The NHMRC report on homeopathy is the most thorough, independent and reliable investigation into the value of homeopathy ever. As its conclusions are devastatingly negative about the value of homeopathy, it is hardly surprising that homeopaths tried everything and anything to undermine it. This new article gives what I believe to be a fair account of the allegations and their validity:
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Since the NHMRC declared homeopathy to be ineffective in treating any health condition, a number of disputes have been made by major organisations in favour of homeopathy. Australia’s two peak industry organisations, Complementary Medicines Australia (CMA) and the AHA, both argue in their letters to the NHRMC that the position was prejudiced based on a draft position statement leaked in 2012 stating it is unethical for health practitioners to treat patients using homeopathy, for the reason that homeopathy (as a medicine or procedure) has been shown not to be efficacious [19,20]. Furthermore, both the CMA and AHA highlight serious concerns regarding the prelude to and instigation of the work of the NHMRC’s HWC as well as the conduct of the review itself to finalise their conclusion on the use of homeopathy. Several grave issues were raised in both letters with five common key flaws cited: (1) no explanation was provided as to why level 1 evidence including randomised control trials were excluded from the review; (2) the database search used was not broad enough to capture complementary medicine and homeopathic specific content, and excluded non-human and non-English studies; (3) no homeopathic expert was appointed in the NHMRC Review Panel; (4) prior to publication, the concerns raised over the methodology and selective use of data by research contractor(s) engaged for the HWC review were abandoned for unknown reasons; and (5) no justification was provided as to why only systematic reviews were used [19,20]. Other serious accusations made by the AHA in their response letter to the NHMRC involved the blatant bias of the NHMRC evident by: the leakage of their draft position statement in April 2011 and early release of the HWC Draft Review regarding homeopathy to the media; no discussion of prophylactic homeopathy i.e. preventative healthcare; and no reference to the cost-effectiveness, safety, and quality of homeopathic medicines .
Despite the NHMRC findings being strongly disputed, they are further supported by positions taken by a number of large and respected organisations. For example, in 2009, the World Health Organization (WHO) advised against the use of homeopathic medicines for various serious diseases following significant concerns being raised by major health authorities, pharmaceutical industries, and consumers regarding its safety and quality . They reported the clinical effects were compatible with placebo effects . Similarly, in Australia, the Australian Medical Association (AMA) further supports the NHMRC findings by stating in their position statement released in 2012 that there is limited efficacy evidence regarding most complementary medicines, thereby posing a risk to patient health . More recently, in May 2015, the Royal College of General Practitioners (RACGPs) strongly advocated in their position statement against general practitioners prescribing homeopathic medicines, and pharmacists against supporting or recommending it, given the lack of evidence regarding its efficacy . This is particularly pertinent to conventional vaccines given the recent case between the Australian Competition and Consumer Commission (ACCC) vs. Homeopathy Plus! Australia Pty Ltd. The Federal Court found Homeopathy Plus! Australia Pty Ltd guilty of contravening the Australian Consumer Law by engaging in misleading and deceptive conduct through claiming that homeopathic remedies were a proven, safe, and effective alternative to the conventional vaccine against whooping cough .
The positions of the NHMRC, WHO, AMA, and the RACGPs regarding homeopathy is further supported by Cochrane reviews, which provide high-quality evidence with minimal bias . Of the twelve homeopathy Cochrane reviews available in the database, only seven address homeopathic remedies directly and were related to the following conditions: irritable bowel syndrome , attention deficit/hyperactivity disorder or hyperkinetic disorder , chronic asthma , dementia , induction of labour , cancer , and influenza . Given most of these reviews were authored by homeopaths, bias against homeopathy is unlikely [26-32]. The overarching conclusions from these reviews fail to reveal compelling evidence regarding the efficacy of homeopathic remedies [26-32]. For example, Mathie, Frye and Fisher show that there is â€œno significant difference between the effects of homeopathic Oscillococcinum® and placebo in prevention of influenza-like illness: risk ratio (RR) = 0.48, 95% confidence interval (CI) 0.17-1.34, p-value = 0.16 . The key reasons given for this failure to provide compelling evidence relate to low quality or unclear data, and lack of replicability, suggesting homeopathic remedies are unlikely to have clinical effects beyond placebo [26-32].
Sadly, the ACCC vs. Homeopathy Plus! Australia Pty Ltd is not the only case that has made headlines in Australia in recent years. An article in the Journal of Law and Medicine coincided with the NHMRC report regarding the number of deaths attributable to favouring homeopathy over conventional medical treatment in recent years . One such case was that of Jessica Ainscough, who passed away earlier this year after losing her battle with a rare form of cancer “epithelioid sarcoma“ after rejecting conventional treatment in favour of alternative therapies . Although doctors recognise Ms. Ainscough’s right to choose her own cancer treatments and understand why she refused the disfiguring surgery to save her life, they fear her message may influence others to reject conventional treatments that could ultimately save their lives . Another near death case was that of an eight-month-old boy whose mother was charged with â€œreckless grievous bodily harm and failure to provide for a child causing danger to deathâ€ after ceasing conventional medical and dermatological treatment for her son’s eczema as advised by her naturopath (an umbrella term that includes homeopathy) . The all-liquid treatment plan left the boy severely malnourished and consequently, he now suffers from developmental issues . This case is rather similar to that of R vs. Sam in 2009, where the parents of a nine-month-old girl were convicted of manslaughter by criminal negligence after favouring homeopathic treatment over conventional medical treatment for their daughter’s eczema. The girl died from septicaemia after her eczema became infected [36,37].[references are provided in the original document]
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The NHMRC report stated that
Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments.
