MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

children

In the past, I have been involved in several court cases where patients had complained about mistreatment by charlatans. Similarly I have acted as an expert witness for the General Medical Council in similar circumstances.

So, it is true, quacks are sometimes being held to account by their victims. But, generally speaking, patients seem to complain very rarely when they fall in the hands of even the most incompetent of quacks.

Here is one telling reminder showing how long it can take until a complaint is finally filed.

Dr Julian Kenyon is, according to his websitean integrated medicine physician and Medical Director of the Dove Clinic for Integrated Medicine, Winchester and London. Dr Julian Kenyon is Founder-Chairman of the British Medical Acupuncture Society in 1980 and Co-Founder of the Centre for the Study of Complementary Medicine in Southampton and London where he worked for many years before starting The Dove Clinic in 2000. He is also Founder/President of the British Society for Integrated Medicine and is an established authority in the field of complementary treatment approaches for a wide range of medical conditions. He has written approximately 20 books and has had many academic papers published in peer review journals* and has several patents to his name. He graduated from the University of Liverpool with a Bachelor of Medicine and Surgery and subsequently with a research degree, Doctor of Medicine. In 1972, he was appointed a Primary Fellow of the Royal College of Surgeons, Edinburgh.

*[I found only 4 on Medline]

Kenyon has been on sceptics’ radar for a very long time. For instance, he is one of the few UK doctors who use ‘LIVE BLOOD ANALYSIS’, a bogus diagnostic method that can harm patients through false-negative or false-positive diagnoses. A 2003 undercover investigation for BBC 1 South’s ‘Inside Out’ accused Dr Julian Kenyon of using yet another spurious diagnostic test at his clinic near Winchester. Kenyon has, for many years, been working together with George Lewith, another of the country’s ‘leading’ complementary doctors. In 1994, the two published an article about their co-operation; here is its abstract:

This paper outlines the main research effort that has taken place within the Centre for the Study of Complementary Medicine over the last 10 years. It demonstrates the Centre’s expertise and interest in a whole variety of areas, including the social implications and development of complementary medicine, clinical trial methodology, the evaluation of complementary medical machinery, the effects of electromagnetic fields on health and the investigation of the subtle energetic processes involved in complementary medicine. Our future plans are outlined.

Lewith and Kenyon have been using a technique called electrodermal testing for more than 20 years. Considering the fact that the two doctors authored a BMJ paper which concluded that electrodermal machines couldn’t detect environmental allergies, this seems more than a little surprising.

Using secret filming, ‘Inside Out’ showed Dr Kenyon testing a six-year-old boy and then deciding that he is sensitive to dust mites. Later, Dr Kenyon insists that he made his diagnosis purely on the boy’s symptoms and that he didn’t use the machine to test for dust mites. The BBC then took the boy for a conventional skin prick test, which suggested he didn’t have any allergies at all. But Dr Kenyon then says the conventional test may not be accurate: “He may be one of the 10% who actually are negative to the skin tests but benefit from measures to reduce dust mite exposure.”

Despite this very public disclosure, Kenyon was able to practice unrestrictedly for many years.

In December 2014, it was reported in the Hampshire Chronicle that Dr Kenyon eventually did, after a complaint from a patient, end up in front of the General Medical Council’s conduct tribunal. The panel heard that, after a 20-minute consultation, which cost £300, Dr Kenyon told one terminally-ill man with late-stage cancer: “I am not claiming we can cure you, but there is a strong possibility that we would be able to increase your median survival time with the relatively low-risk approaches described here.” He also made bold statements about the treatment’s supposed benefits to an undercover reporter who posed as the husband of a woman with breast cancer.

After considering the full details of the case, Ben Fitzgerald, for the General Medical Council, had called for Dr Kenyon to be suspended, but the panel’s chairman Dr Surendra Kumar said Dr Kenyon’s misconduct was not serious enough to warrant a ban. The panel eventually imposed restrictions on Kenyon’s licence lasting for 12 months.

I estimate that patients are exposed to quackery from doctors and alternative practitioners thousands of times every day. Why then, I ask myself, do so few of them complain? Here are some of the possible answers to this important question:

  • They do not dare to.
  • They feel embarrassed.
  • They don’t know how to.
  • They cannot be bothered and fear the agro.
  • They fail to identify quackery and fall for the nonsense they are being told.
  • They even might perceive benefit from treatments which, in fact, are pure quackery.

Whatever the reasons, I think it is regrettable that not far more quacks are held to account – regardless of whether the charlatan in question as studied medicine or not. If you disagree, consider this: not filing a complaint means that many more patients will be put at risk.

Adults using unproven treatments is one thing; if kids do it because they are told to, that is quite another thing. Children are in many ways more vulnerable than grown-ups and they usually cannot give fully informed consent. It follows that the use of such treatments for kids can be a delicate and complex matter.

