality of a paper and the frequency with which it is cited, I’d have to say NO.
  • If you asked me, is there a correlation between the importance of a paper and the frequency with which it is cited, I’d have to say NO again.

If you thought that osteopathy is for spinal problems, think again. This study aimed to determine whether osteopathic manipulation of the T9-T10 vertebrae improves the evolution of tonsillitis. A randomized, stratified, controlled clinical trial with blinded patients, evaluator, and data analyst was performed.

The patients in the control group (CG) received a “sham” manipulation consisting of a 150° passive flexion of the shoulders, with a gentle contact of the osteopath’s knees in the middle thoracic vertebrae, without impulse or causing tension. A high-speed, low-amplitude technique was applied to the T9-T10 vertebrae in the osteopathic manipulative group (OMG) patients.

The number of days needed to resolve the tonsillitis was significantly lower (p = 0.025) in the OMG (2.03 ± 0.95 days) than the CG (2.39 ± 0.82 days). Additionally, the number of episodes of tonsillitis after the treatment decreased significantly more in the OMG (0.8 ± 1.88 episodes/year in total) than the CG (2 ± 2.12) (p = 0.005). In the OMG, 60.8% had no recurrences of tonsillitis, compared to 22.5% of the CG, in the following year (χ2 (1) = 15.57, p < 0.001). No patients reported adverse effects.

The authors concluded that during an episode of tonsillitis, the number of days to resolution was significantly lower after the application of an osteopathic manipulation of the T9-T10 vertebrae, compared to a sham manipulation. The number of subsequent year tonsillitis episodes was greatly reduced in both groups, significantly more in the OMG than in the CG patients.

This is an interesting study. Its exceptional feature is that it is sham-controlled. This must mean that the results are reliable and that osteopathic manipulation is indeed an effective treatment of tonsillitis.

Or perhaps not?

It is, of course, most laudable to introduce a sham control group into such a study. But let us for a moment reflect on what purpose it serves. Its main purpose, no doubt, is to render patients unaware of which treatment they received, sham or verum. This is only possible if the sham is indistinguishable from the verum. In this study, this was clearly not the case. Patients in the verum group felt that they received the verum, and patients in the sham group felt that they had the placebo. Thus the former expect to get better, while the latter don’t.

So, we are left with two very different interpretations of the findings:

  1. Osteopathic manipulations are effective for tonsillitis.
  2. Osteopathic manipulations are not effective for tonsillitis, but the patients’ expectations determined the outcomes.

Which is more likely?

What do you think?

Of all the many forms of so-called alternative medicine (SCAM), essential oils (EOs) are perhaps the most popular and least harmful – at least this is what we are supposed to believe. The truth is, as so often in SCAM, a little different.

Some EOs are claimed to have anticonvulsant activity and might benefit people with epilepsy. Lemongrass, lavender, clove, dill, and other EOs containing constituents such as asarone, carvone, citral, eugenol, or linalool are good candidates for evaluation as antiepileptic drugs. Conversely, other EOs are suspected to have pro-convulsant properties. These EOs are present in many balms and oils available freely over the counter. The effect of exposure to these EOs and occurrence of seizure has not been studied systematically. The aim of this study was therefore to evaluate the relationship between essential oils and the first episode of seizure and breakthrough seizures in known epileptic patients.

This multi-center prospective study was conducted in four hospitals in India over four years. Every person presenting with the first episode of seizure or breakthrough seizure was asked about exposure to EOs, mode of exposure, time to onset of a seizure in relation to exposure, duration of seizure, type of seizure, and antiepileptic drug therapy.

During the four-year period, there were 55 patients with essential oil-related seizures (EORS). 22 (40 %) had essential oil-induced seizures (EOIS) and 33 (60 %) had essential oil-provoked seizures (EOPS). The female: male ratio was 1:1.1, the age of the patients ranged from 8 months to 77 years. In the EOIS group, 95 % had generalized tonic-clonic seizures and 5% had focal impaired awareness seizures. In the EOPS group, 42.4 % had focal impaired awareness seizures, 27.3 % generalized tonic-clonic seizures, 15 % focal to bilateral tonic-clonic seizures, and 15 % focal aware motor seizures. EOs implicated were preparations containing eucalyptus and camphor.

