MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

bias

1 2 3 38

THE CONVERSATION recently carried an article shamelessly promoting osteopathy. It seems to originate from the University of Swansea, UK, and is full of bizarre notions. Here is an excerpt:

To find out more about how osteopathy could potentially affect mental health, at our university health and well-being academy, we have recently conducted one of the first studies on the psychological impact of OMT – with positive results.

For the last five years, therapists at the academy have been using OMT to treat members of the public who suffer from a variety of musculoskeletal disorders which have led to chronic pain. To find out more about the mental health impacts of the treatment, we looked at three points in time – before OMT treatment, after the first week of treatment, and after the second week of treatment – and asked patients how they felt using mental health questionnaires.

This data has shown that OMT is effective for reducing anxiety and psychological distress, as well as improving patient self-care. But it may not be suitable for all mental illnesses associated with chronic pain. For instance, we found that OMT was less effective for depression and fear avoidance.

All is not lost, though. Our results also suggested that the positive psychological effects of OMT could be further optimised by combining it with therapy approaches like acceptance and commitment therapy (ACT). Some research indicates that psychological problems such as anxiety and depression are associated with inflexibility, and lead to experiential avoidance. ACT has a positive effect at reducing experiential avoidance, so may be useful with reducing the fear avoidance and depression (which OMT did not significantly reduce).

Other researchers have also suggested that this combined approach may be useful for some subgroups receiving OMT where they may accept this treatment. And, further backing this idea up, there has already been at least one pilot clinical trial and a feasibility study which have used ACT and OMT with some success.

Looking to build on our positive results, we have now begun to develop our ACT treatment in the academy, to be combined with the osteopathic therapy already on offer. Though there will be a different range of options, one of these ACT therapies is psychoeducational in nature. It does not require an active therapist to work with the patient, and can be delivered through internet instruction videos and homework exercises, for example.

Looking to the future, this kind of low cost, broad healthcare could not only save the health service money if rolled out nationwide but would also mean that patients only have to undergo one treatment.

END OF QUOTE

So, they recruited a few patients who had come to receive osteopathic treatments (a self-selected population full of expectation and in favour of osteopathy), let them fill a few questionnaires and found some positive changes. From that, they conclude that OMT (osteopathic manipulative therapy) is effective. Not only that, they advocate that OMT is rolled out nationwide to save NHS funds.

Vis a vis so much nonsense, I am (almost) speechless!

As this comes not from some commercial enterprise but from a UK university, the nonsense is intolerable, I find.

Do I even need to point out what is wrong with it?

Not really, it’s too obvious.

But, just in case some readers struggle to find the fatal flaws of this ‘study’, let me mention just the most obvious one. There was no control group! That means the observed outcome could be due to many factors that are totally unrelated to OMT – such as placebo-effect, regression towards the mean, natural history of the condition, concomitant treatments, etc. In turn, this also means that the nationwide rolling out of their approach would most likely be a costly mistake.

The general adoption of OMT would of course please osteopaths a lot; it could even reduce anxiety – but only that of the osteopaths and their bank-managers, I am afraid.

In Germany, homeopathy had been an undisputed favourite for a very long time. Doctors prescribed it, Heilpraktiker recommended it, patients took it and consumers, politicians, journalists, etc. hardly ever questioned it. But recently, this has changed; thanks not least to the INH and the ‘Muensteraner Kreis‘, some Germans are finally objecting to paying for the homeopathic follies of others. Remarkably, this might even have led to a dent in the sizable profits of homeopathy producers: while in 2016 the industry sold about 55 million units of homeopathic preparations, the figure had decreased to ‘just’ ~53 million in 2017.

Enough reason, it seems, for some manufacturers to panic. The largest one is the DHU (Deutsche Homoeopathische Union), and they recently decided to go on the counter attack by investing into a large PR campaign. This article (in German, I’m afraid) explains:

…Unter dem Hashtag #MachAuchDuMit lädt die Initiative Anwenderinnen und Anwender ein, ihre guten Erfahrungen in Sachen Homöopathie zu teilen. “Über 30 Millionen zufriedene Menschen setzen für ihre Gesundheit auf Homöopathie und vertrauen ihr. Mit unserer Initiative wollen wir das Selbstbewusstsein der Menschen stärken, sich für die Homöopathie zu entscheiden oder mindestens für eine freie Wahl einzustehen,” so Peter Braun, Geschäftsführer der DHU…

“Die Therapiefreiheit, die in unserem Slogan mit “Meine Entscheidung!” zum Ausdruck kommt, ist uns das wichtigste in dieser Initiative”, unterstreicht Peter Braun. Und dafür lohnt es sich aktiv zu werden, wie der Schweizer weiß. 2017 haben sich die Menschen in der Schweiz per Volksabstimmung für das Konzept einer integrativen Medizin entschieden. Neben der Schulmedizin können dort auch weitere Therapieverfahren wie Homöopathie oder Naturmedizin zum Einsatz kommen.

