Positive Health Online

Many Positive Health readers will be familiar with Prof Ernst and his team's work at the University of Exeter published in Fact, a journal devoted to searching and analysing the research body of literature in complementary medicine according to established criteria, regarding the methodology and quality of published research, with particular emphasis upon randomized control trials (RCTs). To read a selection of Ernst's work in this regard, search our internet site (from the Home page, select Articles, then Search, using Ernst as the searchable term). I have reproduced here one fairly illustrative example of their searches.

Cooke and Ernst, Department of Complementary Medicine, School of Postgraduate Medicine and Health Sciences, University of Exeter, UK, conducted a systematic review (28 references) of aromatherapy.

Background: In this study the authors stated that Aromatherapy is becomingincreasingly popular despite the fact there are few clear indications for its use. The authors reviewed the literature on aromatherapy in order to discover whether any clinical indication may be recommended for its use.

Methods: Computerised literature searches were performed to retrieve all randomised controlled trials of aromatherapy from the following databases: MEDLINE, EMBASE, British Nursing Index, CISCOM, and AMED. The methodological quality of the trials was assessed using the Jadad score. Trials were independently evaluated and data were extracted in a pre-defined, standardized fashion.

Results: Twelve trials were located: six of them had no independent replication; six related to the relaxing effects of aromatherapy combined with massage. These studies suggest that aromatherapy massage has a mild, transient anxiolytic effect.

Conclusions: The authors concluded that based on a critical assessment of the six studies relating to relaxation, the effects of aromatherapy are probably not strong enough for it to be considered for the treatment of anxiety. The hypothesis that it is effective for any other indication is not supported by the findings of rigorous clinical trials.

Cooke B and Ernst E. Aromatherapy: a systematic review. British Journal of General Practice 50(455): 493-6. Jun 2000.

The Desktop Guide to Complementary and Alternative Medicine, a sort of Physicians Desk Reference for complementary medicine, extends this type of critique to the global entirety of complementary therapies, including acupuncture, aromatherapy, Chinese and herbal medicine, homeopathy, massage, reflexology, relaxation, spiritual healing, etc., even tai chi and yoga!! This, despite the fact that this book is compiled and edited solely by medical doctors, and does not have even an advisory panel of experts from each of the many fields covered in this book.

In other words, the entire judgement of the many complementary disciplines regarding clinical efficacy or otherwise, or whether a therapy ought to be recommended for a health complaint, is based solely upon the results of the research of a relatively few RCTs, without considering any of the sometimes quite considerable clinical body of evidence, or even the clinical experience of practitioners in the field.

The mind boggles at how such a book could even be commissioned by this highly respectable medical publisher. Contrast this to two other scholarly books intended for medical doctors: Integrated Cancer Care – Holistic, complementary, and creative approaches (Editor Jennifer Barraclough, Oxford University Press, 2001) reviewed in Issue 63 and Mind-Body Medicine – A Clinician's Guide to Psychoneuroimmunology (Editor Dr Alan Watkins's Churchill Livingstone 1997) as well as the journal Advances in Mind-Body Medicine published by Harcourt, which investigates research regarding mind-body medicine. As Dr Jane Buckle so correctly reminds us (see Letters, page 40) "Many medical procedures have never been tested scientifically and only 15% of medical procedures have any scientific basis." The Merck Manual and Physicians Desk Reference books would be decimated indeed if only evidence-based clinical practice were used.

The book is divided into 6 sections: How to use the book; Diagnostic methods; Therapies; Herbal and non-herbal medicine; Conditions; and General topics. There is also a free CDROM included. At the outset, Prof Ernst announces that in this book, in contrast to the approaches taken by the US Food and Drug Association and the UK Medicines Control Agency, all medicines are contraindicated for pregnancy and lactation, even if there is no evidence that these may be harmful. This results in the bizarre contraindications for cranberry, garlic, ginger, even green tea for pregnancy and lactation!!! Given the wholly healthy ingredients present in most people's diet (burgers, ice cream, chocolate, soft drinks), it is a wonder that eating has not been contraindicated for pregnant and lactating women.

