Updated Edition!
These days, I am often not sure what puzzles me more, Boris Johnson or homeopathy. Come to think of it, our PM seems, in fact, to have a lot in common with homeopathy/homeopaths. With my tongue lodged firmly in my cheek, I can see some communalities:
- They are both popular in the UK but have their origins elsewhere.
- They were both laughed at by people who are serious.
- They have both been around for far too long.
- They both are useless.
- They both have plenty of charisma.
- They both, however, have little more than that.
- They have a long history of misleading the public.
- They have both been taken to court.
- They both failed to accept the judgement when it went against them.
- They are both particularly successful with the female section of the population.
- They both thrive on personal attacks.
- They both make far-reaching claims which turn out to be false.
- They both claim to want only the best for the public.
- They both consider themselves as progressive.
- In truth, however, they are both deeply regressive.
- They both do not to think that ethics are all that important.
- They both irritate people who are rational thinkers.
- They both negate the evidence and act in overt contradiction to the evidence.
- They both tend to think that popularity is a measure of efficacy.
- They both managed to mislead even the Queen.
- Nevertheless, they both enjoy royal support (at least for the time being).
- They both seem to think that the laws (of the land/of nature) do not apply to them.
- They are both only bearable when highly diluted.
- They are both a complete waste of money.
- They are both dangerous when the public follow their advice.
Have I forgotten anything?
Do tell me, please.
Reiki has been a regular topic on this blog (see for instance here, here and here). In my recent book (Alternative medicine, a critical assessment of 150 modalities), I evaluated it as follows:
Reiki is a form of paranormal or energy healing popularised by Japanese Mikao Usui (1865-1926). Rei means universal spirit (sometimes thought of as a supreme being) and ki is the assumed universal life energy.
- Reiki is based on the assumptions of Traditional Chinese Medicine and the existence of ‘chi’, the life-force that determines our health.
- Reiki practitioners believe that, with their hands-on healing method, they can transfer ‘healing energy’ to a patient which, in turn, stimulates the self-healing properties of the body. They assume that the therapeutic effects of this technique are obtained from a ‘universal life energy’ that provides strength, harmony, and balance to the body and mind.
- There is no scientific basis for such notions, and reiki is therefore not plausible.
- Reiki is used for a number of conditions, including the relief of stress, tension and pain.
- There have been several clinical trials testing the effectiveness of reiki. Unfortunately, their methodological quality is usually poor.
- A systematic review summarising this evidence concluded that the evidence is insufficient to suggest that reiki is an effective treatment for any condition. Therefore, the value of reiki remains unproven.[1] And a Cochrane review found that there is insufficient evidence to say whether or not Reiki is useful for people over 16 years of age with anxiety or depression or both.[2]
- Reiki appears to be generally safe, and serious adverse effects have not been reported. Some practitioners advise caution about using reiki in people with psychiatric illnesses because of the risk of bringing out underlying psychopathology.
| PLAUSIBILITY | Negative |
| EFFICACY | Negative |
| SAFETY | Positive |
| COST | Positive |
| RISK/BENEFIT BALANCE | Negative |
[1] https://www.ncbi.nlm.nih.gov/pubmed/?term=lee+pittler+ernst%2C+reikiv
[2] https://www.ncbi.nlm.nih.gov/pubmed/25835541
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Now a new study has been published. Will it overturn my assessment?
This within-subject design experiment was conducted to test the feasibility and efficacy of Reiki to provide pain relief among paediatric patients undergoing hematopoietic stem cell transplantation (HSCT).
Paediatric patients undergoing HSCT during the inpatient phase in the Stem Cell Transplantation Unit were eligible to participate to the study. Short and medium effects were assessed investigating the increase or decrease of patient’s pain during three specific time periods of the day: morning of the Reiki session versus assessment before Reiki session (within subjects control period), assessment before Reiki session versus assessment after Reiki session (within subjects experimental period) and assessment after Reiki session versus morning the day after Reiki session (within subject follow-up period). The long-term effects were verified comparing the pain evolution in the day of the Reiki session with the following rest day.
The effect of 88 Reiki therapy sessions in nine patients was analysed following a short, medium, and long-term perspective. Repeated-measures analysis of variance revealed a significant difference among the three periods. A decrease of the pain occurred in the experimental period in short and medium term, while in the follow-up period, the pain level remained stable.
The authors concluded that this study demonstrates the feasibility of using Reiki therapy in pediatric cancer patients undergoing HSCT. Furthermore, these findings evidence that trained paediatric oncology nurses can insert Reiki into their clinical practice as a valid instrument for diminishing suffering from cancer in childhood.
This is basically an observational study without a control group. Therefore it cannot possibly test the efficacy of Reiki. The conclusion that Reiki is a valid instrument for diminishing suffering from cancer in childhood is therefore simply incorrect. The only rational verdict therefore remains this: REIKI FAILS TO GENERATE MORE GOOD THAN HARM.
The sooner we stop misleading the public about it, the better for us all.
On this blog, we have often noted that (almost) all TCM trials from China report positive results. Essentially, this means we might as well discard them, because we simply cannot trust their findings. While being asked to comment on a related issue, it occurred to me that this might be not so much different with Korean acupuncture studies. So, I tried to test the hypothesis by running a quick Medline search for Korean acupuncture RCTs. What I found surprised me and eventually turned into a reminder of the importance of critical thinking.
