The evidence base in Anthroposophic Medicine

Anthroposophic Medicine (AM) is a European system of medicine (1) which turned one hundred years old in 2020 (2). It is an integrative system that includes the human being in their physical, living-functional, soul and spiritual dimensions in the diagnosis and in the resulting therapy concept. AM extends evidence-based medicine through various forms of therapy based on an anthroposophical understanding of the human being, such as eurythmy therapy and other movement and body therapies, art therapies, psychotherapy and biography work. Specific medicinal products and external applications such as Einreibung, compresses and wraps are a pillar of the therapy.

Therefore both the whole medical system (3) and individual therapeutic measures are the subject of investigation in AM research, with the establishment of the "evidence house" as a modern and innovative approach (4). Evidence-based methods are used as well as force effects that are not (yet) measurable in an established way with technical methods, but which can be scientifically investigated (5). Benefit evaluation plays an essential role here (6).

Other research aspects include measuring quality of care specific to AM (7), the action of AM medicinal products – which exhibit excellent safety, but some with so far limited evidence regarding clinical benefit (8) – and the measurement of regulatory processes (9). There are 500 publications under the search query "Anthroposoph* AND Medic*" in the PubMed® database. Specific AM interventions such as eurythmy therapy (10) require separate searches.

Anthroposophic Medicine was also academically oriented from the beginning, something which is reflected in the numerous dissertations and postdoctoral theses: https://medsektion-goetheanum.org/fileadmin/user_upload/pdf/Dissertations_and_thesis_on_Anthroposophic_Medicine_2021.pdf.

To date, basic research in AM has been devoted in particular to the pharmacological mode of action of medicinal substances and the preclinical phase. It is undertaken by the anthroposophical pharmaceutical manufacturers Weleda, WALA, Helixor, Abnoba and others. An excellent example of such publications is provided by the Verein für Krebsforschung (Association for Cancer Research): https://www.vfk.ch/science/scientific-information/publications.

Short expert reviews on research methodology, fields and institutes can be found at: https://medsektion-goetheanum.org/forschung/research-in-anthroposophic-medicine.

In March 2023, the WHO Benchmarks for Training in Anthroposophic Medicine were published by the World Health Organisation. This made publicly binding the already existing practice in all AM training and further training professions that there should be knowledge transfer from AM research, and that its scientific foundations and methodologies should be understood.

The original WHO publication can be found at: https://apps.who.int/iris/bitstream/handle/10665/366645/9789240067431-eng.pdf.

The methodology of clinical research is a focal point of Anthroposophic Medicine (11). In addition to using established methods, innovative ones have also been developed: for example, combined bias suppression in single-arm therapy trials (12) and systematic comparison of the order of magnitude of single-arm cohorts with corresponding therapy cohorts (13). Other research has looked at the methodology of the individual case (14, 15):

Medicine consists of individual cases. Case reports have an important place in medicine and provide relevant information that complements data from clinical trials. They are often the first presentation of discoveries: new diseases, new therapies, new perspectives in pathogenesis, innovative diagnostic procedures. Another area is side effects. About 40 percent of all side effects are revealed through case reports (16). They can examine the applicability of clinical guidelines in clinical practice and contribute to their implementation.

Medical training and the development of expertise and specialist knowledge also depend on learning from cases; even hazard ratios from randomised controlled trials and meta-analyses need to be linked to stories to make them memorable (17, 18).

As the quality and transparency of case reports is often insufficient, recommendations for training and publication have been published. In addition, an international group of researchers, medical editors and clinicians has come together to develop consensus-based publication guidelines for writing case reports – in which anthroposophical colleagues have been involved (19, 20, 21, 22, 23, 24). Many case reports on Anthroposophic Medicine, especially on mistletoe therapy, have been written in accordance with these recommendations. Examples: (25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, -36).

At evidence levels IIIa, IIIb and IV, AM has a well-documented high level of competence. For examples of AM studies with higher levels of evidence, see 5.

A basis for the assessment of efficacy is the literature review of the Swiss Complementary Medicine Evaluation Programme (Programm Evaluation Komplementärmedizin, PEK), updated in 2011, in the sense of a Health Technology Assessment (HTA). This has resulted in 70 new clinical trials and a total of 265 clinical trials, 253 of which had positive results for AM interventions (37). The spectrum of indications was broad and the patient population typically showed a preference for complementary medicine interventions (6). The Anthroposophic Medicine Outcomes Study (AMOS) prospectively investigated anthroposophic therapies in 1631 patients with various indications. Twenty-one publications documented the efficacy (38). In particular, outpatients who received AM therapy for chronic conditions showed significant and sustained improvements in disease symptoms and health-related quality of life (39).