The authors concluded that exposure to essential oils of eucalyptus and camphor is an under-recognized cause of the first and breakthrough seizure. Identifying the true causative factor will prevent unnecessary antiepileptic drug therapy and future recurrence.

These results are, of course, far from conclusive. However, they seem important enough to bear in mind and to stimulate further research. Meanwhile, patients with epilepsy might be well advised to be cautious with essential oils, particularly those from eucalyptus and camphor.

French researchers aimed to assess the efficacy of osteopathic manipulation for fibromyalgia (FM) in a randomized clinical trial. Patients were randomized to osteopathic or sham treatment. Treatment was administered by experienced physical medicine physicians, and consisted of six sessions per patient, over 6weeks. Treatment credibility and expectancy were repeatedly evaluated.

For the osteopathic treatment, the patient was first placed in a prone position. Each vertebra from C7 to L5 was mobilized in a dorsoventral direction by progressive pressure on the spinous process (SP), and in rotation by applying pressure on the lateral surface of the SP (bilaterally). The sacral bone was repeatedly mobilized in nutation–counternutation (5–10 times). The piriformis muscles were progressively stretched. The hip joint was then progressively mobilized in extension combined with abduction and adduction to stretch the adductor, abductor, and flexor muscles (10 times). The shoulders were progressively mobilized, one by one, with a repeated circumduction movement of the glenohumeral joint (10 times). The patient was then placed in a supine position, for the following maneuvers. At the neck, bimanual traction was performed, followed by repeated mobilization in lateral flexion and in rotation (both sides, five times, 3–5 times each). At the shoulders, we first performed cranial traction of both arms and then repeated caudal traction of one arm and then the other, by blocking the clavicle, thereby opening the acromioclavicular and glenohumeral joints (three times). At the hips, repeated tractions were performed on the legs (three times) and the hip joint was mobilized by circumduction movements. Finally, the patient was placed in the lateral decubitus position for mobilization of the lumbar and thoracolumbar spine. Thrust manipulations were allowed at any level, according to the patient’s complaint.

The sham treatment followed the same order, but the maneuvers were stopped halfway through to prevent joint mobilization at the spine. At the hips and shoulders, the stretching techniques were also stopped halfway. The joint techniques were simulated, with no significant mobilization. Thrust manipulation was forbidden.

Patients completed standardized questionnaires at baseline, during treatment, and at 6, 12, 24, and 52 weeks after randomization. The primary outcome was pain intensity (100-mm visual analog scale) during the treatment period. Secondary outcomes included fatigue, functioning, and health-related quality of life. Primarily intention-to-treat analyses were adjusted for credibility, using multiple imputations for missing data.

In total, 101 patients (94% women) were included. Osteopathic treatment did not significantly decrease pain relative to sham treatment (mean difference during treatment: −2.2mm; 95% confidence interval, −9.1 to 4.6mm). No significant differences were observed for secondary outcomes. No serious adverse events were observed, despite a likely rebound in pain and altered functioning at week 12 in patients treated by osteopathy. Patient expectancy
was predictive of pain during treatment, with a decrease of 12.9mm (4.4–21.5mm) per 10 points on the 0–30 scale. Treatment credibility and expectancy were also predictive of several secondary outcomes.

The authors concluded that osteopathy conferred no benefit over sham treatment for pain, fatigue, functioning, and quality of life in patients with FM. These findings do not support the use of osteopathy to treat these patients. More attention should be paid to the expectancy of patients in FM management.

The French team should be congratulated on this excellent piece of research. This is a very well conducted and reported study. It should serve as a blueprint to researchers of manual therapies for future trials. The results are clear and not unexpected: osteopathy is little more than a theatrical placebo.

The General Chiropractic Council’s (GCC) Registrant Survey 2020 was conducted in September and October 2020. Its aim was to gain valuable insights into the chiropractic profession to improve the GCC’s understanding of chiropractic professionals’ work and settings, qualifications, job satisfaction, responsibilities, clinical practice, future plans, the impact of the COVID-19 pandemic on practice, and optimism and pessimism about the future of the profession.

The survey involved a census of chiropractors registered with the GCC. It was administered online, with an invitation email was sent to every GCC registrant, followed by three reminders for those that had not responded to the survey. An open-access online survey was also available for registrants to complete if they did not respond to the mailings. This was promoted using the GCC website and social media channels. In total, 3,384 GCC registrants were eligible to take part in the survey. A fairly miserable response rate of 28.6% was achieved.

