The Nature Cure

by Andreas Michalsen

  THE EFFECTIVENESS OF LEECH THERAPY

  I couldn’t stop thinking about the many successes in treating osteoarthritis of the knees that I experienced during my time at the Moabit Hospital. Many years later, when I was at the Department for Internal and Integrative Medicine at the University Hospital in Essen, I got the opportunity to do research on medicinal leeches. I wondered if it was possible I was misremembering the effectiveness of the therapy. It’s easy to forget treatment courses that weren’t quite so successful, and patients whom you couldn’t treat effectively often don’t return to the hospital—and so they stay out of one’s personal focus. I wanted to actually examine the efficacy of leech therapy with a critical eye.

  I planned an initial pilot study with a total of sixteen patients who suffered severe discomfort from osteoarthritis of the knees. Ten of them agreed to receiving leech therapy; six preferred the standard treatment involving intensive medical gymnastics, physical therapy, manual treatments, as well as massages. At the beginning of the study we asked all participants to evaluate their pain on a scale from one to ten and to repeat this evaluation daily. They did this up until four weeks after the treatment was finished.

  The results were surprisingly conclusive. In the ten patients who received leech therapy, the therapy’s effect was so pronounced that their discomfort was reduced immensely. Instead of a seven, they evaluated their pain at a one. The conventional physical therapy also brought relief, but much less so. Subsequently, I wrote a scientific report and sent it to the renowned British journal Annals of the Rheumatic Diseases.9 Its publishers very much wanted a photo of the leech therapy. After I had given it to them, they published it on the front cover. The media response was accordingly big, even though it was just a small study.

  I particularly enjoy remembering the first patient of this study, a gentleman well into his eighties, who had been gravely restricted in his mobility because of his knee ailment. He was a little doubtful about this therapy, but he was ready to try anything. I asked him to get in touch one year after the study and was surprised to hear that he was still mostly pain-free at that point. He no longer required a walking stick, which he needed before the therapy. The surgery he had been contemplating before leech therapy—a total endoprosthesis of the knee—was no longer an option on the table.

  Since the results of the pilot study were so promising, I made plans for a follow-up study on a larger scale. The second study was designed to have a solid structure with a longer follow-up observational period of three months, extensive questionnaires, and a higher scientific standard. This time fifty-one patients participated. It was determined at random which patients would receive treatment with leeches and which patients, the control group, would receive an anti-inflammatory cream (Diclofenac) to be applied to the skin several times a day for pain relief. The start of the study was widely reported in the media, expectations were high, and in order not to disappoint the patients who were assigned to the control group we gave them the option of also receiving treatment with leeches after the study had been terminated. In research jargon, this is called waitlist design.

  The results were impressive. Not only did pain decrease this time, but we were also able to demonstrate continued improvement of knee joint function, and, as a result of these two things, an improvement of the patients’ quality of life. This time, the study was published in the American journal Annals of Internal Medicine.10 Even the “Bible” of science, Nature magazine, reported on it.11 Magazines like these, which review studies before publication, are of great importance for international scientific recognition. Of course, where scientific news is concerned, it’s also a matter of whether the news can be visualized well. Luckily that was the case for us, because television crews from channels such as the BBC and the Discovery Channel came by to film this exotic therapy in our naturopathic clinic in Essen.

  A short while later, another team of researchers at the University Hospital in Aachen conducted an even bigger study on leech therapy in osteoarthritis of the knees.12 In order to determine the placebo effect precisely—the effect that is only caused by the atmosphere, the doctors’ friendliness, and the application of the leeches (independent of the substances they release)—this study was single-blinded. This meant that one group actually received leeches as treatment, the other group received a minuscule cut in the skin and a thick bandage—both groups received treatment with a “dressing screen” in between. The patients in question would not be able to tell who got what, neither from pain nor the puncture site. Not only did the study demonstrate that leech therapy had a strong effect, it also showed that the benefits go beyond the placebo effect: The group that received the leeches did notably better than the other group afterward.

