With special thanks to Ian Townsend, University of Central Lancashire, for his supervisory assistance on this BSc dissertation.
This dissertation investigates into the outcome of existent research on the homeopathic treatment of sports-injuries, the experience and efficacy in practice, and the presence and discussion of homeopathy in the media. What is described by sports injuries are injuries that result from acute trauma or repetitive stress associated with athletic activities. The review of research trials and studies with this central discussion point revealed that in this dissertation, primary focus needed to be diverted onto the standards and quality of the available documentation. The large discrepancy in results of existent studies gave rise to many questions surrounding the conduction, and evaluation of research and educed criticism in structure and methodology of trails. It became evident that within this subject of investigation, as with any other range of application of homeopathy, lay the broader discussion of the controversy over the efficacy of homeopathy in general. Therefore a comparative and critical look at existent meta-analyses and reviews, the methodology of trails and the efficacy of homeopathy was incorporated into this dissertation.
The presence of homeopathy for sports in the recent written media was investigated by conducting an internet search via Google of articles published in magazines and newspapers.
This was done in the English, French, Portuguese, Spanish and German language. In the German language sector there is the widest range of reporting on and discussing of the use of homeopathy in sports.
For trials and studies, online data bases were searched: Medline, Sciencedirect, Ebscohost, Elsevier, and Amed. Most articles were available from Medline, Sciencedirect, and Elsevier. Some articles were found using Google scholar. A disappointing source of relevant information was Sportdiscus, where many articles were available as abstracts, but few in full-text, most of which Sciencedirect had already brought forth. A large amount of useful articles came from resources of the Karl and Veronica Carstens Stiftung that have a large database of homeopathic articles. One article came from contacts at the sports department of UCLAN.
The investigation into the experience in practice, was conducted via a search of websites of practicing homeopaths and articles published on homeopathic ezine and other homeopathic platforms like homeopathic societies, centres, associations and institutes in Germany, France, Austria, Switzerland, U.K., U.S.A., Canada, Portugal, Spain, Brazil and Argentina. The findings were deficient. Personal contact, via e-mail to the D.F.B. – the German football association, the LIS – the Institute for achievement diagnostics and sports traumatology, the Institute Boiron and Heel – one of the world’s largest producer of homeopathic complex-remedies and initiator of a survey on the use of homeopathy in sports, yielded no replies. Personal contact with practicing homeopaths rendered little response and only marginally useful information.
The initial catalyst to this dissertation subject was an article published in the renowned German magazine “Der Spiegel” following the publication of a survey which investigated into the use of homeopathy in professional football. The survey was conducted amongst all premiere and secondary league football teams of the Bundesliga, with the result that 92% of German football teams treat their players with homeopathy. Of these, 76% are using complex/combination-preparations in their treatment. The overall conclusion for a homeopathic treatment, as seen by doctors and physiotherapists to the football teams, is that of a positive and a preventative influence on the immune system. A similar survey was carried out in the U.K., assessing the extent of use of complementary therapies. Of the 20 premier league football clubs only 13 had replied to the survey and of those there were only 2 clubs that treated their players with homeopathy.
An article published in “Die Welt” evaluates statistics on injuries contracted during sports, and concludes that no other type of sport results in as many injuries as does football. In the professional German leagues this means 85000 days of sick leave per football season, and incidentally treatment and personnel expenses of 90 million Euros. The main reason for this, according to Zittlau6, is the lack of sufficient time for physical regeneration of the overstressed constitution7, which is why practitioners like Dr. Hans-Wilhelm Müller-Wohlfahrt, the medical attendant of the German national football team and Dieter Trzolek, the physiotherapist of the team of Bayer Leverkusen are leading the trend towards gentler, alternative methods of treatment6.
In the Medical tribune8 sports physician and manager of the LIS, the Institute for achievement diagnostics and sports traumatology in Koblenz, Professor Dr. Billigmann, points out that his customers, most being sports professionals, demand treatment with alternative methods to improve endurance and reduce the recuperation time required after injury. He explains that, complex homeopathic preparations have a great significance to him and other practitioners. Intensive training of the athlete stresses the body and in recuperation, the physique should not have to tackle the possible impacts caused by allopathic medication9.
