An incomplete list of alternative therapies, and comment on some of the benefits and risks.

Acupuncture

Acupuncture involves sticking needles in a patient. It is claimed by advocates of acupuncture that it works by regulating the flow of Qi and Blood by way of points found on “meridians”, which are described as pathways. There is no evidence at all to support the existence of Qi or meridians.

Studies comparing acupuncture with sham acupuncture have found little or no difference between the two, which implies that the benefits of ‘genuine’ acupuncture are due to placebo effects. There are several reviews of acupuncture. One paper concluded that there was no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation. A systematic review described a small analgesic effect of acupuncture, which seems to lack clinical relevance and cannot be clearly distinguished from bias. A paper looking at pain due to osteoarthritis of the knee concluded that acupuncture provided no additional improvement in pain scores compared with a course of six sessions of physiotherapy-led advice and exercise. Update: Cochrane review of acupuncture for osteoarthritis – statistically significant benefits, which are small, do not meet the authors’ pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding.

There are side-effects to this treatment – most commonly minor, temporary adverse effects due to the insertion of needles (minor pain, bleeding, or bruising), but also rare serious adverse effects such as infection due to lack of proper sterilisation of needles and puncturing of organs such as the lungs. See here for discussion of deaths associated with acupuncture.

In short: acupuncture has little or no benefit; meridians and Qi are meaningless; acupuncture is not without risk.*

Aromatherapy

Wikipedia notes that aromatherapy is used for a number of conditions, including pain and anxiety reduction, enhancement of energy and short-term memory, relaxation, hair loss prevention, and reduction of eczema-induced itching.

This review of treatments for eczema and itching states that:

Although the present meta-analysis revealed that psychological interventions had a significant ameliorating effect on eczema severity, itching intensity and scratching in atopic dermatitis patients, a definite conclusion about their effectiveness seems premature.

Here, the authors found a lack of studies evaluating the role of aromatherapy for pain management in labour and stated that: “Further research is needed before recommendations can be made for clinical practice.”

The trials found no difference between groups for the primary outcomes of pain intensity, assisted vaginal birth (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.48 to 2.28, one trial, 513 women; RR 0.83, 95% CI 0.06 to 11.70, one trial, 22 women), and caesarean section (RR 0.98, 95% CI 0.49 to 1.94, one trial, 513 women; RR 2.54, 95% CI 0.11 to 56.25, one trial, 22 women) […] The trials found no differences between groups for the secondary outcomes of use of pharmacological pain relief (RR 0.35, 95% CI 0.04 to 3.32, one trial, 513 women; RR 2.50, 95% CI 0.31 to 20.45, one trial, 22 women), spontaneous vaginal delivery (RR 1.00, 95% CI 0.94 to 1.06, one trial, 513 women; RR 0.93, 95% CI 0.67 to 1.28, one trial, 22 women) or length of labour and augmentation (RR 1.14, 95% CI 0.90 to 1.45, one trial, 513 women).

The authors of this paper on aromatherapy and relaxation found that “Although this study did not show aromatherapy to be effective based on statistical analysis, patients did generally report the lavender scent to be pleasant.” While this paper concludes that “The findings imply that the previous associations of lavender aroma with assisted relaxation may have been influenced by expectancy biases, and that the relevant expectancies are easily manipulable.”

The BUPA website has some discussion of the risks of aromatherapy, which include dermatitis.

Aromatherapy appears to be generally safe,* but the benefits are dubious.

Chiropractic

Straight chiropractors adhere to the philosophy of DD Palmer. A vitalistic philosophy (see Wikipedia and Skepdic). Chiropractic treatment involves spinal manipulation. Straight chiropractors believe that misaligned spines impede the flow of innate intelligence and cause all disease. While this is clearly a ridiculous proposition, researchers have nonetheless studied chiropractic treatment for several conditions. Below are links to a couple of reviews of studies looking at chiropractic treatment.

There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea.

Risks of chiropractic treatment include minor adverse effects, unnecessary exposure to X-rays, and vertebral artery dissection. This post discusses (in detail, with appropriate references) the risks, lack of benefit, history and philosophy of chiropractic, including comment on unnecessary exposure to X-rays and vertebral artery dissection.

In short: chiropractic has little or no benefit; the concept of “innate intelligence” is as meaningless as the concepts of meridians and Qi; chiropractic has some common, relatively minor risks and rarer (but extremely serious) risks* such as stroke due to vertebral artery dissection.

Herbalism

Some herbal remedies contain substances that have physiological effects. This means that it is possible that they can be effective, but it also means that they can be toxic. In Singh and Ernst’s Trick or Treatment, herbal remedies are reviewed and it is stated that the evidence for some is “good”. These remedies include garlic (high cholesterol), St John’s wort (mild to moderate depression), and kava (anxiety).

The authors of this paper found that “Garlic reduces TC [total cholesterol] to a modest extent, an effect driven mostly by the modest reductions in TAG, without appreciable LDL lowering or HDL elevation.” As garlic thins the blood, high consumption could increase the risk of bleeding.

Ernst and Pittler concluded that “kava extract appears to be an effective symptomatic treatment option for anxiety”. Kava is also linked to hepatotoxicity.

The authors of this review found that St John’s wort was effective for depression, but noted that the association of country of origin and precision with effects sizes complicates the interpretation. See here for more on the association of country of origin with effects sizes. St John’s wort is one of the herbs that may interact with drugs.