In Deutschland will die DHU mit ihrer Initiative Transparenz schaffen und die Homöopathie hinsichtlich Fakten und Erfolge realistisch darstellen. Dafür besteht offensichtlich Bedarf: “Wir als DHU haben in der jüngsten Vergangenheit dutzende spontane Anfragen bekommen, für die Homöopathie Flagge zu zeigen”.

Was die Inhalte der Initiative angeht betont Peter Braun, dass es dabei nie um ein “Entweder-Oder” zwischen Schulmedizin und anderen Therapieverfahren gehen soll: “Die Kombination der jeweils am besten für den Patienten passenden Methode im Sinne von “Hand-in-Hand” ist das Ziel der modernen integrativen Medizin. In keiner Art und Weise ist eine Entscheidung für die Homöopathie eine Entscheidung gegen die Schulmedizin. Beides hat seine Berechtigung und ergänzt sich in vielen Fällen.”

——————————————————————————————————————

For those who do not read German, I will pick out a few central themes from the text.

Amongst other things, the DHU proclaim that:

  1. Homeopathy has millions of satisfied customers in Germany.
  2. The campaign aims at defending customers’ choice.
  3. The campaign declares to present the facts realistically.
  4. The decision is “never an ‘either or’ between conventional medicine (Schulmedizin) and other methods”; combining those therapies that suit the patient best is the aim of modern Integrative Medicine.

It is clear to anyone who is capable of critical thinking tha
t these 4 points are fallacious to the extreme. For those to whom it isn’t so clear, let me briefly explain:

  1. The ‘appeal to popularity’ is a classical fallacy.
  2. Nobody wants to curtail patients’ freedom to chose the therapy they want. The discussion is about who should pay for ineffective remedies. Even if homeopathy will, one day, be no longer reimbursable in Germany, consumers will still be able to buy it with their own money.
  3. The campaign has so far not presented the facts about homeopathy (i. e. the remedies contain nothing, homeopathy relies on implausible assumptions, the evidence fails to show that highly diluted homeopathic remedies are effective beyond placebo).
  4. Hahnemann called all homeopaths who combined his remedies with conventional treatments ‘traitors’ (‘Verraeter’) and coined the term ‘Schulmedizin’ to defame mainstream medicine.

The DHU campaign has only started recently, but already it seems to backfire big way. Social media are full with comments pointing out how pathetic it truly is, and many Germans have taken to making fun at it on social media. Personally, I cannot say I blame them – not least because the latest DHU campaign reminds me of the 2012 DHU-sponsored PR campaign. At the time, quackometer reported:

A consortium of pharmaceutical companies in Germany have been paying a journalist €43,000 to run a set of web sites that denigrates an academic who has published research into  their products.

These companies, who make homeopathic sugar pills, were exposed in the German newspaper Süddeutsche Zeitung in an article, Schmutzige Methoden der sanften Medizin (The Dirty Tricks of Alternative Medicine.)

This story has not appeared in the UK media. And it should. Because it is a scandal that directly involves the UK’s most prominent academic in Complementary and Alternative Medicine.

The newspaper accuses the companies of funding the journalist, Claus Fritzsche, to denigrate critics of homeopathy. In particular, the accusation is that Fritzsche wrote about UK academic Professor Edzard Ernst on several web sites and then linked them together in order to raise their Google ranking. Fritzsche continually attacks Ernst of being frivolous, incompetent and partisan…

This story ended tragically; Fritzsche committed suicide.

My impression is that the PR-campaigns of homeopaths in general and the DHU in particular are rather ill-fated. Perhaps they should just forget about PR and do what responsible manufacturers should aim at doing: inform the public according to the best evidence currently available, even if this might make a tiny dent in their huge profits.

On this blog, we have seen more than enough evidence of how some proponents of alternative medicine can react when they feel cornered by critics. They often direct vitriol in their direction. Ad hominem attacks are far from being rarities. A more forceful option is to sue them for libel. In my own case, Prince Charles went one decisive step further and made sure that my entire department was closed down. In China, they have recently and dramatically gone even further.

This article in Nature tells the full story:

A Chinese doctor who was arrested after he criticized a best-selling traditional Chinese remedy has been released, after more than three months in detention. Tan Qindong had been held at the Liangcheng county detention centre since January, when police said a post Tan had made on social media damaged the reputation of the traditional medicine and the company that makes it.

