Yesterday, I wrote about a new acupuncture trial. Amongst other things, I wanted to find out whether the author who had previously insisted I answer his questions about my view on the new NICE guideline would himself answer a few questions when asked politely. To remind you, this is what I wrote:
This new study was designed as a randomized, sham-controlled trial of acupuncture for persistent allergic rhinitis in adults investigated possible modulation of mucosal immune responses. A total of 151 individuals were randomized into real and sham acupuncture groups (who received twice-weekly treatments for 8 weeks) and a no acupuncture group. Various cytokines, neurotrophins, proinflammatory neuropeptides, and immunoglobulins were measured in saliva or plasma from baseline to 4-week follow-up.
Statistically significant reduction in allergen specific IgE for house dust mite was seen only in the real acupuncture group. A mean (SE) statistically significant down-regulation was also seen in pro-inflammatory neuropeptide substance P (SP) 18 to 24 hours after the first treatment. No significant changes were seen in the other neuropeptides, neurotrophins, or cytokines tested. Nasal obstruction, nasal itch, sneezing, runny nose, eye itch, and unrefreshed sleep improved significantly in the real acupuncture group (post-nasal drip and sinus pain did not) and continued to improve up to 4-week follow-up.
The authors concluded that acupuncture modulated mucosal immune response in the upper airway in adults with persistent allergic rhinitis. This modulation appears to be associated with down-regulation of allergen specific IgE for house dust mite, which this study is the first to report. Improvements in nasal itch, eye itch, and sneezing after acupuncture are suggestive of down-regulation of transient receptor potential vanilloid 1.
…Anyway, the trial itself raises a number of questions – unfortunately I have no access to the full paper – which I will post here in the hope that my acupuncture friend, who are clearly impressed by this paper, might provide the answers in the comments section below:
- Which was the primary outcome measure of this trial?
- What was the power of the study, and how was it calculated?
- For which outcome measures was the power calculated?
- How were the subjective endpoints quantified?
- Were validated instruments used for the subjective endpoints?
- What type of sham was used?
- Are the reported results the findings of comparisons between verum and sham, or verum and no acupuncture, or intra-group changes in the verum group?
- What other treatments did each group of patients receive?
- Does anyone really think that this trial shows that “acupuncture is a safe, effective and cost-effective treatment for allergic rhinitis”?
In the comments section, the author wrote: “after you have read the full text and answered most of your questions for yourself, it might then be a more appropriate time to engage in any meaningful discussion, if that is in fact your intent”, and I asked him to send me his paper. As he does not seem to have the intention to do so, I will answer the questions myself and encourage everyone to have a close look at the full paper [which I can supply on request].
- The myriad of lab tests were defined as primary outcome measures.
- Two sentences are offered, but they do not allow me to reconstruct how this was done.
- No details are provided.
- Most were quantified with a 3 point scale.
- Mostly not.
- Needle insertion at non-acupoints.
- The results are a mixture of inter- and intra-group differences.
- Patients were allowed to use conventional treatments and the frequency of this use was reported in patient diaries.
- I don’t think so.
So, here is my interpretation of this study:
- It lacked power for many outcome measures, certainly the clinical ones.
- There were hardly any differences between the real and the sham acupuncture group.
- Most of the relevant results were based on intra-group changes, rather than comparing sham with real acupuncture, a fact, which is obfuscated in the abstract.
- In a controlled trial fluctuations within one group must never be interpreted as caused by the treatment.
- There were dozens of tests for statistical significance, and there seems to be no correction for multiple testing.
- Thus the few significant results that emerged when comparing sham with real acupuncture might easily be false positives.
- Patient-blinding seems questionable.
- McDonald as the only therapist of the study might be suspected to have influenced his patients through verbal and non-verbal communications.
I am sure there are many more flaws, particularly in the stats, and I leave it to others to identify them. The ones I found are, however, already serious enough, in my view, to call for a withdrawal of this paper. Essentially, the authors seem to have presented a study with largely negative findings as a trial with positive results showing that acupuncture is an effective therapy for allergic rhinitis. Subsequently, McDonald went on social media to inflate his findings even more. One might easily ask: is this scientific misconduct or just poor science?
I would be most interested to hear what you think about it [if you want to see the full article, please send me an email].
On this blog, I have repeatedly tried to explain why integrative (or integrated) medicine is such a deceptive nonsense; see for instance here, here and here. Today, I have reason to make another attempt: The International Congress on Integrative Medicine & Health.
In 2012, I published an analysis of the ‘3rd European Congress of Integrated Medicine’ which had taken place in December 2010 in Berlin (in Europe they call it ‘integrated’ and in the US ‘integrative’ medicine). For this purpose, I simply read all the 222 abstracts and labelled them according to their contents. The results showed that the vast majority were on unproven alternative therapies and none on conventional treatments.
The abstracts from the International Congress on Integrative Medicine & Health (ICIMH, Green Valley Ranch Resort, Las Vegas, Nevada, USA, May 17–20, 2016) which were just published provide me with the opportunity to check whether this situation has changed. There were around 400 abstracts, and I did essentially the same type of analysis (attributing one subject area to each abstract). And what a tedious task this was! I spotted just two articles of interest, and will report about them shortly.