Even though I found pleanty of articles on acupuncture coming out of Korea, my search generated merely 3 RCTs. Here are their conclusions:
The results of this study show that moxibustion (3 sessions/week for 4 weeks) might lower blood pressure in patients with prehypertension or stage I hypertension and treatment frequency might affect effectiveness of moxibustion in BP regulation. Further randomized controlled trials with a large sample size on prehypertension and hypertension should be conducted.
The results of this study show that acupuncture might lower blood pressure in prehypertension and stage I hypertension, and further RCT need 97 participants in each group. The effect of acupuncture on prehypertension and mild hypertension should be confirmed in larger studies.
Bee venom acupuncture combined with physiotherapy remains clinically effective 1 year after treatment and may help improve long-term quality of life in patients with AC of the shoulder.
So yes, according to this mini-analysis, 100% of the acupuncture RCTs from Korea are positive. But the sample size is tiny and I many not have located all RCTs with my ‘rough and ready’ search.
But what are all the other Korean acupuncture articles about?
Many are protocols for RCTs which is puzzling because some of them are now so old that the RCT itself should long have emerged. Could it be that some Korean researchers publish protocols without ever publishing the trial? If so, why? But most are systematic reviews of RCTs of acupuncture. There must be about one order of magnitude more systematic reviews than RCTs!
Why so many?
Perhaps I can contribute to the answer of this question; perhaps I am even guilty of the bonanza.
In the period between 2008 and 2010, I had several Korean co-workers on my team at Exeter, and we regularly conducted systematic reviews of acupuncture for various indications. In fact, the first 6 systematic reviews include my name. This research seems to have created a trend with Korean acupuncture researchers, because ever since they seem unable to stop themselves publishing such articles.
So far so good, a plethora of systematic reviews is not necessarily a bad thing. But looking at the conclusions of these systematic reviews, I seem to notice a worrying trend: while our reviews from the 2008-2010 period arrived at adequately cautious conclusions, the new reviews are distinctly more positive in their conclusions and uncritical in their tone.
Let me explain this by citing the conclusions of the very first (includes me as senior author) and the very last review (does not include me) currently listed in Medline:
penetrating or non-penetrating sham-controlled RCTs failed to show specific effects of acupuncture for pain control in patients with rheumatoid arthritis. More rigorous research seems to be warranted.
Electroacupuncture was an effective treatment for MCI [mild cognitive impairment] patients by improving cognitive function. However, the included studies presented a low methodological quality and no adverse effects were reported. Thus, further comprehensive studies with a design in depth are needed to derive significant results.
Now, you might claim that the evidence for acupuncture has overall become more positive over time, and that this phenomenon is the cause for the observed shift. Yet, I don’t see that at all. I very much fear that there is something else going on, something that could be called the suspension of critical thinking.
Whenever I have asked a Chinese researcher why they only publish positive conclusions, the answer was that, in China, it would be most impolite to publish anything that contradicts the views of the researchers’ peers. Therefore, no Chinese researcher would dream of doing it, and consequently, critical thinking is dangerously thin on the ground.
I think that a similar phenomenon might be at the heart of what I observe in the Korean acupuncture literature: while I always tried to make sure that the conclusions were adequately based on the data, the systematic reviews were ok. When my influence disappeared and the reviews were done exclusively by Korean researchers, the pressure of pleasing the Korean peers (and funders) became dominant. I suggest that this is why conclusions now tend to first state that the evidence is positive and subsequently (almost as an after-thought) add that the primary trials were flimsy. The results of this phenomenon could be serious:
- progress is being stifled,
- the public is being misled,
- funds are being wasted,
- the reputation of science is being tarnished.
Of course, the only right way to express this situation goes something like this:
BECAUSE THE QUALITY OF THE PRIMARY TRIALS IS INADEQUATE, THE EFFECTIVENESS OF ACUPUNCTURE REMAINS UNPROVEN.
It is hard to deny that many practitioners of so-called alternative medicine (SCAM) advise their patients to avoid ‘dangerous chemicals’. By this they usually mean prescription drugs. If you doubt how strong this sentiment often is, you have not followed the recent posts and the comments that regularly followed. Frequently, SCAM practitioners will suggest to their patients to not take this or that drug and predict that patients would then see for themselves how much better they feel (usually, they also administer their SCAM at this point).
Lo and behold, many patients do indeed feel better after discontinuing their ‘chemical’ medicines. Of course, this experience is subsequently interpreted as a proof that the drugs were dangerous: “I told you so, you are much better off not taking synthetic medicines; best to use the natural treatments I am offering.”
But is this always interpretation correct?
I seriously doubt it.
Let’s look at a common scenario: a middle-aged man on several medications for reducing his cardiovascular risk (no, it’s not me). He has been diagnosed to have multiple cardiovascular risk factors. Initially, his GP told him to change his life-style, nutrition and physical activity – to which he was only moderately compliant. Despite the patient feeling perfectly healthy, his blood pressure and lipids remained elevated. His doctor now strongly recommends drug treatment and our chap soon finds himself on statins, beta-blockers plus ACE-inhibitors.
