MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

bogus claims

This new RCT by researchers from the National Institute of Complementary Medicine in Sydney, Australia was aimed at ‘examining the effect of changing treatment timing and the use of manual, electro acupuncture on the symptoms of primary dysmenorrhea’. It had four arms:

  1. low frequency manual acupuncture (LF-MA),
  2. high frequency manual acupuncture (HF-MA),
  3. low frequency electro acupuncture (LF-EA)
  4. and high frequency electro acupuncture (HF-EA).

A total of 74 women were given 12 treatments over three menstrual cycles, either once per week (LF groups) or three times in the week prior to menses (HF groups). All groups received a treatment in the first 48 hours of menses. The primary outcome was the reduction in peak menstrual pain at 12 months from trial entry.

During the treatment period and 9 month follow-up all groups showed statistically significant reductions in peak and average menstrual pain compared to baseline. However, there were no differences between groups. Health related quality of life increased significantly in 6 domains in groups having high frequency of treatment compared to two domains in low frequency groups. Manual acupuncture groups required less analgesic medication than electro-acupuncture groups. HF-MA was most effective in reducing secondary menstrual symptoms compared to both–EA groups.

The authors concluded that acupuncture treatment reduced menstrual pain intensity and duration after three months of treatment and this was sustained for up to one year after trial entry. The effect of changing mode of stimulation or frequency of treatment on menstrual pain was not significant. This may be due to a lack of power. The role of acupuncture stimulation on menstrual pain needs to be investigated in appropriately powered randomised controlled trials.

If I were not used to reading rubbish research of alternative medicine in general and acupuncture in particular, this RCT would amaze me – not so much because of its design, execution, or write-up, but primarily because of its conclusion (why, oh why, I ask myself, did PLOS ONE publish this paper?). They are, I think, utterly barmy.

Let me explain:

  • acupuncture treatment reduced menstrual pain intensity” – oh no, it didn’t; at least this is not what the study proves; the fact that pain was perceived as less could be due to a host of factors, for instance regression towards the mean, or social desirability; as there was no proper control group, nobody can tell;
  • the lack of difference between treatments “may be due to a lack of power”. Yes, but more likely it is due to the fact that all versions of a placebo therapy generate similar outcomes.
  • acupuncture stimulation on menstrual pain needs to be investigated in appropriately powered randomised controlled trials”. Why? Because the authors have a quasi-religious belief in acupuncture? And if they have, why did they not design their study ‘appropriately’?

The best conclusion I can suggest for this daft trial is this: IN THIS STUDY, THE PRIMARY ENDPOINT SHOWED NO DIFFERENCE BETWEEN THE 4 TREATMENT GROUPS. THE RESULTS ARE THEREFORE FULLY COMPATIBLE WITH THE NOTION THAT ACUPUNCTURE IS A PLACEBO THERAPY.

Something along these lines would, in my view, have been honest and scientific. Sadly, in acupuncture research, we very rarely get such honest science and the ‘National Institute of Complementary Medicine in Sydney, Australia’ has no track record of being the laudable exception to this rule.

An article by Rabbi Yair Hoffman for the Five Towns Jewish Times caught my eye. Here are a few excerpts:

“I am sorry, Mrs. Ploni, but the muscle testing we performed on you indicates that your compatibility with your spouse is a 1 out of a possible 10 on the scale.”

“Your son being around his father is bad for his energy levels. You should seek to minimize it.”

“Your husband was born normal, but something happened to his energy levels on account of the vaccinations he received as a child. It is not really his fault, but he is not good for you.”

Welcome to the world of Applied Kinesiology (AK) or health Kinesiology… Incredibly, there are people who now base most of their life decisions on something called “muscle testing.” Practitioners believe or state that the body’s energy levels can reveal remarkable information, from when a bride should get married to whether the next Kinesiology appointment should be in one week or two weeks. Prices for a 45 minute appointment can range from $125 to $250 a session. One doctor who is familiar with people who engage in such pursuits remarked, “You have no idea how many inroads this craziness has made in our community.”

… AK (applied kinesiology) is system that evaluates structural, chemical, and mental aspects of health by using “manual muscle testing (MMT)” along with other conventional diagnostic methods. The belief of AK adherents is that every organ dysfunction is accompanied by a weakness in a specific corresponding muscle… Treatments include joint manipulation and mobilization, myofascial, cranial and meridian therapies, clinical nutrition, and dietary counselling. A manual muscle test is conducted by having the patient resist using the target muscle or muscle group while the practitioner applies force the other way. A smooth response is called a “strong muscle” and a response that was not appropriate is called a “weak response.” Like some Ouiji board out of the 1970’s, Applied Kinesiology is used to ask “Yes or No” questions about issues ranging from what type of Parnassa courses one should be taking, to what Torah music tapes one should listen to, to whether a therapist is worthwhile to see or not.