This time I also assessed whether the conclusions of each paper were positive (expressing something favourable about the subject at hand), negative (expressing something negative about the subject at hand) or neither of the two (surveys, for instance, rarely show positive or negative results).
Here are the results: mind-body therapies were the top subject with 49 papers, followed by acupuncture (44), herbal medicine (37), integrative medicine (36), chiropractic and other manual therapies (26), TCM (19), methodological issues (16), animal and other pre-clinical investigations (15) and Tai Chi (5). The rest of the abstracts were on a diverse array of other subjects. There was not a single paper on a conventional therapy and only 4 focussed on risk assessments.
The 36 articles on integrative medicine deserve perhaps a special mention. The majority of these papers were about using alternative therapies as an add-on to conventional care. They focussed on the alternative therapies used and usually concluded that this ‘integration’ was followed by good results. None of these papers discussed integrative medicine and its assumptions critically, and none of these investigations cast any doubt about the assumption that integrative medicine is a positive thing.
I should also mention that my attributions of the subject areas were not always straight forward. I allowed myself only one subject per paper, but there were, of course, many that could be categorised in more than one subject area ( for instance, a paper on an herbal medicine might be in that category, or in TCM or in pre-clinical). So I tried to attribute the subject that seemed to dominate the abstract in question.
My analysis according to the direction of the conclusions was equally revealing: I categorised 260 papers as positive, 5 as negative and 116 as neither of the two. That means for every negative result there were 52 positive ones. I find this most remarkable.
Essentially, my two analyses of conference abstracts published 6 years apart show the same phenomenon: on the ‘scientific level’, integrative medicine is not about the ‘best of both worlds’ (i. e. the best alternative medicine has to offer integrated with the best conventional medicine offers) – the slogan by which advocates of integrative medicine usually try to ‘sell’ their dubious approach to us. It is almost exclusively about alternative therapies which advocates of integrative medicine aim to smuggle into mainstream healthcare. Critical analysis seems to be unwelcome in this area, and – perhaps worse of all – in the last 6 years, there does not seem to have been any improvement.
And that’s just on the ‘scientific level’, as I said. If you wonder what is happening on the ‘practical level’, you will find that, in the realm of integrative medicine, every quackery under the sun is being promoted at often exorbitant prices to the often gullible and always unsuspecting public. If you don’t believe me, search for ‘integrative medicine clinic’ on the Internet; I promise, you will be surprised!
Personally, I am sometimes amused by the sheer idiocy of all this, but more often I am enraged and ask myself:
- Why are we allowing quackery to make such a spectacular come-back?
- Why is hardly anyone voicing strong objections?
- Is it not our ethical duty to do something about it and try to prevent the worse?
In 2008, I published a paper entitled ‘CHIROPRACTIC, A CRITICAL EVALUATION’ where I reviewed most aspects of this subject, including the historical context. Here is the passage about the history of chiropractic. I believe it is relevant to much of the current discussions about the value or otherwise of chiropractic.
The history of chiropractic is “rooted in quasi-mystical concepts.” Bone-setters of various types are part of the folk medicine of most cultures, and bone-setting also formed the basis on which chiropractic developed.
The birthday of chiropractic is said to be September 18, 1895. On this day, D.D. Palmer manipulated the spine of a deaf janitor by the name of Harvey Lillard, allegedly curing him of his deafness. Palmer’s second patient, a man suffering from heart disease, was also cured. About one year later, Palmer opened the first school of chiropractic. There is evidence to suggest that D.D. Palmer had learned manipulative techniques from Andrew Taylor Still, the founder of osteopathy. He combined the skills of a bone-setter with the background of a magnetic healer and claimed that “chiropractic was not evolved from medicine or any other method, except that of magnetic.” He coined the term “innate intelligence” (or “innate”) for the assumed “energy” or “vital force,” which, according to the magnetic healers of that time, enables the body to heal itself. The “innate” defies quantification. “Chiropractic is based on a metaphysical epistemology that is not amenable to positivist research or experiment.”
The “innate” is said to regulate all body functions but, in the presence of “vertebral subluxation,” it cannot function adequately. Chiropractors therefore developed spinal manipulations to correct such subluxations, which, in their view, block the flow of the “innate.” Chiropractic is “a system of healing based on the premise that the body requires unobstructed flow through the nervous system of innate intelligence.” Anyone who did not believe in the “innate” or in “subluxations” was said to have no legitimate role in chiropractic.
“Innate intelligence” evolved as a theological concept, the representative of Universal Intelligence ( = God) within each person. D.D. Palmer was convinced he had discovered a natural law that pertained to human health in the most general terms. Originally, manipulation was not a technique for treating spinal or musculoskeletal problems, it was a cure for all human illness: “95% of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints.” Early chiropractic pamphlets hardly mention back pain or neck pain, but assert that, “chiropractic could address ailments such as insanity, sexual dysfunction, measles and influenza.” D.D. Palmer was convinced that he had “created a science of principles that has existed as long as the vertebra.” Chiropractors envision man as a microcosm of the universe where “innate intelligence” determines human health as much as “universal intelligence” governs the cosmos; the discovery of the “innate intelligence” represents a discovery of the first order, “a reflection of a critical law that God used to govern natural phenomena.”
