Controlled trial of homoeopathic treatment of osteoarthritis

An experimental double-blind clinical trial method in homoeopathy

A small number of double-blind, placebo-controlled trials of homœopathic treatment in rheumatological conditions have been carried out. These have used differing methodologies, leading to varying results. This paper describes a novel approach in the treatment of fibrositis, a syndrome which lacks a pathological definition, but is defined solely in terms of its symptomatology.

24 patients were prescribed for 3 months, according to indication, one of three homœopathic remedies (Arnica, Bryonia, Rhus tox.), each patient remaining on the same remedy throughout. They were followed monthly on the following parameters: pain, number of tender spots and sleep. An ‘indication score’ was allotted to each prescription. The results were analyzed by non-parametric statistical methods, showing that homœopathy produced a statistically significant improvement, but only when the prescribed remedy was well indicated.

Complementary Treatment of Varicose Veins — A Randomized, Placebo-Controlled, Double-Blind Trial

The aim of this study was to test the effectiveness of a combined homeopathic medication in primary varicosity. A well-defined population of 61 patients was randomized into active medication (Poikiven®) or placebo. Both were given for 24 d. At the start of the trial, after 12 d medication and at the end of the study, objective and subjective parameters were recorded: venous filling time, leg volume, calf circumference, haemorheological measurements and patients' symptoms such as cramps, itching, leg heaviness, pain during standing and the need to elevate the legs. The results show that venous filling time is changed by 44% towards normal in the actively-treated group. The average leg volume fell significantly more in this group, but calf circumferences did not change significantly and blood rheology was not altered in any relevant way. None of the patients reported side-effects. Subjective complaints were relieved significantly more by Poikiven than by placebo. These results suggest that the oral treatment of primary varicosity using Poikiven is feasable.

Does flare trial design affect the effect size of non-steroidal anti-inflammatory drugs in symptomatic osteoarthritis? A systematic review and meta-analysis

OBJECTIVES

It is thought that the clinical trial benefits of oral non-steroidal anti-inflammatory drugs (NSAIDs) may relate to flare designs. The aim of this study was to examine the difference in NSAID (including cyclooxygenase-2 (COX-2) inhibitors) response in osteoarthritis (OA) trials based on different designs.

METHODS

Systematic review was undertaken of the databases MEDLINE, EMBASE, AMED, CINAHL and the Cochrane library till February 2015. Randomised controlled trials assessing pain, function and/or stiffness following commencement of NSAIDs in flare and non-flare designs were eligible. Trials were assessed using the Cochrane Risk of Bias tool. Meta-analyses were conducted to assess the effect sizes (ES) of NSAIDs for OA with flare versus non-flare trial designs.

RESULTS

Fifty-seven studies including 33 263 participants assessing 26 NSAIDs were included. Twenty-two (39%) were flare design, 24 (42%) were non-flare designs, 11 (19%) were possible flare designs. On meta-analysis, there was no statistically significant difference in ES of NSAIDs versus placebo between flare and non-flare trial designs for absolute pain and function or stiffness at immediate-term (1 week), short-term (2-4 week) or longer-term (12-13 week) follow-up periods (p>0.05). However there was a lower ES for mean change in pain in flare and possible flare trials compared with non-flare trials at short-term follow-up (0.36 vs 0.69; p=0.05).

CONCLUSIONS

Contrary to previous understanding, flare trial designs do not result in an increased treatment effect for NSAIDs in people with OA compared with non-flare design. Whether flare design influences other outcomes such as joint effusion remains unknown.

[Homeopathy confronted with clinical research]

Homeopathy is a medical practice using medications characterized by four basic principles: similitude, dilution, dynamization, and personalization. To date, there is no scientific evidence supporting any of these principles. For this reason, careful examination of clinical evaluation of homeotherapy trials is the only pragmatic way of evaluating the value of the "homeopathic pharmacy". Many clinical trials have been conducted over the last decade. Clinical trials are not however a prerequisite for marketing these medications since the legal authorities do not require proof of efficacy for marketing authorization. Unfortunately, these trials which are rarely favorable, often present methodological biases which compromise the readability of results and the validity of conclusions. Both meta-analyses and individual trials performed in a broad spectrum of clinical situations exclude severe disease and do not provide data suggesting these products are effective or produce effects reproducible from one team to another or over time. For this reason, and at the present state of our knowledge, their use cannot be recommended. The public authorities should now require the demonstration of efficacy before awarding marketing approval for homeopathic medications.

