In alternative medicine, good evidence is like gold dust and good evidence showing that alternative therapies are efficacious is even rarer. Therefore, I was delighted to come across a brand-new article from an institution that should stand for reliable information: the NIH, no less.
According to its authors, this new article “examines the clinical trial evidence for the efficacy and safety of several specific approaches—acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga—as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain, and severe headaches or migraines.”
The results of this huge undertaking are complex, of course, but in a nutshell they are at least partly positive for alternative medicine. Specifically, the authors state that “based on a preponderance of positive trials vs negative trials, current evidence suggests that the following complementary approaches may help some patients manage their painful health conditions: acupuncture and yoga for back pain; acupuncture and tai chi for OA of the knee; massage therapy for neck pain with adequate doses and for short-term benefit; and relaxation techniques for severe headaches and migraine. Weaker evidence suggests that massage therapy, SM, and osteopathic manipulation might also be of some benefit to those with back pain, and relaxation approaches and tai chi might help those with fibromyalgia.”
This is excellent news! Finally, we have data from an authoritative source showing that some alternative treatments can be recommended for common pain conditions.
Hold on, not so fast! Yes, the NIH is a most respectable organisation, but we must not blindly accept anything of importance just because it appears to come form a reputable source. Let’s look a bit closer at the actual evidence provided by the authors of this paper.
Reading the article carefully, it is impossible not to get troubled. Here are a few points that concern me most:
- the safety of a therapy cannot be evaluated on the basis of data from RCTs (particularly as it has been shown repeatedly that trials of alternative therapies often fail to report adverse effects); much larger samples are needed for that; any statements about safety in the aims of the paper are therefore misplaced;
- the authors talk about efficacy but seem to mean effectiveness;
- the authors only included RCTs from the US which must result in a skewed and incomplete picture;
- the article is from the National Center for Complementary and Integrative Health which is part of the NIH but which has been criticised repeatedly for being biased in favour of alternative medicine;
- not all of the authors seem to be NIH staff, and I cannot find a declaration of conflicts of interest;
- the discussion of the paper totally lacks any critical thinking;
- there is no assessment of the quality of the trials included in this review.
My last point is by far the most important. A summary of this nature that fails to take into account the numerous limitations of the primary data is, I think, as good as worthless. As I know most of the RCTs included in the analyses, I predict that the overall picture generated by this review would have changed substantially, if the risks of bias in the primary studies had been accounted for.
Personally, I find it lamentable that such a potentially worthy exercise ended up employing such lousy methodology. Perhaps even more lamentable is the fact that the NIH (or one of its Centers) can descend that low; to mislead the public in this way borders on scientific misconduct and is, in my view, unethical and unacceptable.
13 Responses to Unacceptable pseudo-science from the NIH
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The article is from the National Center for Complementary and Integrative Health, a division of NIH initially set up by Senator Tom Harkin, who wanted scientific support for his bee pollen therapies. Its first director, Joseph M. Jacobs, was a US parallel to Edzard Ernst, with his Chair of Complementary Medicine at Exeter. Jacobs set up rigorous, scientific studies of CAM and came under heavy fire from believers when his (then) Office of Alternative Medicine failed to provide evidence that CAM didn’t work.
The NCCIH now has a huge budget, and has given up scientific testing in favour of training and the kind of positive publication this post describes. Talk privately to virtually any scientist from the rest of NIH about the NCCIH and you will not get a favourable response!
By the way: “the authors only included RCTs from the US which must result in a skewed and incomplete picture”. This reminds me of an occasion in the 90s when I attended a meeting at NIH, to discuss a novel pharmaceutical product. One of the US officials grumbled about the lack of US-based clinical trials: “Most of them were done in Europe!”, he said. Nationalism is far from dead, as we saw with the UK Brexit referendum.
Correction: “failed to provide evidence that CAM didn’t work.” should have read: “failed to provide evidence that CAM worked.”
The authors are:
So, one chiro and one naturopath. Nahin seems to be an NIH employee, but, as you say, there is no COI declaration. However, a brief search gives the following affiliations (from other recent publications):
Richard L. Nahin: National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
Partap S. Khalsa: Associate Professor, Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY
Program Officer, Division of Extramural Research, National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health (NIH)
Robin Boineau: The National Heart, Lung, and Blood Institute, Bethesda, MD
Barbara J. Stussman: National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
Wendy J. Weber: Bastyr University, Kenmore, WA; currently at National Center for Complementary and Alternative Medicine, Bethesda, MD
the NIH even published a glowing press release about this pseudo-science:
https://nccih.nih.gov/research/results/spotlight/five-painful-conditions
I’ve not had time yet to read the whole paper, but I see the press release says:
Unbelievable, and highlights your last bullet point. Totally misleading.
Clearly, the NIH has become even more politicized than it already was.
more [fairly woolly] comments on this paper in JAMA: http://jamanetwork.com/journals/jama/fullarticle/2579926