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.
Yes, I think he does deserve to join this fast-expanding club which, so far, consists of the following people:
They have been admitted mostly because they have demonstrated that they exclusively or mostly publish positive results about alternative medicine. Therefore, their ‘TRUSTWORTHYNESS INDEX’ is remarkable.
With Peter Fisher, things are a little different, and in a way much more convincing. He also has a remarkable publication record, of course. As the Queen’s homeopath, he is a stark defender of homeopathy. He has just under 100 Medline-listed articles in this area, and, if I am not mistaken, only one of them cast any doubt on the effectiveness of homeopathy.
Peter is also the long-term editor of the journal HOMEOPATHY, and he used this position to fire me from its editorial board. Furthermore, he has been shown to have an unusual attitude towards telling the truth. But the decider for his admission to THE ALT MED HALL OF FAME was the following recent interview for NATURALLYSAVVY where he shows himself as a fierce defender of science, evidence-based medicine and critical thinking:
Andrea Donsky: I understand you arrived yesterday from England. I’m curious what you take for jetlag?
Peter Fisher: We have a traditional combination that we use for jetlag, which is arnica montana, and cocculus indicus. So arnica is something that is traditionally used for bruises, and cocculus is used for sleep problems. So arnica and cocculus combined, 6CH every hour or two, helps with jetlag.
Andrea Donsky: I read about the incredible work you do as an Integrative Medicine Doctor so I thought we would start today’s interview with having you explain what that means.
Peter Fisher: Simply put, it means the best of both worlds: the best of conventional, and the best of complementary medicine. There is also a much longer and more complicated definition, but essentially it’s integrating complementary medicine in care packages to avoid some of the worst excesses of conventional medicines, like over-drugging, and excess use of medication.
Andrea Donsky: I know you don’t see patients with the common cold or flu, but if you did, what would be your protocol?
Peter Fisher: I’ve done quite a lot of research on the flu. It’s quite clear that conventional treatments don’t work all that well, and may even prolong the flu. Most of the conventional treatments push the symptoms down [suppress them] and actually prolong the illness.
Andrea Donsky: So something like Oscillococcinum would be a perfect thing to recommend to people.
Peter Fisher: Yes, and other homeopathic combinations that can speed up the resolution, relieve the symptoms, and make the flu go away quicker.
Andrea Donsky: Tell me a little bit about the European way of practicing medicine. I remember hearing that in Europe doctors prescribe homeopathy alongside medication. Is this true?
Peter Fisher: It varies widely between countries. In France, Germany, and increasingly in Spain, it is the case, but not so much in the UK. A lot of doctors do incorporate it in their practice and they integrate homeopathy when it seems appropriate, but they also use antibiotics and other drugs when they feel it is appropriate.
Andrea Donsky: Do you often approach these skeptics and say: “Listen, you are wrong because there is research behind it!”
Peter Fisher: I will debate with anybody, anytime. The trouble is, skeptics don’t like that because they always lose. I’ve been involved in a series of debates with “so called” skeptics. But many well-known skeptics avoid me because they lose the debate. What they prefer to do is to blog, or tweet, so they can make nasty sneering public remarks and you can’t come back at them. If it’s a proper debate, I say my piece, you say your piece, there’s somebody there to make sure that it’s fair play, and that could be in a journal, it could be in a lower court, I don’t care. There was a big court case in the U.S. that was resolved in September where that happened. An allegation was made that false claims were being made for homeopathic medicines and they lost the case…homeopathy won!
Andrea Donsky: Tell us how you came to be a physician to Her Majesty the Queen.
Peter Fisher: There’s a long tradition of the Royal Family having a homeopathic physician. It actually goes back 150 years to Queen Victoria and her beloved Prince Albert. The founder of our hospital was Prince Albert’s father’s doctor. There has been an official homeopathic physician treating the Royal Family since the 1930s. It’s been me since 2001.
Andrea Donsky: It is nice to hear that the Royal Family is open to integrative medicine. Do you just treat the Queen, or the whole family? I read that Prince Charles eats organic and has an organic garden so I am assuming he is quite open to it as well.