  On average, 80 percent of leech therapy patients experience a pain reduction of more than half (60 percent on average), three days after a one-time therapy with four to six leeches on the knee. In more than two thirds of patients, this effect persists for more than three months. Almost half the patients (45 percent) use less pain medication after ten months.13 Ultimately this means that the effect leeches have—and this should be said quite plainly here—exceeds the effectiveness of all traditional pain-relieving therapies for osteoarthritis of the knees known today by far. In many cases, pain medication can even be discontinued, and side effects can thus be reduced.

  PATIENT HISTORY

  Arthrosis

  Exercise Can Overstrain the Body

  An active life is healthy, but strenuous exercise also has its price. A forty-three-year-old woman, a former professional athlete who now managed a hotel, visited our clinic. After retiring from her sports career, she had continued to work out a lot. But at some point, her knees began to ache. Soon the pain increased. Neither physical therapy nor pain medication worked. She walked around on crutches for almost half a year. At home she took it easy following her orthopedist’s advice, who had recommended rest and elevating the legs. She restructured her job as the manager of a hotel in such a way that she was able to do most of her work at the desk. But the lack of exercise made her nervous. At night, the patient only slept at irregular intervals.

  The orthopedist suggested a retrieval of endogenous stem cells, preparing and subsequently injecting them back into the knee so as to cause new cartilage cells to grow—one of the many more recent therapeutic approaches in orthopedics, but with an uncertain success rate. Other conventional treatments involve cortisone injections or knee arthroscopy to remove cartilage. But this carries a considerable risk of infection. Moreover, extensive studies have shown that a knee arthroscopy is no more effective than a placebo procedure.14 A relative advised the former athlete to exhaust all other possibilities before opting for surgery. That’s how she came to us, and to the leeches.

  We attached six leeches to her left knee. They were still drinking when the swelling in her joint began to noticeably recede. The wounds kept bleeding for twenty-four hours afterward—but the patient was already free of pain, experiencing no discomfort. The effect usually lasts for three to six months, after which the treatment has to be repeated. This patient was pain-free for almost two years after a single treatment. The leeches’ saliva cannot get rid of the arthrosis itself, of course, but it contains pain-relieving and anti-inflammatory substances. Our assumption is that the active ingredients reach the entire area of the joint and its surroundings—ligaments, tendons, and muscles around the bite—so that the patient was able to move more freely immediately after having received the treatment. The animals surely also cause a placebo effect. It does look spectacular, after all, when they attach and drink in the rhythm of the heartbeat.

  Today, the athlete goes to the gym three times a week and has become an enthusiastic fan of the leeches: She has sent acquaintances and friends to us—and even her mother. In her sixty-nine-year-old mother, the pain hasn’t disappeared completely, but her condition has improved. That’s why she is going to come back next spring—to
us “bloodsuckers,” as she calls us affectionately.

  HOW TO APPLY LEECHES

  So how exactly is leech therapy carried out? First, the site that is to be treated should be cleaned with water—and only water—since leeches don’t like aromatic substances and disinfectants and won’t bite if those are applied. If the skin in the treatment area is cool and pale, the circulation of that area should be increased with a hot bath or hot patches. The leech is then positioned onto the area gently. It’s best to do this by hand, while wearing gloves. Forceps should only be used in exceptional cases so as not to unnecessarily torture or injure the leech. To prevent the leech from wandering from the treatment area, a small shot glass or cupping glass can be placed over it. Once the leech has bitten, you leave it undisturbed until it detaches by itself, usually after twenty to sixty minutes.

  The wound is then dressed loosely with thick cotton dressing or a large, absorbent compress so that the ensuing bleeding isn’t hindered. The site of the bite should be checked by a doctor the following day. Cooling methods, such as a cold pack or a quark poultice, relieve potential itching or redness.