Here are 6 results that I found noteworthy:

  • Registrants who worked in clinical practice were asked if performance was monitored at any of the clinical practices they worked at. Just over half (55%) said that it was and a third (33%) said it was not. A further 6% said they did not know and 6% preferred not to say. Of those who had their performance monitored, only 37% said that audits of clinical care were conducted.
  • Registrants working in clinical practice were asked if any of their workplaces used a patient safety incident reporting system. Just under six in ten (58%) said at least one of them did, whilst 23% said none of their workplaces did. A further 12% did not know and 7% preferred not to say.
  • Of the 13% who said they had a membership of a Specialist Faculty, a third (33%) said it was in paediatric chiropractic, 25% in sports chiropractic, and 16% in animal chiropractic. A further 13% said it was in pain and the same proportion (13%) in orthopaedics.
  • Registrants who did not work in chiropractic research were asked if they intended to work in that setting in the next three years. Seven in ten (70%) said they did not intend to work in chiropractic research in the next three years, whilst 25% did not know or were undecided. Only 5% said they did intend to work in chiropractic research.
  • Registrants were also asked how easy it is to keep up to date with recommendations and advances in clinical practice. Overall, two-thirds (67%) felt it was easy and 30% felt it was not.
  • Registrants were asked in the survey whether they felt optimistic or pessimistic about the future of the profession over the next three years. Overall, half (50%) said they were optimistic and 23% were pessimistic. A further 27% said they were neither optimistic nor pessimistic.

Perhaps even more noteworthy are those survey questions and subject areas that might have provided interesting information but were not included in the survey. Here are some questions that spring into my mind:

  • Do you believe in the concept of subluxation?
  • Do you treat conditions other than spinal problems?
  • How frequently do you use spinal manipulations?
  • How often do you see adverse effects of spinal manipulation?
  • Do you obtain informed consent from all patients?
  • How often do you refer patients to medical doctors?
  • Do you advise in favour of vaccinations?
  • Do you follow the rules of evidence-based medicine?
  • Do you offer advice about prescribed medications?
  • Which supplements do you recommend?
  • Do you recommend maintenance treatment?

I wonder why they were not included.


By guest blogger Les Rose

This is a follow-up to Edzard’s post back in October last year, about a paper by Christina Ross, entitled “Energy Medicine: Current Status and Future Perspectives”. You will see from the post, and from the paper itself, that it is a curious mish-mash of scraps of real science and a large volume of speculative and invented garbage. Its opening gambit majors on physics, which caught the attention of Richard Rasker, who has a background in medical instrumentation, and whose comments were insightful and excoriating.

Edzard and I wrote to the editors of the journal, pointing out the paper’s misleading content and requesting a retraction. In particular, we asked if the paper had been reviewed by a physicist. Here is what they responded:

“This paper underwent appropriate scientific peer review. We don’t intend to retract the paper, but we encourage you to submit an official Letter to the Editor through the Journal’s website. This approach would give the author of this paper the opportunity to respond to your critiques.”

This was received on 28th October 2020. Note that they did not answer our question about a review by a physicist. The journal limits letters to 500 words, and the paper warranted rather more analysis than that, so in partnership with Richard, we posted a detailed critique on my own blog. The plan was to refer to the blog post in the letter, which we submitted on 12th November. We suggested that the paper’s poor scientific underpinnings (to put it mildly) should be sufficient reason for retraction. At the very least, we requested that our critique and the paper itself be subjected to proper scientific review, and that our letter be published alongside the paper. Well here we are five months later and still, our letter has not been published.

The journal Global Advances in Health and Medicine specialises in so-called `integrative medicine’, which is a euphemism for shoehorning quackery into mainstream practice without the inconvenience of doing rigorous research. It publishes papers on such groundbreaking disciplines as shamanic journeying and intention host devices. The joint editors are in post at Wake Forest School of Medicine, where Christina L Ross, the author of the paper at issue, is on the staff.