A recent systematic review was aimed at summarizes the international findings for prevalence and predictors of complementary and alternative medicine (CAM) use among children/adolescents. The authors systematically searched 4 electronic databases (PubMed, Embase, PsycINFO, AMED; last update in 07/2013) and reference lists of existing reviews and all included studies. Publications without language restriction reporting patterns of CAM utilization among children/adolescents without chronic conditions were selected for inclusion. The prevalence rates for overall CAM use, homeopathy, and herbal drug use were extracted with a focus on country and recall period (lifetime, 1 year, current use). As predictors, the authors extracted socioeconomic factors, child‘s age, and gender.

Fifty-eight studies from 19 countries could be included in the review. There were strong variations regarding study quality. Prevalence rates for overall CAM use ranged from 10.9 – 87.6 % for lifetime use, and from 8 – 48.5 % for current use. The respective percentages for homeopathy (highest in Germany, United Kingdom, and Canada) ranged from 0.8 – 39 % (lifetime) and from 1 – 14.3 % (current). Herbal drug use (highest in Germany, Turkey, and Brazil) was reported for 0.8 – 85.5 % (lifetime) and 2.2 – 8.9 % (current) of the children/adolescents. Studies provided a relatively uniform picture of the predictors of overall CAM use: higher parental income and education, older children. But only a few studies analyzed predictors for single CAM modalities.

The authors drew the following conclusion: CAM use is widespread among children/adolescents. Prevalence rates vary widely regarding CAM modality, country, and reported recall period.

In 1999, I published a very similar review; at the time, I found just 10 studies. Their results suggested that the prevalence of CAM use by kids was variable but generally high. CAM was often perceived as helpful. Insufficient data existed about safety and cost. Today, the body of surveys monitoring CAM use by children seems to have grown almost six-fold, and the conclusions are still more or less the same – but have we made progress in answering the most pressing questions? Do we know whether all these CAM treatments generate more good than harm for children?

Swiss authors recently published a review of Cochrane reviews which might help answering these important questions. They performed a synthesis of all Cochrane reviews published between 1995 and 2012 in paediatrics that assessed the efficacy, and clinical implications and limitations of CAM use in children. Main outcome variables were: percentage of reviews that concluded that a certain intervention provides a benefit, percentage of reviews that concluded that a certain intervention should not be performed, and percentage of studies that concluded that the current level of evidence is inconclusive.

A total of 135 reviews were included – most from the United Kingdom (29/135), Australia (24/135) and China (24/135). Only 5/135 (3.7%) reviews gave a recommendation in favour of a certain intervention; 26/135 (19.4%) issued a conditional positive recommendation, and 9/135 (6.6%) reviews concluded that certain interventions should not be performed. Ninety-five reviews (70.3%) were inconclusive. The proportion of inconclusive reviews increased during three, a priori-defined, time intervals (1995-2000: 15/27 [55.6%]; 2001-2006: 33/44 [75%]; and 2007-2012: 47/64 [73.4%]). The three most common criticisms of the quality of the studies included were: more research needed (82/135), low methodological quality (57/135) and small number of study participants (48/135).

The Swiss authors concluded that given the disproportionate number of inconclusive reviews, there is an ongoing need for high quality research to assess the potential role of CAM in children. Unless the study of CAM is performed to the same science-based standards as conventional therapies, CAM therapies risk being perpetually marginalised by mainstream medicine.

And what about the risks?

To determine the types of adverse events associated with the use of CAM that come to the attention of Australian paediatricians. Australian researchers conducted a monthly active surveillance study of CAM-associated adverse events as reported to the Australian Paediatric Surveillance Unit between January 2001 and December 2003. They found 39 reports of adverse events associated with CAM use, including four reported deaths. Reports highlighted several areas of concern, including the risks associated with failure to use conventional medicine, the risks related to medication changes made by CAM practitioners and the significant dangers of dietary restriction. The reported deaths were associated with a failure to use conventional medicine in favour of a CAM therapy.

These authors concluded that CAM use has the potential to cause significant morbidity and fatal adverse outcomes. The diversity of CAM therapies and their associated adverse events demonstrate the difficulty addressing this area and the importance of establishing mechanisms by which adverse effects may be reported or monitored.

So, we know that lots of children are using CAMs because their parents want them to. We also know that most of the CAMs used for childhood conditions are not based on sound evidence. The crucial question is: can we be sure that CAM for kids generates more good than harm? I fear the answer is a clear and worrying NO.

Guest post by Jan Oude-Aost

ADHD is a common disorder among children. There are evidence based pharmacological treatments, the best known being methylphenidate (MPH). MPH has kind of a bad reputation, but is effective and reasonably safe. The market is also full of alternative treatments, pharmacological and others, some of them under investigation, some unproven and many disproven. So I was not surprised to find a study about Ginkgo biloba as a treatment for ADHD. I was surprised, however, to find this study in the German Journal of Child and Adolescent Psychiatry and Psychotherapy, officially published by the “German Society of Child and Adolescent Psychiatry and Psychotherapy“ (Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie und Psychotherapie). The journal’s guidelines state that studies should provide new scientific results.