Priorities and methods for developing the evidence profile of homeopathy Recommendations of the ECH General Assembly and XVIII Symposium of GIRI

To achieve scientific acceptance, homeopathy must investigate several questions: 1. The activity of very highly diluted preparations. The consensus of the meeting was that there is clear evidence of this. 2. The content of very highly diluted homeopathic preparations. More research is needed but evidence exists that a specific signal is present in homeopathic preparations. 3. A theoretical framework in which the effects of homeopathic diluted preparations can be explained. The 'Body Information Theory' is such a theory. 4. The clinical effectiveness of homeopathy. Because they avoid the placebo effect, animal studies are a priority. For human trials using Quality of Life questionnaires, studies on the activity, content and theoretical basis of homeopathic preparations were reviewed approximately 70% of cases; more in children showed improvement. Homeopathy reduced costs and allowed a better improvement in work-days lost compared with conventional practice. Randomised controlled trials (RCTs) implicitly test the placebo hypothesis; RCTs have been performed and meta-analyses conclude that there is clear evidence of efficacy which cannot be attributed to placebo effect. Priorities depend on the audience. More research is needed especially regarding the content of homeopathic preparations and the transmission of information. Theoretical issues are also important to avoid incorrect design of research protocols. More effort should be dedicated to veterinary research. Clinical effects analysis in humans remains important. Many other questions should be prioritised, such as the potential of homeopathy to avoid invasive procedures in children and the long-term effects of homeopathy in preventing chronic complications.

[Therapeutic management of osteoarthritis in the beginning of the third millennium. Part II: non pharmacological strategies]

COMMENT

Osteoarthritis represents one of the most frequent pathologies today, and its current management requires the combination of pharmaceutical and non pharmacological strategies. Moreover, osteoarthritis constitutes one of the main diseases leading to the requirement to the alternative medicines.

NEWS AND KEY POINTS

This overview resumes the main recommendations in the light of recent controlled clinical trials concerning the not medicinal coverage of osteoarthritis : importance of the information and the education of the patient, the importance of the establishment of programs of physical exercises, the need for a reduction of the weight excess for knee osteoarthitis. Some controlled studies tried to estimate the symptomatic efficiency of acupuncture, homoeopathy or the contribution of minerals, vitamins. The appeal to the alternative said medicines is approached on this review.

PERSPECTIVES AND PROJECTS

If certain not medicinal strategies have a sufficient proof of efficiency today, on the other hand number of propositions still have not, at the moment, demonstrated by superiority and by efficiency versus placebo. Numerous controlled studies should be organized to confirm or exclude the place of treatments such as homoeopathy, minerals.

The research evidence base for homeopathy: a fresh assessment of the literature

BACKGROUND

The claims made for the clinical effects of homeopathy are controversial. The results of several meta-analyses of clinical trials are positive, but they fail in general to highlight specific medical conditions that respond well to homeopathy.

AIMS

This review examines the cumulative research from randomised and/or double-blind clinical trials (RCTs) in homeopathy for individual medical conditions reported since 1975, and asks the question: What is the weight of the original evidence from published RCTs that homeopathy has an effect that is statistically significantly different from that in a comparative group?

METHOD

Analysis of the 93 substantive RCTs that compare homeopathy either with placebo or another treatment.

RESULTS

50 papers report a significant benefit of homeopathy in at least one clinical outcome measure, 41 that fail to discern any inter-group differences, and two that describe an inferior response with homeopathy. Considering the relative number of research articles on the 35 different medical conditions in which such research has been carried out, the weight of evidence currently favours a positive treatment effect in eight: childhood diarrhoea, fibrositis, hayfever, influenza, pain (miscellaneous), side-effects of radio- or chemotherapy, sprains and upper respiratory tract infection. Based on published research to date, it seems unlikely that homeopathy is efficacious for headache, stroke or warts. Insufficient research prevents conclusions from being drawn about any other medical conditions.

CONCLUSIONS

The available research evidence emphasises the need for much more and better-directed research in homeopathy. A fresh agenda of enquiry should consider beyond (but include) the placebo-controlled trial. Each study should adopt research methods and outcome measurements linked to a question addressing the clinical significance of homeopathy's effects.