But let’s return to the main story. Our letter was submitted in the usual way via the Manuscript Central website, and its status remains at `awaiting reviewer selection’. We have never heard of a letter to the editor requiring peer review. One month after submitting it, ie 12th December, SAGE Publishing finally acknowledged receiving our letter, and told us it was under review from their legal team and their editors. It seemed odd that it needed legal review. I replied thus on 20th December:

“Thanks for the update. We wrote directly to the editors asking them to retract the paper, but they refused, and advised us to write a letter for publication. This was so that the author could reply publicly. We still want that to happen. I am not sure why this is a legal matter, it is about science. In the interests of transparency, please tell us when our letter will be published.”

By 9th January 2021, there was no reply to this, so I chased up SAGE Publishing, who replied on 12th:

“The status in the system is misleading, as your Letter is not in need of any peer review. As you are aware, SAGE provides Editors and/or authors with the opportunity to respond to any Letters we receive. If they choose to do so, it is our policy that the Letter and any responses are published together all at once. However, before any adequate response can be put together, an investigation of the issues raised must first be completed. Although you are correct that this is not a Legal matter,

the nature of the complaints we have received prompted us to seek their guidance, and we will be publishing a Statement of Concern on this article while finishing this investigation. Your Letter has been waiting out this process, which unfortunately has taken slightly longer than usual due to all of the recent holidays and office closures. I do appreciate that you are anxious to see this matter resolved, and am sorry for any further frustration this has caused. The original author has been given a deadline to provide her comments, and upon receiving her response, your Letter will be published immediately. I expect this will happen within the next 2-3 weeks, but can certainly keep you updated going forward.”

The emphasis is mine. I asked what happens if the author doesn’t wish to respond, and was told that “we would then move forward with publishing your Letter on its own”. The deadline for the author to respond was stated to be “the end of next week”, ie 22nd January. So I was fully expecting the letter to be published a few days after that, and certainly by the end of January. But on 27th I was told that the author did not want to respond, and that they “do not yet have a firm publication date to share, but I have a meeting to discuss this with the Editors this week”. So the assurance highlighted above, about immediate publication, was valueless.

A few days later, on 31st January, an expression of concern was published, stating that several(!) complaints about the science of the paper had been received. By 17th February I was getting somewhat exasperated, and wrote again to the publishing editor:

“I am trying to be patient, but I really don’t see why a letter to the editors can take months to be published, in this day and age. Other journals such as the BMJ publish rapid responses in hours. I realise that our letter is critical of your journal’s peer review process, but delaying publication for so long does not look good. Surely you can publish the letter and respond in some way as publisher of the article in question? Some sort of response seems appropriate, in view of the original author’s silence. As we have raised this issue, readers may well appreciate some insight into your peer review process.

“I note that the journal’s editors are colleagues of the author. How do you manage this conflict of interest?”

The publishing editor did not reply directly to this, and passed it to the joint editor in chief Professor Remy Coeytaux. After a further two weeks I still had not heard anything from either party, so again I chased them up. The reply from Professor Coeytaux on 3rd March is worth reading in full:

“I ask for your forgiveness and understanding for the time this process is taking. By way of introduction and explanation, I am the co-Editor-in-Chief who has collaborated with Dr. Christina Ross in the past. Our other co-Editor-in-Chief, Dr. Suzanne Danhauer, has no relationship with the author of the paper in question. As is typical for medical journals, Global Advances in Health and Medicine does not have a policy that precludes members of the same academic institution as the Editors-in-Chief from submitting manuscripts for review and possible publication.

“Manuscripts submitted to the Journal are assigned to either Dr. Danhauer or myself. We then assign the manuscripts to Associate Editors as indicated. Dr. Ross’ manuscript was assigned to Dr. Danhauer. I had no role whatsoever in the peer review process or decision making for this manuscript. Throughout that process, there was no conflict of interest to manage. To re-iterate, Dr. Danhauer had no conflict with Dr. Ross and I had no involvement in any way or at any time in or with the peer review process.

“All of us at the Journal are taking your concerns seriously. Dr. Danhauer and I have complementary scientific expertise. She is a psychologist by training, while I am a physician and epidemiologist by training. We decided that I should be the one to manage the process of arriving at the most appropriate resolution to the concerns that you have brought to our attention. Your Letter to the Editor was assigned to me, and I am personally managing the process of seeking independent input from an additional set of peer reviewers for Dr. Ross’ original paper. By “personally,” I mean that I have not relegated this important task to one of our Associate Editors.