The study is called “Ginkgo biloba Extract EGb 761® in Children with ADHD“. EGb 761® is the key ingredient in “Tebonin®“, a herbal drug made by “Dr. Wilma Schwabe GmbH“. The abstract states:

One possible treatment, at least for cognitive problems, might be the administration of Ginkgo biloba, though evidence is rare.This study tests the clinical efficacy of a Ginkgo biloba special extract (EGb 761®) (…) in children with ADHD (…).

Eine erfolgversprechende, bislang kaum untersuchte Möglichkeit zur Behandlung kognitiver Aspekte ist die Gabe von Ginkgo biloba. Ziel der vorliegenden Studie war die Prüfung klinischer Wirksamkeit (…) von Ginkgo biloba-Extrakt Egb 761® bei Kindern mit ADHS.“ (Taken from the English and German abstracts.)

The study sample (20!) was recruited among children who “did not tolerate or were unwilling“ to take MPH. The unwilling part struck me as problematic. There is likely a strong selection bias towards parents who are unwilling to give their children MPH. I guess it is not the children who are unwilling to take MPH, but the parents who are unwilling to administer it. At least some of these parents might be biased against MPH and might already favor CAMmodalities.

The authors state three main problems with “herbal therapy“ that require more empirical evidence: First of all the question of adverse reactions, which they claim occur in about 1% of cases with “some CAMs“ (mind you, not “herbal therapy“). Secondly, the question of drug interactions and thirdly, the lack of information physicians have about the CAMs their patients use.

A large part of the study is based on results of an EEG-protocol, which I choose to ignore, because the clinical results are too weak to give the EEG findings any clinical relevance.

Before looking at the study itself, let’s look at what is known about Ginkgo biloba as a drug. Ginkgo is best known for its use in patients with dementia, cognitive impairment und tinnitus. A Cochrane review from 2009 concluded:

There is no convincing evidence that Ginkgo biloba is efficacious for dementia and cognitive impairment“ [1].

The authors of the current Study cite Sarris et al. (2011), a systematic review of complementary treatment of ADHD. Sarris et al. mention Salehi et al. (2010) who tested Ginkgo against MPH. MPH turned out to be much more effective than Ginkgo, but Sarris et al. argue that the duration of treatment (6 weeks) might have been too short to see the full effects of Ginkgo.

Given the above information it is unclear why Ginkgo is judged a “possible“ treatment, properly translated from German even “promising”, and why the authors state that Ginkgo has been “barely studied“.

In an unblinded, uncontrolled study with a sample likely to be biased toward the tested intervention, anything other than a positive result would be odd. In the treatment of autism there are several examples of implausible treatments that worked as long as parents knew that their children were getting the treatment, but didn’t after proper blinding (e.g. secretin).

This study’s aim was to test clinical efficacy, but the conclusion begins with how well tolerated Ginkgo was. The efficacy is mentioned subsequently: “Following administration, interrelated improvements on behavioral ratings of ADHD symptoms (…) were detected (…).“ But the way they where “detected“ is interesting. The authors used an established questionnaire (FBB-HKS) to let parents rate their children. Only the parents. The children and their teachers where not given the FBB-HKS-questionnaires, inspite of this being standard clinical practice (and inspite of giving children questionnaires to determine changes in quality of life, which were not found).

None of the three problems that the authors describe as important (adverse reactions, drug interactions, lack of information) can be answered by this study. I am no expert in statistics but it seems unlikely to me to meaningfully determine adverse effects in just 20 patients especially when adverse effects occur at a rate of 1%. The authors claim they found an incidence rate of 0,004% in “700 observation days“. Well, if they say so.

The authors conclude:

Taken together, the current study provides some preliminary evidence that Ginkgo biloba Egb 761® seems to be well tolerated in the short term and may be a clinically useful treatment for children with ADHD. Double-blind randomized trials are required to clarify the value of the presented data.

Given the available information mentioned earlier, one could have started with that conclusion and conducted a double blind RCT in the first place!

Clinical Significance

The trends of this preliminary open study may suggest that Ginkgo biloba Egb 761® might be considered as a complementary or alternative medicine for treating children with ADHD.“

So, why do I care? If preliminary evidence “may suggest“ that something “might be considered“ as a treatment? Because I think that this study does not answer any important questions or give us any new or useful knowledge. Following the journal’s guidelines, it should therefore not have been published. I also think it is an example of bad science. Bad not just because of the lack of critical thinking. It also adds to the misinformation about possible ADHD treatments spreading through the internet. The study was published in September. In November I found a website citing the study and calling it “clinical proof“ when it is not. But child psychiatrists will have to explain that to many parents, instead of talking about their children’s health.

I somehow got the impression that this study was more about marketing than about science. I wonder if Schwabe will help finance the necessary double-blind randomized trial…

[1] See more at: http://summaries.cochrane.org/CD003120/DEMENTIA_there-is-no-convincing-evidence-that-ginkgo-biloba-is-efficacious-for-dementia-and-cognitive-impairment#sthash.oqKFrSCC.dpuf

The chiropractic profession have been reminded time and times again that their claim to be able to effectively treat paediatric conditions is bogus. Many experts have asked them to produce some compelling evidence or stop this dangerous nonsense. Yet most of them seem to remain in denial, famously documented by the British Chiropractic Association suing Simon Singh for libel after he disclosed that they happily promote bogus treatments.

