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Is there evidence for CAM?
Edzard ErnstComplementary MedicinePeninsula Medical School
Universities of Exeter & Plymouth, UKEmail: [email protected]
Website: www.pms.ac.uk/compmed
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The better title:
What is the evidence for or against CAM?
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Babylonic terminology, e.g:
Alternative
Complementary
CAM
Unorthodox
integrated
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What treatments are we talking
about?
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Acupuncture (6)Alexander technique (1)Animal-assisted therapy (1)Applied kinesiology (1)Aquatic therapy (1)Aromatherapy (4)Art therapy (2)Auricular therapy (1)Autogenic training (2)Biofeedback (4)Bioresonance (1)Chelation (1)Chinese herbalism (3)
Six textbooks of ‘Integrated Medicine’
Chiropractic (5)Counselling (2)Craniosacral therapy (1)Environmental medicine (1)Exercise (2)Herbal medicine (6)Homeopathy (6)Hypnotherapy (5)Imagery (2)Laser therapy (2)Laughter therapy (1)Light therapy (1) Magnet therapy (2)
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Massage (6)Meditation (4)Mind body approaches (2)Mora therapy (1)Music therapy (3)Native American healing (1)Naturopathy (4)Neurolinguistig Programming (1)Nutritional therapies (4)Osteopathy (6)Prayer (1)Probiotics (1)Polarity therapy (1)Progressive relaxation (1)Psychotherapy (1)
Continued…
Qigong (3)Reflexology (2)Reiki (3)Rolfing (1)Spinal cord stimulation (1)Spiritual healing (3)Supplements (1)Tai Chi (2)Therapeutic touch (3)Thermotherapy (1)Trager method (1)Thought field therapy (1)Vitamins (1)Yoga (2)
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Acupuncture (6)Aromatherapy (4)Biofeedback (4)Chiropractic (5)Herbal medicine (6)Homeopathy (6)
Six textbooks of ‘Integrated Medicine’(treatments included in at least 4 books)
Hypnotherapy (5)Massage (6)Meditation (4)Naturopathy (4)Nutritional therapies (4)Osteopathy (6)
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Acupuncture (6)Aromatherapy (4)Biofeedback (4)Chiropractic (5)Herbal medicine (6)Homeopathy (6)
Six textbooks of ‘Integrated Medicine’(treatments included in at least 5 books)
Hypnotherapy (5)Massage (6)Meditation (4)Naturopathy (4)Nutritional therapies (4)Osteopathy (6)
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What is evidence?
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Patients
A
B
Time
Compare
The principle of a clinical trial
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•Like cures like
•Less is more
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…the best evidence… does not warrant positive
recommendations for its [homeopathy’s] use in
clinical practice.
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Harm?
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No molecules…
no side effects!
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Replacement of effective treatments, e.g.
•immunisation
•cancer
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harm
benefit
More good than harm?
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“95 % of all diseases are caused by displaced
vertabrae, the remainder by subluxations of other
joints”
DD Palmer
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NICE recently recommended spinal
manipulation for chroniclow back pain
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Spinal manipulation (SM) for acute back pain
Jüni et al, Ann Rheum Dis 2009
RCT n = 104, SM + standard care (A) vs standard care alone (B)
BA
0 7 14 days
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Chiropractic: non-spinal conditions
“…chiropractic spinal manipulation cannot be considered an effective treatment”
42Hypertension
“There is no evidence to suggest that chiropractic is effective…”
89CTS
“…there is insufficient evidence…”?Fibromyalgia
“No evidence”?Otitis
“No evidence to support the use of chiropractic SM”57Asthma
“…no convincing evidence…”63Infant Colic
“There is no evidence that SM is effective”63Dymenorrhoea
Conclusion of systematic reviews%Condition
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Risks of chiropractic spinal manipulation
~ 50% mild to moderate adverse effects (not disputed)
+Several hundred cases of severe
complications including ~50 documented deaths
(hotly disputed)
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Osteopathy for musculoskeletal pain
Posadzki, Ernst. Clin Rheumatol 2010: 30 Oct
Design:
Sample:
Results:
Systematic review
16 RCTs
•Quality often poor•5 RCTs suggested osteopathy to be superior to various controls•11 RCTs were negative
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Risks of osteopathy
Similar to those of chiropractic
(but less)
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harm
benefit
More good than harm?