Our previously healthy man has thus been turned into a patient with all sorts of symptoms. His persistent cough prompts his GP to change the ACE-inhibitor to a Ca-channel blocker. Now the patients cough is gone, but he notices ankle oedema and does not feel in top form. His GP said that this is nothing to worry about and asks him to grin and bear it. But the fact is that a previously healthy man has been turned into a patient with reduced quality of life (QoL).
This fact takes our man to a homeopath in the hope to restore his QoL (you see, it certainly isn’t me). The homeopath proceeds as outlined above: he explains that drugs are dangerous chemicals and should therefore best be dropped. The homeopath also prescribes homeopathics and is confident that they will control the blood pressure adequately. Our man complies. After just a few days, he feels miles better, his QoL is back, and even his sex-life improves. The homeopath is triumphant: “I told you so, homeopathy works and those drugs were really nasty stuff.”
When I was a junior doctor working in a homeopathic hospital, my boss explained to me that much of the often considerable success of our treatments was to get rid of most, if not all prescription drugs that our patients were taking (the full story can be found here). At the time, and for many years to come, this made a profound impression on me and my clinical practice. As a scientist, however, I have to critically evaluate this strategy and ask: is it the correct one?
The answer is YES and NO.
YES, many (bad) doctors over-prescribe. And there is not a shadow of a doubt that unnecessary drugs must be scrapped. But what is unnecessary? Is it every drug that makes a patient less well than he was before?
NO, treatments that are needed should not be scrapped, even if this would make the patient feel better. Where possible, they might be altered such that side-effects disappear or become minimal. Patients’ QoL is important, but it is not the only factor of importance. I am sure this must sound ridiculous to lay people who, at this stage of the discussion, would often quote the ethical imperative of FIRST DO NO HARM.
So, let me use an extreme example to explain this a bit better. Imagine a cancer patient on chemo. She is quite ill with it and QoL is a thing of the past. Her homeopath tells her to scrap the chemo and promises she will almost instantly feel fine again. With some side-effect-free homeopathy see will beat the cancer just as well (please, don’t tell me they don’t do that, because they do!). She follows the advice, feels much improved for several months. Alas, her condition then deteriorates, and a year later she is dead.
I know, this is an extreme example; therefore, let’s return to our cardiovascular patient from above. He too followed the advice of his homeopath and is happy like a lark for several years … until, 5 years after discontinuing the ‘nasty chemicals’, he drops dead with a massive myocardial infarction at the age of 62.
I hope I made my message clear: those SCAM providers who advise discontinuing prescribed drugs are often impressively successful in improving QoL and their patients love them for it. But many of these practitioners haven’t got a clue about real medicine, and are merely playing dirty tricks on their patients. The advise to stop a prescribed drug can be a very wise move. But frequently, it improves the quality, while reducing the quantity of life!
The lesson is simple: find a rational doctor who knows the difference between over-prescribing and evidence-based medicine. And make sure you start running when a SCAM provider tries to meddle with necessary prescribed drugs.
Some people seem to think that all so-called alternative medicine (SCAM) is ineffective, harmful or both. And some believe that I am hell-bent to make sure that this message gets out there. I recommend that these guys read my latest book or this 2008 article (sadly now out-dated) and find those (admittedly few) SCAMs that demonstrably generate more good than harm.
The truth, as far as this blog is concerned, is that I am constantly on the lookout to review research that shows or suggests that a therapy is effective or a diagnostic technique is valid (if you see such a paper that is sound and new, please let me know). And yesterday, I have been lucky:
This paper has just been presented at the ESC Congress in Paris.
Its authors are: A Pandey (1), N Huq (1), M Chapman (1), A Fongang (1), P Poirier (2)
(1) Cambridge Cardiac Care Centre – Cambridge – Canada
(2) Université Laval, Faculté de Pharmacie – Laval – Canada
Here is the abstract in full:
Yes, this study was small, too small to draw far-reaching conclusions. And no, we don’t know what precisely ‘yoga’ entailed (we need to wait for the full publication to get this information plus all the other details needed to evaluate the study properly). Yet, this is surely promising: yoga has few adverse effects, is liked by many consumers, and could potentially help millions to reduce their cardiovascular risk. What is more, there is at least some encouraging previous evidence.
But what I like most about this abstract is the fact that the authors are sufficiently cautious in their conclusions and even state ‘if these results are validated…’
SCAM-researchers, please take note!
Dr Alice Hodkinson is a GP in Cambridge, England. She says of herself that she is interested in supporting people to make informed choices about their own health, reduce the burden of illness and lighten the load of medication on patients and the country’s National Health Service. She is studying medical ethics and law at King’s College London.
Even though we live in the same town, I don’t know Dr Hodkinson personally and never met her. My only contact with her is the one depicted here: on Twitter I had posted my recent article entitled ‘A new, comprehensive review: HOMEOPATHY = PLACEBO THERAPY‘. This prompted the following exchange:
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Alice @HodkinsonAlice
At the very least homeopathy and placebos don’t cause harm that medicines do.
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Edzard Ernst @EdzardErnst
have you heard of something called ‘risk/benefit balance’?
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Alice @HodkinsonAlice
Which is precisely where homeopathy wins over toxins I prescribe as medication.