Some chiropractors now say that things have changed and that chiropractors are finally getting their act together. If that is true, progress must be painfully slow – so slow, in fact, that it is hard to see it at all. There are still far too many chiropractors who carry on just as before. There are hundreds, if not thousands of articles promoting chiropractic for childhood conditions; a very basic Google search for ‘chiropractic for children’ returns more than 7 million hits many of which advertise this sort of approach. Take this website, for instance; it makes its bogus claims entirely unabashed:

Even as an infant your child may have spinal nerve stress, known as subluxations. Although subluxations may not be painful, they can pose serious threats to your child’s development. If your baby was in a difficult position in the womb, or experienced a traumatic birth they may have developed subluxations. A common condition attributed to subluxations in children is known as Blocked Atlantal Nerve Syndrome. This condition may be the primary cause of ear and upper respiratory infections, and chronic tonsillitis.

Even regular childhood activities such as tumbles taken while learning to walk and run, bike riding, and participation in sports can also cause stress on your child’s body. Emotional stress and trauma may also be a cause of subluxations. Unless they are corrected they can affect future nerve function and the development of your child’s nervous system. They can also cause problems as your child grows and develops into adulthood.

With regular chiropractic care your child may be at less risk for common childhood disease such as colds and fevers. Some children show a marked improvement in asthma symptoms with regular chiropractic care and nutritional counselling. While chiropractors do no treat disease or sickness, they can identify and remove subluxations which interfere with your child’s natural ability to heal. By removing this stress from your child’s spinal system their immune system may function more efficiently and your child may have a better defense to disease. Their overall health may improve as their natural healing power is released. Children who receive regular chiropractic care may also be able to handle emotional and physical stress better and this care may contribute to their natural development.

Your child is never too young to start chiropractic care. Well-child care starts are early as the first month of life. Doctors use a very gentle pressure to treat children (no more pressure than picking up a tomato in the grocery store) and their treatments are very soothing to your child. After their first visit it is recommended that they receive treatments every three months up to age three, and then every six to 12 month after that. You may also want to visit your chiropractor after major milestones in your child’s life such as learning to sit up, crawl, and walk. They should also be seen if they experience any falls or trauma, and if you notice any balance issues they may be experiencing. These may include head tilting and limping.

Pediatric chiropractic care has many benefits. Children as young as infants may see an improvement in their development and overall health with regular care. Doctors of chiropractic take a proactive approach to health by striving to return and maintain your body’s natural balance. If you are looking for an alternative or supplement to traditional medical care, look into chiropractic care for your entire family.

Just a few rotten apples!… the apologists would probably say. But this is clearly not true. I find it even hard to locate the non-rotten apples in this decomposing and disgusting mess. More importantly, if it were true that things were now changing, one would expect that the progressive sections of the chiropractic profession protest regularly, sharply and effectively to shame the many charlatans amongst their midst. Crucially, one would expect the chiropractic professional organisations  to oust their bogus members systematically and swiftly.

The sad truth, however, is that none of this is really happening – certainly not in the US or the UK. On the contrary, organisations like THE INTERNATIONAL PEDIATRIC ASSOCIATION, books entitled CHIROPRACTIC PEDIATRICS, and periodicals like the JOURNAL OF PEDIATRIC, MATERNAL AND FAMILY CHIROPRACTIC remain popular and respected within the chiropractic profession. A few lip-services here and there, yes. But truly effective action? No!

The tolerance of quackery, I would argue, must be one of the most important hallmarks of a quack profession.

Acute tonsillitis (AT) is an upper respiratory tract infection which is prevalent, particularly in children. The cause is usually a viral or, less commonly, a bacterial infection. Treatment is symptomatic and usually consists of ample fluid intake and pain-killers; antibiotics are rarely indicated, even if the infection is bacterial by nature. The condition is self-limiting and symptoms subside normally after one week.

Homeopaths believe that their remedies are effective for AT – but is there any evidence? A recent trial seems to suggest there is.

It aimed, according to its authors, to determine the efficacy of a homeopathic complex on the symptoms of acute viral tonsillitis in African children in South Africa.

The double-blind, placebo-controlled RCT was a 6-day “pilot study” and included 30 children aged 6 to 12 years, with acute viral tonsillitis. Participants took two tablets 4 times per day. The treatment group received lactose tablets medicated with the homeopathic complex (Atropa belladonna D4, Calcarea phosphoricum D4, Hepar sulphuris D4, Kalium bichromat D4, Kalium muriaticum D4, Mercurius protoiodid D10, and Mercurius biniodid D10). The placebo consisted of the unmedicated vehicle only. The Wong-Baker FACES Pain Rating Scale was used for measuring pain intensity, and a Symptom Grading Scale assessed changes in tonsillitis signs and symptoms.