Early chiropractic displayed many characteristics of a religion. Both D.D. Palmer and his son, B.J. Palmer, seriously considered establishing chiropractic as a religion. Chiropractic “incorporated vitalistic concepts of an innate intelligence with religious concepts of universal intelligence,” which substituted for science. D.D. Palmer declared that he had discovered the answer to the timeworn question, “What is life?” and added that chiropractic made “this stage of existence much more efficient in its preparation for the next step – the life beyond.”
Most early and many of today’s chiropractors agree: “Men do not cure. It is that inherent power (derived from the creator) that causes wounds to heal, or a part to be repaired. The Creator…uses the chiropractor as a tool…chiropractic philosophy is truly the missing link between Religion or Power of the various religions.” Today, some chiropractors continue to relate the “innate” to God. Others, however, warn not to “dwindle or dwarf chiropractic by making a religion out of a technique.”
Initially, the success of chiropractic was considerable. By 1925, more than 80 chiropractic schools had been established in the United States. Most were “diploma mills” offering an “easy way to make money,” and many “were at one another’s throats.” Chiropractors believed they had established their own form of science, which emphasized observation rather than experimentation, a vitalistic rather than mechanistic philosophy, and a mutually supportive rather than antagonist relationship between science and religion. The gap between conventional medicine and chiropractic thus widened “from a fissure into a canyon.” The rivalry was not confined to conventional medicine; “many osteopaths asserted that chiropractic was a bastardized version of osteopathy.”
Rather than arguing over issues such as efficacy, education, or professional authority, the American Medical Association insisted that all competent health care providers must have adequate knowledge of the essential subjects such as anatomy, physiology, pathology, chemistry, and bacteriology. By that token, the American Medical Association claimed, chiropractors were not fit for practice. Some “martyrs,” including D.D. Palmer himself, went to jail for practicing medicine without a licence.
Chiropractors countered that doctors were merely defending their patch for obvious financial reasons (ironically, chiropractors today often earn more than conventional doctors), that orthodox science was morally corrupt and lacked open-mindedness. They attacked the “germo-anti-toxins-vaxiradi-electro-microbioslush death producers” and promised a medicine “destined to the grandest and greatest of this or any age.”
Eventually, the escalating battle against the medical establishment was won in “the trial of the century.” In 1987, sections of the U.S. medical establishment were found “guilty of conspiracy against chiropractors,” a decision which was upheld by the U.S. Supreme Court in 1990. In other countries, similar legal battles were fought, usually with similar outcomes. Only rarely did they not result in the defeat of the “establishment:” In 1990, a Japanese Ministry of Health report found that chiropractic is “not based on the knowledge of human anatomy but subjective and unscientific.”
These victories came at the price of “taming” and “medicalizing” chiropractic. In turn, this formed the basis of a conflict within the chiropractic profession – the dispute between “mixers” and “straights” – a conflict which continues to the present day.
The “straights” religiously adhere to D.D. Palmer’s notions of the “innate intelligence” and view subluxation as the sole cause and manipulation as the sole cure of all human disease. They do not mix any non-chiropractic techniques into their therapeutic repertoire, dismiss physical examination (beyond searching for subluxations) and think medical diagnosis is irrelevant for chiropractic. The “mixers” are somewhat more open to science and conventional medicine, use treatments other than spinal manipulation, and tend to see chiropractors as back pain specialists. Father and son Palmer warned that the “mixers” were “polluting and diluting the sacred teachings” of chiropractic. Many chiropractors agreed that the mixers were “bringing discredit to the chiropractic.”
The “straights” are now in the minority but nevertheless exert an important influence. They have, for instance, recently achieved election victories within the British General Chiropractic Council. Today, two different chiropractic professions exist side by sided “one that wishes to preserve the non-empirical, non-positivist, vitalist foundations (the straights) and the other that wishes to be reckoned as medical physicians and wishes to utilize the techniques and mechanistic viewpoint of orthodox medicine (the mixers).” The International Chiropractic Association represents the “straights” and the American Chiropractic Association the “mixers.”
(for references, see the original article)
Anyone who really wants to get an insight into the ‘homeopathic mind-set’ should read the regular newsletter ‘HOMEOPATHY 4 EVERYONE’. Its current issue is focussed on cardiology. An article on coronary heart disease, a condition that kills about 40% of the population, informs us how homeopaths tackle this killer-disease:
If anything permanent is to be accomplished by treatment, a most careful examination of the individual case must be made. Not the attack alone, but the habits of the patient, his family history and environments must all be studied in every possible light. In the management, each case must be considered separately and the causes that excite an attack sought after. Many of these patients already have recognized the cause in their own case and often it is some irregularity of diet, exercise or mental condition. Many times it is not an easy matter to control the mental state, as the worry and strain of business life presses upon many of these patients, and is responsible for many cases of arterial degeneration that give rise to apoplexy, Bright ‘s disease, aneurysm or angina pectoris. The age and occupation of the patient, and the condition of the vascular system should be taken into consideration.