Eurythmy therapy shows positive results in a systematic literature review (11 publications of 5 studies), but with great variation (10).

Another source is the evidence review of the German S3 Guideline for Complementary Medicine in the Treatment of Oncological Patients (40), which integrates a large number of studies and systematic literature reviews on mistletoe therapy (6).

Below we outline 13 studies of different types and levels of evidence; with Ib represented as the highest level.

• Kienle GS, Glockmann A, Grugel R, Hamre HJ, Kiene H. Klinische Forschung zur Anthroposophischen Medizin – Update eines „Health Technology Assessment“-Berichts und Status Quo. Forschende Komplementärmedizin 2011;18(5):269–282. DOI: https://doi.org/10.1159/000331812.
  • Study type: Systemic review.
  • An overview and evaluation of a total of 265 studies on the efficacy of Anthroposophic Medicine or on special therapeutic procedures of Anthroposophic Medicine.
  • Result: Studies of different design and quality describe a medically good treatment outcome for AM and a satisfactory, safe and presumably also cost-effective treatment outcome for patients in a large number of diseases.
    
    
• Hamre HJ, Kiene H, Ziegler R, Tröger W, Meinecke C, Schnürer C, Vögler H, Glockmann A, Kienle GS. Overview of publications from the anthroposophic medicine outcomes study (AMOS): a whole systems evaluation study. Global Advances in Health and Medicine 2014;3(1):54–70. DOI: https://doi.org/10.7453/gahmj.2013.010.
  • Study type: Review.
  • The Anthroposophic Medicine Outcomes Study (AMOS) was a prospective, multicentre observational study of 1631 outpatients who had started anthroposophic therapy for anxiety disorders, asthma, attention deficit hyperactivity disorder, depression, lower back pain, migraine and other chronic indications under routine conditions in Germany.
  • Result: Anthroposophic treatment was safe and associated with clinically relevant improvements in symptoms and quality of life without increasing costs; improvements were seen in all age, diagnosis and treatment groups and were maintained after 48 months.
    
    
• Hamre HJ, Fischer M, Heger M, Riley D, Haidvogl M, Baars E, Bristol E, Evans M, Schwarz R, Kiene H. Anthroposophic vs. conventional therapy of acute respiratory and ear infections: a prospective outcomes study. Wiener Klinische Wochenschrift 2005;117(7/8):256–268. DOI: https://doi.org/10.1007/s00508-005-0344-9.
  • Study type: Prospective outcome study.
  • The study compares anthroposophical and conventional medical treatment of acute respiratory and ear conditions in terms of disease progression, drug use and safety, and patient satisfaction. 29 GP practices in Germany, Great Britain, the Netherlands, Austria and the USA participated.
  • Result: Compared to conventional medical treatment, anthroposophical treatment of GP patients with acute respiratory or ear conditions achieved more favourable disease courses, lower antibiotic prescription rates and fewer drug side effects with higher patient satisfaction.
    
    
• Hamre HJ, Glockmann A, Schwartz R, Riley DS, Baars EW, Kiene H, Kienle GS. Antibiotic use in children with acute respiratory or ear infections: prospective observational comparison of anthroposophic and conventional treatment under routine primary care conditions. Evid Based Complement Altern Med. 2014; Article ID 243801. DOI: https://doi.org/10.1155/2014/243801.
  • Study type: Observational study.
  • Children with acute respiratory or ear infections (RTI/OM) are often prescribed antibiotics unnecessarily. Antibiotic resistance is a major public health problem. Anthroposophical treatment of RTI/OM includes anthroposophic medicines, non-drug therapies and, if necessary, antibiotics. This secondary analysis of an observational study included 529 children <18 years of age from Europe or the USA whose caregivers had chosen to consult physicians who offered anthroposophic (A) or conventional (C) treatment for RTI/OM. During the 28-day follow-up period, 5.5 percent of the A patients and 25.6 percent of the C patients were prescribed antibiotics.
  • Result: Compared to C patients, significantly fewer conventional painkillers were used in A patients and the symptoms subsided somewhat faster.
    