Patients should inform their doctor about any decision to use any form of alternative medicine. This is particularly important for therapies such as herbalism that includes treatments that have serious risks.*

Homeopathy

A system of medicine based on the magical thinking that ‘like cures like’, homeopathy also involves Succussion and High Dilutions. Homeopaths not only believe that the smaller the dose the more powerful the medicine, they also believe that a medicine containing not a single molecule of active ingredient is more powerful still. Despite this being an utterly implausible remedy, time, money and effort have been expended exploring the effects of homeopathy.

Shang et al found that “there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects.” There have been several systematic reviews of trials studying this implausible therapy, and a systematic review of systematic reviews of homeopathy:

Eleven independent systematic reviews were located. Collectively they failed to provide strong evidence in favour of homeopathy. In particular, there was no condition which responds convincingly better to homeopathic treatment than to placebo or other control interventions. Similarly, there was no homeopathic remedy that was demonstrated to yield clinical effects that are convincingly different from placebo. It is concluded that the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.

Unsurprisingly, homeopathy appears to be safe but does not work. Properly prepared, highly dilute remedies should be ineffective but safe,* given that they are indistinguishable from the water, sugar, or alcohol from which they are prepared. As Kate Chatfield of the Society of Homeopaths has said, homeopathic remedies can be distinguished from each other “only by the label”.

Nutritionism

Some vitamin and mineral supplements may be useful. Examples include folic acid (it is recommended that folic acid be taken by women while they are trying to conceive and they “should continue taking this dose for the first 12 weeks of pregnancy, when the baby’s spine is developing”), iron for premenopausal women, and vitamin D for groups at risk of deficiency (e.g., people who have low exposure to sunlight, a poor diet, or a diet restricted to certain food groups). Some nutritionists believe in the benefits of high dose food supplements to treat various conditions, but their claims generally lack evidence.

I looked at the evidence relating to recommendations (made by media nutritionist Patrick Holford, and others) that people take vitamin B for depression and was distinctly underwhelmed. Holford and others also recommend B vitamins to lower homocysteine. Holford in particular is keen to recommend expensive tests and supplements. This is something that has been discussed several times on the HolfordWatch blog. See also some discussion of homocysteine as a false surrogate end point on this blog.

Antioxidant supplements have long been popular with nutritionists. As physiological research as well as observational studies suggested that antioxidant supplements may improve survival, this was understandable. Up to the point where researchers investigated antioxidant supplements. The authors found no evidence to support antioxidant supplements for primary or secondary prevention and stated that:

Vitamin A, beta-carotene, and vitamin E may increase mortality. Future randomised trials could evaluate the potential effects of vitamin C and selenium for primary and secondary prevention. Such trials should be closely monitored for potential harmful effects. Antioxidant supplements need to be considered medicinal products and should undergo sufficient evaluation before marketing.

While registered dietitians are the only qualified health professionals that assess, diagnose and treat diet and nutrition problems at an individual and wider public health level, are statutorily regulated, and governed by an ethical code to ensure that they always work to the highest standard… anyone can call themself a nutritionist. In fact, it is possible to register your dead cat as a certified member of the American Association of Nutritional Consultants (AANC).

A recent investigation by Which? magazine found that the advice given could potentially endanger the health of the researchers who were investigating nutritionists.

Some food supplements may be beneficial, some may be useless, and some may be harmful. For advice on diet and supplements, you should see a registered dietitian rather than a nutritionist.

Reflexology

Reflexologists believe that the blockage of an energy field, invisible life force, or Qi, can prevent healing. There is no evidence to support this belief.

There is a randomised controlled trial for reflexology and hot flushes – reflexology was not shown to be more effective than non-specific foot massage in the treatment of psychological symptoms occurring during the menopause. This is from a paper looking at reflexology and asthma: The authors do not find that this investigation demonstrates that foot zone therapy is of effect on the disease bronchial asthma.

Reflexology is nothing more than a foot massage with added nonsense about an invisible life force. To be honest, it sounds rather fun. As long as you don’t confuse it with medical treatment.*

Reiki

As with reflexology, chiropractic and acupuncture, reiki involves a belief in the flow of a ‘vital force’.

So, Jiang and Qin, in a Cochrane review of touch therapies, found only three trials on reiki that met the inclusion criteria for their review. They concluded that: “Touch therapies may have a modest effect in pain relief. More studies on HT and Reiki in relieving pain are needed.”

Lee, Pittler and Ernst conducted a systematic review and concluded that “the evidence is insufficient to suggest that reiki is an effective treatment for any condition. Therefore the value of reiki remains unproven”.

Reiki seems to be without serious physical risk to the patient – which is unsurprising, given that it involves the practitioner holding their hands on or near the body. There is no reason to think it might be either effective, or dangerous.*

General comments on risks and benefits of alternative medicine

Benefits of alternative treatment will include placebo effects. The benefits will, in most cases, be limited to placebo. Treatments that can be shown to have significant effects beyond placebo cease to be alternative and simply become part of medicine.

*One common risk of alternative medicine is that a patient might not seek proper treatment for a serious condition. Some of the cases discussed at What’s The Harm are good examples of this. This applies to all alternative medicine. Some therapies may have side effects but even therapies that are safe by virtue of their inert nature (such as reiki or homeopathy) become dangerous when used as alternatives to effective treatments for serious conditions. Anyone considering using any alternative medicine should consult their doctor.

Another risk is the dissemination of bullshit. This likely applies to every form of alternative medicine. Whether or not you view this as a risk depends on how highly you value rationality.

More

A shorter guide can be seen here on David Colquhoun’s Improbable Science blog.

Simon Singh and Edzard Ernst have written a guide to what works and what doesn’t in alternative medicine titled Trick or Treatment.

Edits

22/1/2012: Fixed link to acupuncture paper; added link to Cochrane review of acupuncture.