Following an attack the condition of the heart may require absolute rest, from a day to a week or more; this is especially true if the attacks are precipitated by a slight degree of exercise, which shows that the heart is not able to propel the blood under anything but normal conditions. Under no condition should quick movements and strong emotions be associated. Steady quiet exercise as walking upon level ground is beneficial. If the cardiac weakness is such as to forbid this, massage, or the resistance exercise of the Schott’s method may be tried. This exercise should not follow immediately after a meal.
But this is not all. There are plenty more papers on life-threatening cardiac conditions. Take the article on pericarditis for instance. This is how homeopaths are told how to treat this medical emergency:
Remedies that may be indicated are as follows: If traumatic, Arnica. For the inflammatory outset, Aconite or Vera- trum viride. The anguish of Aconite distinguishes its inflammation from that attending the stupor of Veratrum. For the pain Bryonia or Spigelia. They may be indicated in this order, Bryonia for the first stage and Spigelia for the subsequent myalgia. In these cases there may be met with indications for Belladonna (its flushed face), Arsenicum (dyspnoea on lying down), Digitalis (its weak pulse), Cactus (severe myalgia) or Kali carb (stitching pains). General symptoms may call for Colchicum, Aesculus, Kali iod., Cimicifuga, Kahnia, Squilla
A further article tackles diseases of the blood vessels. The article on thrombosis informs the homeopath that
Thrombosis is a blocking of the local circulation either spontaneously, after injuries or from slow and imperfect circulation forming a clot. In thrombosis the part becomes pale and edematous. The remedies are Aconite for first stage. Hamamelis, Lachesis or Lycopodium may be indicated. If suppuration threatens Sulphur or Hepar. Rest and a supporting diet.
The same article also tells us how to treat aneurysms:
Select the remedy carefully. Lycopodium 12 has cured aneurism of the carotid (Hughes). If the attack is due to a sudden strain or injury, Arnica; if from fear or fright, Aconite; if from syphilis, Mercurius, Kali hydr. or Nitric acid; if from alcoholism, Arsenicum or Nux vomica; if from fatty degeneration, Phosphorus; if from fibrous inflammation and degeneration, Bryonia; if there is great arterial excitement and delirium, Veratrum viride; if circulation sluggish, Digitalis. Secale has cured aneurism. Consult Carbo veg., Spigelia. See Heart Therapeutics.
After reading the entire issue, I was not sure whether this wasn’t a hoax. Are we supposed to laugh or to cry? Personally I did giggle a lot while reading this. But if I imagine for a minute that some homeopaths might take this seriously, I am not far from crying.
Edzard Ernst – why he changed his mind! This is the title of a blog which I just found. It is such fun to read that I must show it to you in full [I added a few numbered footnotes in square brackets]:
BBC Radio 4 gave Professor Edzard Ernst a 15 minute slot to explain “Why I Changed My Mind’ on Wednesday 4th May 2016. It was repeated on 12th May 2016. He was interviewed by Dominic Lawson . The programme demonstrates the lengths to which the BBC is prepared to go in order under undermine Alternative Medicine, and Homeopathy, in particular .
Lawson set the tone. Ernst, he stated, is hated by alternative health practitioners, the Prince of Wales tried to get him sacked, and he eventually lost his academic post because of the criticism he attracted for his work. Ernst was left to agree with this dreadfully unfair and unreasonable treatment . So Ernst was then led to explain his ‘change of mind’ about homeopathy. As a friend and colleague of mine said,
“Ernst (says) that as a German, he was raised on Homeopathy, and later treated his patients with homeopathy. And it worked! But when he approached it ‘scientifically’, he concluded that it’s merely placebo.”
So let’s be clear. Ernst’s experience of homeopathy has been that it does work , but that the science he has looked at does not demonstrate that it works. (Even this is wrong , but leave that for now!) So people do get better as the result of homeopathic treatment, but ‘science’, or at least Ernst’s science , does not understand why it should . Ernst also said that he was convinced, at the time, that he was ‘helping patients’.
Lawson then asked his most difficult question (sic). If he knew that homeopathy worked, why did it work? Ernst’s response was that it was charlatanism and quackery, and was “quite puzzling’ really . So as homeopathy worked, but science said it should not work , he went on to study this in his post at Exeter University.
Lawson, in the great tradition of BBC impartiality , (sic), continued to lead him on. “When did you decide that homeopathy was useless, delusional?”
Ernst said that when he ‘did the science’ it became clear that homeopathy is placebo.
Now, lets look at this word, placebo. The Oxford English Dictionary defines ‘the placebo effects’ as”
“A beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient’s belief in that treatment”
So by using the term ‘placebo’ Ernst is once again saying the homeopathy has a ‘beneficial effect’ on patients who are ill . Lawson did ask Ernst whether there was anything wrong using placebo if this brought positive benefits to patients. Ernst said that people got better anyway! (Is it really is a simple as this?) 
Lawson, now thoroughly convinced of Ernst’s arguments, asked his whether he thought homeopaths were lying. With some apparent grace, Ernst said that lying was a strong term, by the were ‘deluded’, and ‘treated homeopathy as a religion’.
Lawson came back, asking why there were lots of qualified doctors who believe in homeopathy, and whether they should they be struck off, or stopped from practising? No, said Ernst, they were just not thinking critically, and needed to be educated out of their delusions.