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Edzard Ernst @EdzardErnst
oh really? I do worry about the students you teach
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Alice @HodkinsonAlice
I worry about the over-use of toxins that harm. Lots of ppl get much better when meds are stopped. They come back from the dead and live much happier. Lots of evidence for this.
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Edzard Ernst @EdzardErnst
” Lots of ppl get much better when meds are stopped.” surely this is a sign that they never needed them; in other words, it is the mistake of the GP who did the prescription
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Alice @HodkinsonAlice
It’s a sign meds’ aren’t reviewed and they do harm. Water doesn’t harm, unless in excess. Promoting water as a cure might be harmful, yet there are sooooo many conditions where medicine has no answers, and for these, homeopathy comes up trumps.
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Edzard Ernst @EdzardErnst
I am sooooooo pleased you are not my GP!
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Alice @HodkinsonAlice
I’m bored. Go poison yourself on prescribed medication!
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END OF EXCHANGE
I don’t know why this shocks me more than any of the often much more disagreeable disputes I have with other proponents of homeopathy on Twitter or on this blog. Perhaps it is because it occurred with a person who is a doctor like myself, or because it happened with a complete stranger, or because it was with someone who is, for all I know, an entirely reasonable clinician in other medical matters, or because Dr Hodkinson is studying medical ethics? I really don’t know.
Or perhaps nobody have ever told me to poison myself?
In a paper discussed in a previous blog, Ioannidis et al published a comprehensive database of a large number of scientists across science. They used Scopus data to compile a database of the 100,000 most-cited authors across all scientific fields based on their ranking of a composite indicator that considers six citation metrics (total citations; Hirsch h-index; coauthorship-adjusted Schreiber hm-index; number of citations to papers as single author; number of citations to papers as single or first author; and number of citations to papers as single, first, or last author). The authors also added this caution:
Citation analyses for individuals are used for various single-person or comparative assessments in the complex reward and incentive system of science. Misuse of citation metrics in hiring, promotion or tenure decision, or other situations involving rewards (e.g., funding or awards) takes many forms, including but not limited to the use of metrics that are not very informative for scientists and their work (e.g., journal impact factors); focus on single citation metrics (e.g., h-index); and use of calculations that are not standardized, use different frames, and do not account for field. The availability of the data sets that we provide should help mitigate many of these problems. The database can also be used to perform evaluations of groups of individuals, e.g., at the level of scientific fields, institutions, countries, or memberships in diversely defined groups that may be of interest to users.
It seems thus obvious and relevant to employ the new metrics for defining the most ‘influential’ (most frequently cited) researchers in so-called alternative medicine (SCAM). Doing this creates not one but two non-overlapping tables (because ‘complementary&alternative medicine’ is listed both as a primary and a secondary field (not sure about the difference)). Below, I have copied a small part of these tables; the first three columns are self-explanatory; the 4th relates to the number of published articles, the 4th to the year of the author’s first publication, the 5th to the last, the 6th column is the rank amongst 100 000 scientists of all fields who have published more than a couple of papers.
TABLE 1
| Ernst, E. | University of Exeter | gbr | 2253 | 1975 | 2018 | 104 |
| Davidson, Jonathan R. T. | Duke University | usa | 426 | 1972 | 2017 | 1394 |
| Kaptchuk, Ted J. | Harvard University | usa | 245 | 1993 | 2018 | 6545 |
| Eisenberg, David M. | Harvard University | usa | 127 | 1991 | 2018 | 8641 |
| Lundeberg, Thomas | 340 | 1983 | 2016 | 17199 | ||
| Linde, Klaus | Technische Universitat Munchen | deu | 276 | 1993 | 2018 | 19488 |
| Schwartz, Gary E. | University of Arizona | usa | 264 | 1967 | 2018 | 21893 |
| Eloff, J.N. | University of Pretoria | zaf | 204 | 1997 | 2018 | 23830 |
| Birch, Stephen | McMaster University | can | 244 | 1985 | 2018 | 31925 |
| Wilson, Kenneth H. | Duke University | usa | 76 | 1976 | 2017 | 40760 |