Homeopathic aggravations: a systematic review of randomised, placebo-controlled clinical trials

Homeopathic aggravations have often been described anecdotally. However, few attempts have been made to scientifically verify their existence. This systematic review aimed at comparing the frequency of homeopathic aggravations in the placebo and verum groups of double-blind, randomised clinical trials. Eight independent literature searches were carried out to identify all such trials mentioning either adverse effects or aggravations. All studies thus found were validated and data were extracted by both authors. Twenty-four trials could be included. The average number of aggravations was low. In total, 50 aggravations were attributed to patients treated with placebo and 63 to patients treated with homoeopathically diluted remedies. We conclude that this systematic review does not provide clear evidence that the phenomenon of homeopathic aggravations exists.

Clinical trials of classical homeopathy: reflections on appropriate research designs

The growing popularity of complementary medicine has been accompanied by a call for controlled clinical studies to examine the efficacy and validity of its various methods. The difficulties encountered in applying the evaluation methods of conventional medicine to complementary medicine are the result of the different paradigms underlying these two methods of medicine, and the differences in the healing process. This paper attempts to bridge the gap between these two approaches and to suggest a possibility to use conventional research methodology in clinical studies of classical homeopathy. Two methods are described. One is the randomization into a placebo or a treatment group after an individual remedy is chosen for each patient. This method requires an experienced homeopath and is reproducible only by the same homeopath in the same population. On the other hand, the expected success rate will be high. Another method is prescribing and treating according to so-called keynotes, a set of symptoms known to respond to a particular remedy that must be present in a patient in order to elicit a reaction from the remedy. This method is more suitable to a conventional design of a clinical study and is reproducible by anyone. Yet the expected success rate is much lower. Some general design issues that may have a particular impact on clinical trials of classical homeopathy are discussed, including the need for sufficiently powered trials to detect relatively small effects, strategies to deal with patient preference and embracing the use of "active-control" pragmatic trial designs.

A systematic review of the quality of homeopathic clinical trials

BACKGROUND

While a number of reviews of homeopathic clinical trials have been done, all have used methods dependent on allopathic diagnostic classifications foreign to homeopathic practice. In addition, no review has used established and validated quality criteria allowing direct comparison of the allopathic and homeopathic literature.

METHODS

In a systematic review, we compared the quality of clinical-trial research in homeopathy to a sample of research on conventional therapies using a validated and system-neutral approach. All clinical trials on homeopathic treatments with parallel treatment groups published between 1945-1995 in English were selected. All were evaluated with an established set of 33 validity criteria previously validated on a broad range of health interventions across differing medical systems. Criteria covered statistical conclusion, internal, construct and external validity. Reliability of criteria application is greater than 0.95.

RESULTS

59 studies met the inclusion criteria. Of these, 79% were from peer-reviewed journals, 29% used a placebo control, 51% used random assignment, and 86% failed to consider potentially confounding variables. The main validity problems were in measurement where 96% did not report the proportion of subjects screened, and 64% did not report attrition rate. 17% of subjects dropped out in studies where this was reported. There was practically no replication of or overlap in the conditions studied and most studies were relatively small and done at a single-site. Compared to research on conventional therapies the overall quality of studies in homeopathy was worse and only slightly improved in more recent years.

CONCLUSIONS

Clinical homeopathic research is clearly in its infancy with most studies using poor sampling and measurement techniques, few subjects, single sites and no replication. Many of these problems are correctable even within a "holistic" paradigm given sufficient research expertise, support and methods.

Homeopathic treatment of acute otitis media in children: a preliminary randomized placebo-controlled trial

BACKGROUND

The use of antibiotics in the initial treatment of acute otitis media is currently being questioned. Homeopathy has been used historically to treat this illness, but there have been no methodologically rigorous trials to determine whether there is a positive treatment effect.

METHODS

A randomized double blind placebo control pilot study was conducted in a private pediatric practice in Seattle, WA. Seventy-five children ages 18 months to 6 years with middle ear effusion and ear pain and/or fever for no more than 36 h were entered into the study. Children received either an individualized homeopathic medicine or a placebo administered orally three times daily for 5 days, or until symptoms subsided, whichever occurred first. Outcome measures included the number of treatment failures after 5 days, 2 weeks and 6 weeks. Diary symptom scores during the first 3 days and middle ear effusion at 2 and 6 weeks after treatment were also evaluated.

RESULTS

There were fewer treatment failures in the group receiving homeopathy after 5 days, 2 weeks and 6 weeks, with differences of 11.4, 18.4 and 19.9%, respectively, but these differences were not statistically significant. Diary scores showed a significant decrease in symptoms at 24 and 64 h after treatment in favor of homeopathy (P < 0.05). Sample size calculations indicate that 243 children in each of 2 groups would be needed for significant results, based on 5-day failure rates.