Presumably, for both Lawson and Ernst, using a medical therapy that worked and brought benefit to patients , but which science could not explain, should be restricted, if not banned altogether.
Lawson’s final question clearly demonstrated his impartiality. “Can we justify homeopathy, or any other kind of quackery? (My emphasis). “No”, said Ernst, predictably!
The BBC regularly broadcasts these kind of anti-homeopathy, anti-alternative-medicine programmes, with never an attempt to redress the balance . They will never broadcast a programme that provides an alternative medical view. The BBC appears to be firmly in the camp of the conventional medical establishment , and committed to providing time to anti-homeopaths without any ‘right of reply’.
Why, for example, was there no question about the quality of the ‘science’ Ernst is associated with? Certainly, his science has come under serious scrutiny. For instance, I blogged about “The contribution of Professor Edzard Ernst to disinformation about Homeopathy” in September 1915 [!!!]. This followed an assessment made by Professor Robert Kahn about the quality of Ernst’s science. This was his conclusion .
“I have never seen a science writer so blatantly biased as Edzard Ernst: his work should not be considered of any worth at all, and discarded.”
Kahn’s paper shows, in his view, how ‘science’ has been taken over by ideology, (or as I suggested the financial interests of Big Corporations like Big Pharma). He revealed that in order to demonstrate homeopathy is ineffective over 95% of scientific research into homeopathy has to be discarded or removed! 
There was, of course, no mention of this in the BBC programme! 
So if Ernst’s change of mind was ‘scientific’, it was based on bad science , the kind of science much discussed in this blog, bought science, cheque book science, the kind of science based on university faculties funded by the pharmaceutical industry . Ernst’s funding dried up when his academic position had become untenable , and he lost the support of his financial backers . As my friends and colleague said, in response to the programme:
“Ernst’s religion is Science, not the well being of the patients. I wonder how many listeners will
be influenced by him as he does come across as an experienced and rational man?”
I agree with her assessment. Anyone can come over as an ‘experience and rational man’ when given an uncritical platform, such as this BBC programme proved to be. Certainly, Peter Fisher, the Queen’s homeopath, was one of his main critics. Why, Lawson asked Ernst, did homeopathy have ‘such a grip’ on the Royal Family? Ernst did not know, but he did know that “when they get really ill they do not go to a homeopathy, otherwise they would not get so old!”
At this point I began to wonder on what knowledge Ernst used to know how the Royal Family were being treated, and scientific basis his belief that their longevity was nothing to do with homeopathy? The question was never asked, so we will, I fear, never know!   you can listen to the programme here a serious allegation for which no evidence is provided, and I suppose none exists  this is the truth  not true, my experience was that patients got better for which there are good, scientifically sound explanations that do not involve homeopathy  no, it’s not  the best available evidence today which has little to do with ‘my’ science; might this be a little attempt at an ad hominem?  no, science does understand the phenomena involved well: placebo, regression towards the mean, natural history of the disease etc.  a wilful misinterpretation of my words  no, this is not what I said, homeopathic remedies are ineffective and the observed effects are due to other phenomena  not Kahn but Hahn; and his criticism is laughable, see here  the programme is a series of interviews with people who have changed their mind on an important subject; such questions do not belong there  any proof for that other than Hahn?  false and libellous allegation  no, when HRH had filed his complaint; this is all described in detail in my memoir  poor logic: if I had been funded by the ‘enemies of homeopathy’, my funding should have increased  anyone who follows the news bulletins about the Royals will know where they go when seriously ill.
In 2010, we published an investigation of 200 chiropractor websites and 9 chiropractic associations’ World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States. The outcome measure was claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment.
We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain.
At the time, we concluded that the majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.
Have things changed since?
I fear not! I regularly come across websites of chiropractors where they happily make bogus claims. On this website, for instance, chiropractor Karen Smith claims that muscles in the upper neck affect the ear canals. “We don’t actually treat the ear infection, or the symptoms. What we do is, we assist the body’s natural healing ability,” says Smith. “So if there’s something going on with the joints and the muscles soft tissue, the nerves coming out that supply those muscles, those muscles can’t relax, so then they’re almost tight and in spasm, so that can’t allow the drainage to happen properly.”
When fluid builds up in the ears, it’s a breeding ground for bacteria and infection. Smith says specific, gentle adjustments, can help the body drain those fluids through the nose. “What we do is we get some motion in the upper neck, with my hands, or I might use an instrument as well,” says Smith. “There’s a few other techniques that we can do. We can do some sinus drainage. We can drain some of the fluid in the ear.”
A simple ear pull technique can also help. “So what we do is, we just take the ear of the child and we do a little pull and that can actually drain the fluid as well,” says Smith. Smith says a child’s overall health and immune system impacts how quickly they see results from the treatment. In some cases, relief can be instant. “What we notice right after an adjustment is a lot of times you’ll actually see the fluid drain through the nose,” says Smith… Smith says she also treats adults who have had chronic ear issues as a child or who are experiencing pain in the ear.
When I or others expose such nonsense, the apologists say that these are just a few ‘rotten apples’, and that the chiropractic profession is fast progressing. Yet, I very much doubt this claim. For any fast progression, one would want to see the profession taking decisive and effective action against the ‘rotten apples’. This is clearly not happening, at least not to an extend that would stop such dangerous quackery.