“They take everything with such seriousness – they look at it as if it is Torah from Sinai,” remarked one person familiar with such patients. One spouse of an AK patient was shocked to hear that a diagnosis was made concerning himself through the muscle testing of his wife – without the practitioner having ever met him… And the lines at the office of the AK practitioner are long. One husband holds a crying baby for three hours, while his wife attends a 45 minute session. Why so long? The AK practitioner let other patients ahead – because of emergency needs…

END OF EXCERPTS

The article  is a reminder how much nonsense happens in the name of alternative medicine. AK is one of the modalities that is exemplary:

  • it is utterly implausible;
  • there is no good evidence that it works.

The only systematic review of AK was published in 2008 by a team known to be strongly in favour of alternative medicine. It included 22 relevant studies. Their methodology was poor. The authors concluded that there is insufficient evidence for diagnostic accuracy within kinesiology, the validity of muscle response and the effectiveness of kinesiology for any condition. 

Some AK fans might now say: absence of evidence is not evidence of absence!!! There is no evidence that AK does not work, and therefore we should give it the benefit of the doubt and use it.

This, of course, is absolute BS! Firstly, the onus is on those who claim that AK works to prove their assumption. Secondly, in responsible healthcare, we are obliged to employ those modalities for which the evidence is positive, while avoiding those for which the evidence fails to be positive.

 

To a significant extend, this blog has always exposed untruths in the realm of alternative medicine – not just one or two, but hundreds. Obviously, some of them are more clear-cut than others. If, for instance, someone claims that acupuncture has been proven to be effective for a given condition, this many seem like a lie or untruth to you, like a misinterpretation of the evidence to someone else, or like the truth to a third person.

But there are some statements which are demonstrably false. These are often the most irritating lies, frequently forwarded by people who should know better and who nevertheless insist on not being truthful. Below I have listed a few, randomly-chosen examples upon which I have previously commented. For clarity, I have copied the quotes in question, linked them to my original posts, named the authors in brackets, and added a brief comment by myself in bold print.

I was at Exeter when Ernst took over what was already a successful Chair in CAM. (anonymous reviewer of my book at Amazon)

Anyone can check this fairly easily, for instance, in my memoir ‘A SCIENTIST IN WONDERLAND’, there was no pre-existing chair at Exeter.

Ernst’s leak of the Smallwood report (also front page lead in The Times, August 2005), (Dr Peter Fisher, homeopath of the Queen)

This was painfully investigated during a 13 (!) months inquiry which found that I did not leak this report. Again you find the full details in my memoir.

…homeopathic care is recommended for people who have been exposed (or think they have been exposed) to toxic substances… (Dana Ullman US homeopath)

As far as this statement implies that homeopathy is effective for treating intoxications, this is not only a lie but a very dangerous nonsense.

Homeopathy has a long history of being used successfully in veterinary practice for both domestic and farm animals. (UK Faculty of Homeopathy)

If this is to suggest that homeopathy is of proven effectiveness in treating diseases of animals, this is a lie.

Homeoprophylaxis, the homeopathic vaccine alternative, prevents disease through nosodes. (Lisa is the mastermind behind All Natural Ideas)

Homeoprophylaxis has never been proven to prevent any disease; this lie could kill millions.

There are essentially two categories of critics. The first category consists of individuals who are totally ignorant of homeopathy and just repeating propaganda they’ve been exposed to. The second category is people who know that homeopathy works, but have a vested financial interest in destroying it. (Alan Schmukler, US homeopathy)

This lie is quite funny in its transparent defamation of the truth, I think.

Homeopathy works like a vaccine. (Dr Batra, Indian homeopath)

Homeopathy does not even remotely work like a vaccine; in fact, it works like a placebo, if at all.

…UK invests 0% of its research budget on CAM… (Dr Michael Dixon, GP and advisor to Prince Charles)

There has always been a sizable budget for CAM-research in the UK.

Even cancer viruses have, on record, been put into vaccinations. There is no actual vaccine for cancer. The only reason to put cancer viruses in the mix is to create more cases of cancer. In this day and age, one of the most dangerous things you can do for your health is to get vaccinated… (US homeopath)

In this short quote, there are more lies than I care to comment on. The paranoia of the anti-vaccination brigade is astounding and endangers many lives.

A lie is a statement used intentionally for the purpose of deception. In alternative medicine, we encounter so many lies that one would need to continually publish volume after volume to expose just the most harmful untruths. The danger of these lies is that some people might believe them. This could seriously harm their health. Another danger is that we might get used to them, trivialise them, or – like Trump and co – start thinking of them as ‘alternative facts’.

I will continue to do my best to prevent any of this from happening.

 

Isn’t it wonderful when your long-held views are confirmed by someone with influence?

This, of course, is a rhetorical question – I can tell you: it is wonderful!