CONCLUSIONS

These results suggest that a positive treatment effect of homeopathy when compared with placebo in acute otitis media cannot be excluded and that a larger study is justified.

A randomized controlled trial comparing topical piroxicam gel with a homeopathic gel in osteoarthritis of the knee

OBJECTIVE

: To evaluate the efficacy and safety of a homeopathic gel vs an NSAID (piroxicam) gel in the treatment of osteoarthritis of the knee.

METHOD

: One hundred and eighty-four out-patients with radiographically confirmed symptomatic osteoarthritis of the knee were entered into a pragmatic, randomized, double-blind controlled trial and treated with 1 g of gel three times daily for 4 weeks. Main outcome measures were pain on walking as a Visual Analogue Score (VAS) and a single-joint Ritchie index.

RESULTS

: One hundred and seventy-two of the 184 enrolled patients had endpoints for the main outcome parameters. The pain reduction was 16.5 mm VAS in the homeopathy group (n = 86) and 8.1 mm in the piroxicam group (n = 86); the difference between treatment groups was 8.4 mm (95% confidence interval 0.8-15.9), and after adjustment for pain at baseline it was 6.8 mm (95% confidence interval -0.3 to 13.8). There was no significant difference between treatment groups in the single-joint Ritchie index (P = 0.78). Adverse events occurred in 28 patients (12 homeopathy group, 5 withdrawn; 16 piroxicam group, 9 withdrawn); 18 of the events involved a local reaction (7 homeopathy group, 2 withdrawn; 11 piroxicam group, 5 withdrawn).

CONCLUSION

: The homeopathic gel was at least as effective and as well tolerated as the NSAID gel. The presence of a clinically relevant difference between treatment groups cannot be excluded. The homeopathic gel supplemented by simple analgesics if required may provide a useful treatment option for patients with osteoarthritis.

Homeopathy and rheumatic disease

Despite a growing interest in uncovering the basic mechanisms of arthritis, medical treatment remains symptomatic. Current medical treatments do not consistently halt the long-term progression of these diseases, and surgery may still be needed to restore mechanical function in large joints. Patients with rheumatic syndromes often seek alternative therapies, with homeopathy being one of the most frequent. Homeopathy is one of the most frequently used complementary therapies worldwide.

Why I would not recommend complementary or alternative therapies: a physician's perspective

The use of complementary or alternative therapies by patients with rheumatic diseases is widespread and under-reported by patient to physician. The most commonly used forms of therapy are herbal/nutrient supplements, chiropractic, homeopathy, and acupuncture. The use of these therapies for treatment of rheumatic disease is not substantiated by review of the available medical literature. Furthermore, these therapies are expensive and potentially toxic. Incorporation of these treatments into the therapeutic armamentarium of the rheumatologist cannot be recommended until they are shown to be effective, safe, and affordable.

Use of complementary treatment by those hospitalised with acute illness

AIM

To determine the frequency of use of complementary treatment and measure its impact on clinical outcomes in a hospitalised general paediatric population.

METHODS

A population based random sample of children admitted to the general paediatric service at a metropolitan children's hospital in Auckland, New Zealand from February to July 1998. Children with asthma, pneumonia, bronchiolitis, gastroenteritis, or fever were eligible. Data collected by personal interview with parents and by review of the medical records of these children.

RESULTS

251 of 511 eligible children admitted during the study period were enrolled. Forty four children (18%) had received complementary treatment during the hospitalising illness. Most children (77%) had been seen in primary care before hospitalisation. The proportion that were seen in primary care and the number of primary care visits before hospitalisation did not vary with receipt of complementary treatment. The proportion of children who were prescribed medications before hospitalisation was significantly greater for those who had received complementary treatment compared with those who had not (59% v 39%). There was no significant difference between users and non-users of complementary treatment in the severity of the illness at presentation, investigations performed, treatment administered, or length of inpatient stay.

CONCLUSION

A substantial proportion of children hospitalised with acute medical illnesses have received complementary treatment. Alternative health care is used as an adjunct rather than an alternative to conventional health care. Receipt of complementary treatment has no significant effect on clinical outcomes for children hospitalised with common acute medical illnesses.