“We have very nearly completed the process on our end. We are awaiting the comments of one final peer reviewer. We expect to have that process completed within the next three weeks.

“I should also note that we believe it is appropriate for us to wait to publish your Letter to the Editor until we have completed our internal review process that we initiated in response to your concerns. It is for this reason that we have not yet published your Letter. I would like to take this opportunity to ask you, please, to send me another copy of your Letter to the Editor after deleting the reference to the internet link. It is the Journal’s policy to not publish such links. I would like to ask you, please, to send the revised letter to me directly in a PDF format via email attachment.

“Thank you for engaging in this scientific discourse and for your patience during the process.”

Some of this is very odd. He admits to being Ross’ collaborator but says this is not a conflict of interest. The journal’s instructions for authors do not say anything about `internet links’. It is perfectly normal for academic papers to use URLs as references. This looks suspiciously like an exercise in damage limitation. Hence I deleted the embedded hyperlink in the text and added the URL as a reference at the end. I replied the next day, and asked whether the current peer reviewers include those from outside the field of complementary and/or alternative medicine. I have not heard anything further from Professor Coeytaux or the publisher.

Is it really so time-consuming to find an authoritative reviewer? I put the word out, and got a response from Professor Jim Al-Khalili OBE FRS FinstP. He is a very well-known TV presenter on science topics, and as well as an eminent physicist and a professor for the public engagement in science. He could not be more appropriate to review this paper, and here is what he said:

“This notion that the body has ‘different kinds of energy’ is utter nonsense and a clear sign that someone does not have a firm background in science. If we do want to explore what different kinds of energy living organisms have then we can say there is kinetic energy due to macroscopic motion controlled by, say, muscles, then there is thermal energy due to vibrations of the molecules within our cells, chemical energy due to the thousands of biochemical reactions taking place inside cells, and finally electromagnetic energy from for example, the tiny induced magnetic fields due to moving charged particles in ion channels. None of these forms of energy is mysterious and the wording in this paper referring to detecting ‘subtle energies’ or resonances is utterly unscientific. While scanners, such as MRI, x-ray, PET or CT machines can image the body by measuring interactions with, for example, magnetic fields or responses to bombarding electromagnetic radiation, there is no mystery here. We know how they work. After all, it was physicists who invented these machines based on our understanding of the laws of physics. To buy into any of the notions in this paper would mean that the whole edifice of modern physics has to be demolished and rebuilt. And if anyone thinks that may be necessary then I would argue they really have not studied science at all and do not understand the scientific method.

“Basically, the science that this paper challenges is the very science that has allowed us to understand the workings of the body in the first place. You cannot call upon science (quantum field theory) to justify unscientific ideas that would mean that quantum field theory has to be thrown away. Also, using scientific jargon to make something sound clever when it’s not should not fool anyone, and certainly not serious scientific research journals.”

One has to wonder how Ross obtained a degree in physics. I sent this to Professor Coeytaux on 22nd March, pointing out how quick and easy it was to get such a review. I said that the paper had obviously not received “appropriate scientific review”, and asked for a response by return explaining the status of our letter. You guessed it, I have heard nothing.

I always try to go for the ball and not the player, but it’s worth looking in a bit more detail at Christina Ross’ academic credentials. She styles herself as Dr, but her PhD is from Akamai University in Hawaii. Although the university proudly displays a statement of accreditation, it is from the Accreditation Service for International Schools Colleges and Universities (ASIC). This is not listed by the US Department of Education as a recognised accreditation body. It is actually a UK company that validates visas for international students, but its credibility is quite doubtful:

“The legitimacy of ASIC’s international accreditation service is unclear and some of its internationally-accredited institutions have been deemed ‘diploma mills’ offering worthless qualifications.”

Ross is also a `Board Certified Polarity Practitioner’. Americans love the term `board certified’, it lends considerable gravitas. But anyone can set up a board and issue certificates. What is polarity therapy? Well, as is usual with quackery, it is a personality cult, which combines various evidence-free modalities and doesn’t clearly say what use it is. I don’t think I need to look into `Certified Energy Medicine Practitioner’ any further.