Matthew Stanbrook, MD PhD recently published an editorial in CMAJ which I find delightful; let me present you a few quotes from it:

The multibillion-dollar market for “natural” health products has flourished under lax government regulations. These regulations have enabled manufacturers to exploit the public’s difficulty in distinguishing nonprescription drugs, with scientifically proven therapeutic benefits, from herbal or homeopathic preparations and supplements that often make similar health claims with little or no evidence and are frequently grounded in unscientific belief systems about health and disease…

In pharmacies, supermarkets and convenience stores, natural health products are displayed side by side with nonprescription drugs. Both tout their approval by Health Canada as an implicit endorsement of efficacy and safety on package labels that make similar health claims. However, although nonprescription drugs and their therapeutic claims require scientific evidence that is carefully scrutinized by Health Canada, natural health products have a separate regulatory system that typically imposes such minimal requirements that it is effectively a rubber stamp. Unlike nonprescription drugs, if a problem arises with a natural health product, Health Canada has little or no authority to compel any changes to its manufacture, labelling or sale.

…Risk is often difficult to perceive accurately without direct evidence. For example, under the proposed framework, Health Canada would continue to classify most homeopathic preparations as low-risk products and, thus, exempt from scientific review. Recently, a homeopathic product sold in the United States that claimed to relieve teething pain in infants and supposedly contained a very dilute extract from the belladonna plant was associated with several deaths of infants who manifested classic signs of anticholinergic poisoning…

…If consumers are unable to separate products with no scientific proof behind them from products supported by evidence, then we need to separate them in stores. Natural health products should be pulled from the shelves where they are mixed with nonprescription drug products and confined to their own separate section, away from any signage implying a therapeutic use.

The double standard perpetuated by both regulators and retailers that enables the deception of unsuspecting Canadians must end. Alternative medicines with claims based on alternative facts do not deserve an alternative, easy regulatory road to market — at the very least, they need to be moved to an alternative shelf.

END OF QUOTES

This, of course, is Canada. But elsewhere progress is also being made.The Australian reported about plans in Australia whereby pharmacies would be banned from selling useless and possibly dangerous homoeopathic remedies. The Australian last year ­revealed a review of pharmacy regulation, headed by Stephen King from the Productivity ­Commission, identified a potential conflict of interest in pharmacists selling vitamins, for example, that may not have a significant ­evidence base, alongside more stringently regulated and government-subsidised medicines. In its interim report, the review panel was “concerned that the sale of complementary medicines alongside other medicines may mislead consumers”. It therefore concludes that “complementary medicines should be held in a separate area within community pharmacies, where customers can easily access a pharmacist for appropriate advice.”

“To avoid potential harm, or the confusion between the efficacies of different types of medicines, pharmacists need to be easily ­accessible to give needed advice when consumers choose a complementary or pharmacy-only medicine,” the review panel said. It was scathing of homo­eopathy and the perception of legitimacy given to those so-called remedies sold in pharmacies. “The only defence put to the panel regarding homoeopathy was that it was harmless and able to be used as a placebo in certain circumstances,” the review panel noted. “The panel does not believe that this argument is sufficient to justify the continued sale of these products in pharmacies …”

AUSTRALIAN JOURNAL OF PHARMACY (AJP) noted that the interim report of the Review of Pharmacy Remuneration and Regulation states that “there are unacceptable risks where community pharmacies are allowed to sell homeopathic products”.

In 2015 Pharmaceutical Society of Australia (PSA) said it did not support the sale of homeopathy in pharmacy. “Our position is that pharmacists must use their professional judgement to prevent the supply of products with evidence of no effect,” PSA president Joe Demarte said at the time. Ian Carr, of Saxby’s Pharmacy in Taree, NSW, and Friends of Science in Medicine member, told the AJP that “in terms of homeopathic products being recommended not to be sold by PBS-approved pharmacies, I one hundred per cent heartily agree with that finding. “I love saying that I believe homeopathy works. But it has never been shown to work better than placebo. There are many things that will work as well as placebo, but it’s not ethical to be selling them as a cure or treatment for something. I would have a bit more time for it if there was a plausible theory behind it, but its basis is entirely implausible – it pushes all the buttons for being a pseudoscience, so I agree it has no place in Australian pharmacy. However, I am at a bit of a loss to understand why they haven’t carried some of that logic over into the comments on complementary medicines generally.”

Mr Carr also told the AJP that “If one conceives of complementary medicines as being vitamins and minerals, that’s one thing. But the marketing of those items has become so diffuse and so wide that on most of these CM shelves we have traditional medicines, we’ve got herbal medicines, we’ve got items that are basically just marketing formulas for certain conditions. The evidence behind most of these things is very very slim, and we still have the possibility of health fraudsters just marching in and taking advantage of the lack of regulation in the industry.”

So, Canada and Australia are making progress in protecting consumers from bogus healthcare products and from pharmacists selling them.

Hurray!!!

When, I ask myself, are the UK, the US and other countries following suit?

 

This recently published report provides updated clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance.