What practical lesson can be learnt from such insights?
The only responsible advice I can think of is this: IF YOU OR YOUR CHILD IS ILL, AVOID CONSULTING A CHIROPRACTOR.
Shiatsu is a popular alternative therapy with a remarkable void of research. According to one of the rare reviews on the subject, Shiatsu is a form of Japanese massage, working on the meridian system of the body; the energetic pathways along which the acupuncture points are placed. The theory for shiatsu is based in the system of traditional Chinese medicine, understood in China for over 2000 years. Shiatsu can be valuable for reintegrating the body, mind and spirit, helping with the general energy level of the body as well as specific symptoms… Feelings of deep relaxation, support and increased vitality are common following a shiatsu treatment. The method, strength and frequency of treatment can be varied to suit individual need…
If this seems an optimistic evaluation to you, have a look on the Internet where bogus claims for Shiatsu abound. But such uncritical nonsense is, of course, neither informative nor responsible. In a previous post, I have been a little more critical about the value of Shiatsu and concluded that is an unproven therapy. I reached this conclusion mainly because, for our Oxford Handbook of Complementary Medicine (2008), we systematically researched the evidence and found very little of it. In fact, we concluded that NO CONVINCING DATA AVAILABLE TO SUGGEST THAT SHIATSU IS EFFECTIVE FOR ANY CONDITION.
Since then, a systematic review has been published. The Shiatsu studies found comprised just one single RCT, three controlled non-randomised, one within-subjects study, one observational study and 3 uncontrolled studies investigating mental and physical health issues. The authors, who usually are very much in favour of alternative therapies, concluded that more research is needed, particularly for Shiatsu, where evidence is poor.
This seems to indicate that our verdict of 2008 is still not far off the mark.
And what about the risks?
On this aspect of Shiatsu, it is even harder to find reliable information. One website, for instance, warns that certain individuals should take caution and consult a physician before receiving shiatsu. For example, there’s some concern that shiatsu may have harmful effects in pregnant women, patients who have recently undergone chemotherapy or radiation, and people with such conditions as osteoporosis, heart disease, and blood clotting disorders. Additionally, shiatsu should not be performed directly over bruises, inflamed skin, unhealed wounds, tumors, abdominal hernia, or areas of recent fractures. Shiatsu should also be avoided immediately after surgery, and by people with infectious skin disease, rash, or open wounds.
But what about adverse reactions and complications?
Another website, tells us that, when performed properly, shiatsu is not associated with any significant side effects. Some people may experience mild discomfort, which usually disappears during the course of the treatment session.
So, is Shiatsu without side-effects?
The answer, I am afraid, is NO – but has to dig deep to find even a tentative answer to this question.
A prospective, 6 months cohort, pragmatic study of the effects and experience of shiatsu within three countries (Austria, Spain and the UK) has been published by UK authors in 2009 . Data were collected via postal questionnaires, including on client-perceived negative responses. Shiatsu was delivered by the practitioner in routine practice. 633 clients provided full follow-up data, a response rate of 67%. A prevalence rate of 12-22 per 100 of client-perceived ‘negative responses’ was found across the three countries. Transitional effects accounted for 82% of all the client-described ‘negative’ responses. Nine clients (1.4% of the total), relating to 10 sets of written comments, reported a negative response that was classified as ‘a potentially adverse event or effect’ that might represent a risk to client safety.
In addition there are much more serious complications such as strokes. These might be extreme rarities – but who knows? Nobody! Why? Because, as with most alternative therapies, there is no reporting or monitoring system for such events. Therefore the true prevalence is anyone’s guess.
The bottom line, I am afraid, is all too familiar: There is no good evidence for effectiveness and some evidence of risk – which can only mean one thing: the proven benefits do not outweigh the potential harm.
I just came across this website entitled 11 HARD QUESTIONS ABOUT CHIROPRACTIC PHYSICIANS. The title fascinated me; I am always in favour of addressing hard questions. I therefore read the 11 questions with interest; and I quite liked them. However, the answers provided by the author, a chiropractor of course, struck me as being more than a little uncritical towards chiropractic (feel free to click on the above link and see for yourself). Therefore, I decided to try my own answers (except for No 5). And then – being in the swing of it – I added a few more supplementary questions as well.
In other words, the first 11 questions are the ones posed by the chiro but the 4 additional ones are mine, and so are all the answers. Here we go:
Question No 1: What can a chiropractic physician do for me that another doctor can’t?
Question No 2: Does chiropractic therapy really work?
No. The best evidence available today fails to show that chiropractic spinal manipulations work for any condition. If one is generous, one might make an exception for back pain, but even for this symptom, the evidence is flimsy.
Question No 3: What other types of health problems can chiropractic treatment help?
Question No 4: What does a chiropractic physician do to find my problem?
He/she often uses non-validated diagnostic techniques that are prone to give fantasy-results. You might also get extensive X-rays – mostly because the chiropractor wants to pay for the expensive equipment.
Question No 5: What therapies do chiropractic physicians use?
