Edzard Ernst

MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

Project 2025 is a set of proposals from the US Heritage Foundation to reform the US according to right-wing ideology and to consolidate executive power should the Trump win the 2024 presidential election. The project is a most frightening blueprint for fascism in the US and would have serious implications for the rest of the world. It would also profoundly impact on healthcare (my expertise) in multiple ways.

Here are some of them:

According to Project 2025, the federal government should prohibit Medicare from negotiating drug prices and promote the Medicare Advantage program, which consists of private insurance plans. Federal healthcare providers should deny gender-affirming care to transgender people and eliminate insurance coverage of the morning-after-pill Ella. Project 2025 also suggests a number of ways to cut funding for Medicaid, such as caps on federal funding, limits on lifetime benefits per capita, and letting state governments impose stricter work requirements for beneficiaries of this program. Other proposals include limiting state use of provider taxes, eliminating preexisting federal beneficiary protections and requirements, increasing eligibility determinations and asset test determinations to make it harder to enroll in, apply for and renew Medicaid, providing an option to turn Medicaid into a voucher program, and eliminating federal oversight of state medicaid programs.

Project 2025 insists that life begins at conception. The Mandate says that the Department of Health and Human Services (HHS) should “return to being known as the Department of Life”. Project 2025 says it would reposition department policies “by explicitly rejecting the notion that abortion is health care and by restoring its mission statement under to include furthering the health and well-being of all Americans ‘from conception to natural death’.”

The project opposes any initiatives that, in its view, subsidize single parenthood. Project 2025 encourages the next administration to rescind some of the provisions of the Family Planning Services and Population Research Act of 1970, which offers reproductive healthcare services, and to require participating clinics to emphasize the importance of marriage to potential parents.

According to Project 2025, the Food and Drug Administration is “ethically and legally obliged to revisit and withdraw its initial approval” of the abortion pills mifepristone and misoprostol. It recommends that the Centers for Disease Control and Prevention “update its public messaging about the unsurpassed effectiveness of modern fertility awareness-based methods” of contraception, such as smartphone applications that track a woman’s menstrual cycle. The project also seeks to restore Trump-era “religious and moral exemptions” to contraceptive requirements under the Affordable Care Act, including emergency contraception, which it deems an abortifacient, to defund Planned Parenthood, and to remove protection of medical records involving abortions from criminal investigations if the owners of said records cross state lines.

Project 2025 aims to prohibit sending abortion pills and medical equipment used for abortions through the mail; the plan would allow criminal prosecution for senders and receivers of abortion pills. Project 2025 does not explicitly promote the prohibition of abortion, but some legal experts and abortion rights advocates said adopting the Project’s plan would cut off access to medical equipment used in surgical abortions to create a de facto national abortion ban.

Project 2025 advises the federal government to deprecate what it considers promotion of abortion and high-risk sexual behaviors among adolescents. It also seeks to remove the role of the Department of Health and Human Services in shaping sex education in the United States, arguing that this is tantamount to creating a monopoly.

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If you think this part on healthcare (within my area of expertise) is crazy or dangerous, you should see the rest of the document (not my area of expertise)!

Donald Trump tried hard to deny that he has anything to do with the project. But this as been largely in vain. However, the Democratic National Committee is rolling out a media blitz connecting him to it. This campaign will erect splashy billboards in major cities throughout the battleground states including Atlanta, Las Vegas, Raleigh, Charlotte, Philadelphia, Detroit, Lansing, Grand Rapids, Green Bay, and Phoenix.

Project 2025 is being staffed with countless members of Trump’s administration as well as close advisers. “I know nothing about Project 2025. I have not seen it, have no idea who is in charge of it, and, unlike our very well received Republican Platform, had nothing to do with it,” “Trump’s Plan to be a dictator day one: Project 2025. Google it,” reads one billboard. Another explains how Project 2025 will eviscerate our checks and balances, enable a Trump revenge tour, and ban abortion nationally. It is, in the truest sense, a blueprint for a fascist America.

It has been announced that advertisements for three supplement brands claiming to treat a range of medical conditions, including autism and ADHD, have been banned in the UK.

A paid-for Facebook advert for Aspire Nutrition in April said: “The secret weapon parents of ASD kids swear by”, while text in the form of a review attributed to “Tara K. Verified Buyer”, read: “This has helped my five-year-old with level two autism so much. “Within the first week his meltdowns decreased by 80%. He is communicating so much better… he is starting to show kindness and empathy to his little sister.” Further text read: “As parents of children with autism, we all share the same dream: to see our children thrive in school.”

