PC2-2011-Orebro lecture v1 - 1

Is there evidence for CAM?

Edzard ErnstComplementary MedicinePeninsula Medical School

Universities of Exeter & Plymouth, UKEmail: Edzard.Ernst@pms.ac.uk

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.