The practice guidelines are based on a systematic literature review from 1990 through 2015. The recommendations are as follows:

  • Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction.
  • Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders.
  • Meditation and yoga are recommended to improve quality of life.
  • Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting.
  • Acetyl-L-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy due to a possibility of harm.
  • No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment-related side effects.

The authors conclude that there is a growing body of evidence supporting the use of integrative therapies, especially mind-body therapies, as effective supportive care strategies during breast cancer treatment. Many integrative practices, however, remain understudied, with insufficient evidence to be definitively recommended or avoided.

I have to admit that I am puzzled by this paper.

The first obvious point to make is that these treatments are not ‘integrative therapies’; they are alternative or complementary and I fail to see what is integrative about them.

The second point is that the positive recommendations are based on often poor-quality studies which did not control for placebo effects.

The third point is that the negative recommendations are woefully incomplete. There are many more alternative therapies for which there is no strong evidence.

The forth point is the conclusion implying that treatment supported by insufficient evidence should be avoided. I would not claim that any of the mentioned treatments is backed by SUFFICIENT evidence. Therefore, we should avoid them all, one might argue.

But these concerns are perhaps relatively trivial or far-fetched. More important is the fact that a very similar article been published in 2014. Here is the abstract:

Background

The majority of breast cancer patients use complementary and/or integrative therapies during and beyond cancer treatment to manage symptoms, prevent toxicities, and improve quality of life. Practice guidelines are needed to inform clinicians and patients about safe and effective therapies.

Methods

Following the Institute of Medicine’s guideline development process, a systematic review identified randomized controlled trials testing the use of integrative therapies for supportive care in patients receiving breast cancer treatment. Trials were included if the majority of participants had breast cancer and/or breast cancer patient results were reported separately, and outcomes were clinically relevant. Recommendations were organized by outcome and graded based upon a modified version of the US Preventive Services Task Force grading system.

Results

The search (January 1, 1990–December 31, 2013) identified 4900 articles, of which 203 were eligible for analysis. Meditation, yoga, and relaxation with imagery are recommended for routine use for common conditions, including anxiety and mood disorders (Grade A). Stress management, yoga, massage, music therapy, energy conservation, and meditation are recommended for stress reduction, anxiety, depression, fatigue, and quality of life (Grade B). Many interventions (n = 32) had weaker evidence of benefit (Grade C). Some interventions (n = 7) were deemed unlikely to provide any benefit (Grade D). Notably, only one intervention, acetyl-l-carnitine for the prevention of taxane-induced neuropathy, was identified as likely harmful (Grade H) as it was found to increase neuropathy. The majority of intervention/modality combinations (n = 138) did not have sufficient evidence to form specific recommendations (Grade I).

Conclusions

Specific integrative therapies can be recommended as evidence-based supportive care options during breast cancer treatment. Most integrative therapies require further investigation via well-designed controlled trials with meaningful outcomes.

I have harshly criticised this review on this blog in 2016. For instance, I voiced concern about the authors declaration of conflicts of interest and stated:

 

I know none of the authors (Heather Greenlee, Lynda G. Balneaves, Linda E. Carlson, Misha Cohen, Gary Deng, Dawn Hershman, Matthew Mumber, Jane Perlmutter, Dugald Seely, Ananda Sen, Suzanna M. Zick, Debu Tripathy) of the document personally. They made the following collective statement about their conflicts of interest: “There are no financial conflicts of interest to disclose. We note that some authors have conducted/authored some of the studies included in the review.” I am a little puzzled to hear that they have no financial conflicts of interest (do not most of them earn their living by practising integrative medicine? Yes they do! The article informs us that: “A multidisciplinary panel of experts in oncology and integrative medicine was assembled to prepare these clinical practice guidelines. Panel members have expertise in medical oncology, radiation oncology, nursing, psychology, naturopathic medicine, traditional Chinese medicine, acupuncture, epidemiology, biostatistics, and patient advocacy.”). I also suspect they have other, potentially much stronger conflicts of interest. They belong to a group of people who seem to religiously believe in the largely nonsensical concept of integrative medicine

The just-published update has a different statement about conflicts of interest:

DISCLOSURES: Linda E. Carlson reports book royalties from New Harbinger and the American Psychological Association. Misha R. Cohen reports royalties from Health Concerns Inc., outside the submitted work. Matthew Mumber owns stock in I Thrive. All remaining authors report no conflicts of interest.

Is this much better than the previous statement? Was the previous statement therefore false?

I wonder.

What do you think?

The homeopath and homeopathic entrepreneur Fran Sheffield has made appearances on this blog before; for instance, I quoted her stating that homeoprophylaxis has a remarkable record of safety – vaccines less so. From the homeopath’s point of view they are still associated with risks: the dose is too strong, they have toxic additives, and they’re given by inappropriate pathways. Homeoprophylaxis has avoided these problems. It’s also versatile, inexpensive, quick to produce and easy to distribute…

I believe such irresponsible nonsense brought her into trouble; a Federal judge concluded that: “there is no reasonable basis, in the sense of an adequate foundation, in medical science to enable the First Respondent and the Second Respondent to state that Homeopathic Treatments are safe and effective as an alternative to the Vaccine for the Prevention of Whooping Cough”.