Another paid-for Facebook ad in January, for Drop Supplements, stated: “For people with stress, anxiety, brain fog, ADHD … Happy Mind Drops – your new secret adaptogen against stress! Prepare yourself to unleash your true potential and banish your mental barriers.”

A third paid-for Facebook ad for Spectrum Awakening stated: “My five-year-old son Scout is diagnosed with receptive expressive language disorder and sensory disorder. Until I found Spectrum Awakening he could barely put a sentence together with very limited speech and words and lots of jargon.” It went on: “The first supplement we tried was Power and Focus and within the first three days he started using way more words. Within a week he was speaking sentences. I’m absolutely amazed that I can’t wait to order more.”

The Advertising Standards Authority (ASA) found that the claims that each supplement, or substances in them, could help to prevent, treat or cure autism breached regulations after investigations.

Aspire Nutrition said they had stopped sending adverts to UK residents who visited their website and had withdrawn the ad entirely for all audiences after being informed of the complaint. Drop Supplements said their adverts featuring Happy Mind made no direct or implied statements about curing, treating or preventing ailments or diseases. However, the ASA said the advert’s claims would be understood by most consumers as implied claims that the product could prevent, treat or cure human disease. Spectrum Awakening did not respond to the ASA’s inquiries.

The ASA told each firm to ensure their future advertising did not claim that food – in these cases in the form of a supplement – could prevent, treat or cure human disease.

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Such work by the ASA is most laudable, in my view. Misleading advertising is endangering the health of consumers thousands of times every day. However, the firms affected by the ASA reprimands are probably not all that worried. In fact, I imagine that they are laughing their heads off:

  • The chances of getting caught for misleading advertising are truly minimal.
  • If they are unlucky and do get caught the punishment is negligible.
  • There is little to stop them re-offending.

It is time that the ASA (and the equivalent organisations in other countries) get more power, more support and more money to effectively go after offenders in such a way that others think twice before breaking advertising rules.

International guidelines have recommended cognitive behavioural therapy, including acceptance and commitment therapy (ACT), as it offers validated benefits for managing fibromyalgia; however, it is inaccessible to most patients.  This study aimed to evaluate the effect of a 12-week, self-guided, smartphone-delivered digital ACT programme on fibromyalgia management.

In the PROSPER-FM randomised clinical trial conducted at 25 US community sites, adult participants aged 22–75 years with fibromyalgia were recruited and randomly assigned (1:1) to the digital ACT group or an active control group that offered daily symptom tracking and monitoring and access to health-related and fibromyalgia-related educational materials. Randomisation was done with a web-based system in permuted blocks of four at the site level. We used a blind-to-hypothesis approach in which participants were informed they would be randomly assigned to one of two potentially effective therapies under evaluation. Research staff were not masked to group allocation, with the exception of a masked statistics group while preparing statistical programming for the interim analysis. The primary endpoint was patient global impression of change (PGIC) response rate at week 12. Analyses were by intention to treat. The trial was registered with ClinicalTrials.govNCT05243511 (now fully closed).

Between Feb 8, 2022, and Feb 2, 2023, 590 individuals were screened, of whom 275 (257 women and 18 men) were randomly assigned to the digital ACT group (n=140) and the active control group (n=135). At 12 weeks, 99 (71%) of 140 ACT participants reported improvement on PGIC versus 30 (22%) of 135 active control participants, corresponding to a difference in proportions of 48·4% (95% CI 37·9–58·9; p<0·0001). No device-related safety events were reported.

The authors concluded that digital ACT was safe and efficacious compared with digital symptom tracking in managing fibromyalgia in adult patients.

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These conclusions might well be valid – but then again, they might not!

Here is why I have my doubts:

  • The patients treated with digital ACT knew that they were getting a novel and thus exciting treatment.
  • The patients randomised to the control group, on the other hand, would most likely be disappointed not to receive this therapy. In other words, there were high expectations in the experimental group and disappointment in the control group.
  • In addition, the unmasked researchers would have had the ambition that their innovation would be successful. Thus they would have used verbal and non-verbal communications with the ACT patients to bring about the desired result.

It is therefore conceivable – I think even likely – that these factors would add up to generate a false-positive finding, particularly since the endpoint was entirely subjective.
In view of all this, I am surprised that a journal like THE LANCET has published such a flimsy study with such a over-optimistic conclusion, and I suggest re-phrasing the conclusions as follows:

Digital ACT seemed safe and effective compared with digital symptom tracking in managing fibromyalgia in adult patients. However, due to the design of the study, it is possible that digital ACT is entirely ineffective and the positive outcome is caused by a number of context effects.