Peter Fisher: I treat the entire family. I think Kate and Will are too young and healthy so they don’t need medicine. But the Prince of Wales, Prince Charles, is very friendly, and he is more than willing to stick his neck out to actually say things. He has spoken at the World Health Assembly, which is the AGN of the World Health Organization. So he’s really quite fond of integrative medicine.
Andrea Donsky: I think that’s incredible. As a conventionally trained physician, how did you become interested in homeopathy?
Peter Fisher: At the end of the Cultural Revolution I went to visit China. I was a medical student at the time, and I remember the moment when it became clear to me. I was in the operating room of a small Chinese provincial town and there was a woman lying on the operating table with her entire abdomen open, fully conscious talking to the anesthetist with three needles in her left ear.
Andrea Donsky: Acupuncture needles?
Peter Fisher: Yes.
Andrea Donsky: That’s amazing.
Peter Fisher: The needles were connected to a little electrical box. I thought, “That doesn’t happen. They didn’t tell us about this at Cambridge.” I went to the best medical school, Cambridge, a very elite medical school, and I just thought, “This can’t happen. This doesn’t happen.” That experience is what made me think that there was more to medicine than what we were taught in medical school. Then a few years later, I became ill myself. I was still a medical student so I went to see a very distinguished professor at my medical school who made a precise diagnosis and said, “Tough, nothing can be done.” So my friends suggested I try homeopathy, and I did, and it helped. So it snowballed from there.
Andrea Donsky: Oftentimes we need to see things for ourselves and/or experience it to believe it.
Peter Fisher: Yes. I got almost obsessed by it, you know. In many ways as a scientific thing it shouldn’t work. I mean I do understand to that extent where the skeptics are coming from. There does appear to be a good reason why it can’t possibly work, and yet it does.
Andrea Donsky: Can you define what homeopathy is and how it works?
Peter Fisher: Homeopathy is based on the idea of like curing like. So you give a very small dose of something that could cause a similar illness if given an enlarged dose. Some people say it’s like holding a mirror up to nature. You’re saying to the body, “OK, this is what your problem is, this is what the disease is.” The idea is that the body has very strong self-healing capabilities; it is strong, but sometimes it can be stupid like when it comes to autoimmune diseases. In that case it is actually the body’s defensive mechanism being misdirected.
Andrea Donsky: Can you explain the difference between a single remedy and a combination?
Peter Fisher: A single remedy is one remedy and a combination is multiple. Broadly speaking, there are two kinds of homeopathy. One is the so-called “keynote prescribing way,” where you prescribe for one or two keynote symptoms like a cold, sore throat, or runny nose.Then there is “constitutional medicine” where you are not so much treating the disease, but rather the person. So for example, if someone has insomnia, muscular aches and pains or even a cold and/or flu, they can take a combination of two, three, four, or even five different homeopathic medicines, which will likely cover the symptoms. This is more for self-treatment, rather than doctor prescribed.
Andrea Donsky: That makes sense. I like that there is a role in homeopathy for both self (like for the common cold) and expert prescribing.
Peter Fisher: Yes. It is one thing if someone has a short-term health issue, but it is another thing if they have a chronic complicated, multi-faceted issue. I mean one of the interesting things about homeopathy is the idea of treating the person, and not the disease
I AM CONFIDENT THAT THE MAJORITY OF MY READERS AGREE TO ADMIT DR FISHER TO THE ALT MED HALL OF FAME.
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.
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.
Amidst the current controversy of chiropractic spinal manipulation for new-born babies, the previous director of Chiropractor’s Association of Australia NSW, Alex Fielding, published an interesting article. In it, he declared:
- I do not condone the chiropractic treatment of children for non-musculoskeletal conditions it is simply not our place. There is little to no evidence for it and it should not be done. If a chiro is report them to AHPRA.
- There is no evidence for “subluxation” it simply has not been shown to exist by any credible source.
- Chiropractic does not equal spinal manipulative therapy (SMT) or adjustment. We are trained to assess and treat musculoskeletal conditions, use exercise rehab, various forms of manual therapy including SMT, give sound evidence based advice and refer to better suited health professionals in the appropriate circumstance. To say there is no evidence for chiropractic is an ill informed politically charged statement, if you mean SMT, say SMT.