Perhaps this is why Fran is now focussing on less contentious (but equally profitable) subjects? In any case, Fran is back with an article claiming that homeopathy is effective for treating over-sexed children and adults.

If you happen to be a bit under the weather today, you should read it – it will cheer you up, I am sure:

START OF QUOTE

Hyos [Hyoscyamus niger]…is frequently well-suited to over-sexualised behaviour in either children or adults. Other helpful remedies also exist but Hyos is especially useful when the child is prone to jealousy, foolishness, silly, irritating behaviour they refuse to stop, anxiety about water, twitching, jerking and grimacing, and restless hands that constantly move, touch and pull at things. While not all these symptoms have to be present before Hyos can be prescribed, some degree of similarity should exist. In pronounced cases, epilepsy and mania may be present.

When parents in my clinic first hear that a homeopathic remedy like Hyos can return their child’s over-sexualised behaviour back to normal they usually look at me with disbelief but within a week of taking a dose, significant changes have usually taken place. By the next appointment, some weeks later, I normally hear that the silly behaviour and jealousy have reduced – or gone completely – along with the inappropriate sexuality. All this and more from one simple remedy.

On reading this, if you are wondering if treatment has to be forever, the answer is no. As with any form of homeopathic treatment, when physical and behavioural symptoms improve, the remedy is given less often. Once the symptoms have stopped so is the remedy as the child is back to a healthy state and no further treatment is needed.

If your child has this embarrassing and annoying problem, hopefully it helps to know that its not “just the way they are” but  an imbalance that can be corrected. To achieve this, please see a reputable and qualified homeopath who can help you in your child’s treatment. The bonus is that as their precocious behaviour improves with treatment, so will their other health problems and life will become easier and more pleasant for all.

Fran Sheffield (Homeopath)

References

http://www.news.com.au/national/red-light-on-abnormal-child-sex-behaviour/story-e6frfkvr-1226264224011 

END OF QUOTE

If you think that Fran is an oddity amongst homeopaths in prescribing homeopathic remedies for sexual problems (or if you assume that there is a jot of evidence for homeopathic treatments of such conditions), you are mistaken. The Internet is full with similar advice. My favourite site must be this one because it offers very concrete help. Here are some of the prescriptions:

Some of the common and effective homeopathic remedies for treatment of loss of libido are Iodium, Plumbum Metallicum, Argentum Nitricum.

  • Iodium: A useful remedy in men with loss of sexual power, with atrophied testes.
  • Plumbum Metallicum: Valuable remedy in men with loss of sexual desire with constricted feeling of the testicles, and loss of sexual desire with progressive muscular atrophy.
  • Argentum Nitricum: Useful remedy in nervous and anxious men with Complete loss of libido or in whom erection fails when coition is attempted.

Some of the common remedies used in treatment of impotence are Agnus castus, Argentum nitricum, Caladium, Causticum, Lycopodium, Selenium metallicum, Staphysagria.

  • Agnus castus: If impotence develop after you have led a life of intense and frequent sexual activity for many years Agnus castus may be useful. If you feel a cold sensation in the genitals Agnus castus is indicated.
  • Argentum nitricum: Useful remedy in men whose erection fails when sexual intercourse is attempted, particularly if thinking about the problem makes it worse.
  • Caladium: Useful remedy for men whose genitals are completely limp…

The question that occurred to be when reading this is the following: Is there any conceivable stupidity in which homeopaths do not indulge?

 

Systematic reviews are aimed at summarising and critically evaluating the evidence on a specific research question. They are the highest level of evidence and are more reliable than anything else we have. Therefore, they represent a most useful tool for both clinicians and researchers.

But there are, of course, exceptions. Take, for instance, this recent systematic review by researchers from the

  • Texas Chiropractic College, Pasadena, the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport,
  • Department of Planning, Policy and Design, University of California, Irvine,
  • VA Puget Sound Health Care System, Tacoma,
  • New York Chiropractic College, Seneca Falls,
  • Logan University College of Chiropractic, Chesterfield,
  • University of Western States, Portland.

Its purpose was to evaluate the effectiveness of conservative non-drug, non-surgical interventions, either alone or in combination, for conditions of the shoulder. The review was conducted from March 2016 to November 2016 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and was registered with PROSPERO. Eligibility criteria included randomized controlled trials (RCTs), systematic reviews, or meta-analyses studying adult patients with a shoulder diagnosis. Interventions qualified if they did not involve prescription medication or surgical procedures, although these could be used in the comparison group or groups. At least 2 independent reviewers assessed the quality of each study using the Scottish Intercollegiate Guidelines Network checklists. Shoulder conditions addressed were

  • shoulder impingement syndrome (SIS),
  • rotator cuff-associated disorders (RCs),
  • adhesive capsulitis (AC),
  • nonspecific shoulder pain.