To accuse anyone of an abuse of science is a hefty charge, I know. In the case of proponents of so-called alternative medicine (SCAM) doing science, it is, however, often justified. Let me explain this by using the example of chiropractors (I could have chosen homeopathy, faith heaalers, acupuncturists or almost any other type of SCAM professional, but in recent times it was the chiros who provided the clearest examples of abuse).

Science can be seen as a set of tools that is used to estabish the truth. In therapeutics, science is employed foremost to answer three questions:

  1. Is the therapy plausible?
  2. Is the therapy effective?
  3. Is the therapy safe?

The way to answer them is to falsify the underlying hypotheses, i.e. to demonstrate that:

  1. The therapy is not plausible.
  2. The therapy is not effective.
  3. The therapy is not safe.

Only if rigorous attempts at falsifying these hypotheses have falied can we conclude that:

  1. The therapy is plausible.
  2. The therapy is effective.
  3. The therapy is safe.

I know, this is rather elementary stuff. It is taught during the first lessons of any decent science course. Yet, proponents of SCAM are either not being properly taught or they are immune to even the most basic facts about science. On this blog, we regularly have the opportunity to observe exactly that when we read and are bewildered by the comments made by SCAM proponents. This is often clearest in the case of chiropractors.

  1. They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is plausible.
  2. They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is effective.
  3. They cherry-pick the evidence to persuade us that their hallmark intervention, spinal manipulation, is safe.

If they conduct research, they set up their investigations in such a way that they confirm their beliefs:

  1. Spinal manipulations are plausible.
  2. Spinal manipulations are effective.
  3. Spinal manipulations are safe.

In other words, they do not try to falsify hypotheses, but they do their very best to confirm them. And this, I am afraid, is nothing other than an abuse of science.

QED

And how can the average consumer (who may not always be in a position to realize whether a study is reliable or not) tell when such abuse of science is occurring? How can he or she decide who to trust and who not?

A simplest but sadly not fool-proof advice might consist in 2 main points:

  1. Never rely on a single study.
  2. Check whether there is a discrepancy in the results and views of SCAM proponents and independent experts; e.g.:
    • Chiropractors claim one thing, while independent scientists disagree or are unconvinced.
    • Homeopath claim one thing, while independent scientists disagree or are unconvinced.
    • Acupuncturists claim one thing, while independent scientists disagree or are unconvinced.
    • Energy healers claim one thing, while independent scientists disagree or are unconvinced.
    • Naturopaths claim one thing, while independent scientists disagree or are unconvinced.
    • Etc., etc.

In all of those cases, your alarm bells should ring and it might be wise to be cautious and avoid the treatment in question.

Yesterday, I stumbled across this remarkable notice. As it is in German, I took the libery of translating it for you:

Am 6. April 2024 war es wieder soweit: Die ÖGHM und die Schwabe Austria GmbH luden zur Verleihung des mit 4.000,- Euro dotierten Dr. Peithner Preises ein.

Dieses Mal wurde der Forschungspreis für die zwei eingereichte Arbeiten „Recommendations in the design and conduction of randomized controlled trials in human and veterinary homoeopathic medicine“ und „Recommendations for Designing, Conducting and Reporting Clinical Observational Studies in Homeopathic Veterinary Medicine“ an Katharina Gaertner, Klaus von Ammon, Philippa Fibert, Michael Frass, Martin Frei-Erb, Christien Klein-Laansma, Susanne Ulbrich-Zuerni und Petra Weiermayer vergeben.

Wir freuen uns sehr und gratulieren den Preisträger:innen zum verdienten Erfolg. Ein herzliches Dankeschön geht auch an die ÖGHM und die Schwabe Austria, die nicht nur mit diesem traditionellen Forschungspreis die Wissenschaft unterstützt.

Here is my translation:

On 6 April 2024, the time had come again: the ‘Austrian Society for Homeopathic Medicine’ (ÖGHM) and Schwabe Austria GmbH hosted the award ceremony for the Dr Peithner Prize, which is endowed with 4,000 euros.

This time, the research prize was awarded to Katharina Gaertner, Klaus von Ammon, Philippa Fibert, Michael Frass, Martin Frei-Erb, Christien Klein-Laansma, Susanne Ulbrich-Zuerni and Petra Weiermayer for the two submitted papers “Recommendations in the design and conduction of randomised controlled trials in human and veterinary homoeopathic medicine” and “Recommendations for Designing, Conducting and Reporting Clinical Observational Studies in Homeopathic Veterinary Medicine”.