Few other reports have previously expressed our concerns about homeopathy so clearly – little wonder then that the world of homeopathy was (and still is) up in arms.
The last time something similar happened was during the Third Reich when homeopathy had been evaluated thoroughly by leading scientists and the conclusions turned out to be just as devastatingly negative. At the time, German homeopaths allegedly made the report disappear, and all we have today about this comprehensive research programme is a very detailed eye witness report of a homeopath who had been intimately involved in the research.
Today, it is thankfully no longer possible to make major research documents disappear. So, homeopaths have to think of other strategies to defend their trade. In the case of the NHMRC report, they act like all cults tend to do and resort to misleading statements and slanderous allegations. This, I feel, is unsurprising and will inevitably turn out to be unsuccessful.
The Rubicon Group (TRG) is a collaboration of chiropractic educational institutions, emerging educational efforts and interested parties. The seven institutional members include Barcelona College of Chiropractic (Barcelona, Spain); the Chiropraktik Akademie (Dresden, Germany); Life Chiropractic College West (San Francisco, California, USA); Life University (Atlanta, Georgia, USA); McTimoney College of Chiropractic (Abingdon, Oxfordshire, UK); New Zealand College of Chiropractic (Auckland, New Zealand); and Sherman College of Chiropractic (Spartanburg, South Carolina, USA).
TRG has issued the following statement:
The term ‘subluxation’ has been used by the chiropractic profession for over a century.1, 2 It is an important element of chiropractic practice, embedded in legislation and regulation, and its clinical implications have been, and continue to be, scientifically explored.2, 3
The term subluxation, as used by chiropractors, is a researchable concept that is important to health and health care delivery.1, 2, 4 The need to properly define this entity has been widely recognized as a high priority within the profession, as evidenced by the number of groups and organizations who have offered definitions of subluxation.1, 2, 5-10
Many of the past definitions do not provide a testable definition of chiropractic subluxation.11
Some do not reflect the current research that supports a neurologically-centered model of subluxation. 2 The Rubicon Group (TRG) has utilized the current available scientific evidence to define the chiropractic subluxation. Contemporary neurophysiological language and concepts, based on current scientific publications on the topic, have been used. As this definition is subject to ongoing scientific exploration that is likely to lead to new findings and understandings, modifications may be anticipated. However, this definition reflects what is currently known, and it is congruent with current neurophysiological scientific understanding.
“We currently define a chiropractic subluxation as a self-perpetuating, central segmental motor control problem that involves a joint, such as a vertebral motion segment, that is not moving appropriately, resulting in ongoing maladaptive neural plastic changes that interfere with the central nervous system’s ability to self-regulate, self-organize, adapt, repair and heal.”
(The Rubicon Group, May 2017.)
There are three key elements, namely:
A chiropractic subluxation often relates to the spine and its connecting structures. 1 Chiropractic subluxation assessment generally involves evaluating the pathophysiological consequences of the central segmental motor control problem; 4, 12 these may include pain, asymmetry, biomechanical or postural changes (such as changes in relative range of intervertebral motion), changes in tissue temperature, texture and/or tone, and other findings that can be identified using special tests. 12 Once identified, subluxations are corrected using a variety of techniques including high velocity low amplitude chiropractic adjustments, instrument assisted adjustments, and lower force manual techniques and approaches.13
A growing body of scientific evidence has demonstrated that spinal function impacts central neural function in multiple ways,3, 4, 14-19 and that improving spinal function has an impact on clinical outcomes.20-24 Scientists have known for several decades that neurons continuously adapt in structure and function in response to our ever-changing environment.25-27 This ability to adapt is known as ‘neural plasticity’,27 and it is now well understood that the central nervous system can reorganize in response to altered input.28-35 Examples of increased sensory input that can lead to neural plastic changes include repetitive muscular activity 29, 36-41, such as typing or playing the piano, or repeated tactile sensory input such as occurs with blind Braille readers.42 Similar central nervous system change or reorganization may take place due to a decrease in behavior or activity.+ 32, 43-49 Thus the concept, that alterations in paraspinal muscle function due to abnormal spinal movement patterns are capable of changing central neural function, is totally congruent with current neuroscience understanding, as well as current scientific findings.3, 4, 14-19
[references can be found in the original]
Subluxation is not so much a ‘self-perpetuating motor control problem’ as a self-perpetuating money-maker for chiropractors, it seems to me. The history of the use of this term shows that chiropractors have changed its meaning each time they were unable to deny its nonsensicality. To throw subluxation over board is not an option because chiropractic is at its hear a subluxation cult.
Yet, we have repeatedly been told that chiropractors have all but given up the concept of ‘subluxation’. This is clearly not the case. The above statement of TRG speaks for itself, and so does a recent study showing that “the majority of [North American chiropractic] students would like to see an emphasis on correction of vertebral subluxation”. It is the correction of the non-existent subluxation that stimulates the cash flow of chiropractors, a fact known even to the novices of the cult.