The role of complementary medicine in European and Asian patients with inflammatory bowel disease

Three hundred and eighty-two patients with known inflammatory bowel disease (IBD) (190 European and 192 Asians) and 190 with coeliac disease were sent a previously validated questionnaire to investigate patients' use of alternative medicine and their views on its effectiveness. Details sought included whether they have ever consulted an alternative practitioner, whether they had followed a course of treatment and its clinical effects. Information about where patients had heard about such alternative practitioners and whether they were told to discontinue their current allopathic medication was sought. Results were analysed after three consecutive mailings, including one in Gujurati to Asian patients. A randomly selected group was re-interviewed four months later. To validate the study alternative medicine practitioners were also interviewed to investigate what percentage of their attendees have IBD and how many of those clients were Asians. One hundred and fifty-eight questionnaires were returned from European patients with IBD (response rate = 83%), 145 from patients with coeliac disease (response rate = 76%) but only 81 Asian patients with IBD (response rate = 42%). Forty-seven European and Asian patients with inflammatory bowel disease sought advice or treatment from an alternative practitioner, compared with only 11 with coeliac disease (chi(2) = 11.64, df = 12, P < 0.003). There was no significant difference in consultation rates between Asian and European patients with IBD (Yates corrected chi(2) = 0.78, ns). The most common practitioners consulted by all groups were homeopaths (n = 23) and herbalists (n = 27) but 20 patients consulted more than one practitioner at a time. Patients with coeliac disease and European patients with IBD had consulted osteopaths (n = 6) and reflexologists (n = 7). Ten patients with IBD had also attended a spiritualist and five Asian patients a hakim. Common sources of information about alternative remedies included friends and relatives (n = 13), the media (n = 11), word of mouth (n = 11) and family practitioners (n = 6). Most patients were advised to continue their current medications, although two had been told to stop and 10 advised to reduce the dose of their allopathic medications. Twenty alternative medicine practitioners stated that overall between 2-5% of their attendees have IBD with 10% of those clients being Asian. Asians preferred to consult Asian practitioners rather than European practitioners. There was no clear consensus as to whether complementary therapies were felt beneficial, although many patients with IBD believed them to be helpful.

Establishing a research agenda for investigating alternative medical interventions for chronic pain

This article describes the University of Maryland School of Medicine's Center for Complementary Medicine Research approach to developing an agenda for investigating alternative medical treatments for chronic pain syndromes. This agenda includes conducting extensive literature searches and analyses to form a knowledge base for making clinical decisions on which chronic pain syndromes are in greatest need of better therapies, as well as which alternative medical therapies offer the greatest therapeutic promise for these specific chronic pain syndromes. To date, the Center has identified back pain, arthritis, and fibromyalgia as the chronic pain syndromes that contribute the greatest clinical and economic burden to overall chronic pain statistics. Not coincidentally, patients with these diagnoses are the greatest users of alternative therapies. The Center has identified acupuncture, homeopathy, manual/manipulative therapies, and mind-body therapies as the alternative medical therapies offering the greatest clinical potential for these three general chronic pain diagnoses. Preliminary data from the Center's ongoing clinical trials programs are presented.

Homeopathy in office practice

Homeopathy is widely used around the world and is regaining popularity in the United States where it enjoyed popular and therapeutic success in the 1800s. Relying on systematic principles of health and disease first set forth by Samuel Hahnemann in 1810, it offers a powerful and inexpensive means of promoting self-care and of augmenting therapeutic options for the family physician. History, theory and practical considerations are reviewed.

Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials

BACKGROUND

Homeopathy seems scientifically implausible, but has widespread use. We aimed to assess whether the clinical effect reported in randomised controlled trials of homeopathic remedies is equivalent to that reported for placebo.

METHODS

We sought studies from computerised bibliographies and contracts with researchers, institutions, manufacturers, individual collectors, homeopathic conference proceedings, and books. We included all languages. Double-blind and/or randomised placebo-controlled trials of clinical conditions were considered. Our review of 185 trials identified 119 that met the inclusion criteria. 89 had adequate data for meta-analysis, and two sets of trial were used to assess reproducibility. Two reviewers assessed study quality with two scales and extracted data for information on clinical condition, homeopathy type, dilution, "remedy", population, and outcomes.

FINDINGS

The combined odds ratio for the 89 studies entered into the main meta-analysis was 2.45 (95% CI 2.05, 2.93) in favour of homeopathy. The odds ratio for the 26 good-quality studies was 1.66 (1.33, 2.08), and that corrected for publication bias was 1.78 (1.03, 3.10). Four studies on the effects of a single remedy on seasonal allergies had a pooled odds ratio for ocular symptoms at 4 weeks of 2.03 (1.51, 2.74). Five studies on postoperative ileus had a pooled mean effect-size-difference of -0.22 standard deviations (95% CI -0.36, -0.09) for flatus, and -0.18 SDs (-0.33, -0.03) for stool (both p < 0.05).