Other advantages of homeopathy are seen in the aspects that make medicines indifferent to doping restrictions, as homeopathic remedies have no doping profile7 4 10 6. The fact that there are practically no side effects to a homeopathic treatment, that this treatment can be combined with any other form of therapeutic interaction11 and may enhance the conventional treatment12 describe other reasons for the increasing demand for homeopathy in the treatment of sports lesions or trauma.
According to a press release13 ´Traumeel`, a homeopathic complex preparation marketed by Heel, is the best investigated and documented homeopathic medication on the market today. Its homeopathic formula is designed to regulate inflammatory catalysts and promote discharge of anti-inflammatory cytokines14. Traumeel is considered the ´Diclofenac` of homeopathy9. Results of studies investigating into the efficacy of ´Traumeel` suggest that this preparation, employed in the treatment of trauma and injuries conducted during physical activity, is in its action superior to a therapeutic intervention with nonsteroidal anti-inflammatory drugs. This has been emphasised in cases of acute symptomatic tendinopathy15; in the treatment of mild to moderate injuries16 and in the relief of symptoms in epicondylitis17.
An investigation into the efficacy of ´Traumeel` in rats, which tested the reaction of single constituents of ´Traumeel` against the combination, revealed that the efficacy was increased in the complex preparation, but was also evident in milder form in the single prescriptions18. The healing process was accelerated with the use of ´Traumeel`18. The equality, if not superiority of ´Traumeel` over conventional Non-steroidal anti-inflammatory drugs is implied in three studies and tolerability has been rated best over conventional treatment.17 15 16. A study by Boehmer and Ambrus19 came to the conclusion that two ´Traumeel` preparations (-S and -Sine) are of equal efficacy but “strongly superior to placebo”19 (p. 260). One study done in France with inpatients at a Marseille hospital, on a combination preparation called ´Urarthone`, showed a large benefit of the homeopathic product over placebo20.
Studies on single remedy prescriptions recommended for sports injuries are fewer in number and are restrictive to mainly two types of remedies, namely Arnica and Rhus toxicodendron. The dilutions in experimentation for the conduction of these studies were mainly in decimal potency; a dilution of 9 drops of carrier substance and 1 drop of medicinal essence21. In 1983 Hildebrandt and Eltze22 investigated into the efficacy of Rhus tox. given in D4, a 4 time decimal dilution fabricated according to the manufacturing procedures outlined in the homeopathic pharmacopeia, following the procedures described in Aphorism 269 and 270 of the Organon23. This administration was deemed effective in speeding up the process of recovery in the treatment of muscle soreness. A second study Hildebrandt and Eltze24 published shortly afterwards, explored how dosage and potency may influence the effectiveness of a homeopathic prescription. They came to the conclusion that lower potencies had a significant effect, and with increased dosage there was a stronger impact on the improvement of experimentally induced muscle soreness24. One study on Arnica investigated into the outcome using a centesimal dilution25, where the dilution is of 1 drop of medicinal substance with 99 drops of carrier solution21. Although the above studies are attributing a medical benefit to the treatment with homeopathic single preparations, the authors admit that the question whether the presence of allopathic principles of action are active or whether the efficacy is created by homeopathic action mechanisms is not resolved22 24 25. A review by Sommer26 of an explorative study on the efficacy of Arnica in homeopathic decimal potencies comes to the same conclusion. In injuries of the ankle and knee in athletes, homeopathy has the broadest use of all non-conventional therapies27.Tveiten and Bruset28 pooled the results from two of their studies on Arnica D30 in marathon runners and suggest a positive effect on muscle soreness. Jawara, Lewith, Vickers, Mullee, & Smith29 suggest that there is clinical benefit of Arnica and Rhus tox.
Two studies emerged from the conducted literature search taking a different approach to a homeopathic treatment for sports injuries. One is a study by Sao and Delaunay30 investigating into the preventative action of homeopathic remedies. Barrois´s 31 study aim is not focused on an ultimate improvement of existent pathology, but amelioration of performance, and therefore does not fall into the common categories of healing or prevention. It is laid out only for increase of achievement. Both studies had positive results in favour for homeopathy.