The results showed that the treatment group had a statistically significant improvement in the following symptoms compared with the placebo group: pain associated with tonsillitis, pain on swallowing, erythema and inflammation of the pharynx, and tonsil size.

The authors drew the following conclusions: the homeopathic complex used in this study exhibited significant anti-inflammatory and pain-relieving qualities in children with acute viral tonsillitis. No patients reported any adverse effects. These preliminary findings are promising; however, the sample size was small and therefore a definitive conclusion cannot be reached. A larger, more inclusive research study should be undertaken to verify the findings of this study.

Personally, I agree only with the latter part of the conclusion and very much doubt that this study was able to “determine the efficacy” of the homeopathic product used. The authors themselves call their trial a “pilot study”. Such projects are not meant to determine efficacy but are usually designed to determine the feasibility of a trial design in order to subsequently mount a definitive efficacy study.

Moreover, I have considerable doubts about the impartiality of the authors. Their affiliation is “Department of Homoeopathy, University of Johannesburg, Johannesburg, South Africa”, and their article was published in a journal known to be biased in favour of homeopathy. These circumstances in itself might not be all that important, but what makes me more than a little suspicious is this sentence from the introduction of their abstract:

“Homeopathic remedies are a useful alternative to conventional medications in acute uncomplicated upper respiratory tract infections in children, offering earlier symptom resolution, cost-effectiveness, and fewer adverse effects.”

A useful alternative to conventional medications (there are no conventional drugs) for earlier symptom resolution?

If it is true that the usefulness of homeopathic remedies has been established, why conduct the study?

If the authors were so convinced of this notion (for which there is, of course, no good evidence) how can we assume they were not biased in conducting this study?

I think that, in order to agree that a homeopathic remedy generates effects that differ from those of placebo, we need a proper (not a pilot) study, published in a journal of high standing by unbiased scientists.

My 2008 evaluation of chiropractic concluded that the concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt. It also pointed out that the advice of chiropractors often is dangerous and not in the best interest of the patient: many chiropractors have a very disturbed attitude towards immunisation: anti-vaccination attitudes till abound within the chiropractic profession. Despite a growing body of evidence about the safety and efficacy of vaccination, many chiropractors do not believe in vaccination, will not recommend it to their patients, and place emphasis on risk rather than benefit.

In case you wonder where this odd behaviour comes from, you best look into the history of chiropractic. D. D. Palmer, the magnetic healer who ‘invented’ chiropractic about 120 years ago, left no doubt about his profound disgust for immunisation: “It is the very height of absurdity to strive to ‘protect’ any person from smallpox and other malady by inoculating them with a filthy animal poison… No one will ever pollute the blood of any member of my family unless he cares to walk over my dead body… ” (D. D. Palmer, 1910)

D. D. Palmer’s son, B. J. Palmer (after literally walking [actually it was driving] over his father’s body)  provided a much more detailed explanation for chiropractors’ rejection of immunisation: “Chiropractors have found in every disease that is supposed to be contagious, a cause in the spine. In the spinal column we will find a subluxation that corresponds to every type of disease… If we had one hundred cases of small-pox, I can prove to you, in one, you will find a subluxation and you will find the same condition in the other ninety-nine. I adjust one and return his function to normal… There is no contagious disease… There is no infection…The idea of poisoning healthy people with vaccine virus… is irrational. People make a great ado if exposed to a contagious disease, but they submit to being inoculated with rotten pus, which if it takes, is warranted to give them a disease” (B. J. Palmer, 1909)

Such sentiments and opinions are still prevalent in the chiropractic profession – but today they are expressed in a far less abrupt, more politically correct language: The International Chiropractors Association recognizes that the use of vaccines is not without risk. The ICA supports each individual’s right to select his or her own health care and to be made aware of the possible adverse effects of vaccines upon a human body. In accordance with such principles and based upon the individual’s right to freedom of choice, the ICA is opposed to compulsory programs which infringe upon such rights. The International Chiropractors Association is supportive of a conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health.

Not all chiropractors share such opinions. The chiropractic profession is currently divided over the issue of immunisation. Some chiropractors now realise that immunisations have been one of the most successful interventions ever for public health. Many others, however, do still vehemently adhere to the gospel of the Palmers.  Statements like the following abound:

Vaccines. What are we taught? That vaccines came on the scene just in time to save civilization from the ravages of infectious diseases. That vaccines are scientifically formulated to confer immunity to certain diseases; that they are safe and effective. That if we stop vaccinating, epidemics will return…And then one day you’ll be shocked to discover that … your “medical” point of view is unscientific, according to many of the world’s top researchers and scientists. That many state and national legislatures all over the world are now passing laws to exclude compulsory vaccines….

Our original blood was good enough. What a thing to say about one of the most sublime substances in the universe. Our original professional philosophy was also good enough. What a thing to say about the most evolved healing concept since we crawled out of the ocean. Perhaps we can arrive at a position of profound gratitude if we could finally appreciate the identity, the oneness, the nobility of an uncontaminated unrestricted nervous system and an inviolate bloodstream. In such a place, is not the chiropractic position on vaccines self-evident, crystal clear, and as plain as the sun in the sky?