INTERPRETATION

The results of our meta-analysis are not compatible with the hypothesis that the clinical effects of homeopathy are completely due to placebo. However, we found insufficient evidence from these studies that homeopathy is clearly efficacious for any single clinical condition. Further research on homeopathy is warranted provided it is rigorous and systematic.

How should we research unconventional therapies? A panel report from the Conference on Complementary and Alternative Medicine Research Methodology, National Institutes of Health

Research in unconventional medicine requires a number of different questions to build up a "mosaic" of evidence. Choice of research design depends on the question being asked and is independent of the therapy under investigation. Despite the doubts of some practitioners, randomized trials are of value for determining certain questions in alternative medicine.

The development of research methodology in homoeopathy

Homoeopathy is a form of complementary medicine based on treating 'like with like'. Its popularity with the public, and credibility with health professionals, has increased rapidly as a result of recent clinical trials demonstrating its efficacy. The results of a systematic review of clinical trials of homoeopathy are summarized. The main scientific obstacle to the acceptance of homoeopathy is its use of very high 'ultramolecular' dilutions. The action of these dilutions cannot be explained in terms of existing pharmacological concepts. This has lead to the 'information medicine' hypothesis, which postulates the storage of information in water and its transmission to sensitized biosystems. This hypothesis is starting to be supported by physics. 'Proving' drugs in order to determine their effects on healthy volunteers is a form of research practised by homoeopaths for 200 years, the methodology is continuing to evolve. Clinical trials in homoeopathy are complicated by the fact that treatment is highly individualised. Various approaches to the problem of individualization in controlled trials, including 'homoeopathy as indicated', 'single homoeopathic medicine' and 'individualized isopathy' are discussed. To improve homoeopathic practice its results should be critically audited, a method for doing this is described.

Clinical trials of homoeopathy

OBJECTIVE

To establish whether there is evidence of the efficacy of homoeopathy from controlled trials in humans.

DESIGN

Criteria based meta-analysis. Assessment of the methodological quality of 107 controlled trials in 96 published reports found after an extensive search. Trials were scored using a list of predefined criteria of good methodology, and the outcome of the trials was interpreted in relation to their quality.

SETTING

Controlled trials published world wide.

MAIN OUTCOME MEASURES

Results of the trials with the best methodological quality. Trials of classical homoeopathy and several modern varieties were considered separately.

RESULTS

In 14 trials some form of classical homoeopathy was tested and in 58 trials the same single homoeopathic treatment was given to patients with comparable conventional diagnosis. Combinations of several homoeopathic treatments were tested in 26 trials; isopathy was tested in nine trials. Most trials seemed to be of very low quality, but there were many exceptions. The results showed a positive trend regardless of the quality of the trial or the variety of homeopathy used. Overall, of the 105 trials with interpretable results, 81 trials indicated positive results whereas in 24 trials no positive effects of homoeopathy were found. The results of the review may be complicated by publication bias, especially in such a controversial subject as homoeopathy.

CONCLUSIONS

At the moment the evidence of clinical trials is positive but not sufficient to draw definitive conclusions because most trials are of low methodological quality and because of the unknown role of publication bias. This indicates that there is a legitimate case for further evaluation of homoeopathy, but only by means of well performed trials.

Feverfew in rheumatoid arthritis: a double blind, placebo controlled study

Feverfew, reputed by folklore to be effective in arthritis, has in vitro properties that could be beneficial in the control of inflammatory disease. Forty one female patients with symptomatic rheumatoid arthritis received either dried chopped feverfew (70-86 mg) or placebo capsules once daily for six weeks. Allocation was random and not known by patient or observer. Variables assessed included stiffness, pain (visual analogue scale), grip strength, articular index, full blood count, erythrocyte sedimentation rate, urea, creatinine, C reactive protein, complement breakdown products (C3dg), rheumatoid factor titre, immunoglobulins (IgG, IgA, IgM), functional capacity, and patient and observer global opinions. One patient (placebo) withdrew after three days and was not included in the analysis. Treatment and placebo groups (20 patients each) were well matched at entry. No important differences between the clinical or laboratory variables of the groups were observed during the six week period. This study therefore shows no apparent benefit from oral feverfew in rheumatoid arthritis.