The condition for which the greatest number of placebo controlled trials have been undertaken, is delayed onset muscle soreness. A review of studies and trials on Arnica montana for this specific condition32, and for exercise induced muscle soreness have not succeeded in extrapolating a supportive conclusion for the efficacy of homeopathic treatment of sports injuries beyond the effect of a placebo32 33 34. Even at higher potency (200C) the result of a study by Plezbert and Burke35 does not endorse clinical effectiveness of Arnica for DOMS or muscular dysfunction. Vickers et al.36, state that a 30C of homeopathic Arnica is ineffective for muscle soreness caused by long-distance running.
Ernst and Pittler37 (p.1187) state that, “Arnica is the homeopathic remedy that is most frequently studied in placebo-controlled clinical trials”. Their review of 8 trials on the homeopathic treatment for tissue trauma does not substantiate a positive conclusion of homeopathic efficacy of Arnica on the account of deficient methodologically conducted placebo controlled trials. This argumentation is in actual fact a recurring discussion concerning the conduction of trails with the aim of confirming and concluding homeopathic efficacy.
It is evident from the studies and trials on the efficacy of homeopathy for sports injuries that no one conclusion can be drawn from the data. Whether condition-specific or remedy-specific, trials do not lead to equal results for the studies conducted.
In the same way that studies on specific conditions come to no congruent findings on the efficacy of homeopathic treatment so do existent meta-analyses come to differing conclusions. In a meta-analysis conducted in 1997, Linde, Clausius, Ramirez, Melchart, Eitel, Hedges, & Jonas38 declare, that the efficacy of the clinical effects of homeopathy are not entirely due to placebo. On the other hand, Shang, Huwiler-Müntener, Nartey, Jüni, Doering, Sterne, Pewsner, & Egger39 in their meta-analysis of 2005, come to the conclusion that any effect of homeopathic prescribing is one of placebo.
Reviews and analyses following onto the conduction of these meta-analyses aim at disproving what the meta-reviews have claimed, and again come to differing results. Why is there such discrepancy in the results of studies?
The main criticism of any trial done on homeopathy is that of the violation of fundamental principles of homeopathic treatment philosophy35 34. Basic homeopathic treatment has a holistic approach, taking into account individual factors of a patient40 35, making any treatment patient-specific, rather than condition- or remedy- specific. To administer the same remedy to all patients for a specific condition constitutes the methodology of clinical testing that is par to conventional medicine41 and can therefore not yield a successful treatment for all patients ingesting the remedy.
The two fundamental factors of a homeopathic treatment are totality and idiosyncrasy. Hahnemann23 describes in Aphorism 5 of the Organon that the fundamental, the root of an ailment has to be recognised and the totality of symptoms have to be the cardinal, the only aim to recognise and remove in the patient, in order to restore health23 (Aph.7). In Aphorism 17 he points out that to abolish the perceptible expressions of illness means that the total of disease, the fundamental causation, is to be removed, and health will be restored.
He indicates that the epitome of symptoms and circumstances perceived in each and every case of ailment, are the only indicators of the remedy to chose23 (Aph.18). Hahnemann23 further speaks of the importance of individual appraisal of the case of illness in Aph.82. He states there that “no true healing can take place without the strict individualisation of each case of illness”23 (p.75). Following onto this indication of idiosyncrasy, he points to the importance of obtaining a clear picture of a presently prevalent disease by seeing it as new and unknown, to investigate it from the root, looking out for own signs that differ from that of other diseases23 (Aph.100). These rules clearly indicate that standard allopathic testing structures are inappropriate in homeopathy35 42, as individual, qualitative elevation is no procedure conducive to conventional clinical settings.
Allopathic trial methodology in practice gives identical treatment to great quantities of people, disregarding individual differences amongst patients and differences in symptom expressions25. Standard clinical testing procedures are devoid of the individual aspects of the patients participating and are therefore difficult to adopt for homeopathic studies and likely to produce flawed results42 25.
Though an evident factor of studies on homeopathy, the idiosyncrasy of the homeopathic case-taking42 43 is not the only discrepancy of clinical trials in this field. Bias exists across a larger range of aspects and is often dependant on the size of group participating in the study. Publication bias, as a significant form of prejudice study-designs are subject to44 38, is less probable where larger numbers of test-subjects are participating. The work input associated and the expenditures made for a larger trial are bound to increase the chance of publication of the study41, even if the outcome is negative to the aim of the study. At the same time studies with fewer participants may never be considered for publication, not submitted or rejected, if their results are un-conducive to the study claim41.