| Kemper, Kathi J. | Ohio State University | usa | 181 | 1988 | 2017 | 45193 |
| Oken, Barry S. | Oregon Health and Science University | usa | 121 | 1974 | 2018 | 51325 |
| Pittler, M.H. | 155 | 1997 | 2016 | 53183 | ||
| Postuma, Ronald B. | McGill University | can | 159 | 1998 | 2018 | 61018 |
| Patwardhan, Bhushan | University of Pune | ind | 144 | 1989 | 2018 | 64465 |
| Krucoff, Mitchell W. | Duke University | usa | 261 | 1986 | 2016 | 66028 |
| Chiesa, Alberto | 87 | 1973 | 2017 | 82390 | ||
| Baliga, Manjeshwar Shrinath | 142 | 2002 | 2018 | 83030 | ||
| Mischoulon, David | Harvard University | usa | 194 | 1992 | 2018 | 91705 |
| Büssing, Arndt | University of Witten/Herdecke | deu | 207 | 1980 | 2018 | 95907 |
| Langevin, Helene M. | Harvard University | usa | 67 | 1999 | 2018 | 98290 |
| Creath, Katherine | 84 | 1984 | 2017 | 99709 | ||
| Kuete, Victor | University of Dschang | cmr | 239 | 2005 | 2018 | 128347 |
TABLE 2
| White, Adrian | University of Plymouth | gbr | 294 | 1990 | 2016 | 16714 |
| Astin, John A. | California Pacific Medical Center | usa | 50 | 1994 | 2014 | 21379 |
| Kelly, Gregory S. | 37 | 1985 | 2011 | 31037 | ||
| Walach, Harald | University of Medical Sciences Poznan | pol | 246 | 1996 | 2018 | 31716 |
| Berman, Brian M. | University of Maryland School of Medicine | usa | 211 | 1986 | 2018 | 34022 |
| Lewith, George | University of Southampton | gbr | 380 | 1980 | 2018 | 34830 |
| Kidd, Parris M. | University of California at Berkeley | usa | 38 | 1976 | 2011 | 36571 |
| Jonas, Wayne B. | 187 | 1992 | 2018 | 42445 | ||
| MacPherson, Hugh | University of York | gbr | 143 | 1996 | 2018 | 49923 |
| Bell, Iris R. | University of Arizona | usa | 142 | 1984 | 2015 | 51016 |
| Patrick, Lyn | 21 | 1999 | 2018 | 57086 | ||
| Ritenbaugh, Cheryl | University of Arizona | usa | 172 | 1981 | 2018 | 63248 |
| Boon, Heather | University of Toronto | can | 188 | 1988 | 2017 | 69066 |
| Aickin, Mikel | University of Arizona | usa | 149 | 1996 | 2014 | 72040 |
| Lee, Myeong Soo | 430 | 1996 | 2018 | 72358 | ||
| Lao, Lixing | University of Hong Kong | hkg | 247 | 1990 | 2018 | 74896 |
| Witt, Claudia M. | Charite – Universitatsmedizin Berlin | deu | 238 | 2001 | 2018 | 78849 |
| Sherman, Karen J. | 136 | 1984 | 2017 | 82542 | ||
| Verhoef, Marja J. | University of Calgary | can | 190 | 1989 | 2016 | 84314 |
| Smith, Caroline A. | University of Western Sydney | aus | 135 | 1979 | 2018 | 94130 |
| Miller, Alan L. | 30 | 1980 | 2016 | 94421 | ||
| Paterson, Charlotte | University of Bristol | gbr | 71 | 1995 | 2017 | 95130 |
| Milgrom, Lionel R. | London Metropolitan University | gbr | 107 | 1979 | 2017 | 112943 |
| Adams, Jon | University of Technology NSW | aus | 294 | 1999 | 2018 | 128486 |
| Litscher, Gerhard | Medical University of Graz | aut | 245 | 1986 | 2018 | 133122 |
| Chen, Calvin Yu-Chian | China Medical University Taichung | chn | 130 | 2007 | 2016 | 164522 |
No other researchers are listed in the ‘Complementary&Alternative Medicine’ categories and made it into the list of the 100 000 most-cited scientists.
To make this easier to read, I have ordered all SCAM researchers according to their rank in one single list and, where known to me, added the respective focus in SCAM research (ma = most areas of SCAM):
- ERNST EDZARD (ma)
- DONALDSON JONATHAN
- KAPTCHUK TED (acupuncture)
- EISENBERG DAVID (TCM)
- WHITE ADRIAN (acupuncture)
- LUNDEBERG THOMAS (acupuncture)
- LINDE KLAUS (homeopathy)
- ASTIN JOHN (mind/body)
- SCHWARTZ GARRY (healing)
- ELOFF JN
- KELLY GREGORY
- WALLACH HARALD (homeopathy)
- BIRCH STEVEN (acupuncture)
- BERMAN BRIAN (acupuncture)
- LEWITH GEORGE (acupuncture)
- KIDD PARRIS
- WILSON KENNETH
- JONAS WAYNE (homeopathy)
- KEMPER KATHIE (ma)
- MACPHERSON HUGH (acupuncture)
- BELL IRIS (homeopathy)
- OKEN BARRY (dietary supplements)
- PITTLER MAX (ma)
- PATRICK LYN
- RITENBAUGH CHERYL (ma)
- POSTUMA RONALD
- PATWARDHAN BHUSHAN
- KRUCOFF MICHELL
- BOON HEATHER
- AICKIN MIKEL (ma)
- LEE MYEONG SOO (TCM)
- LAO LIXING (acupuncture)
- WITT CLAUDIA (ma)
- CHIESA ALBERTO
- SHERMAN KAREN (acupuncture)
- BALIGA MANJESHWAR
- VERHOEF MARIA (ma)
- MISCHOULON DAVID
- SMITH CAROLINE (acupuncture)
- MILLER ALAN
- PATERSON CHARLOTTE (ma)
- BUESSING ARNDT (anthroposophical medicine)
- LANGEVIN HELENE (ma)
- CREATH KATHERINE
- MILGROM LIONEL (homeopathy)
- KUETE VICTOR
- ADAMS JON (ma)
- LITSCHER GERHARD
- CHEN CALVIN
The list is interesting in several regards. Principally, it offers individual SCAM researchers for the first time the opportunity to check their international standing relative to their colleagues. But, as the original analysis in Ioannidis’s paper contains much more data than depicted above, there is much further information to be gleaned from it.