Chiropractic physicians may use manual and physical therapies including manipulation of the spine and joints of the arms and legs. Supportive therapies may also include massage, myofascial release, and therapeutic modalities such as ultrasound, electric stimulation and diathermy. Rehabilitative measures are often used such as specific corrective exercises to stabilize your problem. (This is the only answer I roughly agreed with, and I therefore left it unchanged.)
Question No 6: What is the standard length of treatment?
This depends mainly on the patient’s ability to pay. As a rule of thumb, as many treatments as possible will be given. Many chiros even advocate ‘maintenance treatment’ which means you receive regular spinal manipulations even when there is nothing wrong with you. The little porky they give you as an explanation is that this prevents future illnesses.
Question No 7: Is chiropractic care covered by insurance?
Because of very active lobbying by chiro interest groups, it may well be.
Question No 8: If I need a referral, how do I ask my doctor to refer me to a chiropractic physician?
Chiros are presently trying very hard to be accepted as ‘primary care physicians’; this means you can consult them directly without the need of a referral.
Question No 9: If I go see a chiropractor do I need to keep on going?
Only if you believe the nonsense about maintenance treatment they often tell you (see above) for which there is not a jot of convincing evidence.
Question No 10: What training do chiropractors have?
Not enough to realise that their spinal adjustments fail to generate more good than harm.
Question No 11: How should I select a good chiropractic physician?
If you are ill, it’s best to see are real doctor and avoid chiros.
AND NOW MY SUPPLEMENTARY QUESTIONS
No 1 Are chiros really physicians?
The definition of a physician is : ‘A person trained and licensed to practice medicine; a medical doctor’. Therefore, the answer is no.
No 2 What are the risks of spinal manipulations or adjustments, the main treatments used by chiros?
~50% of all patients have mild to moderate adverse effects that last 2-3 days.
In addition, several hundred cases of severe complications have been noted, including strokes and deaths.
No 3 How are such adverse outcomes monitored?
There is no effective monitoring system at all.
No 4 Is such an omission responsible or ethical?
Reiki is one of the most popular types of ‘energy healing’. Reiki healers believe to be able to channel ‘healing energy’ into patients’ body thus enabling them to get healthy. If Reiki were not such a popular treatment, one could brush such claims aside and think “let the lunatic fringe believe what they want”. But as Reiki so effectively undermines consumers’ sense of reality and rationality, I feel I should continue informing the public about this subject – despite the fact that I have already reported about it several times before, for instance here, here, here, here, here and here.
A new RCT, published in a respected journal looks interesting enough for a further blog-post on the subject. The main aim of the study was to investigate the effectiveness of two psychotherapeutic approaches, cognitive behavioural therapy (CBT) and a complementary medicine method Reiki, in reducing depression scores in adolescents. The researchers from Canada, Malaysia and Australia recruited 188 adolescent depressed adolescents. They were randomly assigned to CBT, Reiki or wait-list. Depression scores were assessed before and after 12 weeks of treatments/wait list. CBT showed a significantly greater decrease in Child Depression Inventory (CDI) scores across treatment than both Reiki (p<.001) and the wait-list control (p<.001). Reiki also showed greater decreases in CDI scores across treatment relative to the wait-list control condition (p=.031). Male participants showed a smaller treatment effects for Reiki than did female participants. The authors concluded that both CBT and Reiki were effective in reducing the symptoms of depression over the treatment period, with effect for CBT greater than Reiki.
I find it most disappointing that these days even respected journals publish such RCTs without the necessary critical input. This study may appear to be rigorous but, in fact, it is hardly worth the paper it was printed on.
The results show that Reiki produced worse results than CBT. That I can well believe!
However, the findings also suggest that Reiki was nevertheless “effective in reducing the symptoms of depression”, as the authors put it in their conclusions. This statement is misleading!
It is based on the comparison of Reiki with doing nothing. As Reiki involves lots of attention, it can be assumed to generate a sizable placebo effect. As a proportion of the patients in the wait list group are probably disappointed for not getting such attention, they can be assumed to experience the adverse effects of their disappointment. The two phenomena combined can easily explain the result without any “effectiveness” of Reiki per se.
If such considerations are not fully discussed and made amply clear even in the conclusions of the abstract, it seems reasonable to accuse the journal of being less than responsible and the authors of being outright misleading.
As with so many papers in this area, one has to ask: WHERE DOES SLOPPY RESEARCH END AND WHERE DOES SCIENTIFIC MISCONDUCT BEGIN?
A recent comment to a blog-post about alternative treatments for cancer inspired me to ponder a bit. I think it is noteworthy because it exemplifies so many of the comments I hear in the realm of alternative medicine on an almost daily basis. Here is the comment in question:
“Yes…it appears that the medical establishment have known for years that chemotherapy a lot of the time kills patients faster than if they were untreated…what’s more, it worsens a person’s quality of life in which many die directly of the severe effects on the endocrine, immune system and more…cancers often return in more aggressive forms metastasising with an increased risk of apoptosis. In other words it makes things worse whereas there are many natural remedies which not only do no harm but accumulating evidence points to their capacity to fight cancer…some of it is bullshit whilst some holds some truth!! So turning away from toxic treatments that kill towards natural approaches that are showing more hope with the backing of trials kinda reverses the whole argument of this article.”