  Leech therapy can be repeated—at an interval of four to six weeks, or when the effect has worn off—and is an effective long-term treatment method for treating arthroses. But if a patient doesn’t respond after three treatment attempts, success is unlikely. In practice, treating the affected joints in patients with arthrosis at least twice a year has proven successful.

  RHIZARTHRITIS, TENDINITIS, AND BACK PAINS

  There have been other medical successes with leeches: We conducted a study on their effectiveness in the treatment of rhizarthritis—arthrosis of the thumb joint. This ailment affects many people, especially women over the age of fifty. The treatment options are quite limited, usually surgery to preserve function of the joint is required sooner or later. Here, leeches showed a clear superiority to the Diclofenac control group. We were able to publish the results in the renowned journal Pain.15 This heralded a renaissance of an ancient therapy.

  Subsequently, we were also able to demonstrate the effectiveness of leech therapy in the treatment of tennis elbow (epicondylitis), a very painful tendinitis that can occur as a result of chronic excessive strain after sporting activities, but that can also be occupational.16 In 2016, when I was already working at the Immanuel Hospital in Berlin, my group and I conducted a study on the effectiveness of leech therapy in the treatment of chronic lower back pain: The results were published in 2018 in the journal of the German Medical Association (Deutsches Äerzteblatt) and again, leech therapy showed a considerable advantage over conventional therapeutic exercise in this common ailment.17

  But where does leech therapy go from here? The findings of all studies on osteoarthritis of the knees have been summarized in a metanalysis by Gustav Dobos and his team in Essen; these are statistical examinations that calculate procedural differences with the aim of reaching an overall evaluation.18 In light of this data, which is in favor of using leeches, medical insurance companies should be inclined to cover the funding of this therapy for the treatment of arthroses and pain. In the overall evaluation, leeches have proven to be the best possible pain-relieving therapy for painful arthroses—better than antirheumatics, pain medication, or certain surgeries. But despite the scientific evidence available, the prejudices against this “archaic” therapy are hard to overcome. That’s why many of my patients are still forced to pay for the treatment out of their own pocket, while the costs of orthopedic injections, arthroscopies, and other technical interventions, which are by no means more effective, are covered. I hope that we can eventually overcome our biases against leeches, so that more of us can take advantage of their incredible healing power.

  CUPPING: A CLASSICAL HEALING METHOD REDISCOVERED

  After realizing the efficacy of leeches, I became curious. Could there be something to other “archaic” treatment methods? Cupping, for example? Reports about its positive effect on pain, dizziness, or inflammation of the joints can be found in all traditional healing systems—in Tibetan, Chinese, Indian, Greco-Roman, Arabic, and Medieval European medicine.19 That said, skeptics of naturopathic methods would argue that a treatment method’s long tradition doesn’t attest to its effectiveness.

  This is a worthwhile question to consider. But I think it is hasty of us to completely dismiss a treatment method when a procedure has endured for such a long time and has a history of demonstrated success in folk medicine. Cupping, in particular, also isn’t as implausible as critics say. The operating principle of the cupping glasses is negative pressure, which is caused when the glass cools off or by pumping out the contained air through a rubber ball. The negative pressure lifts the top layer of the skin off the deeper-lying layers, which increases the blood flow locally and stimulates the lymph flow. At the same time, cupping also affects areas that are farther removed through certain neural pathways.

  But studies that have systematically tested the potential applications of cupping are still rare. At the Moabit Hospital, a research group headed by Malte Bühring examined the effect of wet cupping.20 In wet cupping, a small incision is made into the skin before the cupping glass is placed onto it. Over the next ten to fifteen minutes, the glass becomes filled with a mixture of blood and lymphatic fluid. The cupping glasses can be applied to different zones such as the back, neck, or hip. What is fascinating is that a treatment carried out on the shoulder can have an effect on carpal tunnel syndrome (pain in the wrist). But in naturopathy, phenomena like this is not uncommon. Anatomically speaking, such reflex zones, i.e., skin, muscle, and connective tissue zones that span the entire surface of the body, have been proven more than a hundred years ago.21 So, it is possible to experience pain in the shoulder blade when suffering from biliary colic, or discomfort in the lower back when suffering from inflammation of the bladder. And that’s why a treatment at the neck and the shoulder can have an effect on the hands.