For instance, I looked at the rate of self-citation (not least because I have sometimes been accused of overdoing this myself). It turns out that, with 7%, I am relative modest and well below average in that regard. Most of my colleagues are well above that figure. Researchers who have exceptionally high self-citation rates include Buessing (30%), Kuete (43%), Adams (36%), Litscher (45%), and Chen (53%).
The list also opens the possibility to see which countries dominate SCAM research. The dominance of the US seems fairly obvious and would have been expected due to the size of this country and the funds the US put into SCAM research. Considering the lack of funds in the UK, my country ranks surprisingly high, I find. No other country is well-represented in this list. In particular Germany does not appear often (even if we would classify Wallach as German); considering the large amounts of money Germany has invested in SCAM research, this is remarkable and perhaps even a bit shameful, in my view.
Looking at the areas of research, acupuncture and homeopathy seem to stand out. Remarkably, many of the major SCAMs are not or not well represented at all. This is in particular true for herbal medicine, chiropractic and osteopathy.
The list also confirms my former team as the leaders in SCAM research. (Yes, I know: in the country of the blind, the one-eyed man is king.) Pittler, White and Lee were, of course, all former co-workers of mine.
Perhaps the most intriguing finding, I think, relates to the many SCAM researchers who did not make it into the list. Here are a few notable absentees:
- Behnke J – GERMANY (homeopathy)
- Bensoussan A – AUSTRALIA (acupuncture)
- Brinkhaus B – GERMANY (acupuncture)
- Bronfort G – US (chiropractic)
- Chopra D – US (mind/body)
- Cummings M – UK (acupuncture)
- Dixon M – UK (ma)
- Dobos G – GERMANY (ma)
- Fisher P – UK (homeopathy)
- Fonnebo V – NORWAY (ma)
- Frass M – AUSTRIA (homeopathy)
- Goertz C – US (chiropractic)
- Hawk C -US (chiropractic)
- Horneber M – GERMANY (ma)
- Jacobs J – US (homeopathy)
- Jobst K – UK (homeopathy)
- Kraft K – GERMANY (naturopathy)
- Lawrence D – US (chiropractic)
- Long CR – US (chiropractic)
- Meeker WC – US (chiropractic)
- Mathie R – UK (homeopathy)
- Melchart – GERMANY (ma)
- Michalsen A – GERMANY (ma)
- Mills S – UK (herbal medicine)
- Peters D – UK (ma)
- Reilly D -US (homeopathy)
- Reily D – UK (homeopathy)
- Robinson N – UK (ma)
- Streitberger K – GERMANY (acupuncture)
- Tuchin PJ – US (chiropractic)
- Uehleke – GERMANY (naturopathy)
- Ullman D – US (homeopathy)
- Weil A – US (ma)
I leave it to you to interpret this list and invite you to add more SCAM researchers to it.
(thanks to Paul Posadski for helping with the tables)
I have often felt that practitioners of so-called alternative medicine (SCAM) tend to be foolishly overconfident, often to the point of being dangerous. In a word, they are plagued by hubris.
Here is an example of osteopathic hubris:
The aim of this study was to determine the impact of visceral osteopathy on the incidence of nausea/vomiting, constipation and overall quality of life (QoL) in women operated for breast cancer and undergoing adjuvant chemotherapy in Centre Georges François Leclerc, CGFL.
Ninety-four women operated for a breast cancer stage 1-3, in complete resection and to whom a 3 FEC 100 chemotherapy was prescribed, were randomly allocated to experimental or placebo group. Experimental group underwent a visceral osteopathic technique and placebo group was subjected to a superficial manipulation after each chemotherapy cycle. Rate of grade ≥1 nausea/vomiting or constipation, on the first 3 cycles of FEC 100, were reported. QoL was evaluated using the EORTC QLQ-C30 questionnaire.
Rate of nausea/vomiting episodes of grade ≥1 was high in both experimental and placebo group. Constipation episodes of grade ≥1 were also frequent. No significant differences were found between the two groups concerning the rate of nausea/vomiting (p = 0.569) or constipation (p = 0.204) according to clinician reported side-effects but patient reported impact of constipation and diarrhoea on quality of life was significantly lower in experimental group (p = 0.036 and p = 0.038, respectively).
The authors concluded that osteopathy does not reduce the incidence of nausea/vomiting in women operated for breast cancer and undergoing adjuvant chemotherapy. In contrast, patient reported digestive quality of life was significantly ameliorated by osteopathy.
Visceral osteopathy has been discussed here several times already (for instance here and here). In my new book, I summarise the evidence as follows:
Several studies have assessed the diagnostic reliability of the techniques involved. The totality of this evidence fails to show that they are sufficiently reliable to be of practical use.
Other studies have tested whether the therapeutic techniques used in visceral osteopathy are effective in curing disease or alleviating symptoms. The totality of this evidence fails to show that visceral osteopathy works for any condition.