Here I only want to comment on his last point. I think it is important, not least because we hear it ad nauseam. As soon as there emerges new evidence to show that SMT does little for back or neck pain or is ineffective for non-spinal conditions, chiropractors insist that they do so much more than just SMT, and therefore any such findings do not ever lend themselves to a verdict about chiropractic care.
In my view, this argument is a bit like ‘wanting the cake and eat it’ (chiros want to be different from physios by adhering to SMT, but they don’t want to be judged by the uselessness of SMT). It begs the following questions:
- What other modalities do chiros use?
- For which conditions do they use them?
- What is the evidence for or against them?
- In what percentage of patients do chiros use SMT?
The last question may be the most important one. I am not aware of data from ‘down under’ but, in the UK, the percentage is close to 100%. This is why I often call SMT the ‘hallmark therapy of chiropractors’. No other profession employ it more frequently. It is the treatment that defines the chiropractic profession.
If the evidence for SMT is flimsy or negative or non-existent, it seems not unreasonable to voice doubts about the profession that uses it most. The fact that chiropractors also administer other modalities – most of which, by the way, have a shaky evidence-base too – is simply a smoke-screen used to mislead us.
An example might make this a bit clearer. Imagine a surgeon who takes out the tonsils of every patient he sees, regardless of any tonsillitis or other tonsil-related condition (historically, this fad once existed; tonsillectomy was even used to treat depression). This surgeon also does all sorts of other things: he prescribes pain-killers, gives antibiotics, orders bed-rest, gives life-style advice etc. etc. Yet he is a charlatan because his hallmark intervention is not effective and even puts patients at unnecessary risks.
I know, the analogy is not perfect, but it makes the point: chiropractors refuse to be judged by the uselessness of SMT. Yet it is what defines them and they continue using SMT pretty much regardless of the evidence. Fielding pleads: To say there is no evidence for chiropractic is an ill informed politically charged statement, if you mean SMT, say SMT. I’d say there is no good evidence for SMT nor for chiropractic care that includes SMT.
My advice for chiropractors therefore is: abandon SMT and become physiotherapists. This will make you a bit better grounded in evidence, but at least you would have rid yourself of the Palmer-cult with all the BS that comes with it.
The current issues of ‘homeopathy 4 everyone’ (April 2016) carries several articles on homeoprophylaxis, the use of homeopathic remedies for the prevention of mostly infectious diseases promoted by homeopathy as a safe and effective alternative to immunizations. They are worth reading – but watch your blood pressure! Here I will give you a flavour by citing from one of these articles:
“…As I have been teaching about Homeoprophylaxis (“HP”) throughout the United States and in Europe, some things have become unmistakably clear. One is the ever increasing desire of people to know that there is a nontoxic alternative when it comes to disease prevention. Another is a profound misunderstanding or, perhaps better said, a lack of education among many regarding HP…
The effectiveness of HP is being shown fairly consistently to be about 90%1, which is comparable to any vaccine. With this in mind, too, those who utilize homeoprophylaxis work to help their clients understand fundamentally that disease is generally not to be feared—that disease-causing pathogens are a necessary part of our environment and that the body generally becomes healthier once it has been exposed to a disease and has worked its way through it…
My passion regarding spreading the word and helping people learn about homeoprophylaxis led to my becoming the co-founder/director of the first international conference of its type in the world—Homeoprophylaxis: A Worldwide Choice, which took place in Dallas, Texas, USA in October, 2015. Isaac Golden was our keynote speaker…
Frequently seen is the protocol Isaac Golden utilizes. This is a once monthly method, where one single remedy/nosode is introduced at potency. If following, for example, a pediatric regimen that lists several nosodes, it will be the next month that either a larger dose of that same nosode is taken, or the next nosode is introduced. For pediatric HP, this is cycled through until all nosodes in the protocol are taken, the higher potency being started after the lower potency is completed. A booklet is provided to the clientele to keep track of these…
Ultimately, homeoprophylaxis has been in use since the days of Hahnemann. What is apparent when one considers the entire picture, noting the meticulous studies that have been and are yet being done as well as the current increasing demand of people worldwide— perhaps especially parents— for a nontoxic alternative for disease prevention, it truly makes sense to be promoting homeoprophylaxis. Our children are the most vulnerable in our society and deserve our utmost attention and concern. Not every practitioner needs to utilize HP. However, because there are many who do, support of this should be encouraged. It is an alternative people deserve to know about so that they can make an educated choice, and health for our society, especially our children, can be promoted.”