So this is what happens when pseudoscience is called out in academia. SAGE Publishing is obviously not a bit concerned about science, despite their assurances, or they would never have launched a journal such as this. The editors do not worry about conflicts of interest or scientific evidence. They try to obfuscate when detailed criticism is published. The author does not even attempt to defend what she has written. I assume all of them are hoping that we will get weary of this and give up. They are wrong about that as well.

My recent book discusses 20 of the worst and 20 of the best so-called alternative treatments. Some people are surprised and ask HOW DID YOU MANAGE TO FIND 20? WHAT THERAPIES ARE YOU TALKING ABOUT? As the book is in German, I have for non-German speakers the translated list and my concluding remarks from the book about the 20 best:

  • Alexander technique
  • Autogenic training
  • Chondroitin
  • Feldenkrais technique
  • Fish oil
  • Glucosamine
  • Hypnotherapy
  • Hypericum
  • Garlic
  • Laughing therapy
  • Lymphdrainage
  • Music therapy
  • Oil pulling
  • Pilates
  • Progressive muscle relaxation
  • Cupping
  • Tai chi
  • Triggerpoint therapy
  • Visualization
  • Yoga

When I look at the ’20 best’, I notice a few things that are perhaps worth highlighting again. The most striking thing is certainly that they are often therapies that are so close to conventional medicine that they can hardly be counted as alternative medicine anymore. Autogenic training, chondroitin, Feldenkrais therapy, fish oil, glucosamine, hypnotherapy, St. John’s wort, laughter therapy, lymphatic drainage, music therapy, and trigger point therapy are all procedures that are now at least partially integrated into conventional medicine. This brings to mind Tim Minchin’s bon mot, “You know what they call alternative medicine that’s been proven to work? – Medicine.”

The ’20 best’ can be roughly divided into three main categories:

1. physical therapies such as Alexander Technique, Feldenkrais Therapy, Lymphatic Drainage, Pilates, Tai Chi, and Yoga.
2. relaxation therapies such as autogenic training, hypnotherapy, laughter therapy, music therapy, progressive muscle relaxation, and visualization.
3. pharmacological therapies such as chondroitin, fish oil, glucosamine, St. John’s wort, and garlic.

That exercise, relaxation, and pharmacology can be effective is probably no surprise to anyone. In other words, unlike the ’20 Most Questionable’, almost all of the ’20 Best’ are supported by some plausibility. Very rarely does one find a therapy that is both implausible and effective. Among the procedures discussed in this book, this is the case only for Feldenkrais therapy.

In the review of the ’20 Best’, I have repeatedly emphasized that the evidence, while positive, is seriously flawed and therefore not as convincing as one might wish. There may be several reasons for this:

– In most cases, there is too little research funding available to conduct a sufficient number of good studies.
– Even if the money were available, the expertise (and occasionally the will) to test the methods scientifically is often lacking.
– Clinical trials of alternative medicine are often considerably more difficult to design and conduct than studies in conventional medicine. For instance, it is not always easy to find an adequate placebo. For example, what is an appropriate placebo for a study of hypnotherapy that allows patients to be blinded?

It follows that we must occasionally turn a blind eye, but ultimately cannot be completely certain that the procedure in question is in fact anything more than a placebo.

While the ’20 Most Questionable’ include many procedures that have been touted as panaceas, this is rarely the case with the ’20 Best’. On the contrary, most of the treatments in this category are effective for only a very few indications. Here the saying of one of my clinical teachers comes to mind, “If a therapy is supposed to be good for everything, it most likely won’t work for anything.”

What further strikes me as important is the fact that while all of the methods mentioned are effective, they are invariably symptomatic. None of the ’20 Best’ represents a causal therapy that can address a disease causally and thus actually cures it. This is in stark contrast to the many claims of healing made by alternative medicine providers, who all too often advertise their methods as addressing the root cause of a condition.

If we take a close look at the ’20 best’, we must finally also ask ourselves which of these methods are actually better than the conventional treatment of the same condition. All 20 have been positively evaluated by me in terms of their benefit/risk ratio. But this does not mean that they are superior to conservative therapy with respect to this important criterion. St. John’s wort is the most likely to meet this condition; it is as effective as conventional antidepressants for mild to moderate depression and has fewer side effects than them. Its benefit/risk ratio is thus superior to that of conventional antidepressants. I am not sure about any of the other treatments in the ’20 Best’ category.

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