The treatment itself is probably safe, yet the risks of visceral osteopathy are nevertheless considerable: if a patient suffers from symptoms related to her inner organs, a visceral osteopath is likely to misdiagnose them and subsequently mistreat them. If the symptoms are due to a serious disease, this would amount to medical neglect and could, in extreme cases, cost the patient’s life.
| PLAUSIBILITY | negative |
| EFFICACY | negative |
| SAFETY | debatable |
| COST | negative |
| RISK/BENEFIT BALANCE | negative |
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The key message here should be that visceral osteopathy lacks plausibility. So why test its effectiveness for any condition, especially chemo-induced nausea where there is no conceivable mechanism of action and no hint that it might work?
The answer, I am afraid, might be quite simple: osteopathic hubris!
Archives of Psychiatric Nursing disseminates original, peer-reviewed research that is of interest to psychiatric and mental health care nurses. The field is considered in its broadest perspective, including theory, practice and research applications related to all ages, special populations, settings, and interdisciplinary collaborations in both the public and private sectors. Through critical study, expositions, and review of practice, Archives of Psychiatric Nursing is a medium for clinical scholarship to provide theoretical linkages among diverse areas of practice.
If peer-review, critical study and clinical scholarship are not just empty platitudes, what – if anything – should such a journal publish about Bach flower remedies? Perhaps something like this (straight from my new book)?
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Bach flower remedies were invented in the 1920s by Dr Edward Bach (1886-1936), a doctor homeopath who had previously worked in the London Homeopathic Hospital. They have since become very popular in Europe and beyond.
- Bach flower remedies are clearly inspired by homeopathy; however, they are not the same because they do not follow the ‘like cures like’ principle and are they potentised.
- They are manufactured by placing freshly picked specific flowers or parts of plants in water which is subsequently mixed with alcohol, bottled and sold.
- Like most homeopathic remedies, they are highly dilute and thus do not contain therapeutic amounts of the plant printed on the bottle.
- Bach developed 38 different remedies, each corresponding to an emotional state which he believed to be the cause of all illness:
Agrimony – mental torture behind a cheerful face
Aspen – fear of unknown things
Beech – intolerance
Centaury – the inability to say ‘no’
Cerato – lack of trust in one’s own decisions
Cherry Plum – fear of the mind giving way
Chestnut Bud – failure to learn from mistakes
Chicory – selfish, possessive love
Clematis – dreaming of the future without working in the present
Crab Apple – the cleansing remedy, also for self-hatred
Elm – overwhelmed by responsibility
Gentian – discouragement after a setback
Gorse – hopelessness and despair
Heather – self-centredness and self-concern
Holly – hatred, envy and jealousy
Honeysuckle – living in the past
Hornbeam – procrastination, tiredness at the thought of doing something
Impatiens – impatience
Larch – lack of confidence
Mimulus – fear of known things
Mustard – deep gloom for no reason
Oak – the plodder who keeps going past the point of exhaustion
Olive – exhaustion following mental or physical effort
Pine – guilt
Red Chestnut – over-concern for the welfare of loved ones
Rock Rose – terror and fright
Rock Water – self-denial, rigidity and self-repression
Scleranthus – inability to choose between alternatives
Star of Bethlehem – shock
Sweet Chestnut – extreme mental anguish, when everything has been tried and there is no light left
Vervain – over-enthusiasm
Vine – dominance and inflexibility
Walnut – protection from change and unwanted influences
Water Violet – pride and aloofness
White Chestnut – unwanted thoughts and mental arguments
Wild Oat – uncertainty over one’s direction in life
Wild Rose – drifting, resignation, apathy
Willow – self-pity and resentment
Rescue Remedy, a combination remedy made up of five different remedies, is promoted against anxiety and stress.
- There are only few clinical trials of Bach flower remedies. Collectively, they fail to show that they are effective beyond placebo. A systematic review of all 7 studies concluded that the most reliable clinical trials do not show any differences between flower remedies and placebos.[1]
- Since they do not contain any pharmacologically active molecules (other than alcohol), Bach flower remedies are unlikely to cause adverse effects other than those to the consumer’s wallet.
- Considering that Bach flower remedies are not effective, their risk/benefit balance cannot be positive.
| PLAUSIBILITY | Negative |
| EFFICACY | Negative |
| SAFETY | Positive |
| COST | Negative |
| RISK/BENEFIT BALANCE | Negative |
[1] https://www.ncbi.nlm.nih.gov/pubmed/20734279
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And what did the journal in fact publish? Here is an excerpt from a truly remarkable article that just appeared in the Archives of Psychiatric Nursing:
… Bach Flowers are liquids that come in 10 and 20 ml “mother” bottles. The liquids are the essence of the substance used in the remedy preserved in a small amount of brandy. As is the case with homeopathic remedies, Bach Flowers are essences or energetic remedies.
Two drops from the mother bottle of the specific Bach Flower remedy are placed in a 1 oz glass dropper bottle that is filled with water. Because the Bach system is an energetic plant remedy system, using more than two drops in a bottle is not harmful but is also unnecessary as it is not more useful. The most important part in the use of the system is picking the correct remedy. There are books and the original Bach website (www.bachcentre.com) that provide Bach’s descriptions of the patterns of behaviors and health patterns associated with each of the remedies. For example, those who feel overwhelmed by their responsibilities can try taking “elm.”