Yes, I do agree: the position of far too many chiropractors is ‘crystal clear’ – unfortunately it is also dangerously wrong.

The question whether infant colic can be effectively treated with manipulative therapies might seem rather trivial – after all, this is a benign condition which the infant quickly grows out of. However, the issue becomes a little more tricky, if we consider that it was one of the 6 paediatric illnesses which were at the centre of the famous libel case of the BCA against my friend and co-author Simon Singh. At the time, Simon had claimed that there was ‘not a jot of evidence’ for claiming that chiropractic was an effective treatment of infant colic, and my systematic review of the evidence strongly supported his statement. The BCA eventually lost their libel case and with it the reputation of chiropractic. Now a new article on this intriguing topic has become available; do we have to reverse our judgements?

The aim of this new systematic review was to evaluate the efficacy or effectiveness of manipulative therapies for infantile colic. Six RCTs of chiropractic, osteopathy or cranial osteopathy alone or in conjunction with other interventions were included with a total of 325 infants. Of the 6 included studies, 5 were “suggestive of a beneficial effect” and one found no evidence of benefit. Combining all the RCTs suggested that manipulative therapies had a significant effect. The average crying time was reduced by an average of 72 minutes per day. This effect was sustained for studies with a low risk of selection bias and attrition bias. When analysing only those studies with a low risk of performance bias (i.e. parental blinding) the improvement in daily crying hours was no longer statistically significant.

The quality of the studies was variable. There was a generally low risk of selection bias but a high risk of performance bias. Only one of the studies recorded adverse events and none were encountered.

From these data, the authors drew the following conclusion: Parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not and this difference was statistically significant. Most studies had a high risk of performance bias due to the fact that the assessors (parents) were not blind to who had received the intervention. When combining only those trials with a low risk of such performance bias the results did not reach statistical significance.

Does that mean that chiropractic does work for infant colic? No, it does not!

The first thing to point out is that the new systematic review included not just RCTs of chiropractic but also osteopathy and cranio-sacral therapy.

The second important issue is that the effects disappear, once performance bias is being accounted for which clearly shows that the result is false positive.

The third relevant fact is that the majority of the RCTs were of poor quality. The methodologically best studies were negative.

And the fourth thing to note is that only one study mentioned adverse effects, which means that the other 5 trials were in breach of one of rather elementary research ethics.

What makes all of this even more fascinating is the fact that the senior author of the new publication, George Lewith, is the very expert who advised the BCA in their libel case against Simon Singh. He seems so fond of his work that he even decided to re-publish it using even more misleading language than before. It is, of course, far from me to suggest that his review was an attempt to white-wash the issue of chiropractic ‘bogus’ claims. However, based on the available evidence, I would have formulated conclusions which are more than just a little different from his; something like this perhaps:

The current best evidence suggests that the small effects that emerge when we pool the data from mostly unreliable studies are due to bias and therefore not real. This systematic review therefore fails to show that manipulative therapies are effective. It furthermore points to a serious breach of research ethics by the majority of researchers in this field.

The fact that practitioners of alternative medicine frequently advise their patients against immunising their children has been documented repeatedly. In particular, doctors of anthroposophy, chiropractors and homeopaths are implicated in thus endangering public health. Less is known about naturopaths attitude in this respect. Now new data have emerged which confirm some of our worst fears.

This survey aimed at assessing the attitudes, education, and sources of knowledge surrounding childhood vaccinations of 560 students at National College of Natural Medicine in Portland, US. Students were asked about demographics, sources of information about childhood vaccines, differences between mainstream and CAM education on childhood vaccines, alternative vaccine schedules, adverse effects, perceived efficacy, and credibility of information sources.

A total of 109 students provided responses (19.4% response rate). All students surveyed learned about vaccinations in multiple courses and through independent study. The information sources employed had varying levels of credibility. Only 26% of the responding students planned on regularly prescribing or recommending vaccinations for their patients; 82% supported the general concept of vaccinations for prevention of infectious diseases.

The vast majority (96%) of those who might recommend vaccinations reported that they would only recommend a schedule that differed from the standard CDC-ACIP schedule.

Many respondents were concerned about vaccines being given too early (73%), too many vaccines administered simultaneously (70%), too many vaccines overall (59%), and about preservatives and adjuvants in vaccines (72%). About 40% believed that a healthy diet and lifestyle was more important for prevention of infectious diseases than vaccines. 90% admitted that they were more critical of vaccines than mainstream pediatricians, medical doctors, and medical students.

These results speak for themselves and leave me (almost) speechless. The response rate was truly dismal, and it is fair to assume that the non-responding students held even more offensive views on vaccination than their responding colleagues. The findings seem to indicate that naturopaths are systematically trained to become anti-vaxers who believe that their naturopathic treatments offer better protection than vaccines. They are thus depriving many of their patients of arguably the most successful means of disease prevention that exists today. To put it bluntly: naturopaths seem to be brain-washed into becoming a danger to public health.