One possible factor of bias, and decisive for the outcome of a homeopathic trial, may be the differences of composition of testing substance, that, coming from different producers are liable to varying quality of ingredients, and methods of fabrication. The homeopathic potentization-methodology is only one variable that is distinguishable as source of possible bias by manufacturing41.
Another variable is the accuracy of reporting; features of methodological execution of a trial are frequently incompletely expressed39.
One factor of bias that is mainly subject to influence conventional medicine trials is financial interest. This is where lobbyists, such as pharmaceutical companies, may exert manipulatory impact. The primary focus for these studies is an outcome that is dictated by the monetary interest of the sponsor41. Of interest in this context is the fact that the studies on ´Traumeel`, described above, all come to the conclusion of a beneficial effect of the homeopathic complex preparation. All studies were directly or indirectly funded by Heel, the manufacturer of the ´Traumeel` preparation17 18 15 16.
The influence of flaws, such as lapses in methodology, bias of publication and data mal-interpretation, is not subject only to homeopathy, on the contrary, this is a factor present in allopathic test-series just as well41. Rutten and Stolper45 point out that the results pro efficacy of a conventional or a homeopathic study diminish as the conduction quality of the trial improves. Ezzo, Bausell, Moermann, Berman, & Hadhazy46 (p. 457) have come to the conclusion that, “the number of reviews indicating that the modern biomedical interventions show either no effect or insufficient evidence is surprisingly high”. “Both the number and quality of the primary studies on which much contemporary medical practice stands, are remarkably weak”46 (p. 464) This strongly questions the justification of antagonism often brought up against researching homeopaths from conventional establishments42. Biomedical research is liable to demerit, in homeopathic and in allopathic research. The question is though, in which field are the most lapses evident45.
According to Carlston47 conventional clinical research does not necessarily produce what is considered fundamental truth, but it assists the creation of objectivity to the trials conducted and lends credibility. In order to maintain a standard for the analysis of health interventions, the research methodology for both conventional and complementary medical systems has to be identical48. Yet for homeopathy this means that the fundamental principles have to be taken into consideration to actually produce a valid and significant result47. Therefore the investigation into homeopathy, taking into account the individuality of patients is faulty if conducted in random controlled trials49. There is obviously a problem that requires to be resolved.
Studies should reflect actual clinical practice and the fundamental homeopathic strategy is, with the existent model of RCT´s, not achievable38. As RCT´s are the fundamental basis of evidence based medicine, homeopathy has to adapt to this study design, yet where a “care-package”, that is in form of a therapeutic interaction with the patient and the prescription of a remedy is to be investigated, the applicability of RCT designs is difficult42. RCT´s are unsuited to test the efficacy of homeopathy, but may be adequate for investigations into the specific action of remedies, where there is one specific treatment for a specific indisposition40 49. This is rarely the case in homeopathy40.
Thus the controversy surrounding investigative studies on homeopathy remains, whilst other issues yet unaccounted for in the discussion surrounding homeopathic research, have not even been considered. There are beyond methodological deficiencies, issues such as the evidence for the mode of selection of a remedy and choice of potency to be used, that is lacking41. There is no obvious explanation of the mechanism according to which the homeopathic remedy operates. The working mechanism of homeopathy is the most controversial point. The question of how an ultra-molecular dilution, devoid of material substance, can be liable to pharmacological effectiveness remains unanswered. Past Avogadro’s number (23D/11C) a dilution consists of merely solvent and cannot, according to present scientific knowledge contain any active agent to inflict a pharmacological action40 41 43. Criticism aimed at homeopathy rarely goes beyond this controversial dispute about the dilution of remedies.
The dosage of prescriptions being a fundamental factor of homeopathic prescribing is as debatable a point that is seldom addressed. In conclusion it has to be said that “the scientific evaluation of a treatment is based on its effectiveness, not on our understanding of the mechanism of its effect”47 (p.73).
It must simply be admitted that homeopathy in action, in a clinical setting, is inappropriate for application to a scientific framework. Idiosyncrasy remains the homeopathic dictum and homeopathic practice is subject to abide by it42. The conclusions drawn from trials and studies putting the effects of homeopathic treatment down to merely placebo can interestingly be seen as worthwhile, as it means that the patient-practitioner interaction is enhanced and the individual is pronounced more valuable than the prescription47.