The remedies are also powerful healers in infants and children. Behavior changes can be immediate with the use of the right remedy at the right time. The key is getting to know well the specific patterns of each of the 38 healers. The nurse who is knowledgeable of the 38 healers can then better perceive the patterns reflected in the infant’s behavior and then suggest the remedies that parents might want to read about. For example, walnut is used for those experiencing emotional difficulties related to transition and change. When a new infant is born, other children go through significant change and transition in their view of the world which is their family. Walnut can help all of the children if and when they exhibit signs of distress. Walnut is also helpful when infants are teething. Parents often ask whether a person who is allergic to walnuts would be allergic to the walnut flower essence Bach remedy. “The active ingredient in a flower remedy is an energy from the plant, not a physical substance” (Bach Centre, n.d..). It should not cause allergic reactions and should not interfere with the physical action of other remedies and medicines.
Illness is defined by Bach as it is in many healing traditions as the stagnation of energy flow. The remedies help to move people through emotion; they do not suppress emotions. Bach writes that, “the action of these remedies is to raise our vibrations and open up our channels for the reception of our Spiritual Self, to flood our natures with a particular virtue we need, and wash out from us the fault which is causing harm. They are able like beautiful music…to raise our very natures, and bring us nearer to our Souls…They cure not by attacking disease, but by flooding our bodies with the beautiful vibrations of our Higher Nature, in the presence of which disease melts as snow in the sunshine” (Howard & Ramsell, 1990, p. 62).
The Bach remedies move emotions but they do so very gently. Two drops of any remedy diluted in 1 oz of water can be put in the infant’s mouth or on their skin. One way to get to know the Bach Flower remedy system is to try the Rescue Remedy first, a combination of five of the 38 healers used in cases of stress, anxiety, and trauma. Four drops of Rescue Remedy can be put into any size container of water and then given in sips to help infants experiencing intense stress. For example, I once had to participate in the suturing of the forehead of a two-year-old. He was brought to the clinic by his father, a veteran who had seen combat. The child, who was normally curious and friendly, was wild with fear. He thrashed about with his head throwing blood everywhere. The nurses had a standing order to give Rescue Remedy to any patient and so we got permission from the dad and squirted a dropper of the remedy in his mouth while telling him that the flower remedy would help. It did. The child immediately stopped his thrashing. He did not stop crying or saying “no” as he held onto his father’s hand. But he was whimpering rather than thrashing about as we took care of his wound. The trauma and subsequent memory were abated.
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YES, FOR ONCE, I AM SPEACHLESS.
Is homeopathy an effective treatment for PMS?
No, how could it?
Previous studies have thus had mixed results:
A feasibility study of 2018 showed that, in Germany, the study could not proceed because of legal limitations. In Sweden, recruitment proved extremely difficult. In the Netherlands and Sweden, 60 women were randomized (UC + HT: 28; UC: 32), data of 47/46 women were analyzed (ITT/PP). After 4 months, relative mean change of DRSP scores in the UC + HT group was significantly better than in the UC group (p = 0.03).
A case series with 23 women suggested that homeopathic treatment was well tolerated and seemed to have a positive impact on PMS symptoms. Folliculinum was the most frequent homeopathic medicine prescribed. There appears to be scope for a properly designed, randomized, placebo-controlled trial to investigate the efficacy of individual homeopathic medicines in PMS.
And a pilot study reported that homeopathic treatment was found to be effective in alleviating the symptoms of PMS in comparison to placebo. The use of symptom clusters in this trial may offer a novel approach that will facilitate clinical trials in homeopathy. Further research is in progress.
The authors of this pilot include several prominent homeopath who have honoured their word by publishing their definitive study. This double-blind placebo-controlled RCT tested the efficacy of individually prescribed homeopathic medicines in women with premenstrual syndrome (PMS).
In an outpatient department of a university clinic in Jerusalem, Israel, women with PMS, aged 18 to 50 years, entered a 2-month screening phase with prospective daily recording of premenstrual symptoms by the Menstrual Distress Questionnaire (MDQ). They were included after being diagnosed with PMS. A reproducible treatment protocol was used: women received a homeopathic prescription based on symptom clusters identified in a questionnaire. The symptoms were verified during a complementary, structured, interview. Only women whose symptoms matched the symptom profile of one of 14 pre-selected homeopathic medicines were included. Each participant was administered active medicine or placebo via random allocation. Primary outcome measures were differences in changes in mean daily premenstrual symptom (PM) scores by the MDQ. Analysis was by intention-to-treat.
A total of 105 women were included: 49 were randomized to active medicine and 56 to placebo. Forty-three women in the active medicine group and 53 in the placebo group received the allocated intervention with at least one follow-up measurement and their data were analyzed. Significantly greater improvement of mean PM scores was measured in the active medicine group compared to placebo.
The authors concluded that individually prescribed homeopathic medicines were associated with significantly greater improvement of PM scores in women with PMS, compared to placebo. Replication, with larger sample size and other refinements, is recommended to confirm the efficacy of this treatment in other settings.
Not being able to assess the full paper – remember, I was fired from the journal’s editorial board – I am unable to scrutinise this trial properly. As I suspect that the authors were the victim of some hidden biases, I concur only with the second part of their conclusion: replication is needed before we can accept these findings – but please, make it an INDEPENDENT replication!