There is much debate about the usefulness of chiropractic. Specifically, many people doubt that their chiropractic spinal manipulations generate more good than harm, particularly for conditions which are not related to the spine. But do chiropractors treat such conditions frequently and, if yes, what techniques do they employ?

This investigation was aimed at describing the clinical practices of chiropractors in Victoria, Australia. It was a cross-sectional survey of 180 chiropractors in active clinical practice in Victoria who had been randomly selected from the list of 1298 chiropractors registered on Chiropractors Registration Board of Victoria. Twenty-four chiropractors were ineligible, 72 agreed to participate, and 52 completed the study.

Each participating chiropractor documented encounters with up to 100 consecutive patients. For each chiropractor-patient encounter, information collected included patient health profile, patient reasons for encounter, problems and diagnoses, and chiropractic care.

Data were collected on 4464 chiropractor-patient encounters between 11 December 2010 and 28 September 2012. In most (71%) cases, patients were aged 25-64 years; 1% of encounters were with infants. Musculoskeletal reasons for the consultation were described by patients at a rate of 60 per 100 encounters, while maintenance and wellness or check-up reasons were described at a rate of 39 per 100 encounters. Back problems were managed at a rate of 62 per 100 encounters.

The most frequent care provided by the chiropractors was spinal manipulative therapy and massage. The table shows the precise conditions treated

Distribution of problems managed (20 most frequent problems), as reported  by chiropractors

Problem group No. (%) of recorded diagnoses* (n = 5985) Rate per 100 encounters (n = 4417) 95% CI ICC
Back problem 2757 (46.07%) 62.42 (55.24–70.53) 0.312
Neck problem 683 (11.41%) 15.46 (11.23–21.30) 0.233
Muscle problem 434 (7.25%) 9.83 (6.64–14.55) 0.207
Health maintenance or preventive care 254 (4.24%) 5.75 (3.24–10.22) 0.251
Back syndrome with radiating pain 215 (3.59%) 4.87 (2.91–8.14) 0.165
Musculoskeletal symptom or complaint, or other 219 (3.66%) 4.96 (2.39–10.28) 0.350
Headache 179 (2.99%) 4.05 (2.87–5.71) 0.053
Sprain or strain of joint 167 (2.79%) 3.78 (2.30–6.22) 0.115
Shoulder problem 87 (1.45%) 1.97 (1.37–2.83) 0.022
Nerve-related problem 62 (1.04%) 1.40 (0.72–2.75) 0.072
General symptom or complaint, other 51 (0.85%) 1.15 (0.22–6.06) 0.407
Bursitis, tendinitis or synovitis 47 (0.79%) 1.06 (0.71–1.60) 0.011
Kyphosis and scoliosis 47 (0.79%) 1.06 (0.65–1.75) 0.023
Foot or toe symptom or complaint 48 (0.80%) 1.09 (0.41–2.87) 0.123
Ankle problem 46 (0.77%) 1.04 (0.40–2.69) 0.112
Osteoarthrosis, other (not spine) 39 (0.65%) 0.88 (0.51–1.53) 0.023
Hip symptom or complaint 35 (0.58%) 0.79 (0.53–1.19) 0.006
Leg or thigh symptom or complaint 35 (0.58%) 0.79 (0.49–1.28) 0.012
Musculoskeletal injury 33 (0.55%) 0.75 (0.45–1.24) 0.013
Depression 29 (0.48%) 0.66 (0.10–4.23) 0.288

These findings are impressive in that they suggest that most Australian chiropractors treat non-spinal conditions for which there is no evidence that the most frequently used interventions are effective. The treatments employed are depicted in this graph:
Distribution of techniques and care provided by chiropractors, with 95% CI


[Activator = hand-held spring-loaded device that delivers an impulse to the spine. Drop piece = chiropractic treatment table with a segmented drop system which quickly lowers the section of the patient’s body corresponding with the spinal region being treated. Blocks = wedge-shaped blocks placed under the pelvis.

Chiro system = chiropractic system of care, eg, Applied Kinesiology, Sacro-Occipital Technique, Neuroemotional Technique. Flexion distraction = chiropractic treatment table that flexes in the middle to provide traction and mobilisation to the lumbar spine.]

There is no good evidence I know of demonstrating these techniques to be effective for the majority of the conditions listed in the above table.

A similar bone of contention is the frequent use of ‘maintenance’ and ‘wellness’ care. The authors of the article comment: The common use of maintenance and wellness-related terms reflects current debate in the chiropractic profession. “Chiropractic wellness care” is considered by an indeterminate proportion of the profession as an integral part of chiropractic practice, with the belief that regular chiropractic care may have value in maintaining and promoting health, as well as preventing disease. The definition of wellness chiropractic care is controversial, with some chiropractors promoting only spine care as a form of wellness, and others promoting evidence-based health promotion, eg, smoking cessation and weight reduction, alongside spine care. A 2011 consensus process in the chiropractic profession in the United States emphasised that wellness practice must include health promotion and education, and active strategies to foster positive changes in health behaviours. My own systematic review of regular chiropractic care, however, shows that the claimed effects are totally unproven.