The comment first annoyed me a bit, of course, but later it made me think and consider the differences between conspiracy theories, assumptions, opinions, evidence and scientific facts. Let’s tackle each of these in turn.
A conspiracy theory is an explanatory or speculative theory suggesting that two or more persons, or an organization, have conspired to cause or cover up, through secret planning and deliberate action, an event or situation typically regarded as illegal or harmful.
Part of the above comment bears some of the hallmarks of a conspiracy theory: “…the medical establishment have known for years that chemotherapy a lot of the time kills patients faster than if they were untreated…” The assumption here is that the conventional healthcare practitioners are evil enough to knowingly do harm to their patients. Such conspiracy theories abound in the realm of alternative medicine; they include the notions that
- BIG PHARMA is out to kill us all in order to maximize their profits,
- the ‘establishment’ is suppressing any information about the benefits of alternative treatments,
- vaccinations are known to be harmful but nevertheless being forced on to our children,
- drug regulators are in the pocket of the pharmaceutical industry,
- doctors accept bribes for prescribing dangerous drugs
- etc. etc.
In a previous blog-post, I have discussed the fact that the current popularity of alternative medicine is at least partly driven by the conviction that there is a sinister plot by ‘the establishment’ that prevents people from benefitting from the wonders of alternative treatments. It is therefore hardly surprising that conspiracy theories like the above are voiced regularly on this blog and elsewhere.
An assumption is something taken for granted or accepted as true without proof.
The above comment continues stating that “…[chemotherapy] makes things worse whereas there are many natural remedies which not only do no harm but accumulating evidence points to their capacity to fight cancer…” There is not proof for these assertions, yet the author takes them for granted. If one were to look for the known facts, one would find the assumptions to be erroneous: chemotherapy has saved countless lives and there simply are no natural remedies that will cure any form of cancer. In the realm of alternative medicine, this seems to worry few, and assumptions of this or similar nature are being made every day. Sadly the plethora of assumptions or bogus claims eventually endanger public health.
The above comment continues with the opinion that “…turning away from toxic treatments that kill towards natural approaches that are showing more hope with the backing of trials kinda reverses the whole argument of this article.” In general, alternative medicine is based on opinions of this sort. On this blog, we have plenty of examples for that in the comments section. This is perhaps understandable; evidence is usually in short supply, and therefore it often is swiftly replaced with often emotionally loaded opinions. It is even fair to say that much of alternative medicine is, in truth, opinion-based healthcare.
One remarkable feature of the above comment is that it is bar of any evidence. In a previous post, I have tried to explain the nature of evidence regarding the efficacy of medical interventions:
The multifactorial nature of any clinical response requires controlling for all the factors that might determine the outcome other than the treatment per se. Ideally, we would need to create a situation or an experiment where two groups of patients are exposed to the full range of factors (e. g. placebo effects, natural history of the condition, regression towards the mean), and the only difference is that one group does receive the treatment, while the other one does not. And this is precisely the model of a controlled clinical trial.
Such studies are designed to minimise all possible sources of bias and confounding. By definition, they have a control group which means that we can, at the end of the treatment period, compare the effects of the treatment in question with those of another intervention, a placebo or no treatment at all.
Many different variations of the controlled trial exist so that the exact design can be adapted to the requirements of the particular treatment and the specific research question at hand. The over-riding principle is, however, always the same: we want to make sure that we can reliably determine whether or not the treatment was the cause of the clinical outcome.
Causality is the key in all of this; and here lies the crucial difference between clinical experience and scientific evidence. What clinician witness in their routine practice can have a myriad of causes; what scientists observe in a well-designed efficacy trial is, in all likelihood, caused by the treatment. The latter is evidence, while the former is not.
Don’t get me wrong; clinical trials are not perfect. They can have many flaws and have rightly been criticised for a myriad of inherent limitations. But it is important to realise that, despite all their short-comings, they are far superior than any other method for determining the efficacy of medical interventions.
There are lots of reasons why a trial can generate an incorrect, i.e. a false positive or a false negative result. We therefore should avoid relying on the findings of a single study. Independent replications are usually required before we can be reasonably sure.
Unfortunately, the findings of these replications do not always confirm the results of the previous study. Whenever we are faced with conflicting results, it is tempting to cherry-pick those studies which seem to confirm our prior belief – tempting but very wrong. In order to arrive at the most reliable conclusion about the efficacy of any treatment, we need to consider the totality of the reliable evidence. This goal is best achieved by conducting a systematic review.
In a systematic review, we assess the quality and quantity of the available evidence, try to synthesise the findings and arrive at an overall verdict about the efficacy of the treatment in question. Technically speaking, this process minimises selection and random biases. Systematic reviews and meta-analyses [these are systematic reviews that pool the data of individual studies] therefore constitute, according to a consensus of most experts, the best available evidence for or against the efficacy of any treatment.
Some facts related to the subject of alternative medicine have already been mentioned:
- chemotherapy prolongs survival of many cancer patients;
- no alternative therapy has achieved anything remotely similar.
The comment above that motivated me to write this somewhat long-winded post is devoid of facts. This is just one more feature that makes it so typical of the comments by proponents of alternative medicine we see with such embarrassing regularity.