On 17 April, a provincial court found the police evidence for the case insufficient. Tan, a former anaesthesiologist who has founded several biomedical companies, was released on bail on that day. Tan, who lives in Guangzhou in southern China, is now awaiting trial. Lawyers familiar with Chinese criminal law told Nature that police have a year to collect more evidence or the case will be dismissed. They say the trial is unlikely to go ahead…

The episode highlights the sensitivities over traditional Chinese medicines (TCMs) in China. Although most of these therapies have not been tested for efficacy in randomized clinical trials — and serious side effects have been reported in some1TCM has support from the highest levels of government. Criticism of remedies is often blocked on the Internet in China. Some lawyers and physicians worry that Tan’s arrest will make people even more hesitant to criticize traditional therapies…

Tan’s post about a medicine called Hongmao liquor was published on the Chinese social-media app Meipian on 19 December…Three days later, the liquor’s maker, Hongmao Pharmaceuticals in Liangcheng county of Inner Mongolia autonomous region, told local police that Tan had defamed the company. Liangcheng police hired an accountant who estimated that the damage to the company’s reputation was 1.4 million Chinese yuan (US$220,000), according to official state media, the Beijing Youth Daily. In January, Liangcheng police travelled to Guangzhou to arrest Tan and escort him back to Liangcheng, according to a police statement.

Sales of Hongmao liquor reached 1.63 billion yuan in 2016, making it the second best-selling TCM in China that year. It was approved to be sold by licensed TCM shops and physicians in 1992 and approved for sale over the counter in 2003. Hongmao Pharmaceuticals says that the liquor can treat dozens of different disorders, including problems with the spleen, stomach and kidney, as well as backaches…

Hongmao Pharmaceuticals did not respond to Nature’s request for an interview. However, Wang Shengwang, general manager of the production center of Hongmao Liquor, and Han Jun, assistant to the general manager, gave an interview to The Paper on 16 April. The pair said the company did not need not publicize clinical trial data because Hongmao liquor is a “protected TCM composition”. Wang denied allegations in Chinese media that the company pressured the police to pursue Tan or that it dispatched staff to accompany the police…

Xia is worried that the case could further silence public criticism of TCMs, environmental degredation, and other fields where comment from experts is crucial. The Tan arrest “could cause fear among scientists” and dissuade them from posting scientific comments, he says.

END OF QUOTE

On this blog, we have repeatedly discussed concerns over the validity of TCM data/material that comes out of China (see for instance here, here and here). This chilling case, I am afraid, is not prone to increase our confidence.

Reflexology is an alternative therapy that is subjectively pleasant and objectively popular; it has been the subject on this blog before (see also here and here). Reflexologists assume that certain zones on the sole of our feet correspond to certain organs, and that their manual treatment can influence the function of these organs. Thus reflexology is advocated for all sorts of conditions, including infant colic.

The aim of this new study was to explore the effect of reflexology on infantile colic.

A total of 64 babies with colic were included in this study. Following a paediatrician’s diagnosis, two groups (study and control) were created. Socio-demographic data (including mother’s age, educational status, and smoking habits of parents) and medical history of the baby (including gender, birth weight, mode of delivery, time of the onset breastfeeding after birth, and nutrition style) were collected. The Infant Colic Scale (ICS) was used to estimate the colic severity in the infants. Reflexology was applied to the study group by the researcher and their mother 2 days a week for 3 weeks. The babies in the control group did not receive reflexology. Assessments were performed before and after the intervention in both groups.

The results show that the two groups were similar regarding socio-demographic background and medical history. While there was no difference between the groups in ICS scores before application of reflexology, the mean ICS score of the study group was significantly lower than that of control group at the end of the intervention.

The authors concluded that reflexology application for babies suffering from infantile colic may be a promising method to alleviate colic severity.

The authors seem to attribute the outcome to specific effects of reflexology.

However, they are mistaken!

Why?

Because their study does not control for the non-specific effects of the intervention.

Reflexology has not been shown to work for anything (“the best clinical evidence does not demonstrate convincingly reflexology to be an effective treatment for any medical condition“), and there is plenty of evidence to show that holding the baby, massaging it, cuddling it, rocking it or doing just about anything with it will have an effect, e. g.:

This trial of massage treatment for infantile colic showed statistically significant or clinically relevant effect in comparison with the rocking group.

The majority of the included trials appeared to indicate that the parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not…

…kangaroo care for infants with colic is a promising intervention…

I think, in a way, this is rather good news; we do not need to believe in the hocus-pocus of reflexology in order to help our crying infants.

“In at least one article on chiropractic, Ernst has been shown to be fabricating data. I would not be surprised if he did the same thing with homeopathy. Ernst is a serial scientific liar.”