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PC2-2011-Orebro lecture v1 - 33Glazov et al Acup Med 2009: 27:94-100
RCT with 100 patients, laser-acupuncture for 6 weeks
Acupuncture for chronic back pain
1
2
3
4
5
acupuncture
5.7
3.4
4.1
3.6
6 weeks 12 weeks 6 months
.
.
.
.
PC2-2011-Orebro lecture v1 - 34Glazov et al Acup Med 2009: 27:94-100
RCT with 100 patients, laser-acupuncture for 6 weeks
Acupuncture for chronic back pain
1
2
3
4
5
acupuncture
5.7
3.4
4.1
3.6
6 weeks 12 weeks 6 months
.
.
Sham acupuncture
.
.
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Acupuncture for IBS
Lembo et al, Am J Gastroenterol 2009
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Summary of clinical evidence for acupuncture
OODepressionOOConstipationOChronic heart failure
OOCancer, palliative (nausea)
OOOBack painOOOAsthmaOAlzheimer
OAIDS/HIV infection (symptomatic)
Direction of evidence2005
Weight of evidence2005
Conditions
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Summary of clinical evidence for acupuncture
OOOInsomniaOOHeadacheOOHayfever (treatment)OHayfever (prevention)OOFibromyalgiaOOErectile dysfunction
OOODrug/alcohol dependence (cocaine & opiates)
OODrug/alcohol dependence (alcohol)
Direction of evidence2005
Weight of evidence2005
Conditions
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Summary of clinical evidence for acupuncture
OOONausea and vomiting induced by chemotherapy
OOOPostoperative nausea and vomiting
OOONausea of pregnancyOOOMigraineOMenopause
OOIrritable bowel syndrome
Direction of evidence2005
Weight of evidence2005
Conditions
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Summary of clinical evidence for acupuncture
OOOStrokeOOOSmoking cessation
OOTinnitus
OORheumatoid arthritisOOOOverweight/obesityOOOOsteoarthritisOOONeck pain
OOMotion sickness , acupoint stimulation
Direction of evidence2005
Weight of evidence2005
Conditions
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Acupuncture: conclusive evidence
(OOO )
• Nausea of pregnancy
• Nausea of chemotherapy
• Osteoarthritis (pain)
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Risks of acupuncture
• ~10% mild to moderate adverse effects
• Serious complications (including ~80 documented deaths) exist but are rare
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harm
benefit
More good than harm?
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harm
benefit
More good than harm?
But only for a few conditions
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Herbal Medicine
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St John’s wort
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“…Hypericum is a safe and effective symptomatic
treatment for… depression.”
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“…Hypericum is a safe and effective symptomatic
treatment for… depression.”
Meanwhile: ~ 50 RCTs
~12 systematic reviews
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Risks of St John’s Wort
Posadzki, Ernst. Clin Rheumatol 2010: 30 Oct
Adverse effects:
Interactions:
Similar to placebo
~ 50% of prescription drugs
(sometimes with dramatic consequences)
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harm
benefit
More good than harm?
(St John’s Wort for depression)
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Massage therapy
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Massage for cancer palliation
Ernst. Support Care Cancer 2009: 17: 333
Design:
Sample:
Results:
Systematic review
14 RCTs
Massage can alleviate a wide range of symptoms.
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Massage: other indications supported by systematic reviews
Anxiety ++HIV patients’ QoL +Back pain +Constipation +Depression +Labour pain +Shoulder pain +Autism spectrum disorder +
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Conclusions
•‘Integrated’ medicine is a smokescreen for smuggling unproven and disproven therapies into clinical practice.
•Of the large range of CAMs only few have been shown to generate more good than harm.
•Many areas are grossly under researched.