So is it that in practice, treating sports injuries with homeopathic preparations, the therapeutic relationship is the prime factor that leads to the improvement of muscle trauma and lesions, that the ´only` agent of action is the therapeutic conversation? In the least for the combination preparation, ´Traumeel`, this does not hold true, as can be seen in the studies conducted on ´Traumeel`, where a beneficial activity has been proven17 18 15 16; even though some consideration has to be given to possible financial bias.
What then is the experience with the use of homeopathy for sports injuries in practice?
It needs to be taken into consideration that numerous allopathic prescriptions, where the action mechanisms, like in homeopathy, are unknown to the scientific world, are recommended and prescribed to patients without any concern50. The utility of homeopathy should experience a similar acceptance. The treatment approach of allopathic medication is one that is focused on removing or suppressing symptoms50; whereas homeopathy assist the organism in the healing process50 51. Rogers50 states that, “A symptom is a sign that something is wrong, but it is also part of the healing process”. He considers homeopathy as “probably the safest of all medical systems”.
Ullman52 deputizes a different point of view. He considers the homeopathic treatment of sports injuries a fairly basic task. He argues that high individualization is in fact not as prevalently required in sports injuries, as physical bruising and trauma does not necessarily underlie patient specific characteristics, but is a turn of fate of a physical exertion. He proclaims that homeopathic treatments should be considered as a complementation to allopathic measures27 53 and not as a substitution.
The question of dosage and potency, as mentioned above, is one not much subject to interrogation and is easily defined. Ullman52 explains the use of potency as such, that the higher the potency prescribed to the patient, the more influential and quickly the remedy develops its action; and the higher the potency chosen in a prescription, the more specific and accurate the choice of remedy has to be. He goes on to describe his dogma of dose, which he points out is, to give as little as is necessary and as much as is required.
According to Schepper51, homeopathic remedies constitute a mild, rapid and secure treatment approach for sports injuries. It is therefore surprising, that this form of treatment has found little attention in professional sports51 5 even though recuperation time of active sports persons may be reduced by homeopathic treatment and subsequent outfall costs for sports teams could be reduced7 51 6. Schepper51 is one of the practitioners that suggest certain remedies may even be taken as prophylaxis, so to speak before the physical exertion. Yarrow and Strauder54, recommend homeopathic remedies because this alternative medical system, in opposition to conventional medical prescribing has no adverse reactions and does not contain ingredients that run the risk of being doping legislatively prohibited. Laubender53 points out and adds to the statement of lacking side-effects, “if application is done correctly”. He considers homeopathic remedies for sports injuries as a form of legal doping. “Improvement of performance attained with the assistance of homeopathy is extremely efficient” 53. This has nothing in common with what doping is normally defined by, but refers to a release and activation of the innate forces within, that have the ability to enhance the positive properties that in the organism of the athlete are fallow. Legal doping as Laubender53 calls it, the increase in efficiency, means an improvement of the weaknesses of the constitution and a balancing of the mind and spirit. Homeopathy utilised to increase performance stands for “regulation and optimization of physical functions and disengagement from mental disturbances”53. Homeopathy, in the common sense, is not valid as an agent for pain relief. The phenomenon of pain is known to be a correlation of physical and psycho-neural pain-perception. Homeopathy may therefore positively influence harmonisation of mood and mind and may as such reduce the sensitivity to pain in the patient53.
The relevance of homeopathic prescribing in competitive sports is continually increasing, and yet is subject to a tightrope walk. As doping restrictions have become more rigorous and conventional medicine has less potent medication at its disposal, homeopathic influence in the treatment of sports injuries has become more and more important. Homeopathic remedies are, due to their high dilutions, devoid of detectability in doping analyses. But, the utilisation of substances on the red list of the doping association, even in homeopathic preparations, is prohibited55. Whilst in the professional sector, tournament timetables and competition schedules prevent adequate regeneration of the athlete; in lay sports the absence of knowledge of professional workout is what often provokes injuries55. Whilst professional sport is becoming increasingly aware of homeopathic treatment options, it is in the lay sector that homeopathy has no place of existence at present56 10.