The new definition, it seems to me, is little more than self-serving nonsense. Wikipedia – I know, it’s not always the most reliable source, but in this case it is miles better that TRG – has this to say about subluxation: “In chiropractic, vertebral subluxation is a supposed misalignment of the spinal column leading to a set of signs and symptoms sometimes termed vertebral subluxation complex. It has no biomedical basis and is categorized as pseudoscientific by leading authorities. Traditionally, the “specific focus of chiropractic practice” is the chiropractic subluxation and historical chiropractic practice assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body’s function and its innate intelligence, as promulgated by D. D. Palmer, the inventor of chiropractic.”
Wikipedia furthermore mentions that “in 2015, 8 internationally accredited chiropractic colleges: AECC, WIOC, IFEC-Paris, IFEC-Toulouse, USD-Odense, UZ-Zurich, UJ-Johannesburg and Durban University of Technology made an open statement which included: “The teaching of the vertebral subluxation complex as a vitalistic construct that claims that it is the cause of disease is unsupported by evidence. Its inclusion in a modern chiropractic curriculum in anything other than an historic context is therefore inappropriate and unnecessary”.”
Subluxation currently divides the chiropractic profession as we have seen here, for instance. But it is certainly not a concept that most chiropractors have been wise enough to declare obsolete.
The website of ‘HOMEOPATHY 360’ has just published a new post offering a handy instruction for killing patients suffering from acute appendicitis. If you do not believe me – I don’t blame you, I too found it hard to believe – read this short excerpt advocating homeopathy for this life-threatening condition (for readers without a medical background: if acute appendicitis is not treated promptly, the inflamed appendix might burst, spilling faecal material into the abdominal cavity, resulting in a life-threatening peritonitis):
The post is entitled “A Cure of Acute Appendicitis Using Frequent Homeopathic Doses in Solution”
Here is the abstract:
“Placing centesimal potencies in solution and prescribing them frequently for acute conditions is not widely practiced. It can be superior to dry doses in many cases, where a persistent mild medicinal action is preferred to a strong aggravation. By prescribing dissolved doses of Arnica Montana 1m, a case of acute appendicitis was cured quickly. This suggests that centesimal potencies given frequently in solution may be more efficacious, prompt and gentle than treatment with dry doses.”
Fascinating, isn’t it?
Here are more details demonstrating that the author has done his homework:
“When treating a patient with acute medical condition, in certain cases we fail to cure. Even though our case taking, evaluation, analysis, remedy and potency selection seem correct. What is the cause? In the Organon 5th edition (1833) Dr. Hahnemann introduced olfaction and dissolved centesimal remedies as a new method of administering doses. Around the year 1840 Hahnemann began to introduce LM potencies into his practice. From 1840 to 1843 he used both centesimal and LM potencies side by side in medicinal solutions. By these methods he hoped to avoid unwanted aggravations and provide rapid cure.
In some acute cases the aggravation can be discouragingly prolonged and often cannot be discerned from the patient’s own disease. Many times we change the original prescription which could very well have been the simillimum. In acute diseases, a dry dose will many times produce an unnecessary aggravation because of the patient’s increased susceptibility. I have much experience now with what I call a “watery dose.” To prepare it, one or two globules of size 10 are diluted in 15ml. of distilled water in which 5 drops of alcohol added with 20 to 30 succussions. From this solution 10 drops are added to another 15 ml of water, and from this solution 5 to 10 drops dose repeated according to the severity of the disease. In such diluted solutions the correct number of drops must be precise. Every time before taking the dose the solution is succussed 5 to 10 times. The same solution can be used for several days or weeks. Hahnemann recommended using carefully measured and dosed solutions with sensitive patients. Many times I have used this method with great success. It is not necessary to take 4 oz. to 8 oz. of water, Just fifteen ml. of distilled water is sufficient. This technique of dosing is also known as a split dose because it uses one or two pills in a solution that is then split over several days or weeks.
The results using this type of dosing can be very different from dry doses. There is continuous amelioration of the complaints without aggravation. This comes closer to the ideal of strengthening the weakened vital force than is seen when we simply produce a similar stronger artificial disease in the patient.”
The author also provides a detailed case history of a patient who survived this treatment (of course, without mentioning that acute appendicitis can, in rare cases, have a spontaneous recovery).
I would not recommend Arnica or any other homeopathic remedy for routine use in acute appendicitis (or any other condition) – unless, of course, you want to kill a maximum number of your patients suffering from this medical/surgical emergency.
I am sure you always wanted to know what animal chiropractic is all about!
This website explains it quite well:
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…Animal chiropractic (veterinary spinal manipulative therapy) focuses on the preservation and health/wellness of the neuro-musculo-skeletal system. Chiropractic is the science that is centered around the relationship between the spine and the nervous system. The spine is your body’s foundation and the nervous system, including your brain, spinal cord and nerves, controls your entire body. They must work together harmoniously to improve one’s general health and their ability heal. If the systems are not functioning to their highest potential you may experience changes in digestion, heart and lung function, reproduction and most evidently musculature. When adjacent joints are in an abnormal position, called a subluxation, the nervous system and all that it controls will be negatively impacted. If these subluxations are not corrected, they can result in prolonged inappropriate stimulation of nerves. This could result in reduced function internally, musculo-skeletal dysfunction and pain.