    
• Plangger N, Rist L, Zimmermann R, von Mandach U. Intravenous tocolysis with Bryophyllum pinnatum is better tolerated than beta agonist application. European Journal of Obstetrics & Gynecology and Reproductive Biology 2006:124(2):168–172. DOI: https://doi.org/10.1016/j.ejogrb.2005.05.013.
  • Study type: Retrospective study.
  • The aim of the study was to compare the tolerability and the labour-inhibiting effect of the intravenously infused plant extract Bryophyllum pinnatum with conventional labour inhibitors (betamimetics). A retrospective study compared 67 pairs of pregnant women with preterm labour treated with intravenous bryophyllum or with betamimetics.
  • Result: In the treatment of preterm labour, the anthroposophical bryophyllum preparation used is no less effective than beta agonists, but is clearly better tolerated.
    
    
• Tröger W, Galun D, Reif M, Schumann A, Stankovic N, Milicevic M. Quality of life of patients with advanced pancreatic cancer during treatment with mistletoe – a randomized controlled trial. Deutsches Ärzteblatt International 2014; 111(29–30):493–502. DOI: https://doi.org/10.3238/arztebl.2014.0493.
  • Study type: Randomised controlled phase III trial.
  • Treating cancer patients with mistletoe extract is intended to prolong their survival and, above all, improve their quality of life. The study investigated whether mistletoe extract can improve the quality of life of patients with advanced pancreatic cancer. An open, blinded so-called phase III study was conducted at a therapy centre. Two hundred and twenty patients with locally advanced or metastatic pancreatic cancer, who received no other treatment apart from the best possible support, were enrolled in this study.
  • Result: In patients with locally advanced or metastatic pancreatic cancer, mistletoe therapy significantly improves quality of life and survival compared to best supportive care alone.
    
    
• Schad F, Thronicke A, Steele ML, Merkle A, Matthes B, Grah C, Matthes H. Overall survival of stage IV non-small cell lung cancer patients treated with Viscum album L.in addition to chemotherapy, a real-world observational multicenter analysis. PLoS One. 2018;13(8):e0203058. DOI: https://doi.org/10.1371/journal.pone.0203058.
  • Study type: Multicentre observational study.
  • The aim of this study was to investigate the effect of mistletoe therapy in addition to chemotherapy on the survival of patients with stage IV NSCLC. The observational study was conducted using data from the clinical registry of the Oncology Network, an accredited joint clinical registry of German oncology clinics, general practitioners and outpatient centres.
  • Result: Overall survival was significantly prolonged in the mistletoe therapy group. Overall survival rates after one and three years were higher with chemotherapy plus mistletoe therapy than with chemotherapy alone. This suggests that adjuvant mistletoe therapy is positively associated with survival in patients with stage IV NSCLC treated with standard chemotherapy.
    
    
• Alm JS, Swartz J, Lilja G, Scheynius A, Pershagen G. Atopy in children of families with an anthroposophic lifestyle. Lancet 1999; 353(91630):1485–1488. DOI: https://doi.org/10.1016/S0140-6736(98)09344-1.
  • Study type: Comparative cross-sectional study.
  • People who live an "anthroposophical lifestyle" use antibiotics and conventional painkillers more cautiously, are vaccinated less often and have a healthier diet in terms of their own intestinal flora. The aim of this study was to investigate the frequency of neurodermatitis and bronchial asthma ("atopy") in children with an "anthroposophical lifestyle".
  • Result: The frequency of atopic diseases in children from families with an anthroposophical lifestyle is lower than in children from other families. The study caused quite a stir among experts because it was the first to show how much the incidence of asthma and neurodermatitis is also influenced by the environment, diet and the use of antibiotics in early childhood.
    
    
• Swartz J, Lindblad F, Arinell H, Theorell T, Alm J. Anthroposophic lifestyle and salivary cortisol are associated with a lower risk of sensitization during childhood. Pediatric, Allergy and Immunology 2015;26(2):153–160. DOI: https://doi.org/10.1111/pai.12342.
  • Study type: Comparative study.
  • The aim of the study was to investigate the influence of an anthroposophical lifestyle at the age of six months on allergy sensitisation up to the age of five years. A total of 507 families from maternal health centres participated. The parents' lifestyle was categorised as anthroposophical, partly anthroposophical or non-anthroposophical.
  • Result: Children from families with an anthroposophical lifestyle have a lower risk of developing allergic sensitisation by the age of five than comparison children. This risk is partly explained by a lower stress level with an anthroposophical lifestyle in infancy.
    