I saw this remarkable and charming Tweet yesterday. Its author is ‘Dr’ Avery Jenkins. Initially I was unaware of having had contact with him before; but when I checked my emails, I found this correspondence from August 2010:

Dr. Ernst:

Would you be so kind as to provide the full text of your article? Also, when would you be available for an interview for an upcoming feature article?

Thank you.

Avery L. Jenkins, D.C.

I put his title in inverted commas, because it turns out he is a chiropractor and not a medical doctor (but let’s not be petty!).

‘Dr’ Avery Jenkins runs a ‘Center for Alternative Medicine’ in the US: The Center has several features which set it apart from most other alternative medicine facilities, including the Center’s unique Dispensary.  Stocked with over 300 herbs and supplements, the Dispensary’s wide range of natural remedies enables Dr. Jenkins to be the only doctor in Connecticut who provides custom herbal formulations for his patients. In our drug testing facility, we can provide on-site testing for drugs of abuse with immediate result reporting. Same-day appointments are available. Dr. Jenkins is also one of the few doctors in the state who has already undergone the federally-mandated training which will be necessary for all Department of Transportation Medical Examiners by 2014. Medical examinations for your Commercial Drivers License will take only 25 minutes, and Dr. Jenkins will provide you with all necessary paperwork.

The good ‘doctor’ also publishes a blog, and there I found a post from 2016 entirely dedicated to me. Here is an excerpt:

.. bias and hidden agendas come up in the research on alternative medicine and chiropractic in particular. Mostly this occurs in the form of journal articles using research that has been hand-crafted to make chiropractic spinal manipulation appear dangerous — when, in fact, you have a higher risk of serious injury while driving to your chiropractor’s office than you do of any treatment you receive while you’re there.

A case in point is the article, “Adverse effects of spinal manipulation: a systematic review,” authored by Edzard Ernst, and published in the Journal of the Royal Society of Medicine in 2007. Ernst concludes that, based on his review, “in the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.”

This conclusion throws up several red flags, beginning with the fact that it flies in the face of most of the already-published, extensive research which shows that chiropractic care is one of the safest interventions, and in fact, is  safer than medical alternatives.

For example, an examination of injuries resulting from neck adjustments over a 10-year period found that they rarely, if ever, cause strokes, and lumbar adjustments by chiropractors have been deemed by one of the largest studies ever performed to be safer and more effective than medical treatment.

So the sudden appearance of this study claiming that chiropractic care should be stopped altogether seems a bit odd.

As it turns out, the data is odd as well.

In 2012, a researcher at Macquarie University in Australia, set out to replicate Ernst’s study. What he found was shocking.

This subsequent study stated that “a review of the original case reports and case series papers described by Ernst found numerous errors or inconsistencies,” including changing the sex and age of patients, misrepresenting patients’ response to adverse events, and claiming that interventions were performed by chiropractors, when no chiropractor was even involved in the case.

“In 11 cases of the 21…that Ernst reported as [spinal manipulative therapy] administered by chiropractors, it is unlikely that the person was a qualified chiropractor,” the review found.

What is interesting here is that Edzard Ernst is no rookie in academic publishing. In fact, he is a retired professor and founder of two medical journals. What are the odds that a man with this level of experience could overlook so many errors in his own data?

The likelihood of Ernst accidentally allowing so many errors into his article is extremely small. It is far more likely that Ernst selected, prepared, and presented the data to make it fit a predetermined conclusion.

So, Ernst’s article is either extremely poor science, or witheringly inept fraud. I’ll let the reader draw their own conclusion.

Interestingly enough, being called out on his antics has not stopped Ernst from disseminating equally ridiculous research in an unprofessional manner. Just a few days ago, Ernst frantically called attention to another alleged chiropractic mishap, this one resulting in a massive brain injury.

Not only has he not learned his lesson yet, Ernst tried the same old sleight of hand again. The brain injury, as it turns out, didn’t happen until a week after the “chiropractic” adjustment, making it highly unlikely, if not impossible, for the adjustment to have caused the injury in the first place. Secondly, the adjustment wasn’t even performed by a chiropractor. As the original paper points out, “cervical manipulation is still widely practiced in massage parlors and barbers in the Middle East.”  The original article makes no claim that the neck adjustment (which couldn’t have caused the problem in the first place) was actually performed by a chiropractor.

It is truly a shame that fiction published by people like Ernst has had the effect of preventing many people from getting the care they need. I can only hope that someday the biomedical research community can shed its childish biases so that we all might be better served by their findings.