Spinal manipulation is the art of restoring full and pain free range of motion to joints and can greatly benefit an animal after they have experienced subluxations. The veterinarian will use their hands to palpate joints both statically and in motion. By doing this, they can determine where the animal is experiencing decreased motion or misaligned joints. Once identified, an adjustment can be performed. An adjustment or spinal manipulation is a gentle, specific, quick and low force thrust that will be applied at an angle specific to the different areas of motion in the spine and extremities. Only a certified animal chiropractor will understand the complexity involved in adjustments and can best assess if an animal can benefit from chiropractic care.
Many animals can benefit from this alternative therapy. If you notice that your animal has a particularly sensitive spot somewhere on their body, is walking or trotting differently and or not performing to the same ability they have previously, they may be a candidate for a chiropractic assessment. However, an animal does not need to be sick or injured to benefit from chiropractic care. Animals in good health or ones used for sporting activities are also prime candidates for chiropractic care. By maintaining your pet’s proper spinal alignment and mobility they will attain optimal function of muscles, nerves and tissues that support the joints. When the body can move freely your pet will experience improved mobility, stance and flexibility, which can evolve into improved agility, endurance and overall performance. Finally, many people have never considered that chiropractic care can also benefit their animal by boosting their immune response. It can aid in providing a healthier metabolism and a vibrant nervous system which all facilitate your animal’s natural ability to heal themselves from within. Chiropractic care can enhance the quality of your pet’s life ensuring many active and healthy years to come.
…during veterinary school I began the process of researching how to become an animal chiropractor or veterinary spinal manipulative therapist. As I researched further, I noticed that this specialized profession has grown. It became apparent that one should be certified by either the College of Animal Chiropractors or American Veterinary Chiropractic Association to practice on animals… It was surprising to find out that there are only four programs in the USA and Canada that are approved by both organizations. The courses consisted of over 200 hours of intensive study and hands on learning followed by certification testing…
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Yes, I did shorten the quote a bit but, rest assured, I did not cut out a single word about the efficacy of animal chiropractic. Even if I had wanted to, I couldn’t: there is no mention of it in the article.
I wonder why!
Looking into Medline, I found several reports related to the subject:
- One study suggested an association between chiropractic findings in the lumbar vertebrae and urinary incontinence and retention in dogs.
- A case report highlighted the potential benefits of combining traditional medical management with chiropractic treatment and physical therapy techniques for management of severe acute-onset torticollis in a giraffe.
- A review explained that there is limited evidence supporting the effectiveness of spinal mobilization and manipulation in animals.
- An observational study suggested that chiropractic manipulations elicit slight but significant changes in thoracolumbar and pelvic kinematics.
- A comparative study measured the spinal mechanical nociceptive thresholds in 38 horses, and showed that they increased by 27, 12 and 8% in the chiropractic, massage and phenylbutazone groups, respectively.
… and that was basically it. Not a single study to suggest that chiropractic is effective for specific conditions of animals.
Frustrated, I went on the site of the ‘College of Animal Chiropractic’; surely there I would find the evidence I was looking for. They offer lots of platitudes and this largely nonsensical statement:
“When a joint become restricted in its range of motion(hypomobile or ‘locked-up’), through trauma, repetitive injury, degenerative changes, or structural stresses, the surrounding tissues are affected. This, in turn, further affects the joints ability to move freely and sensitive structures are activated causing the area to be sensitive or painful. Nerves are the communication links between all tissues in the body to the brain and spinal cord; when joint dysfunction is present, messages to other areas are also affected, which can lead to pain, weakness, reduced function, and compensatory changes. Animal chiropractic focuses on the restoration of movement and the promotion of heath by restoring normal joint mechanics and soft-tissue function, thus, normalizing neurological patterns that facilitate healing . The main tool an animal chiropractor uses to restore joint motion is called an “adjustment”, or veterinary spinal manipulation. This gentle, specialized, manual skill, involves the application of a quick, low-force maneuver that is directed to a specific area of a joint at a specific angle. A certified animal chiropractor understands these joint angles intimately and can best asses if an animal can benefit from chiropractic care, and, is the only professional who is qualified to adjust your pet.”
But no evidence!
By now I was desperate. My last hope was the ‘American Veterinary Chiropractic Association’. All I found there, however, was this: the “American Veterinary Chiropractic Association (AVCA) is a professional membership group promoting animal chiropractic to professionals and the public, and acting as the certifying agency for doctors who have undergone post-graduate animal chiropractic training.”
Not a jot of evidence!
The assumption that animal chiropractic is effective seems to rely on the evidence from human studies…
… and we all know how solid that body of evidence is!
My conclusion from all this: chiropractors treating animals and those treating humans have one important characteristic in common.
THEY HAPPILY PROMOTE BOGUS TREATMENTS.
The fact that some alternative medicine (the authors use the abbreviation ‘CAM’) practitioners recommend against vaccination is well-known and often-documented. Specifically implicated are:
- Physicians practising integrative medicine
- Doctors of anthroposophical medicine
As a result, children consulting homeopaths, naturopaths or chiropractors are less likely to receive vaccines and more likely to get vaccine-preventable diseases. These effects have been noted for several childhood infections but little is known about how child CAM-usage affects influenza vaccination.
A new nationally representative study fills this gap; it analysed ∼9000 children from the Child Complementary and Alternative Medicine File of the 2012 National Health Interview Survey. Adjusting for health services use factors, it examined influenza vaccination odds by ever using major CAM domains: (1) alternative medical systems (AMS; eg, acupuncture); (2) biologically-based therapies, excluding multivitamins/multi-minerals (eg, herbal supplements); (3) multi-vitamins/multi-minerals; (4) manipulative and body-based therapies (MBBT; eg, chiropractic manipulation); and (5) mind-body therapies (eg, yoga).
Influenza vaccination uptake was lower among children ever (versus never) using AMS (33% vs 43%; P = .008) or MBBT (35% vs 43%; P = .002) but higher by using multivitamins/multiminerals (45% vs 39%; P < .001). In multivariate analyses, multivitamin/multimineral use lost significance, but children ever (versus never) using any AMS or MBBT had lower uptake (respective odds ratios: 0.61 [95% confidence interval: 0.44-0.85]; and 0.74 [0.58-0.94]).
The authors concluded that children who have ever used certain CAM domains that may require contact with vaccine-hesitant CAM practitioners are vulnerable to lower annual uptake of influenza vaccination. Opportunity exists for US public health, policy, and medical professionals to improve child health by better engaging parents of children using particular domains of CAM and CAM practitioners advising them.
There is hardly any need to point out that CAM-use is associated with low vaccination-uptake. We have discussed this on my blog ad nauseam – see for instance here, here, here and here. Too many CAM practitioners have an irrational view of vaccinations and advise against their patients against them. Anyone who needs more information might find it right here by searching this blog. Anyone claiming that this is all my exaggeration might look at these papers, for instance, which have nothing to do with me (there are plenty more for those who are willing to conduct a Medline search):
- Lehrke P, Nuebling M, Hofmann F, Stoessel U. Attitudes of homeopathic physicians towards vaccination. Vaccine. 2001;19:4859–4864. doi: 10.1016/S0264-410X(01)00180-3. [PubMed]
- Halper J, Berger LR. Naturopaths and childhood immunizations: Heterodoxy among the unorthodox. Pediatrics. 1981;68:407–410. [PubMed]
- Colley F, Haas M. Attitudes on immunization: A survey of American chiropractors. Journal of Manipulative and Physiological Therapeutics. 1994;17:584–590. [PubMed]
One could, of course, argue about the value of influenza vaccination for kids, but the more important point is that CAM practitioners tend to be against ANY immunisation. And the even bigger point is that many of them issue advice that is against conventional treatments of proven efficacy.
In a previous post I asked the question ‘Alternative medicine for kids: when is it child-abuse?’ I think that evidence like the one reported here renders this question all the more acute.
How often have I pointed out that most studies of chiropractic (and other alternative therapies) are overtly unethical because they fail to report adverse events? And if you think this is merely my opinion, you are mistaken. This new analysis by a team of chiropractors aimed to describe the extent of adverse events reporting in published RCTs of Spinal Manipulative Therapy (SMT), and to determine whether the quality of reporting has improved since publication of the 2010 Consolidated Standards Of Reporting Trials (CONSORT) statement.
The Physiotherapy Evidence Database and the Cochrane Central Register of Controlled Trials were searched for RCTs involving SMT. Domains of interest included classifications of adverse events, completeness of adverse events reporting, nomenclature used to describe the events, methodological quality of the study, and details of the publishing journal. Data were analysed using descriptive statistics. Frequencies and proportions of trials reporting on each of the specified domains above were calculated. Differences in proportions between pre- and post-CONSORT trials were calculated with 95% confidence intervals using standard methods, and statistical comparisons were analysed using tests for equality of proportions with continuity correction.
Of 7,398 records identified in the electronic searches, 368 articles were eligible for inclusion in this review. Adverse events were reported in 140 (38.0%) articles. There was a significant increase in the reporting of adverse events post-CONSORT (p=.001). There were two major adverse events reported (0.3%). Only 22 articles (15.7%) reported on adverse events in the abstract. There were no differences in reporting of adverse events post-CONSORT for any of the chosen parameters.
The authors concluded that although there has been an increase in reporting adverse events since the introduction of the 2010 CONSORT guidelines, the current level should be seen as inadequate and unacceptable. We recommend that authors adhere to the CONSORT statement when reporting adverse events associated with RCTs that involve SMT.
We conducted a very similar analysis back in 2012. Specifically, we evaluated all 60 RCTs of chiropractic SMT published between 2000 and 2011 and found that 29 of them did not mention adverse effects at all. Sixteen RCTs reported that no adverse effects had occurred (which I find hard to believe since reliable data show that about 50% of patients experience adverse effects after consulting a chiropractor). Complete information on incidence, severity, duration, frequency and method of reporting of adverse effects was included in only one RCT. Conflicts of interests were not mentioned by the majority of authors. Our conclusion was that adverse effects are poorly reported in recent RCTs of chiropractic manipulations.
The new paper suggests that the situation has improved a little, yet it is still wholly unacceptable. To conduct a clinical trial and fail to mention adverse effects is not, as the authors of the new article suggest, against current guidelines; it is a clear and flagrant violation of medical ethics. I blame the authors of such papers, the reviewers and the journal editors for behaving dishonourably and urge them to get their act together.
The effects of such non-reporting are obvious: anyone looking at the evidence (for instance via systematic reviews) will get a false-positive impression of the safety of SMT. Consequently, chiropractors are able to claim that very few adverse effects have been reported in the literature, therefore our hallmark therapy SMT is demonstrably safe. Those who claim otherwise are quite simply alarmist.
The website of BMJ Clinical Evidence seems to be popular with fans of alternative medicine (FAMs). That sounds like good news: it’s an excellent source, and one can learn a lot about EBM when studying it. But there is a problem: FAMs don’t seem to really study it (alternatively they do not have the power of comprehension to understand the data); they merely pounce on this figure and cite it endlessly:
They interpret it to mean that only 11% of what conventional clinicians do is based on sound evidence. This is water on their mills, because now they feel able to claim:
THE MAJORITY OF WHAT CONVENTIONAL CLINICIANS DO IS NOT EVIDENCE-BASED. SO, WHY DO SO-CALLED RATIONAL THINKERS EXPECT ALTERNATIVE THERAPIES TO BE EVIDENCE-BASED? IF WE NEEDED PROOF THAT THEY ARE HYPOCRITES, HERE IT IS!!!
The question is: are these FAMs correct?
The answer is: no!
They are merely using a logical fallacy (tu quoque); what is worse, they use it based on misunderstanding the actual data summarised in the above figure.
Let’s look at this in a little more detail.
The first thing we need to understand the methodologies used by ‘Clinical Evidence’ and what the different categories in the graph mean. Here is the explanation:
So, arguably the top three categories amounting to 42% signify some evidential support (if we decided to be more rigorous and merely included the two top categories, we would still arrive at 35%). This is not great, but we must remember two things here:
- EBM is fairly new;
- lots of people are working hard to improve the evidence base of medicine so that, in future, these figures will be better (by contrast, in alternative medicine, no similar progress is noticeable).
The second thing that strikes me is that, in alternative medicine, these figures would surely be much, much worse. I am not aware of reliable estimates, but I guess that the percentages might be one dimension smaller.
The third thing to mention is that the figures do not cover the entire spectrum of treatments available today but are based on ~ 3000 selected therapies. It is unclear how they were chosen, presumably the choice is pragmatic and based on the information available. If an up-to date systematic review has been published and provided the necessary information, the therapy was included. This means that the figures include not just mainstream but also plenty of alternative treatments (to the best of my knowledge ‘Clinical Evidence’ makes no distinction between the two). It is thus nonsensical to claim that the data highlight the weakness of the evidence in conventional medicine. It is even possible that the figures would be better, if alternative treatments had been excluded (I estimate that around 2 000 systematic reviews of alternative therapies have been published [I am the author of ~400 of them!]).
The fourth and possibly the most important thing to mention is that the percentage figures in the graph are certainly NOT a reflection of what percentage of treatments used in routine care are based on good evidence. In conventional practice, clinicians would, of course, select where possible those treatments with the best evidence base, while leaving the less well documented ones aside. In other words, they will use the ones in the two top categories much more frequently than those from the other categories.
At this stage, I hear some FAMs say: how does he know that?
Because several studies have been published that investigated this issue in some detail. They have monitored what percentage of interventions used by conventional clinicians in their daily practice are based on good evidence. In 2004, I reviewed these studies; here is the crucial passage from my paper:
“The most conclusive answer comes from a UK survey by Gill et al who retrospectively reviewed 122 consecutive general practice consultations. They found that 81% of the prescribed treatments were based on evidence and 30% were based on randomised controlled trials (RCTs). A similar study conducted in a UK university hospital outpatient department of general medicine arrived at comparable figures; 82% of the interventions were based on evidence, 53% on RCTs. Other relevant data originate from abroad. In Sweden, 84% of internal medicine interventions were based on evidence and 50% on RCTs. In Spain these percentages were 55 and 38%, respectively. Imrie and Ramey pooled a total of 15 studies across all medical disciplines, and found that, on average, 76% of medical treatments are supported by some form of compelling evidence — the lowest was that mentioned above (55%),6 and the highest (97%) was achieved in anaesthesia in Britain. Collectively these data suggest that, in terms of evidence-base, general practice is much better than its reputation.”
My conclusions from all this:
FAMs should study the BMJ Clinical Evidence more thoroughly. If they did, they might comprehend that the claims they tend to make about the data shown there are, in fact, bogus. In addition, they might even learn a thing or two about EBM which might eventually improve the quality of the debate.
It has been pointed out that many of the discussions we have on this blog are like pigeon chess. The term comes from a comment made by Scott D. Weitzenhoffer about Evolution vs. Creationism: An introduction: “Debating creationists on the topic of evolution is rather like trying to play chess with a pigeon — it knocks the pieces over, craps on the board, and flies back to its flock to claim victory.”
Debating a fan of alternative medicine is frequently just like that: ignorant of the basics of science and logic, he nevertheless insists on playing with you, knocks over the pieces, defecates on the board, flies back to his flock to boast of victory, only to come back a little later to start over again.
The sequence of events is comically stereotypical: in order to start this game, the evangelist of alternative medicine does his best to appear rational and interested in the subject. Once a discussion has commenced, he begins to make more and more irrational claims. When asked to provide evidence for them, he evades the challenge. Instead, he issues all sorts of accusations to you. Some of the favourites include:
- being not competent to discuss the issue at hand,
- having a closed mind,
- being paid by BIG PHARMA,
As the accusations continue, it can be almost impossible to remain polite. Your reminders to produce evidence for the evangelist’s irrational claims become more and more pressing. He then decides to focus on a triviality and pesters you with questions about it which are too silly to answer. Consequently, the temperature of the exchange rises until his accusations become offensive or turn into overt insults (in the past I have sometimes deleted insulting comments and I intend to continue doing this on hopefully rare occasions). The aims of the evangelist are 1) to arrive at a point where you lose your temper and 2) to distract from the fact that he is unable to provide any evidence for his outlandish claims. Eventually your patience is exhausted and you finally start paying him back in the same coinage as he dispensed.
At this stage, the evangelist indignantly shouts:
- YOU HAVE INSULTED ME!!!
- YOU HAVE INSULTED ANYONE WHO DISAGREES WITH YOU!!!
- THIS SHOWS WHAT A BAD, BAD PERSON YOU ARE!!!
Consequently, you give him a real piece of your mind and tell him what you really think of people who are belligerent, ignorant on their chosen subject, provocatively irrational and unable or unwilling to learn. The reaction of the evangelist is predictable: he says THAT’S IT, I AM NOT TALKING TO YOU ANYMORE, announces that he is the winner of the argument, and flies off triumphantly promising never to return.
We all give a sigh of relief. The evangelist has now returned to his fellow conspiracy theorists where he defames you the best he can. Eventually he disappoints your hope of peace and rationality by returning to the table. He pretends nothing has happened and starts over again.
So, what is the solution?
I am not sure there is an ideal way out.
Personally I intend to do the following in future (and I invite others to follow my example): before I reach the point where I lose my temper completely and regrettably, I will refer the evangelist to this blog post entitled ‘A method of ending discussions with belligerent twits’. At the same time, I will inform him (rarely it is a ‘her’) that I am about to break off the discussion with him because I fear that otherwise I might be openly rude, and perhaps even tell him: YOU ARE A FLAMING IDIOT WHO POSTS FAR TO MUCH NONSENSE TO BE TAKEN SERIOUSLY.
This, I hope will get my message across without actually ever tempting me to post a rude word again.
Failing this, I will block him completely, a measure to which so far I only needed rarely to resort.
The website of the HOMEOPATHY HUB gives us intriguing access to the brain of a homeopath. It tells us that “protecting patient choice is at the heart of everything we do. Homeopathy, which is the second largest system of medicine in the world, is a form of treatment which plays a vital role in the lives of hundreds of thousands of people across the UK. There is, however, a movement to try and withdraw homeopathy from the public and make homeopathic medicines difficult to secure. Our intention is to be a central “hub” for accurate information on current campaigns to retain access to homeopathy and details on how you can get involved and make your voice heard. Without public and patient support we will not be successful.”
Here are a few of the above statements that I find doubtful:
- protecting patient choice – choice requires reliable information; as we will see, this is not provided here;
- second largest system of medicine in the world – really?
- plays a vital role – where is the evidence for that claim?
- movement to try and withdraw homeopathy from the public and make homeopathic medicines difficult to secure – nobody works towards this aim, some people are trying to stop wasting public funds on useless therapies, but that’s quite different, I find;
The HOMEOPATHY HUB recently alerted its readers to the fact that the Charity Commission (CC) is currently conducting a public consultation on whether organisations promoting the use of complementary and alternative medicines (CAM) should have charitable status (https://www.gov.uk/government/consultations/consultation-on-complementary-and-alternative-medicines) and urged its readers to defend homeopathy by responding to the CC offering a “few helpful points” to raise. These 7 points give, I think, a good insight into the thinking of homeopaths. I therefore copy them here and add a few of my own comments below:
- there are many types of evidence that should be considered when evaluating the effectiveness of a therapy. These include scientific studies, patient feedback and the clinical experience of doctors who have trained in a CAM discipline. Within Homeopathy there is considerable evidence which can be found (https://www.hri-research.org)
- many conventional therapies and drugs have inconclusive evidence or prove to be useful in only some cases, for example SSRIs (anti-depressants). Inconsistent evidence is often the result of the complexity of both the medical condition being treated and the therapy being used. It is not indicative of a therapy that doesn’t work
- removing all therapies or interventions that have inconsistent or inconclusive evidence would seriously limit the public and the medical profession’s ability to help treat and ease patients suffering.
- all over the world there are doctors, nurses, midwives, vets and other healthcare professional who integrate CAM therapies into their daily practice because they see effectiveness. They would not use these therapies if they did not see their patients benefitting from them. For example in the UK, within the NHS hospital setting, outcome studies demonstrate effectiveness of homeopathy. (http://www.britishhomeopathic.org/evidence/results-from-the-homeopathic-hospitals/)
- practitioners of many CAM therapies belong to registering bodies which expect their members to comply to the highest professional standards in regards to training and practice
- In the UK the producers and suppliers of CAM treatments (homeopathy, herbal medicine etc) are strictly regulated
- as well as providing valuable information to the growing number of people seeking to use CAM as part of their healthcare, CAM charities frequently fund treatment for those people, particularly the elderly and those on a low income, whose health has benefitted from these therapies but who cannot afford them. This meets the charity’s criterion of providing a public benefit.
- “Patient feedback and the clinical experience of doctors” may be important but is not what can be considered evidence of therapeutic effectiveness.
- Yes, in medicine evidence is often inconsistent; this is why we need to rely on proper assessments of the totality of the reliable data. If that fails to be positive (as is the case for homeopathy and several other forms of alternative medicine), we are well advised not to employ the treatment in question in routine healthcare.
- Removing all treatments for which the best evidence fails to show effectiveness – such as homeopathy – would greatly improve healthcare and reduces cost. It is one of the aims of EBM and an ethical imperative.
- Yes, some healthcare professionals do use useless therapies. They urgently need to be educated in the principles of EBM. Outcome studies have normally no control groups and therefore are no adequate tools for testing the effectiveness of medical interventions.
- The highest professional standards in regards to training and practice of nonsense will still result in nonsense.
- The proper regulation of nonsense can only generate proper nonsense.
- Yes, CAM charities frequently fund bogus treatments; hopefully (and with the help of readers of this blog), the CC will put an end to this soon.
I think these 7 points by the HOMEOPATHY HUB are a very poor defence of homeopathy. In fact, they are so bad that it is not worth analysing more closely than I did above. Yet, they do provide us with an insight into the homeopathic mind-set and show how illogical, misguided and wrong the arguments of homeopathy enthusiasts really are.
I do encourage you to give your response to the CC – it wound be hard to use better arguments than the homeopaths!!!
On this blog, we have had (mostly unproductive) discussions with homeopath so often that sometimes they sound like a broken disk. I don’t want to add to this kerfuffle; what I hope to do today is to summarise a certain line of argument which, from the homeopaths’ point of view, seems entirely logical. I do this in the form of a fictitious conversation between a scientist (S) and a classical homeopath (H). My aim is to make the reader understand homeopaths better so that, future debates might be better informed.
HERE WE GO:
S: I have studied the evidence from studies of homeopathy in some detail, and I have to tell you, it fails to show that homeopathy works.
H: This is not true! We have plenty of evidence to prove that patients get better after seeing a homeopath.
S: Yes, but this is not because of the remedy; it is due to non-specific effect like the empathetic consultation with a homeopath. If one controls for these factors in adequately designed trials, the result usually is negative.
I will re-phrase my claim: the evidence fails to show that highly diluted homeopathic remedies are more effective than placebos.
H: I disagree, there are positive studies as well.
S: Let’s not cherry pick. We must always consider the totality of the reliable evidence. We now have a meta-analysis published by homeopaths that demonstrates the ineffectiveness of homeopathy quite clearly.
H: This is because homeopathy was not used correctly in the primary trials. Homeopathy must be individualised for each unique patient; no two cases are alike! Remember: homeopathy is based on the principle that like cures like!!!
S: Are you saying that all other forms of using homeopathy are wrong?
H: They are certainly not adhering to what Hahnemann told us to do; therefore you cannot take their ineffectiveness as proof that homeopathy does not work.
S: This means that much, if not most of homeopathy as it is used today is to be condemned as fake.
H: I would not go that far, but it is definitely not the real thing; it does not obey the law of similars.
S: Let’s leave this to one side for the moment. If you insist on individualised homeopathy, I must tell you that this approach can also be tested in clinical trials.
H: I know; and there is a meta-analysis which proves that it is effective.
S: Not quite; it concluded that medicines prescribed in individualised homeopathy may have small, specific treatment effects. Findings are consistent with sub-group data available in a previous ‘global’ systematic review. The low or unclear overall quality of the evidence prompts caution in interpreting the findings. New high-quality RCT research is necessary to enable more decisive interpretation.
If you call this a proof of efficacy, I would have to disagree with you. The effect was tiny and at least two of the best studies relevant to the subject were left out. If anything, this paper is yet another proof that homeopathy is useless!
H: You simply don’t understand homeopathy enough to say that. I tried to tell you that the remedy must be carefully chosen to fit each unique patient. This is a very difficult task, and sometimes it is not successful – mainly because the homeopaths employed in clinical trials are not skilled enough to find it. This means that, in these studies, we will always have a certain failure rate which, in turn, is responsible for the small average effect size.
S: But these studies are always conducted by experienced homeopaths, and only the very best, most experienced homeopaths were chosen to cooperate in them. Your argument that the trials are negative because of the ineffectiveness of the homeopaths – rather than the ineffectiveness of homeopathy – is therefore nonsense.
H: This is what you say because you don’t understand homeopathy!
S: No, it is what you say because you don’t understand science. How else would you prove that your hypothesis is correct?
H: Simple! Just look at individual cases from the primary studies within this meta-analysis . You will see that there are always patients who did improve. These cases are the proof we need. The method of the RCT is only good for defining average effects; this is not what we should be looking at, and it is certainly not what homeopaths are interested in.
S: Are you saying that the method of the RCT is wrong?
H: It is not always wrong. Some RCTs of homeopathy are positive and do very clearly prove that homeopathy works. These are obviously the studies where homeopathy has been applied correctly. We have to make a meta-analysis of such trials, and you will see that the result turns out to be positive.
S: So, you claim that all the positive studies have used the correct method, while all the negative ones have used homeopathy incorrectly.
H: If you insist to put it like that, yes.
S: I see, you define a trial to have used homeopathy correctly by its result. Essentially you accept science only if it generates the outcome you like.
H: Yes, that sounds odd to you – because you don’t understand enough of homeopathy.
S: No, what you seem to insist on is nothing short of double standards. Or would you accept a drug company claiming: some patients did feel better after taking our new drug, and this is proof that it works?
H: You see, not understanding homeopathy leads to serious errors.
S: I give up.