One does not need to be overly critical to conclude from all this that the chiropractors surveyed in this investigation earn their daily bread mostly by being economical with the truth regarding the lack of evidence for their actions.

Even relatively well-informed people tend to think that homeopathy might be quirky and useless but, so what, it cannot do any harm. This is perhaps true for the homeopathic remedies but it does certainly not apply to the homeopaths. As soon as there is a public health problem, homeopaths claim that their approach offers a solution – never mind the evidence to the contrary. Just look at what they presently try to sell us in terms of cold and flu treatments!

The often criminal fight of homeopaths against public health is nowhere clearer than with their never-ending propaganda against the most successful public health measure in the history of medicine, immunisation. Some professional organisations of homeopathy have issued politically correct statements about this and thus feel they are out of the firing line. But, as far as I can see, most homeopaths are against vaccinations. Their arguments are wilfully misguided; here are just a few examples:

  • It is well known that measles is an important development milestone in the life and maturing processes in children.  Why would anybody want to stop or delay the maturation processes of children and of their immune systems?
  • Homoeopathy offers an option for disease prevention and cure.  There is scientific evidence in favour of homoeopathy for prevention of diseases.
  • Seek out homeopathic, osteopathic, naturopathic, or Chinese medical constitutional treatment to boost your child’s immune system and help them be as healthy as they can be.
  • If your children do get sick, use homeopathy to help their immune system get over it. Homeopathy is very effective in epidemics of acute illness. Either see a homeopath, buy a book on homeopathic acute care, or take a class on acute homeopathic prescribing.
  • It is possible to prevent post-vaccination damage by giving the homeopathic dilution of the vaccine shortly before and    after the vaccination in the C200 dilution.
  • there are many recorded cases of people making dramatic  recoveries with homeopathic medicines following a bad reaction to a  vaccination. Expert advice from a registered homeopath is usually  required.
  • As you would keep your children away from toxic chemicals in the environment as much as possible, inform yourself about the toxicity of the solutions that are being injected into their bloodstream. It’s up to you to find the information: no one loves your children the way you do.

If you think I cherry-picked these quotes, you are mistaken. I simply used the citations as they appeared on my computer screen after a simple Google search. You might try this yourself because there are hundreds, if not thousands more to be discovered.

A typical and interesting example of a homeopathic anti-vaccinationist is Oksana Frolov, D.Hom. graduate of Saint Petersburg, Russia, I.P.Pavlov State Medical University, General Medicine, and graduate of Los Angeles School of Homeopathy. She states that, although I do hold a medical degree, I am not a licensed medical health provider in the United States. As a homeopathic practitioner, I will provide you with the treatment which is alternative or complementary to healing arts that are licensed by the State of California. On her blog, she provides detailed advice for people who might be uncertain whether to vaccinate their children: immunisation… can cause some very serious side effects including permanent brain damage, epilepsy, autism, and mental retardation. With so many vaccinations being required, doctors often have to administer several shots at a time, which can often result in a disaster.  Vaccines, along with the elements that are supposed to create the antibodies, also contain mercury, aluminum, formaldehyde, animal tissue, animal blood, human cell from aborted babies, potatoes, yeast, lactose, phenol, antibiotics and unrelated species of germs that inadvertently get into the vaccines. Do you really want all this to be injected into your child just to prevent him or her from having a chicken pox? Vaccines are said to work by stimulating the body to produce antibodies, which are supposed to protect us from an invasion of harmful germs. Childhood diseases, such as measles, mumps, rubella and chicken pox, affect the immune system in a way that makes most people immune to them for the rest of their lives. Vaccinations, on the other hand, create an artificial immunity that wears off and allows the person to catch the disease later in life….

Homeopathy has proved to be very effective in treatment of childhood diseases, as well as other infections. From its earliest days, homeopathy has been able to treat epidemic disease, such as cholera, typhus, yellow fever, and diphtheria, with a substantial rate of success, when compared to conventional treatments. 

Doctors who practice homeopathy usually claim that only non-medically qualified homeopaths hold such deranged views. Dr Frolov shows us that this assumption is clearly not true. In my experience, most homeopaths, medical or not, advise their patients against immunizations or are at least very cagey about this subject in order to raise doubts in concerned parents. Professional organisations of homeopaths usually hide behind some powerless statement in favour of informed choice; yet they must be well-aware that many of their members fail to abide by it. And what do they do about it? Nothing!

Yes, I am afraid the fight of many homeopaths against public health is active, incessant and often criminal. Of course, they do not for one second believe that they are doing anything wrong; on the contrary, they are convinced of their good intentions. As Bert Brecht once wrote, THE OPPOSITE OF GOOD IS NOT EVIL, BUT GOOD INTENTIONS.

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