END OF QUOTE

Here I will not deal with the criticism a Australian chiropractor published in a chiro-journal 5 years after my 2007 article (which incidentally was not primarily about chiropractic but about spinal manipulation). Suffice to say that my article did NOT contain ‘fabricated’ data. A full re-analysis would be far too tedious, for my taste (especially as criticism of it has been discussed in all of 7 ‘letters to the editor’ soon after its publication)

I will, however, address ‘Dr’ Avery Jenkins’ second allegation related to my recent (‘frantic’) blog-post. I will do this by simply copying the abstract of the paper in question:

Background: Multivessel cervical dissection with cortical sparing is exceptional in clinical practice. Case presentation: A 55-year-old man presented with acute-onset neck pain with associated sudden onset right-sided hemiparesis and dysphasia after chiropractic* manipulation for chronic neck pain. Results and Discussion: Magnetic resonance imaging revealed bilateral internal carotid artery dissection and left extracranial vertebral artery dissection with bilateral anterior cerebral artery territory infarctions and large cortical-sparing left middle cerebral artery infarction. This suggests the presence of functionally patent and interconnecting leptomeningeal anastomoses between cerebral arteries, which may provide sufficient blood flow to salvage penumbral regions when a supplying artery is occluded. Conclusion: Chiropractic* cervical manipulation can result in catastrophic vascular lesions preventable if these practices are limited to highly specialized personnel under very specific situations.

*my emphasis


With this, I rest my case.

The only question to be answered now is this: TO SUE OR NOT TO SUE?

What do you think?

Have you ever wondered whether doctors who practice homeopathy are different from those who don’t.

Silly question, of course they are! But how do they differ?

Having practised homeopathy myself during my very early days as a physician, I have often thought about this issue. My personal (and not very flattering) impressions were noted in my memoir where I describe my experience working in a German homeopathic hospital:

some of my colleagues used homeopathy and other alternative approaches because they could not quite cope with the often exceedingly high demands of conventional medicine. It is almost understandable that, if a physician was having trouble comprehending the multifactorial causes and mechanisms of disease and illness, or for one reason or another could not master the equally complex process of reaching a diagnosis or finding an effective therapy, it might be tempting instead to employ notions such as dowsing, homeopathy or acupuncture, whose theoretical basis, unsullied by the inconvenient absolutes of science, was immeasurably more easy to grasp. 

Some of my colleagues in the homeopathic hospital were clearly not cut out to be “real” doctors. Even a very junior doctor like me could not help noticing this somewhat embarrassing fact… 

But this is anecdote and not evidence!

So, where is the evidence?

It was published last week and made headlines in many UK daily papers.

Our study was aimed at finding out whether English GP practices that prescribe any homeopathic preparations might differ in their prescribing of other drugs. We identified practices that made any homeopathy prescriptions over six months of data. We measured associations with four prescribing and two practice quality indicators using multivariable logistic regression.

Only 8.5% of practices (644) prescribed homeopathy between December 2016 and May 2017. Practices in the worst-scoring quartile for a composite measure of prescribing quality were 2.1 times more likely to prescribe homeopathy than those in the best category. Aggregate savings from the subset of these measures where a cost saving could be calculated were also strongly associated. Of practices spending the most on medicines identified as ‘low value’ by NHS England, 12.8% prescribed homeopathy, compared to 3.9% for lowest spenders. Of practices in the worst category for aggregated price-per-unit cost savings, 12.7% prescribed homeopathy, compared to 3.5% in the best category. Practice quality outcomes framework scores and patient recommendation rates were not associated with prescribing homeopathy.

We concluded that even infrequent homeopathy prescribing is strongly associated with poor performance on a range of prescribing quality measures, but not with overall patient recommendation or quality outcomes framework score. The association is unlikely to be a direct causal relationship, but may reflect underlying practice features, such as the extent of respect for evidence-based practice, or poorer stewardship of the prescribing budget.

Since our study was reported in almost all of the UK newspapers, it comes as no surprise that, in the interest of ‘journalistic balance’, homeopaths were invited to give their ‘expert’ opinions on our work.

Margaret Wyllie, head of the British Homeopathic Association, was quoted commenting: “This is another example of how real patient experience and health outcomes are so often discounted, when in actuality they should be the primary driver for research to improve our NHS services. This study provides no useful evidence about homeopathy, or about prescribing, and gives absolutely no data that can improve the health of people in the UK.”

The Faculty of Homeopathy was equally unhappy about our study and stated: “The study did not include any measures of patient outcomes, so it doesn’t tell us how the use of homeopathy in English general practice correlates with patients doing well or badly, nor with how many drugs they use.”

Cristal Summer from the Society of Homeopathy said that our research was just a rubbish bit of a study.

Peter Fisher, the Queen’s homeopath and the president of the Faculty of Homeopathy, stated: “We don’t know if these measures correlate with what matters to patients – whether they get better and have side-effects.”