The Diagnostic Methods section covers Bioresonance, Chiropractic Diagnostic Techniques, Iridology, Kinesiology, Kirlian Photography, Laboratory Tests, Pulse Diagnosis, Reflexology Charts, Tongue Diagnosis and the Vega-Test. None of these was considered wholly valid; in most cases, according to this book, there was no acceptable evidence to show that they were valid. This is a condemnation of a broad swathe indeed of methodology – encompassing age-old techniques from Chinese Medicine, medically and scientifically developed blood tests for allergies (Elisa IgG, ALCAT, etc), even most commonly used Chiropractic diagnostic methods. The reference cited for denouncing Laboratory Tests was an article by Ernst and Hentschel. Diagnostic methods in complementary medicine. Which craft is witchcraft? Int J Risk Safety Med 7:55-63. 1995.

A few of the anomalies thrown up in the Therapies sections, which demonstrate the lack of expertise and understanding of these authors in these therapies are listed herewith:

Reflexology: Adverse effects: Fatigue, foot tenderness, changes in micturition or bowel function;

Relaxation: Precautions/warnings: Techniques requiring inward focusing may intensify depressed mood;

Spiritual Healing: Adverse effects: Sensations like heat or tingling are often reported in areas under the hands of the healer;

Tai Chi: Adverse effects: Adverse effects are rare, but may include delayed-onset muscle soreness, pulled ligaments or ankle sprains;

Yoga: Precautions/warnings: Physical damage can occur from over-stretching either healthy or, more particularly, diseased joints and ligaments; Adverse effects: Drowsiness may occur; Contraindications: Meditation may precipitate feelings of unreality and depersonalization and should therefore not be used by people with a history of psychotic or personality disorder;

Meditation: Safety concerns: excessive meditation may lead to mental disturbance;

Music Therapy: Safety concerns: Music should not exceed 90 dB as this may lead to hearing impairment;

Qi gong: Safety concerns: Psychosis reported, probably in those with latent condition.

The section on Conditions includes an A-Z ranging from AIDS to Upper respiratory tract infection. In the chapter on Asthma, the RCT research evidence was reviewed for Acupuncture, Autogenic training, Biofeedback, Breathing techniques, Diet, Herbal Medicine, Homeopathy, Hypnotherapy, Massage, Meditation, Relaxation, Spinal Manipulation, Yoga and other therapies. Although there is a considerable amount of evidence, much of it favourable for many of these therapies, in most cases the conclusions were that the evidence was not convincing. A careful reading of the evidence reviewed herein, however stated that the following therapies appeared to have significant clinical effects: Acupuncture; Autogenic Training, Biofeedback, Breathing techniques, Diet (vitamins A, C and E, selenium and magnesium), Herbal medicine, Homeopathy, Hypnotherapy, Massage, Meditation, Relaxation and Yoga.

A noteworthy quote from the chapter on Back Pain is the final sentence: "The most important advice to back pain sufferers is to keep up normal activity as much as possible and to realize that having back problems is not a disease but entirely normal." I wonder if the Professor is a back pain sufferer himself.

However, on one positive note, the authors did recommend the use of saw palmetto for benign prostatic hyperplasia.

Section 6 included interesting chapters regarding the use of complementary medicine in Canada, the US and Europe, with a chapter by Michael Cohen on the legal and ethical issues: "It was only in the late 20th century, for example, that decisions by US courts gave tangible recognition to allegations that the American Medical Association and other groups had engaged in a conspiracy to preserve a professional monopoly…". Dr Adrian White vividly reminds us of the devastating effects of drugs "It has been estimated that on average one in 1200 persons taking NSAIDs for at least 2 months will die from gastroduodenal complications who would not have died had they not taken NSAIDs. In comparison, 32,000 treatments with acupuncture… were only associated with one life-threatening event…"

The tone and language of the book is highly derogatory to many therapies, suggesting that certain therapies are based upon beliefs, not real (scientific) clinical findings, i.e. "12 pulses which are believed to yield information on the status of the 12 internal organs or functions." In general, the derisory and patronizing attitude that comes across again and again in this book, is that, at best, complementary medicine is an inconvenience for doctors, in that it might delay patients seeing their 'real' doctors for 'real' (drug) treatment; at worst, complementary medicine might harm or even kill patients because most therapists are not medically qualified and their therapies might interact with their (highly toxic) drug regimes. Furthermore, among the considerable list of therapies omitted from this book is Diets and Nutrition Advice, which are excluded because they were considered mainstream rather than complementary. Since when were doctors providing dietary and nutritional advice?

If you wish to witness a future with complementary therapies dominated by hyper-critical medical doctors, this is the book to read. What a wasted opportunity!