Twenty-five systematic reviews and 44 RCTs met inclusion criteria. Low- to moderate-quality evidence supported the use of manual therapies for all 4 shoulder conditions. Exercise, particularly combined with physical therapy protocols, was beneficial for SIS and AC. For SIS, moderate evidence supported several passive modalities. For RC, physical therapy protocols were found beneficial but not superior to surgery in the long term. Moderate evidence supported extracorporeal shockwave therapy for calcific tendinitis RC. Low-level laser was the only modality for which there was moderate evidence supporting its use for all 4 conditions.

The authors concluded that the findings of this literature review may help inform practitioners who use conservative methods (eg, doctors of chiropractic, physical therapists, and other manual therapists) regarding the levels of evidence for modalities used for common shoulder conditions.

This review has so many defects that it would be boring to list them here.

The PRISMA guidelines  – I happen to be a co-author – state, for instance, that the abstract (the above text is from the abstract) should provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. It is obvious that the review authors have omitted several of these items.

And that is just the abstract!  There is much, much more to criticise in this paper.

The most striking deficit, in my view, is the useless conclusion: the one from the abstract (the part of the paper that will be read most widely) could have been written before the review had even been started. It is therefore not based on the data presented. Crucially it does not match the stated aim of this review (“to evaluate the effectiveness of conservative…interventions”).

But why? Why did the authors bother to follow PRISMA? Why did they formulate this bizarre conclusion in their abstract? Why did they do a review in the first place?

I fear, the answers might be embarrassingly simple:

  • They only pretended to follow PRISMA guidelines because that gives their review a veneer of respectability.
  • They formulated the conclusions because otherwise they would have needed to state that the evidence for manual therapy is less than convincing.
  • They conducted the review to promote chiropractic, and when the data were not as they had hoped for, they just back-paddled in an attempt to hide the truth as much as possible.

If this were an isolated case, I would not have bothered to mention it. But sadly, in the realm of chiropractic (and alternative medicine in general) we currently witness a plethora of rubbish reviews (published by rubbish journals). To the naïve observer, they might look rigorous and therefore they will be taken seriously. The end-effect of this pollution of the literature with rubbish is that we get a false-positive impression about the validity of the treatments in question. Consequently, we will see a host of wrong decisions on all levels of healthcare.

The big question is: HOW DO WE PROTECT OURSELVES FROM THIS DANGEROUS TREND?

I only see one solution: completely disregard certain journals that have been identified to regularly publish nonsense. Sadly, the wider medical community is far from having arrived at this point. As far as I can see, the problem has not even been identified yet as a serious issue that needs addressing. For the foreseeable future, we will probably have to live with this type of pollution of our medical literature.

I was surprised to receive this email yesterday: “Hello Edzard Ernst, You may remember I got in touch last week regarding losing a loved one to the ravages of drugs or alcohol. I just wanted to remind you that Narconon is here to help. For over fifty years Narconon drug and alcohol rehabilitation centres have been successfully reversing the tide of addiction for men and woman from all walks of life. The Narconon programme has saved them from the misery of addiction, and the potential of an early grave. We not only address the cause of the addiction, we resolve them…”

The email was signed by a man from ‘Narconon International’. First I thought someone has been counting the empty bottles in my bin, then I read it again and noticed the word ‘NARCONON’ and remembered that I once wrote about it. A quick search located my article from THE GUARDIAN 2012:

Imagine a therapy that “enables an individual to rid himself of the harmful effects of drugs, toxins and other chemicals that lodge in the body and create a biochemical barrier to spiritual well-being“. If you were told that the treatment was entirely natural and had already “enabled hundreds of thousands to free themselves from the harmful effects of drugs and toxins and so achieve spiritual gains”, wouldn’t you be tempted to try it?

Who doesn’t want a body free of nasty chemicals? And who wouldn’t be delighted at the chance to counter a growing threat to an “advancement in mental … wellbeing”?

These claims are being made for the “Purification Rundown” (“Purif” for short) and the closely related Narconon detox programmes, which mainly consist of regular exercise, sauna and nutrition, with industrial doses of vitamins and minerals added for good measure. Some of the claims are quite specific: the Purif programme is supposed to increase your IQ, reduce the level of cancer-causing agents in your body, and even enable you to lose weight easily and quickly. The Narconon programme is more specifically targeted at drug and alcohol dependency and is claimed to have an impressive success rate of 75%.

Both programmes were developed by L Ron Hubbard (1911-1986) and are currently marketed by the Church of Scientology. The CoS is not generally known to be an organisation that promotes healthcare programmes. Hubbard, the pulp-fiction writer who founded the CoS, portrayed himself somewhat over-optimistically as a pioneer, innovator and nuclear physicist.

