Slides from the talk given by Prof. Edzard Ernst to the Plymouth Skeptics in the Pub group 13th Sept 2011 Images removed which may otherwise breach (c) Slides with a green background are explained to be tongue in cheek. Yellow backgrounds are "take home messages"

1. Alternative medicine Edzard Ernst Complementary Medicine Peninsula Medical School University of Exeter, UK Email: [email_address] Website: www.pms.ac.uk/compmed

4. I. Background

5. AM: definition … the field of healthcare that re-names itself every 5 years or so.

6. Alternative medicine (AM) Complementary medicine (CM) CAM Natural medicine Holistic medicine Unorthodox medicine Fringe medicine etc etc etc Integrated medicine Babylonic terminology

7. 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) 1

8. 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) 2

9. 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)

11. One-year prevalence of CAM-use in general populations UK Israel Hungary Canada Italy Finland Australia France US Germany Japan 10 20 30 40 50 60 70 80(%) Thomas, et al. J Pub Health 2004;26:152 Shumueli, et al. Isr Med Assoc J 2004;6:3 Buda, et al. Orv Hetil 2002;143:891 Millar. Can J Pub Health 1997;88:154 Menniti-Ippolito, et al. EJCP 2002;58:61 Vaskilampi, et al. Hodder/Stoughton 2004 MacLennon, et al. Lancet 1996;347:569 Bouchayer. Comp Med Res 1990;4:4 Barnes, et al. Adv Data 2004;343:1 H ärtel, et al. FKM 2004;11:327 Yamashita, et al. CTM 2002;10:84

12. So why are we Brits so obsessed with AM?

13. <Picture of the Queen removed for ©>

14. Money spent on AM/year Global ~ 60 billion $ US ~ 47 billion $ ($870m [homeopathy]) UK ~ 1.6 billion £ Germany ~ €250 [homeopathy] = 2015: global supplement market = $93.15 billion

15. ‘ Alternative Medicine’ in the UK media (Source ‘Lexis Nexis’) No of articles/month + 50,000,000 websites

17. II. Unsubstantiated claims

18. AM: definition … the field of healthcare where anyone can make any therapeutic claim without fear of retribution

19. 4 examples

20. Unsubstantiated claim No.1 xy is effective

21. <Picture of Prince Charles looking delighted removed for ©>

22. Unsubstantiated claims: chiropractic Review of 200 websites of chiros and 9 of chiro-organisations: Results : 95%/100% made unsubstantiated claims Ernst, Gilbey. NZMJ 2010:123-36.

23. Chiropractic: non-spinal conditions % = percentage of UK chiros claiming effectiveness Condition % Conclusion of systematic reviews Dymenorrhoea 63 “ There is no evidence that SM is effective” Infant Colic 63 “… no convincing evidence…” Asthma 57 “ No evidence to support the use of chiropractic SM” Otitis ? “ No evidence” Fibromyalgia ? “… there is insufficient evidence…” CTS 89 “ There is no evidence to suggest that chiropractic is effective…” Hypertension 42 “… chiropractic spinal manipulation cannot be considered an effective treatment”

24. Those who can make you believe absurdities can make you commit atrocities Voltaire Ceux qui peuvent vous faire croire des absurdités peuvent vous faire commettre des artosités.

25. Unsubstantiated claim No.2 xy cannot be scientifically tested

26. Yu et al, Pain Manag Nurs. 2011; 12: 41 Perceived effectiveness of CAM for pain Sample: 92 pain patients from Taiwan

27. Patients A B Time Compare The principle of a clinical trial

28. Unsubstantiated claim No.3 there is no money in AM (for research)

29. <Picture of David Beckham holding up a football shirt showing a Herbal company sponsorship removed for ©> PC2-PPS-2011-Alt Med-Quo Vadis-5

31. III. Evidence

32. AM: definition … the area of healthcare where sound evidence and rigorous science struggle more than elsewhere to get accepted

33. Treatments* which demonstrably generate more good than harm. 1 Treatment Condition Acupuncture Nausea/vomiting Osteoarthritis African plum˚ ( Pygeum africanum) Benign prostatic hyperplasia Aromatherapy/massage Cancer palliation Co-enzyme Q10˚ Hypertension Ginkgo biloba ˚ Alzheimer’s disease Peripheral arterial disease Guar gum˚ Diabetes Hypercholesterolaemia Hawthorn˚ ( Crataegus spp) Congestive heart failure Horse chestnut˚ ( Aesculus hippocastanum) Chronic venous insufficiency Hypnosis Labour pain Massage Anxiety Melatonin˚ Insomnia

34. Systematic review: acupuncture for OA Inclusion criteria : Sample : Results : Conclusion : all RCTs, needle-acupuncture, any language 18 RCTs pain: significantly better than sham “… acupuncture seems an option worthy of consideration…” Kwon, et al. Rheumatol. 2006;45:1331-7

35. Treatments* which demonstratably generate more good than harm. Treatments which demonstrably generate more good than harm… cont. Ernst, et al. Desktop guide to complementary medicine. 2 Treatment Condition Music therapy Anxiety Padma 28§˚ Peripheral arterial disease Phytodolor§˚ Osteoarthritis Rheumatoid arthritis Red clover˚ ( Trifolium pratense) Menopause Relaxation Anxiety Insomnia S-Adenosylmethionine˚ Osteoarthritis Saw palmetto˚ (Sereona repens) Benign prostatic hyperplasia Soy˚ Hypercholesterolaemia St John’s wort˚ (Hypericum perforatum) Depression

36. Unsubstantiated claim No.4 AM is natural and therefore safe

37. <Cartoon showing the proprietor of a Natural Herb show dead while 2 police discuss saying “Looks like he died of natural causes” removed for ©>

38. Adverse effects of complementary therapies Abbot, White, Ernst. Nature 1996; 381: 361 Survey of large sample of British CM users +++ ~700 Vascular accidents, strokes or deaths * Estimated order of magnitude Therapy Reporting adverse effects Deaths* Spinal manipulation 15.8 % (~50%) +++ ~100 Acupuncture 12.5 % (7-11%) ~100 Homoeopathy 9.8 % (~20%) ~10 Herbal medicine 7.6 % (depends) ~1000

40. IV. The Future…

41. … has started

42. CAM practitioners in the UK The Times 10 Jan 2004 Design : Endpoints : Results : survey of all UK practitioners of 5 disciplines 5 “best practice criteria” acup chiro osteo hom herb % fulfilling all acup chiro osteo hom herb % fulfilling > 3 37 4 1 80 22 8 4 1 0 0

43. Royal Society 2006 “ CAM, like conventional medicines, should be subject to careful evaluation of their effectiveness and safety. It is important that treatments…are properly tested and that patients do not receive misleading information…NHS provision for CAM…should be confined to treatments that are supported by…evidence of both effectiveness and safety”

44. BCA vs Simon Singh … happily promote bogus treatments…

46. Most UK university degree courses in AM had to close

47. <Picture of someone holding in his mouth a homeopathic bottle labeled “arsen. alb” removed for possible ©> 10:23

48. Homeopathy on the NHS was reduced by ~40% Sales of homeopathic remedies declined in Germany by 2.2% (2009-10)

49. ~600 complaints about UK chiropractors (GCC) + Numerous complaints about homeopaths (ASA)

51. “… anyone in medicine today who does not believe in evidence-based healthcare is in the wrong business…” Reilly BM. BMJ 2004;329:991. Conclusion

52. <Picture of a lion resting on a tree removed for ©> Email: [email_address] Website: www.pms.ac.uk/compmed