END OF QUOTE
By now, you are probably wondering who wrote this article. It was Cathy Lemmon, BA, C.HP, D.Psc, Co-Founder/Director of Homeoprophylaxis: A Worldwide Choice for Disease Prevention, she is also working on future conferences for the promotion of HP. She has studied HP with Isaac Golden of Australia and Ravi Roy and Carola Lage-Roy of Germany. She also has certificates in homeopathic treatment of vaccine injury as well as, through the ARHF in the Netherlands, treatment of epidemics and trauma. She completed studies at the School of Homeopathy and is completing specialized homeopathic studies through Gesundes Bewußtsein in Germany as well as post-graduate work in homeopathy through the College of Practical Homeopathy in London.
With all these ‘qualifications’, she has obviously escaped any education in real science and evidence-based medicine; if not she would know that her views are not just wrong but also dangerous. To Be clear:
- Homeoprophylaxis is not biologically plausible.
- There is no evidence that it works.
- The concept misleads people to think that conventional immunizations are superfluous.
- This has the potential to kill thousands.
The madness of some homeopaths who claim they can cure cancer has irritated me and others repeatedly, for instance here and here. Many apologists of homeopathy say that responsible homeopaths would never make such a claim. They may be right – but the sad reality is than there are far too many irresponsible homeopaths.
This article by Dr Pankaj Aggarwal, a ‘senior homeopathic physician’, marks in my view a new record in homeopathic ineptitude and irresponsibility. Here is an excerpt (it seems that the actual article has disappeared; luckily I saved it before):
“In homeopathy, non-toxic medicines are used to treat this cancer. There are no side-effects associated with homeo medicines for cervical cancer. If this problem is diagnosed at earlier stages, it becomes easier to treat and takes very less time. In advanced stages, more time is required to improve the situation. It is actually possible to treat cancer with homeopathic medicines. In fact, homeopathy is the only treatment method that can completely cure this disease. There are different approaches to treat this disease in homeopathy. Good homeo practitioners usually use a combination of these approaches while treating a cancer patient.
Treatment Approach 1
The first philosophy to treat cancer is to directly target the cancer tumors. In this way, the practitioner selects the proper medicines that match the symptom picture of tumors. An example of such medicine is Conium Maculatum, which can be used to treat immovable, hard and slowly developing tumors. In this approach, other symptoms of patient are also taken into consideration and are treated. This approach targets tumors and reverses their growth to the point where they no more exist or become harmless.
Treatment Approach 2
The second or indirect approach is to strengthen the cell detoxification process and eliminative channels of patients like liver, lymphatic system, urinary tract and kidneys. From this approach, the homeopathy practitioner uses low potency drainage remedies that detoxify particular substances like heavy metals or target particular body systems. The particular medicines used for this drainage is selected after thorough analysis of the particular cancer case.
Treatment Approach 3
In this approach, a complete interview of the patient’s emotional, physical, and mental symptoms is conducted. After that, best matching remedies are selected to address the complete constitution of the patient. Most of the times these homeopathy medicines will affect and target the cancer tumors directly. This treatment, if done properly, can result in complete removal of cancer tumors, resulting in full recovery.”
END OF QUOTE
The facts about homeopathy are very clear and tell a totally different story:
- the assumptions that underpin homeopathy are implausible,
- homeopathic remedies usually are far too dilute to have any effects whatsoever,
- there is no evidence to support any of the above claims,
- believing such claims will almost inevitably cause great harm to patients.
What follows is simple: HOMEOPATHS WHO MAKE THERAPEUTIC CLAIMS BEHAVE UNETHICALLY, ARGUABLY EVEN CRIMINALLY