He taught his followers that, at their core, humans contain a “thetan”. After creating the universe, thetans accidentally became trapped in physical bodies and, through scientology, we can restore the immortal, omnipotent, god-like powers of the “thetan” within us. Weird stuff that is the preserve of Hollywood eccentrics, you might think, but perhaps the CoS’s detox-ventures are an attempt to conquer new territory?

A typical course of treatment lasts several weeks and consists of many hours of exercise and sauna every day. This regimen is supplemented with megadoses of vitamins and minerals, which can cause problems. Niacin, one vitamin that is given in high doses as part of the regimen, can be particularly dangerous. The US National Institutes of Health warns that at high doses it can cause “liver problems, gout, ulcers of the digestive tract, loss of vision, high blood sugar, irregular heartbeat, and other serious problems.” It should not be taken by people who already have liver damage.

Seven fatalities of people undergoing the Narconon programme are currently being investigated in Oklahoma, although the CoS says these deaths are not connected with the treatment regimen itself.

Whatever the truth regarding these deaths, a review of the evidence about the treatment regimen’s effectiveness – carried out by the Norwegian Knowledge Centre for the Health Services in 2008 – found no good evidence that the Narconon programme works:

There is currently no reliable evidence for the effectiveness of Narconon as a primary or secondary drug prevention program. This is partly due to the insufficient research evidence about Narconon and partly due to the non-experimental nature of the few studies that exist.

The claim that such detox treatments eliminate toxins from the body is, of course, easily testable. All we would need to do is define what toxin we are talking about and measure the change in levels of that toxin compared with a control group of volunteers who did not receive the detox.

But such studies are not available. Why? Do the marketing men believe in their own claims? Maybe they feel that profits and evidence are like fire and water? Or possibly the thetans have an aversion to science?

If you think that the Purif, Narconon or any other form of alternative detox eliminates toxins, you might be mistaken. Most clients have lost some money, many have lost their ability to think straight, some may even have lost their lives. But there is no reliable evidence that they have actually lost any toxins.

END OF MY 2012 ARTICLE

In 2012, I found no evidence to suggest that NARCONON works. Now, I looked again and found this article reporting a non-randomised, controlled study:

“In 2004, Narconon International developed a multi-module, universal prevention curriculum for high school ages based on drug abuse etiology, program quality management data, prevention theory and best practices. We review the curriculum and its rationale and test its ability to change drug use behavior, perceptions of risk/benefits, and general knowledge. After informed parental consent, approximately 1000 Oklahoma and Hawai’i high school students completed a modified Center for Substance Abuse Prevention (CSAP) Participant Outcome Measures for Discretionary Programs survey at three testing points: baseline, one month later, and six month follow-up. Schools assigned to experimental conditions scheduled the Narconon curriculum between the baseline and one-month follow-up test; schools in control conditions received drug education after the six-month follow-up. Student responses were analyzed controlling for baseline differences using analysis of covariance. At six month follow-up, youths who received the Narconon drug education curriculum showed reduced drug use compared with controls across all drug categories tested. The strongest effects were seen in all tobacco products and cigarette frequency followed by marijuana. There were also significant reductions measured for alcohol and amphetamines. The program also produced changes in knowledge, attitudes and perception of risk. The eight-module Narconon curriculum has thorough grounding in substance abuse etiology and prevention theory. Incorporating several historically successful prevention strategies this curriculum reduced drug use among youths.”

The question arises: would I send anyone to the NARCONON programme?

My answer is NO!

Not because the trial is lousy (which it is) and not because the programme is too expensive (which it is); I would not send anyone to any institution that has even the slightest links to Scientology.

 

Dr Gabriella Day is a GP in England who describes herself and her beliefs as follows: “I began training in homeopathy as it is clear that for many conditions conventional treatment options are not effective and can have unwanted side effects. It seemed to me that there must be another way to help people suffering from symptoms such as these… I believe in whole person medicine. No illness exists in isolation. The human body is immensely sophisticated and complicated and we do not understand it fully. Therefore the illness cannot be separated from the person suffering the disease. This may be as simple as stress impairing the immune system to far more complex interactions. Homeopathic treatment seeks to match the underlying disturbance in the system and stimulate the body to correct itself.”

I do not know Dr Day, but she caught my attention recently when she published an article in THE HIPPOCRATIC POST (I had never heard of this publication before!). It is, I think, sufficiently noteworthy to show you some excerpts (the references [in square brackets] were added by me, and they refer to my comments below):

START OF QUOTES

…Homeopathy can be helpful for pretty much any condition [1], whether as the main treatment [1], as a complement to a conventional treatment [2] to speed up the healing process [1], or to lessen the side-effects of a pharmacological medication [1]. It can be helpful in the treatment of emotional problems [1], physical problems [1] and for multi-morbidity patients [1]. I find it an invaluable tool in my GP’s toolbox and regularly see the benefits of homeopathy in the patients I treat [3]…