In opposition to the sports professional, for whom his body is a form of equity capital, the average individual practicing leisure sports pays less attention to the symptoms expressed in his physique10. Most patients are not accustomed to observing themselves57. This could explain why complex prescriptions have become increasingly popular. Because of the combination of a number of remedies in such a complex-preparation, a variety of symptom-pictures may be covered by the different remedies4 11 6, and the interrogation into the idiosyncrasy of the patient may be omitted10. The prescription here follows the idea that “something will probably work”57.
Underlying any study or trial on homeopathy, be it condition or remedy specific, is the overall discussion and debate concerning the general acceptance of the efficacy of homeopathy. As long as this controversy exists, all studies pro and contra homeopathic effectiveness will find large opposition; and will be subject to objection due to methodological deficiency and bias. The investigative review of existent meta-analyses did not clarify further in this matter or offer a different conclusion. Unless a more specific system of clinical investigation techniques is incorporated, that takes into account the homeopathic treatment approach and respects the holistic understanding of the therapeutic perspective undertaken in a homeopathically conducted treatment, there will remain uncertainty and bias to errors35. This dissonance is not resolved. “Either homeopathy works or the clinical trial does not”50. Yet, it should not be neglected to mention repeatedly, that all forms of studies and trials, alternative and conventional, have space for imperfection and lapse46 41. For homeopathy this means that beyond the clinical study framework it is necessary to focus on the verification of homeopathic provings in the healthy and to confirm these findings in daily practice43.
“Popularity does not, of course, prove efficacy” 44 (p.587), and the efficacy in practice is not necessarily, yet, comprehended in its mechanism41. Patients do experience recovery and improvement following homeopathic treatment even though the imminent scientific proof for the efficacy of homeopathy is absent44 58. Homeopathy is frequently chosen as a therapy to follow on the failure of a conventional therapeutic intervention59. It is considered a safe form of treatment59 that has no side-effects60 11 54.
The motivation of sports persons, professional and lay alike, to seek alternative and especially homeopathic treatment, is the “inaptitude of conventional medicine to achieve a restoration of health to the original state”10 , to that state of health prior to the infliction with the illness or disease. Patients seek a treatment that focuses on attaining a diagnosis that incorporates individual, qualitative factors, and is met with a therapy that takes into consideration mental, emotional and physical factors, and does not neglect to incorporate the social environment of a patient27.
In practice there is no question of the efficacy of homeopathy, and the overall reporting on homeopathy for sports injuries, in the written media, is of a positive nature. Public opinion sees in homeopathy a modern therapeutic tool for health restoration. Beyond the terrain of the conventional health system, homeopathy is seen as an integration of “Man into his eco-system”61.
What has become evident though is that a quality criterion for a practicing homeopath has become his mode of prescribing. The indirect suggestion, to see the prescription of complex preparations as indication of a treatment of lesser quality13 57 has not been verified by other literature on the subject. But, according to Zittlau57 the association of classical homeopaths in Germany, on their checklist of criteria of what should make up a homeopathic treatment, point out that only a single remedy should be prescribed by a practitioner. In the research for this dissertation it has been noticed that the complex-preparation prescriber is largely the conventionally trained general practitioner that is prescribing homeopathically9 8 4 13 55. The information collected on classical homeopaths’ experience in practice illustrates that practitioners generally prescribe, taking into account individual features of a patient, and prescribe single remedies rather than combination formula50 62 52 63.
The controversy remains. The nonpareil cannot be measured using clinical studies57, but experience in practice confirms with successful treatments what studies and trials have largely not verified. Professional athletes are setting the example. They seek a holistic treatment which swiftly and gently treats their injuries and enhances their performance27. It stands without question that the physique is influenced by the psyche and often “the difference between winning and losing is the champion´s mental clarity and emotional resilience”64. With homeopathy there is a tool that sees this connection and takes into account the patients individual holistic constitution64. “Mens sana in corpora sano – a healthy spirit rests in a healthy body”27 and vice versa!
This article was originally submitted for the award of the BSc Homeopathic Medicine (University of Central Lancashire, Preston, U.K.) where the author is currently a student on the MSc Homeopathy by e-learning program (see http://www.uclan.ac.uk/information/courses/msc_homeopathy_by_elearning.php)
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