A study aimed at determining whether GP practices that prescribe homeopathic preparations differ in their prescribing habits from those that do not prescribe homeopathics can hardly address these questions, Peter. A test of washing machines can hardly tell us much about the punctuality of trains. And an investigation into the risks of bungee jumping will not inform us about the benefits of regular exercise. Call me biased, but to me these comments indicate mainly one thing: HOMEOPATHS SEEM TO HAVE GREAT DIFFICULTIES UNDERSTANDING SCIENTIFIC PAPERS.

I much prefer the witty remarks of Catherine Bennett in yesterday’s Observer: Homeopath-GPs, naturally, have mustered in response and challenge Goldacre’s findings, with a concern for methodology that could easily give the impression that there is some evidential basis for their parallel system, beyond the fact that the Prince of Wales likes it. In fairness to Charles, his upbringing is to blame. But what is the doctors’ excuse?

Amongst all the implausible treatments to be found under the umbrella of ‘alternative medicine’, Reiki might be one of the worst, i. e. least plausible and outright bizarre (see for instance here, here and here). But this has never stopped enthusiasts from playing scientists and conducting some more pseudo-science.

This new study examined the immediate symptom relief from a single reiki or massage session in a hospitalized population at a rural academic medical centre. It was designed as a retrospective analysis of prospectively collected data on demographic, clinical, process, and quality of life for hospitalized patients receiving massage therapy or reiki. Hospitalized patients requesting or referred to the healing arts team received either a massage or reiki session and completed pre- and post-therapy symptom questionnaires. Differences between pre- and post-sessions in pain, nausea, fatigue, anxiety, depression, and overall well-being were recorded using an 11-point Likert scale.

Patients reported symptom relief with both reiki and massage therapy. Reiki improved fatigue and anxiety  more than massage. Pain, nausea, depression, and well being changes were not different between reiki and massage encounters. Immediate symptom relief was similar for cancer and non-cancer patients for both reiki and massage therapy and did not vary based on age, gender, length of session, and baseline symptoms.

The authors concluded that reiki and massage clinically provide similar improvements in pain, nausea, fatigue, anxiety, depression, and overall well-being while reiki improved fatigue and anxiety more than massage therapy in a heterogeneous hospitalized patient population. Controlled trials should be considered to validate the data.

Don’t I just adore this little addendum to the conclusions, “controlled trials should be considered to validate the data” ?

The thing is, there is nothing to validate here!

The outcomes are not due to the specific effects of Reiki or massage; they are almost certainly caused by:

  • the extra attention,
  • the expectation of patients,
  • the verbal or non-verbal suggestions of the therapists,
  • the regression towards the mean,
  • the natural history of the condition,
  • the concomitant therapies administered in parallel,
  • the placebo effect,
  • social desirability.

Such pseudo-research only can only serve one purpose: to mislead (some of) us into thinking that treatments such as Reiki might work.

What journal would be so utterly devoid of critical analysis to publish such unethical nonsense?

Ahh … it’s our old friend the Journal of Alternative and Complementary Medicine

Say no more!

I hear this argument so regularly that it might be worth analysing it (yet again) a bit closer.

It is used with the deepest of convictions by proponents of all sorts of quackery who point out that science does not know or explain everything – and certainly not their (very special) therapy. Science is just not sophisticated enough, they say; in fact, a few years ago, it could not even explain how Aspirin works. And just like Aspirin, their very special therapy – let’s call it energy healing (EH) for the sake of this post – does definitely and evidently work. There even is ample proof:

  • Patients get better after using EH, and surely patients don’t lie.
  • Patients pay for EH, and who would pay for something that does not work?
  • EH has survived hundreds of years, and ineffective therapies don’t.
  • EH practitioners have tons of experience and therefore know best.
  • They are respected by very important people and organisations.
  • EH is even reimbursed by some insurance companies.

You have all heard the argument, I’m sure.

How to respond?

The ‘proofs’ listed above are simply fallacies; as such they do not need more detailed discussions, I hope.

But how can we refute the notion that science is not yet sufficiently advanced to explain EH?

The simplest approach might be to explain that science has already tested EH and found it to be ineffective. There really is nothing more to say. And the often-quoted example of Aspirin does clearly not wash. True, a few decades ago, we did not know how it worked. But we always knew that it worked because we conducted clinical trials, and they generated positive results. These findings we the main reasons why scientists wanted to find out how it works, and eventually they did (and even got a Nobel Prize for it). Had the clinical trials not shown effectiveness, nobody would have been interested in alleged mechanisms of action.

With EH, things are different. Rigorous clinical trials of EH have been conducted, and the totality of this evidence fails to show that EH works. Therefore, chasing after a mechanism of action would be silly and wasteful. It’s true, science cannot explain EH, but this is not because it is not yet sophisticated enough; it is because there is nothing to explain. EH has been disproven, and waffling about ‘science is not yet able to explain it’ is either a deliberate lie or a serious delusion.