We are delighted and congratulate the prizewinners on their well-deserved success. A big thank you also goes to the ÖGHM and Schwabe Austria, who support science with this traditional research prize.

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And where is the irony?

Firstly, homeopaths are not exactly the experts on how to conduct research.

Secondly, there are recommendations and guidelines for conducting clinical research (e.g. here), and there is no reason for homeopathy to not to adopt those.

Thirdly, and most importantly, to award a prize to Michael Frass for telling us how to do research is more than a little ironic. If anything, Frass could teach us a thing or two about how to falsify, fabricate and manipulate research results!

Jay Kennedy is an experienced chiropractor of some standing.

In “2018, ‘The American Chiropractor’ wrote this about Jay Kennedy:

Jay Kennedy, DC, is a 1987 graduate of Palmer Chiropractic College and maintains afull time practice in western Pennsylvania. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy. Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges.

‘The Dynamic Chiropractor’ published plenty of articles authored by Jay Kennedy.

I am telling you this because Jay Kennedy recently posted a comment which is far too important to be burried in the many other comments on this blog. I think it deserves full recognition and loud applause. I have therefore decided to take the unusual step and re-post it here as an entirely seperate post.

Here we go:

I was a DC for 30+ years and a notable one for the last 20 years. I taught 200+ seminars, wrote innumerable articles and taught at many chiropractic colleges. I had (3) private practices and was a technique “guru”: “Kennedy decompression technique” or KDT. We “certified” nearly 5000 DCs to be “decompression experts”!

Kdt still sells farcical traction-tables I developed and designed (labeled as “decompression systems”) as well as useless lasers, ultrasonic vibrators and other scam modalities to confound the DCs and milk the public. (I have been out of it for several years now).

I am not proud of the fact I made a lot of money both in practice and as a lying cultist-entrepreneur.

I have read your blog for several years and many of your books, especially related to Chiropractic. You are not mistaken and I do NOT believe you are biased, the fact that you define the practice as SCAM and a cult is absolutely the case. As has been said before it is “the world’s largest non-scientific healthcare delivery system”. I was fortunate many years ago to meet Stuart McGill PhD. It changed my practice considerably. I opened a gym and focused dramatically on exercise. I also had other income steams from selling bullshit equipment. The regrettable feature is chiropractors sell “treatments”…. Some of which superficially alter pain signals temporarily like many OTHER less expensive and less mendacious things. This “traps” many patients into an erroneous paradigm….one a DC is ready, willing and able to exploit. “Chiropractic treatments” NEVER get to the root of a problem, alter any disease-process or substantially improve a patient. Regrettably selling exercise simply WILL NOT garner the income that selling (and coercing) subluxation-elimination treatments will (and virtually NO DC has the experience or expertise a PT PhD has in that arena).

Interestingly when you do seminars as a chiropractor, most states make you sign a waiver stating that you will not disparage Chiropractic or discuss information that minimize the value of Chiropractic. Can you imagine medical seminars or a scientific seminar having such a waiver? Chiropractic is and has always been a moneymaking scheme. That doesn’t exclude the fact there are many chiropractors who buy into it as a supreme truth….just like Muslims who murder with the thought of getting directly to Heaven to start porking some virgins.

I have discovered most DCs are on the low IQ scale, have poor critical thinking skills and rarely question their golden-goose (or perhaps more sympathetically; never venture outside the bounds of the profession and its rhetoric and hyperbole. They have been effectively able to compartmentalize Chiropractic from rightful and accurate criticism). Most of the successful ones are of course entrepreneurs with ravenous appetites for money, prestige and approval (and have little or no interest in the “truth”…..oops I described myself I guess).

The majority however struggle to get by and are constantly seeking SOMETHING that might actually work. Thus 70%+ use and advertise “decompression”, Activators (and other ridiculous “adjusting guns”), drop-tables, energy-techniques, orthotics and whatever other nonsense some company advertises in Chiropractic Economics with a testimonial of how much money can be made. It always fascinated me that if “subluxation-reduction or elimination” was the solution for disease and pain WHY did the profession embrace all of these other nonsensical modalities? If your guess is: “chiropractic doesn’t really work”…give yourself a beer.

When you graduate as a DC you CAN ONLY be in private SCAM practice….no other opportunities exist. Is it really any wonder that lying is the only avenue available to support a practice and an income stream? Nope.

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I wish to express my thanks to Jay for his courage and honesty in writing these lines.

People living with HIV (PLWH) are common users of so-called alternative medicine (SCAM). The main objective of this study was to study the frequency and patterns of SCAM natural products use in a large cohort of PLWH and to identify potential drug–drug interactions (DDIs) and the impact on their antiretroviral treatment (ART) adherence and efficacy.

This was a cross-sectional multicenter survey including 420 PLWH from different Spanish hospitals. Participants completed a face-to-face questionnaire on SCAM consumption and different sociodemographic and clinical data were collected. DDIs between SCAM and ART were identified and classified according to the Liverpool University Database and patient factors related to SCAM consumption were assessed.

In total, 420 participants were included (82.6% male, mean age 47 years); 209 patients (49.8%) were taking at least one SCAM. The most consumed SCAM were:

  • green, black and red tea (n=146, 25.4%),
  • ginger (n=26, 4.5%),
  • fish oil (n=25, 4.4%),
  • cannabis (n=24, 4.2%).

An ART based on integrase inhibitors was the only factor independently associated with SCAM consumption (OR 1.54, 95% CI 1.04 to 2.26). 50 potential SCAM–ART interactions in 43 (20.6%) patients taking SCAM were identified, being clinically significant in 80% of the cases. SCAM products most frequently involved with a potential significant DDI were supplements containing divalent cations (n=11) and garlic (n=7). No differences in ART efficacy and adherence were observed between patients with and without SCAM consumption.

The authors concluded that almost 50% of patients were taking at least one SCAM product and its use was associated with an integrase inhibitor based ART. One out of every six patients was at risk of presenting with an interaction between a SCAM and their ART, confirming the need to review continuously the use of SCAM as part of the medication review process.

So, the authors found that half of all PLWHs use some form of SCAM (whether I would classify tea as a SCAM is a different question). They also point out that this might put many PLWHs at risk. What I don’t understand is why they do not take the next logical step and ask what the benefits of the SCAMs for PLWHs are.

Allow me to answer this question: they are zero or very close to zero!

And this means that SCAMs generate a risk for PLWHs without creating any meaningful benefit. In other words the risk-benefit balance fails to be positive.

I think that this is an important point which needs to be stressed clearly in the conclusions. Therefore, I suggest to re-formulate them as follows:

Almost 50% of patients were taking at least one SCAM product. One out of every six patients was at risk of presenting with an interaction between a SCAM and their ART. The SCAMs used convey no appreciatable benefit. Therefore, SCAM use fails to generate more good than harm. It follows that responsible healthcare professionals should discurage SCAM use.

The comment sections of this blog have provided plenty of reason to suspect that chiropractic is a cult, a health cult to be precise. A health cult is defined as a system for the cure of disease based on dogma set forth by its promulgator. The promulgator, in this case, is DD Palmer. As discussed previously, he ‘invented’ chiropractic and promoted many extraordinary claims and ideas, e.g.:

  • I was the first to adjust the cause of disease
  • Chiropractors adjust causes instead of treating effects
  • 95% of all diseases are caused by subluxations of the spine
  • Vaccination and inoculation are pathological; chiropractic is physiological
  • It was my ingenious brain which discovered [chiropractic’s] first principle; I was its source; I gave it birth; to me all chiropractors trace their chiropractic lineage
  • Among the wonderful achievements of this century, the discovery and development of chiropractic is preeminent; it is destined to replace all methods which treat effects
  • Dis-ease is a condition of not ease, lack of ease
  • His magnetic cure for cancer involved freeing the stomach and spleen of poisons
  • Chiropractic is a science of healing without drugs
  • Wants to turn chiropractic into a religion (as this would avoid chiropractors being sued for practising medicine without a license)

Since DD Palmer, the chiro-cult has changed. In fact, it has split into two camps. The ‘straights’ have become a Palmer worship cult, while the rest delude themselves of being based on evidence. That the former are cultists is impossible to deny. The latter reject such allegations but, in my mind, they too belong to a cult.

Let me explain.

The criteria for a cult can be defines as follows:

  1. Charismatic Leader: the ‘mixers’ might no longer worship Palmer, yet they are far from free of his ‘philosophy’; after all, they went to chiro-school where they were educated in the Palmer tradition.
  2. Isolation: chiropractors seek surprisingly little co-operation with other healthcare professionals and thus tend to be isolated.
  3. Control: chiropractors are under tight control of their professional bodies, peers, journals, etc. which all make sure that heretic ideas are kept at bay.
  4. Deception: chiropractors are masters of deception in persuading the public and their patients of the value of spinal manipulations, regardless of the actual evidence.
  5. Us vs. Them Mentality: chiropractors tend to create an “us vs. them” mentality, demonizing real doctors and promoting group cohesion.
  6. Exploitation: chiropractors have a long history of exploiting their patients; maintenance care is just one of many examples.
  7. Fear Tactics: chiropractors are scare mongers, for instance, when they diagnose subluxations even in perfectly healthy people and claim that this invented diagnosis needs urgent adjustments.

What, you don’t agree with these arguments?

In this case let me quote a different set criteria that might help to decide whether chiropractic might be a cult. Here they are:

  1. Absolute authoritarianism without accountability
  2. Zero tolerance for criticism or questions
  3. Lack of meaningful financial disclosure regarding budget
  4. Unreasonable fears about the outside world that often involve evil conspiracies and persecutions
  5. A belief that former followers are always wrong for leaving and there is never a legitimate reason for anyone else to leave
  6. Abuse of members
  7. Records, books, articles, or programs documenting the abuses of the leader or group
  8. Followers feeling they are never able to be “good enough”
  9. A belief that the leader is right at all times
  10. A belief that the leader is the exclusive means of knowing “truth” or giving validation

Bearing in mind that not all of the 10 criteria need to be fulfilled, I ask you: is chiropractic a cult?

 

 

This review was aimed at quantifying the proportion attributable to contextual effects of physical therapy interventions for musculoskeletal pain. Randomized placebo-controlled trials evaluating the effect of physical therapy interventions on musculoskeletal pain.

Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (ROB 2.0). The proportion of physical therapy interventions effect that is explained by contextual effects was calculated, and a quantitative summary of the data from the studies was conducted using the random-effects inverse-variance model (Hartung-Knapp-Sidik-Jonkman method).

Sixty-eight studies were included in the systematic review (total number of participants: n=5,238), and 54 placebo-controlled trials informed our meta-analysis (participants: n=3,793). Physical therapy interventions included:

  • soft tissue techniques,
  • mobilization,
  • manipulation,
  • taping,
  • exercise therapy,
  • dry needling.

Placebo interventions included manual, non-manual interventions, or both.

The results show the following:

  • The type of treatment with the largest proportion not attributable to the specific effects (PCE) for pain intensity assessed immediately after the intervention was mobilization, which represented 87% of the overall treatment effect (PCE = 0.87, 95% CI: 0.54, 1.19).
  • For soft tissue techniques, the PCE was 81% of the overall treatment effect (PCE = 0.81, 95% CI: 0.64, 0.97).
  • For dry needling, the PCE was 75% (PCE = 0.75, 95% CI: 0.36, 1.15).
  • For manipulation techniques the PCE was 74% (PCE = 0.74, 95% CI: 0.33, 1.14).
  • For taping the PCE was 69% of the overall treatment effect (PCE = 0.69, 95% CI: 0.48, 0.89).
  • The smallest proportion not attributable to the specific intervention itself for pain intensity was exercise therapy accounting for 46% of the overall treatment effect (PCE = 0.46, 95% CI: 0.41, 0.52).

The authors concluded that the outcomes of physical therapy interventions for musculoskeletal pain were significantly influenced by contextual effects. Boosting contextual effects consciously to enhance therapeutic outcomes represents an ethical opportunity that could benefit patients.

This sounds as though most of the treatments in question rely mainly on placebo effects. But what about conventional therapies? The authors point out that the PCEs of general medicine and surgery in pain-related conditions are also large. In particular, the overall proportion not attributable to the specific effects of general medicine interventions is high (PCE = 65%), with higher values observed in semi-objective and objective outcomes (PCE = 78 and 94%, respectively) than in subjective outcomes (PCE = 50%).

What does that mean for healthcare routine?

As placebo and other context effects are unreliable, usually short-lived, and not normally affecting the cause of the problem (but merely the symptoms), I would say that those treatments with a very high PCE are of limited value, paticularly if they are also expensive or burdened with risks. Of the treatments studied here, I would – based on the current analysis – avoid the following therapies for pain management:

  • mobilization,
  • soft tissue techniques,
  • dry needling,
  • manipulation,
  • taping.

By and large, these are also the conclusions drawn from various other strands of evidence that we have repeatedly discussed in previous posts.

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