  Reflex Zones for Massage Cupping Therapy

  Given the connected effects of these reflex zones, I wanted to take a closer look at the issue of carpal tunnel syndrome. The carpal tunnel is a narrow passageway in the wrist, between the carpal bones and connective tissue. Several tendons pass through it, as well as the hand’s most important nerve, which controls various muscles and regulates the sensory function of the thumb, the index finger, and the middle finger. Injuries, hormonal disorders, rheumatism, or diabetes can cause the tunnel to become narrow and damage the nerve. This leads to symptoms like numbness or tingling in the hands or pain while gripping. This condition often requires surgery. I, on the other hand, wanted to treat this ailment traditionally, with cupping.

  My research group conducted another study. The first group of participants was treated with wet cupping. The second group received a pleasant heat pack on the shoulder. One week later, the results were unambiguous: Cupping led to a very clear relief of the symptoms—not only did the pain diminish, but the sensory dysfunction had diminished as well.22 Other research teams were able to demonstrate the effectiveness of cupping in neck and back pain and even in osteoarthritis of the knees.23, 24, 25

  Incidentally, dry cupping that requires no incision in the skin is quite simple; you can buy the necessary cupping glasses in pharmacies or online. Any two people can carry out dry cupping treatment on each other. Another relaxing and pain-relieving treatment is massage cupping therapy, which has its origins in Chinese medicine: A single cupping glass is moved over oiled skin in a state of negative pressure. Wet cupping, however, should always be carried out by a professional.

  THE DUAL BENEFIT OF DONATING BLOOD

  After cupping proved to be successful, I decided to take matters to the “extreme.” Bloodletting has enjoyed a truly bad reputation in modern medicine. Even though there were enough sources that indicated a reasonable and productive practice in ancient Greece and Rome, this practice became widely misused during the eighteenth and nineteenth centuries.26 Patients were
drained of blood at dangerously high levels. A famous victim of this malpractice was George Washington, whose doctors extracted over one and a half liters of blood from him when he had acute laryngitis in 1799, which may have contributed to his death a few days after the procedure. His doctors thought that they could get rid of the “foul fluids” which, in their opinion, had caused the infection.27

  Did it even make sense to bother examining a therapy of such ill repute in a scientific manner? Well, years before, I had done some research on whether concentrated or less concentrated, i.e., “thick” or “thin” blood influenced a person’s health. I noticed that there was a lot to be said in favor of blood thinning, because blood thinning leads to a lower red blood cell count, decreasing the risk of heart attack and stroke.28 Scientists suspect that menstrual bleeding has something to do with the fact that women who have not yet gone through menopause suffer heart attacks or strokes less frequently than men, though this assumption has never been proven conclusively.29

  And there were more and more indications that people with excess red blood cells could benefit from bloodletting. For example, in 1991, the hematologist Jerome L. Sullivan published an article entitled “Blood Donation May Be Good for the Donor.”30 I decided to go back to the sources—as I had been taught to do. In the translated writings of the Greek physician Galen, I found clear indications on bloodletting: Patients with a propensity for strokes, who are red-faced and overweight, would benefit from this procedure.31 I also discovered a doctoral thesis, supervised by Walter Zidek, currently tenured professor for Hypertensiology and Nephrology at the Charité Hospital. This thesis proved that bloodletting can have an antihypertensive effect in people who have undergone a kidney transplant and whose blood pressure cannot be controlled by medication.32 I contacted my colleague immediately. Zidek confirmed those findings but he also pointed out that he thought the effort it required was too great to treat high blood pressure with bloodletting.