There are many conditions for which I have found homeopathy to be effective [1]… There are, however, a multitude of symptomatic treatments available to suppress symptoms, both on prescription and over-the-counter. Most symptoms experienced by patients in this context result from the body’s attempt to eliminate the infection. Our immune systems have spent thousands of years refining this response; therefore it seems counter-intuitive to suppress it [4].
For these types of acute conditions homeopathy can work with the body to support it [1]. For instance, homeopathic Arsenicum album (arsenic) is a classic remedy for diarrhoea and vomiting that can be taken alongside essential oral rehydration [1]. And in influenza I’ve found Eupatorium perfoliatum (ague or feverwort) to be very helpful if the patient is suffering with bony pain [3].
…Unless it is clinically imperative for a pharmacological intervention, I will always consider homeopathy first [5] and have successfully prescribed the homeopathic remedy Nux vomica (strychnine) for women suffering from morning sickness [5]. Problems associated with breastfeeding such as mastitis have also responded well to the classic remedies Belladonna (deadly nightshade) and Phytolacca (pokeweed), while I have found Urtica urens (dog nettle) effective in switching off the milk supply to prevent engorgement when the mother stops breastfeeding [3].
…“heart sink” patients are clearly suffering from pain and discomfort, which is blighting their lives. This is understandably frustrating for them, for they know full well something is awry but there is no medical evidence for this… Homeopathy affords me another approach in trying to help these patients [1,3]. It doesn’t work for them all, but I’m frequently surprised at how many it does help [3].

Positive side-effects

The beauty of homeopathy is that it combines mental and emotional symptoms with physical symptoms [3]. When the right remedy is found it appears to stimulate the body to recognise how it is being dysfunctional and corrects this, with no suppression, just a correction of the underlying disturbance [3]. Thus homeopathy not only eliminates unwanted symptoms [1], it dramatically improves a patient’s overall well-being [1].
…homeopathy… enables me to reduce the number of painkillers and other drugs I’m prescribing [1,3]. This is particularly true for older multi-morbidity, polypharmacy patients [1] who are often taking huge amounts of medication.
Contrary to what most homeopaths will tell you, I believe homeopathic treatment does have side-effects – positive side-effects! [1] It fosters an enhanced doctor patient relationship [1]. The process of eliciting the relevant information to select a remedy enables me to better understand the patient’s condition and helps me to get to know them better [3]. And the patient, seeing that the doctor is interested in the idiosyncrasies and detail of their disease, finds themselves heard and understood [3]. In short, since training in homeopathy I enjoy my job as a GP and my relationship with patients so much more [3].
Dr Gabriella Day BSc, MBBS, MRCP, DCH, MRCGP, MFHom

END OF QUOTES

MY COMMENTS:

  1. statement without good evidence,
  2. Hahnemann was vehemently against combining homeopathy with other treatments and called clinicians who disregarded this ‘traitors’,
  3. statement of belief,
  4. wrong assumption,
  5. questionable ethics.

I have recently attempted to slip into the brain of lay-homeopaths and shown how illogical, misguided and wrong the arguments of such enthusiasts really are. Surely, the logic of a doctor homeopath must be better, I then thought. Once you have studied medicine, you have learnt an awful lot of things about the body, disease, therapy, etc., etc., I felt.

Judging from the above article, I might have been wrong.

Alternative medicine differs from conventional medicine in numerous ways. One important difference is that patients often opt to try this or that product without consulting any healthcare professional at all. In such cases, the pharmacist might be the ONLY professional who can advise the patient who is about to purchase such a product.

This is why the role of the pharmacist in alternative medicine is crucial, arguably more so than in conventional medicine. And this is why I am banging on about pharmacists who far too often behave like shop-keepers and not like ethical healthcare professionals. A new review addresses these issues and provides relevant information.

Pharmacists from the University of Macau in Macau, China conducted a literature review to extract publications from 2000 to 2015 that related pharmacist to alternative medicine products. 41 publications which reported findings from exploratory studies or discussed pharmacists’ responsibilities towards such products were selected for inclusion.

Seven major responsibilities emerged:

  • to acknowledge the use of alternative medicine products;
  • to be knowledgeable about such products;
  • to ensure safe use of such products;
  • to document the use of such products;
  • to report ADRs related to such products;
  • to educate about such products;
  • to collaborate with other health care professionals in respect to such products.

One point that is not directly covered here is the duty of pharmacists to comply with their own ethical codes. As I have pointed out ad nauseam, this would mean in many instances to not sell alternative medicine products at all, because there is no good evidence to show that they are generating more good than harm and thus are potentially harmful as well as wasteful.

Some pharmacists have realised that there is a problem. Some pharmacists are trying to initiate discussions about these issues within their profession. Some pharmacists are urging to change things. Some pharmacists are well-aware that healthcare ethics are being violated on a daily basis.

All this has been going on now for well over a decade.

And has there been any noticeable change?

Not as far as I can see!

Perhaps it is time to realise that not merely the sale of bogus medicines by pharmacists is unethical, but so is dragging one’s feet in initiating improvements.

 

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