    
• Ostermann T, Appelbaum S, Poier D, Boehm K, Raak C, Bussing A. A systematic review and meta-analysis on the survival of cancer patients treated with a fermented Viscum album L. extract (Iscador): an update of findings. Complementary Medicine Research 2020;27(4):260–271. DOI: https://doi.org/10.1159/000505202.
  • Study type: Systematic review.
  • The aim of the study was to update the assessment of the efficacy of the anthroposophical mistletoe preparation Iscador® in controlled trials on the overall or event-free survival of cancer patients. Methodologically, leading medical databases were searched for clinical trials with cancer patients treated with Iscador. Eighty-two controlled studies met the inclusion criteria.
  • Result: Overall, the studies support a positive therapeutic effect of mistletoe therapy. Significant differences were found between cancer types (p < 0.01), with the strongest positive effects for cervical cancer and less strong effects for lung cancer. The so-called adjuvant treatment of cancer patients with anthroposophical mistletoe therapy can therefore be associated with better survival.
    
    
• Vagedes J, Fazeli A, Boening A, Helmert E, Berger B, Martin D. Efficacy of rhythmical massage in comparison to heart rate variability biofeedback in patients with dysmenorrhea – A randomized, controlled trial. Complementary Therapies in Medicine 2019; 42: 438-444. DOI: https://doi.org/10.1016/j.ctim.2018.11.009.
  • Study type: Randomised controlled trial.
  • A significant proportion of all women suffer from menstrual pain (dysmenorrhoea). The standard treatment for primary dysmenorrhoea (PD) is painkillers such as ibuprofen and oral contraceptives ("the pill"), which are effective but not without side effects. This study investigated the effectiveness of rhythmical massage ( Anthroposophic Medicine) and heart rate variability biofeedback compared to ordinary care (control group) on pain intensity in women with primary dysmenorrhoea.
  • Result: There was a significant difference between the rhythmical massage group and the control group after three months (p = .005). In contrast, no significant differences were found between rhythmical massage and biofeedback and between biofeedback and the control group. The preliminary results suggest that rhythmical massage can improve the pain intensity of menstrual pain after 12 weeks compared to usual care.
    
    
• Oei SL, Thronicke A, Kröz M, von Trott P, Schad F, Matthes H. Impact of Oncological Therapy and Viscum album L. Treatment on Cancer-Related Fatigue and Internal Coherence in Nonmetastasized Breast Cancer Patients. Integrative Cancer Therapies 2020;19:1534735420917211. DOI: https://doi.org/10.1177/1534735420917211.
  • Study type: Longitudinal real-world study.
  • The aim of this study was to investigate the effect of mistletoe therapy on symptom severity during cancer therapy in breast cancer patients. A longitudinal study was conducted using data from the Oncology Network clinical registry. Chemotherapy, conventional immunological and hormonal therapies were found to cause a worsening of 17, 17 and 6 points respectively in the applied test scale for fatigue, while mistletoe therapy caused an improvement of 12 points.
  • Result: It may be concluded that in this practical study, additional mistletoe therapy had an alleviating effect on cancer-related fatigue and insomnia, and a supporting effect on physical functioning and thermocoherence.
    
    
• Kröz M, Quittel F, Reif M, Zerm R, Pranga D, Bartsch C, Brinkhaus B, Büssing A, Gutenbrunner C on behalf of the CRF study group: Four-year follow-up on fatigue and sleep quality of a three-armed partly randomized controlled study in breast cancer survivors with cancer-related fatigue. Scientific Reports 2023;13(1):2705. DOI: https://doi.org/10.1038/s41598-022-25322-y
  • Study type: Three-armed, partially randomised and controlled study.
  • Result: In this study with breast cancer patients without metastases but with CRF, the long-term effects of anthroposophical treatment with sleep education, psychoeducation, eurythmy and painting therapy (multimodal therapy) were compared with endurance exercise – the recommended standard treatment – as well as the effects of a combination therapy of multimodal therapy plus endurance exercise. Anthroposophical CRF treatment was shown to be sustainably superior to standard therapy, both without and with endurance exercise. The affected women were followed up for four years.

Other relevant fields of research are antibiotic resistance and fever management; areas where Anthroposophic Medicine can show effective alternatives (41, 42).

Correspondence address
Dagmar Brauer
Research Associate
Medical Section at the Goetheanum
School of Spiritual Science
Postfach
4143 Dornach, Switzerland
Email: dagmar.brauer@medsektion-goetheanum.ch

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