So far so good. But what if EH had not been submitted to clinical trials?

In such cases, the above line of argument would not work very well.

For instance, as far as I know, there is not a single rigorous clinical trial of crystal healing (CH). Does that mean that perhaps CH-proponents are correct when claiming that it does evidently work and science simply cannot yet understand how?

No, I don’t think so.

Like most of the untested alternative therapies, CH is not based on plausible assumptions. In fact, the implausibility of the underlying assumptions is the reason why such treatments have not and probably never will be submitted to rigorous clinical trials. Why should anyone waste his time and our money running expensive tests on something that is so extremely unlikely? Arguably doing so would even be unethical.

With highly implausible therapies we need no trials, and we do not need to fear that science is not yet sufficiently advance to explain them. In fact, science is sufficiently advanced to be certain that there can be no explanation that is in line with the known laws of nature.

Sadly, some truly deluded fans of CH might still not be satisfied and respond to our reasoning that we need a ‘paradigm shift’. They might say that science cannot explain CH because it is stuck in the straightjacket of an obsolete paradigm which does not cater for phenomena like CH.

Yet this last and desperate attempt of the fanatics is not a logical refuge. Paradigm shifts are not required because some quack thinks so, they are needed only if data have been emerging that cannot possibly be explained within the current paradigm. But this is never the case in alternative medicine. We can explain all the experience of advocates, positive results of researchers and ‘miracle’ cures of patients that are being reported. We know that the experiences are real, but are sure that their explanations of the experience are false. They are not due to the treatment per se but to other phenomena such as placebo effects, natural history, regression towards the mean, spontaneous recovery, etc.

So, whichever way we turn things, and whichever way enthusiasts of alternative therapies twist them, their argument that ‘SCIENCE IS NOT YET ABLE TO EXPLAIN’ is simply wrong.

The UK ‘COLLEGE OF MEDICINE’ has recently (and very quietly) renamed itself; it now is THE COLLEGE OF MEDICINE AND INTEGRATED HEALTH (COMIH). This takes it closer to its original intentions of being the successor of the PRINCE OF WALES FOUNDATION FOR INTEGRATED MEDICINE (PWFIM), the organisation that had to be shut down amidst charges of fraud and money-laundering. Originally, the name of COMIH was to be COLLEGE OF INTEGRATED HEALTH (as opposed to disintegrated health?, I asked myself at the time).

Under the leadership of Dr Michael Dixon, OBE (who also led the PWFIM into its demise), the COMIH pursues all sots of activities. One of them seems to be publishing ‘cutting-edge’ articles.

A recent and superb example is on the fascinating subject of ‘holistic dentistry‘:

START OF QUOTE

Professor Sonia Williams … explores how integrated oral health needs to consider the whole body, not just the dentition…

Complementary and alternative approaches can also be considered as complementary to ‘mainstream’ care, with varying levels of evidence cited for their benefit.

Dental hypnosis (British Society of Medical and Dental Hypnosis) can help support patients including those with dental phobia or help to reduce pain experience during treatment.

Acupuncture in dentistry (British Society of Dental Acupuncture) can, for instance, assist with pain relief and allay the tendency to vomit during dental care.  There is also a British Homeopathic Dental Association.

For the UK Faculty of General Dental Practitioners, holistic dentistry refers to strengthening the link between general and oral health.

For some others, the term also represents an ‘alternative’ form of dentistry, which may concern itself with the avoidance and elimination of ‘toxic’ filling materials, perceived potential harm from fluoride and root canal treatments and with treating dental malocclusion to put patients back in ‘balance’.

In the USA, there is a Holistic Dental Association, while in the UK, there is the British Society for Mercury-free Dentistry. Unfortunately the evidence base for many of these procedures is weak.

Nevertheless, pressure to avoid mercury in dental restorative materials is becoming mainstream.

In summary, integrated health and care in dentistry can mean different things to different people. The weight of evidence supports the contention that the mouth is an integral part of the body and that attention to the one without taking account of the other can have adverse consequences.

END OF QUOTE

Do I get this right? ‘Holistic dentistry’ in the UK means the recognition that my mouth belongs to my body, and the adoption of a few dubious treatments with w ‘weak’ evidence base?

Well, isn’t this just great? I had no idea that my mouth belongs to my body. And clearly the non-holistic dentists in the UK are oblivious to this fact as well. I am sooooooo glad we got this cleared up.

Thanks COMIH!!!

And what about the alternative treatments used by holistic dentists?

The British Society of Medical and Dental Hypnosis (Scotland) inform us on their website that a trained medical and dental hypnotherapists can help you to deal with a large variety of challenges that you face in your everyday life e.g.

Asthma Migraines
Anxiety & Stress Smoking Cessation
Dental Problems Insomnia
Weight Problems Psychosexual Disorders
Depression Pain Management
Irritable Bowel  And many other conditions

I hasten to add that, for most of these conditions, the evidence fails to support the claims.

The British Society of Dental Acupuncture claim on their website that the typical conditions that may be helped by acupuncture are:

  • TMJ (jaw joint) problems
  • Facial pain
  • Muscle spasm in the head and neck
  • Stress headaches & Migraine
  • Rhinitis & sinusitis
  • Gagging
  • Dry mouth problems
  • Post-operative pain
  • Dental anxiety

I hasten to add that, for most of these conditions, the evidence fails to support the claims.

The British Homeopathic Dental Association claim on their website that studies have shown improved bone healing around implants with Symphytum and reduced discomfort and improved healing time with ulcers and beneficial in oral lichen planus.

I hasten to add that none of these claims are not supported by sound evidence.

The COMIH article is entitled “The mouth reflects whole body health – but what does integrated care mean for dentists?’ So, what does it mean? Judging from this article, it means an amalgam (pun intended) of platitudes, bogus claims and outright nonsense.

Pity that they did not change their name to College of Medicine and Integrated Care – I could have abbreviated it as COMIC!

This week, I find it hard to decide where to focus; with all the fuzz about ‘Homeopathy Awareness Week’ it is easy to forget that our friends, the chiros are celebrating  Chiropractic Awareness Week (9-15 April). On this occasion, the British Chiropractic Association (BCA), for instance, want people to keep moving to make a positive impact on managing and preventing back and neck pain.

Good advice! In a recent post, I even have concluded that people should “walk (slowly and cautiously) to the office of their preferred therapist, have a little rest there (say hello to the staff perhaps) and then walk straight back home.” The reason for my advice is based on the fact that there is precious little evidence that the spinal manipulations of chiropractors make much difference plus some worrying indications that they may cause serious damage.

It seems to me that, by focussing their PR away from spinal manipulations and towards the many other things chiropractors sometimes do – they often call this ‘adjunctive therapies’ – there is a tacit admission here that the hallmark intervention of chiros (spinal manipulation) is of dubious value.

A recent article entitled ‘Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative’ seems to confirm this impression. Its objective was to develop a clinical practice guideline on the management of acute and chronic low back pain (LBP) in adults. The specific aim was to develop a guideline to provide best practice recommendations on the initial assessment and monitoring of people with low back pain and address the use of spinal manipulation therapy (SMT) compared with other commonly used conservative treatments.

The topic areas were chosen based on an Agency for Healthcare Research and Quality comparative effectiveness review, specific to spinal manipulation as a non-pharmacological intervention. The panel updated the search strategies in Medline and assessed admissible systematic reviews and randomized controlled trials. Evidence profiles were used to summarize judgments of the evidence quality and link recommendations to the supporting evidence. Using the Evidence to Decision Framework, the guideline panel determined the certainty of evidence and strength of the recommendations. Consensus was achieved using a modified Delphi technique. The guideline was peer reviewed by an 8-member multidisciplinary external committee.

For patients with acute (0-3 months) back pain, we suggest offering advice (posture, staying active), reassurance, education and self-management strategies in addition to SMT, usual medical care when deemed beneficial, or a combination of SMT and usual medical care to improve pain and disability. For patients with chronic (>3 months) back pain, we suggest offering advice and education, SMT or SMT as part of a multimodal therapy (exercise, myofascial therapy or usual medical care when deemed beneficial). For patients with chronic back-related leg pain, we suggest offering advice and education along with SMT and home exercise (positioning and stabilization exercises).

The authors concluded that a multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.

I find this paper most interesting and revealing. Considering that it originates from the ‘Canadian Chiropractic Guideline Initiative’, it is remarkably shy about recommending SMT – after all their vision is “To enhance the health of Canadians by fostering excellence in chiropractic care.” They are thus not likely to be overly critical of the treatment chiropractors use most, i. e. SMT.

Perhaps this is also the reason why, in their conclusion, they seem to have rather a large blind spot, namely the risks of SMT. I have commented on this issue more often than I care to remember. Most recently, I posted this:

The reason why my stance, as expressed on this blog and elsewhere, is often critical about certain alternative therapies is thus obvious and transparent. For none of them (except for massage) is the risk/benefit balance positive. And for spinal manipulation, it even turns out to be negative. It goes almost without saying that responsible advice must be to avoid treatments for which the benefits do not demonstrably outweigh the risks.

 

HAPPY CHIROPRACTIC AWARENESS WEEK EVERYONE!

1 2 3 38
Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories