conflict of interest
D D Palmer was born on March 7, 1845; so, why do chiros celebrate the ‘CHIROPRACTIC AWARENESS WEEK’ from 10 – 16 of April? Perhaps out of sympathy with the homeopaths (many US chiros also use homeopathy) who had their ‘big week’ during the same period? Please tell me, I want to know!
Anyway, the HAW almost ‘drowned’ the CAW – but only almost.
The British Chiropractic Association did its best to make sure we don’t forget the CAW. On their website, we find an article that alerts us to their newest bit of research. Here are some excerpts:
The consumer survey by the British Chiropractic Association (BCA) of more than 2,000 UK adults who currently suffer from back or neck pain, or have done so in the past, found that almost three in five (56%) people experienced pain after using some form of technological device. Despite this, only 27% of people surveyed had limited or stopped using their devices due to concerns for their back or neck health and posture. The research showed people were most likely to experience back or neck pain after using the following technological devices:
• Laptop computer (35%)
• Desktop computer (35%)
• Smart phone (22%)
• Tablet (20%)
• Games console (17%)
The age group most likely to experience back or neck pain when using their smart phone were 16-24 year olds, while nearly half (45%) of young adults 25-34 year olds) admitted to experiencing back or neck pain after using a laptop. One in seven (14%) 16-24 year olds attributed their back or neck pain to virtual reality headsets.
As part of Chiropractic Awareness Week (10-16 April) the BCA is calling for technology companies to design devices with posture in mind, to help tech proof our back health. BCA chiropractor Rishi Loatey comments: “We all know how easy it is to remain glued to our smart phone or tablet, messaging friends or scrolling through social media. However, this addiction to technology could be causing changes to posture, which can lead to increased pressure on the muscles, joints and discs in the spine. Technology companies are now starting to issue older phone models which hark back to a time before smart phones enabled people to do everything from check emails and take pictures, to internet banking. Returning to a time of basic functionality, which may see people look to limit the time spent on their phone, can only be good news for our backs. Yet, in an age where people can now track their health and wellbeing using their phone, technology companies should also start looking at ways to make their devices posture friendly from the outset, encouraging us to take time away from our desks and breaks from our scrolling, gaming and messaging.”
END OF QUOTE
So, here we have it: another piece of compelling, cutting edge research by the BCA. They have made us giggle before but rarely have I laughed so heartily about a ‘professional’ organisation confusing so unprofessionally correlation with causation.
Considering the amount of highly public blunders they managed to inflict on the profession in recent years, I have come to the conclusion that the BCA is a cover organisation of BIG PHARMA with the aim of giving chiropractic a bad name!
‘What Doctors Don’t Tell You’ (WDDTY) have been shown to be strangely economical with the truth many times before (for instance here, here and here). Now they have published an article entitled ‘Ombudsman investigates ‘flawed’ homeopathic study that claimed it doesn’t work’ It attacks in no uncertain terms the ‘NHMRC Statement on Homeopathy and NHMRC Information Paper – Evidence on the effectiveness of homeopathy for treating health conditions’ which I believe to be a sound evaluation of homeopathy and therefore have mentioned repeatedly on this blog. Here is what WDDTY stated:
START OF QUOTE
A major and influential review of homeopathy concluded that the controversial therapy doesn’t work—but it was so riddled with error and bad science that it’s sparked an official ombudsman investigation.
The world’s media announced that homeopathy was a scam after the Australia government’s National Health and Medical Research Council (NHMRC) published its findings in 2015 that “there are no health conditions for which there is reliable evidence that homeopathy is effective.”
But now the Commonwealth Ombudsman is investigating the review’s procedures after receiving reports of inaccuracies, mishandling of evidence and conflicts of interest.
The review has been triggered by the Australian Homeopathic Association (AHA), supported by the Homeopathic Research Institute (HRI), which began questioning the review’s processes after several solid studies that demonstrated homeopathy’s benefits had been overlooked.
The NHMRC review team set arbitrary parameters that only studies that involved more than 150 people—and which met standards that even drug trials rarely achieve—would be considered. Those requirements reduced the number of qualifying studies to just five—from an initial pool of more than 1,800 trials—and none of these showed that homeopathy was effective.
One of the NHMRC’s own reviewers produced a mysterious first report that has never been published, and hasn’t been released despite Freedom of Information requests.
And the AHA has discovered that Prof Peter Brooks, chair of the NHMRC committee that carried out the homeopathy review, never declared that he was a member of the anti-homeopathy lobby group, Friends of Science in Medicine.
There are solid studies that demonstrate homeopathy is effective against childhood diarrhea, sinusitis and hay fever—but they all involve fewer than 150 people, said HRI chief executive Rachel Roberts. “The public has a right to know that there are high quality studies showing homeopathy works for some medical conditions—information that was lost only due to NHMRC’s mishandling of the evidence.”
The homeopaths aren’t alone in challenging the NHMRC review: Australia’s independent Cochrane Centre said its conclusions are not an accurate reflection of the evidence, and a second expert also said he felt “uncertain of the definitive nature of the report’s conclusions.”
END OF QUOTE
As it happens, I am in contact with the lead author of this report, Paul Glasziou, not least because he very kindly wrote the foreword for my book HOMEOPATHY, THE UNDILUTED FACTS. So, we corresponded and discussed the latest WDDTY diatribe. Thus I am now in a position to put a few things straight (I hope Paul does not mind).
ISSUE 1. – The NHMRC review team set arbitrary parameters that only studies involving more than 150 people—and which met standards that even drug trials rarely achieve—would be considered.
The truth is that report focused on systematic reviews of trials, not individual trials. The 57 included systematic reviews found 176 individual trials which covered 61 conditions: an average of about 3 trials per condition. But some conditions only had 1 trial, and one small trial would, of course, not be considered a reasonable basis for reliable conclusions. GRADE – the international standard for assessing evidence – downgrades reviews for “imprecision” – the GRADE Handbook suggests “whenever there are sample sizes that are less than 400, review authors and guideline developers should certainly consider rating down for imprecision.” Hence the criterion of 150 which the Australians decided to use is considerably more lenient than the current GRADE guideline.
ISSUE 2 – Those requirements reduced the number of qualifying studies to just five—from an initial pool of more than 1,800 trials—and none of these showed that homeopathy was effective.
This is simply not correct. The report found 57 systematic reviews that contained 176 individual trials, not 5. These 176 trials, which covered 61 conditions, formed the body of evidence for the NHMRC report’s conclusions.
ISSUE 3 – There are solid studies that demonstrate homeopathy is effective against childhood diarrhoea, sinusitis and hay fever—but they all involve fewer than 150 people, said HRI chief executive Rachel Roberts.
The NHMRC report focused on systematic reviews that covered all trials for individual conditions. Given the conventional p-value of 0.05, one would expect 1 in 20 single trials to be “false positives”. So with 176 trials, we expect about 9 “false positive” trials. But using systematic reviews that combine all trials for individual conditions, reduces this risk of false positives. Most national evidence review bodies require more than 1 trial, e.g, the FDA requires 2 positive trials, whereas many others require a systematic review which has at least 2 trials. Replication of findings is obviously a cornerstone of science.
ISSUE 4 The homeopaths aren’t alone in challenging the NHMRC review: Australia’s independent Cochrane Centre said its conclusions are not an accurate reflection of the evidence, and a second expert also said he felt “uncertain of the definitive nature of the report’s conclusions.”
The truth is that the Cochrane Centre, which provided an independent check during the processes of the NHMRC review, concluded that “Overall, the conclusions arising from the review appear justified based on the evidence presented.”
I REST MY CASE.
This new systematic review by proponents of homeopathy (and supported by a grant from the Manchester Homeopathic Clinic) tested the null hypothesis that “the main outcome of treatment using a non-individualised (standardised) homeopathic medicine is indistinguishable from that of placebo“. An additional aim was to quantify any condition-specific effects of non-individualised homeopathic treatment. In reporting this paper, I will stay very close to the published text hoping that this avoids both misunderstandings and accusations of bias on my side:
Literature search strategy, data extraction and statistical analysis followed the methods described in a pre-published protocol. A trial comprised ‘reliable evidence’ if its risk of bias was low or it was unclear in one specified domain of assessment. ‘Effect size’ was reported as standardised mean difference (SMD), with arithmetic transformation for dichotomous data carried out as required; a negative SMD indicated an effect favouring homeopathy.
The authors excluded the following types of trials: studies of crossover design; of radionically prepared homeopathic medicines; of homeopathic prophylaxis; of homeopathy combined with other (complementary or conventional) intervention; for other specified reasons. The final explicit exclusion criterion was that there was obviously no blinding of participants and practitioners to the assigned intervention.
Forty-eight different clinical conditions were represented in 75 eligible RCTs; 49 were classed as ‘high risk of bias’ and 23 as ‘uncertain risk of bias’; the remaining three trials displayed sufficiently low risk of bias to be designated reliable evidence. Fifty-four trials had extractable data: pooled SMD was -0.33 (95% confidence interval (CI) -0.44, -0.21), which was attenuated to -0.16 (95% CI -0.31, -0.02) after adjustment for publication bias. The three trials with reliable evidence yielded a non-significant pooled SMD: -0.18 (95% CI -0.46, 0.09). There was no single clinical condition for which meta-analysis produced reliable evidence.
A meta-regression was performed to test specifically for within-group differences for each sub-group. The results showed that there were no significant differences between studies that were and were not:
- included in previous meta-analyses (p = 0.447);
- pilot studies (p = 0.316);
- greater than the median sample (p = 0.298);
- potency ≥ 12C (p = 0.221);
- imputed for meta-analysis (p = 0.384);
- free from vested interest (p = 0.391);
- acute/chronic (p = 0.796);
- different types of homeopathy (p = 0.217).
After removal of ‘C’-rated trials, the pooled SMD still favoured homeopathy for all sub-groups, but was statistically non-significant for 10 of the 18 (included in previous meta-analysis; pilot study; sample size > median; potency ≥12C; data imputed; free of vested interest; not free of vested interest; combination medicine; single medicine; chronic condition). There remained no significant differences between sub-groups—with the exception of the analysis for sample size > median (p = 0.028).
Meta-analyses were possible for eight clinical conditions, each analysis comprising two to 5 trials. A statistically significant pooled SMD, favouring homeopathy, was observed for influenza (N = 2), irritable bowel syndrome (N = 2), and seasonal allergic rhinitis (N = 5). Each of the other five clinical conditions (allergic asthma, arsenic toxicity, infertility due to amenorrhoea, muscle soreness, post-operative pain) showed non-significant findings. Removal of ‘C’-rated trials negated the statistically significant effect for seasonal allergic rhinitis and left the non-significant effect for post-operative pain unchanged; no higher-rated trials were available for additional analysis of arsenic toxicity, infertility due to amenorrhoea or irritable bowel syndrome. There were no ‘C’-rated trials to remove for allergic asthma, influenza, or muscle soreness. Thus, influenza was the only clinical condition for which higher-rated trials indicated a statistically significant effect; neither of its contributing trials, however, comprised reliable evidence.
The authors concluded that the quality of the body of evidence is low. A meta-analysis of all extractable data leads to rejection of our null hypothesis, but analysis of a small sub-group of reliable evidence does not support that rejection. Reliable evidence is lacking in condition-specific meta-analyses, precluding relevant conclusions. Better designed and more rigorous RCTs are needed in order to develop an evidence base that can decisively provide reliable effect estimates of non-individualised homeopathic treatment.
I am sure that this paper will lead to lively discussions in the comments section of this blog. I will therefore restrict my comments to a bare minimum.
In my view, this new meta-analysis essentially yield a negative result and confirms most previous, similar reviews.
- It confirms Linde’s conclusion that “insufficient evidence from these studies that homeopathy is clearly efficacious for any single clinical condition”.
- It confirms Linde’s conclusion that “there was clear evidence that studies with better methodological quality tended to yield less positive results”.
- It confirms Kleinjen’s conclusion that “most trials are of low methodological quality”.
- It also confirms the results of the meta-analysis by Shang et al (much-maligned by homeopaths) than “finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects.”
- Finally, it confirms the conclusion of the analysis of the Australian National Health and Medical Research Council: “Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness. People who are considering whether to use homeopathy should first get advice from a registered health practitioner. Those who use homeopathy should tell their health practitioner and should keep taking any prescribed treatments.”
Another not entirely unimportant point that often gets missed in these discussions is this: even if we believe (which I do not) the most optimistic interpretation of these (and similar data) by homeopaths, we ought to point out that there is no evidence whatsoever that homeopathy cures anything. At the very best it provides marginal symptomatic relief. Yet, the claim of homeopaths that we hear constantly is that homeopathy is a causal and curative therapy.
The first author of the new meta-analysis is an employee of the Homeopathy Research Institute. We might therefore forgive him that he he repeatedly insists on dwelling on largely irrelevant (i. e. based on unreliable primary studies) findings. It seems obvious that firm conclusions can only be based on reliable data. I therefore disregard those analyses and conclusions that include such studies.
In the discussion, the authors of the new meta-analysis confirm my interpretation this by stating that they “reject the null hypothesis (non-individualised homeopathy is indistinguishable from placebo) on the basis of pooling all studies, but fail to reject the null hypothesis on the basis of the reliable evidence only.” And, in the long version of their conclusions, we find this remarkable statement: “Our meta-analysis of the current reliable evidence base therefore fails to reject the null hypothesis that the outcome of treatment using a non-individualised homeopathic medicine is not distinguishable from that using placebo.” A most torturous way of stating the obvious: the more reliable data show no difference between homeopathy and placebo.
As many of you know, my own verdict on homeopathy has changed over time. As a young clinician straight out of medical school, I was taken by homeopathy. Years later, as a researcher, I had to realize that the scientific evidence spoke quite clearly against it (those who are interested should read the full account here). Since then, I have expressed this in several ways. Perhaps the most scientific (based on a sound assessment of the totality of the data) way was here: “…the best clinical evidence for homeopathy available to date does not warrant positive recommendations for its use in clinical practice.” This was 15 years ago, and meanwhile the evidence has become – if anything – more definitively negative.
When I tell this to homeopaths and their followers, they often seem to get annoyed with me and claim that I have an axe to grind, am not objective, am paid by ‘BIG PHARMA’ etc. It is hard or even impossible to persuade them that they are mistaken, and I certainly don’t expect anyone to blindly take my word for anything, not even for my verdict on homeopathy. Therefore, I have tried to collect all the ‘official’ verdicts that I could find. By ‘official’ verdict I mean recent a statement from national or international organisations (rather than from single individuals) with research expertise that:
- are independent,
- employed a thorough assessment of the evidence,
- have a reputation of being beyond reproach,
- and represent scientific consensus.
For obvious reasons, I excluded statements from organisations of (or close to) homeopaths and those with an ideological or commercial interest in homeopathy. It is important to stress that the direction of the verdict (positive or negative) was NOT a selection criterion.
HERE ARE THE VERDICTS I MANAGED TO FIND:
“The principles of homeopathy contradict known chemical, physical and biological laws and persuasive scientific trials proving its effectiveness are not available”
Russian Academy of Sciences, Russia
“Homeopathy should not be used to treat health conditions that are chronic, serious, or could become serious. People who choose homeopathy may put their health at risk if they reject or delay treatments for which there is good evidence for safety and effectiveness.”
National Health and Medical Research Council, Australia
“These products are not supported by scientific evidence.”
Health Canada, Canada
“Homeopathic remedies don’t meet the criteria of evidence based medicine.”
Hungarian Academy of Sciences, Hungary
“The incorporation of anthroposophical and homeopathic products in the Swedish directive on medicinal products would run counter to several of the fundamental principles regarding medicinal products and evidence-based medicine.”
Swedish Academy of Sciences, Sweden
“We recommend parents and caregivers not give homeopathic teething tablets and gels to children and seek advice from their health care professional for safe alternatives.”
Food and Drug Administration, USA
“There is little evidence to support homeopathy as an effective treatment for any specific condition”
National Centre for Complementary and Integrative Health, USA
“There is no good-quality evidence that homeopathy is effective as a treatment for any health condition”
National Health Service, UK
“Homeopathic remedies perform no better than placebos, and that the principles on which homeopathy is based are “scientifically implausible””
House of Commons Science and Technology Committee, UK
I suspect that there are many more statements from similar organisations that I failed to locate. So, if any of my readers know such verdicts, please post them (if possible with a link to the source) in the comments section below. With your help, I might then be able to publish a complete list.
Homeopathic remedies work for animals and therefore they cannot be placebos!!!
This argument is the standard reply of believers in homeopathy (not least of Prince Charles). It shows, I think, two things:
- Believers in homeopathy fail to understand the placebo effect.
- They are ill-informed or lying about the evidence regarding homeopathy in animals.
As we have explained on this blog over and over again: the evidence for homeopathy in animals is very much like that in humans: it fails to show that highly diluted homeopathic remedies are more than placebos (see, for instance here, here and here). Now a further study confirms this fact.
The objective of this triple-blind, randomized controlled trial was to assess the efficacy of homeopathic treatment in bovine clinical mastitis. The study was conducted on a conventionally managed dairy farm between June 2013 and May 2014. Dairy cows with acute mastitis were randomly allocated to homeopathy (n = 70) or placebo (n = 92), for a total of 162 animals. The homeopathic treatment was selected based on clinical symptoms but most commonly consisted of a combination of nosodes with Streptococcinum, Staphylococcinum, Pyrogenium, and Escherichia coli at a potency of 200c. Treatment was administered to cows in the homeopathy group at least once per day for an average of 5 d. The cows in the placebo group were treated similarly, using a placebo preparation instead (lactose globules without active ingredients). If necessary, the researchers also used allopathic drugs (e.g., antibiotics, udder creams, and anti-inflammatory drugs) in both groups. They recorded data relating to the clinical signs of mastitis, treatment, time to recovery, milk yield, somatic cell count at first milk recording after mastitis, and culling. Cows were observed for up to 200 d after clinical recovery. Base-level data did not differ between the homeopathy and placebo groups. Mastitis lasted for an average of 6 d in both groups. No significant differences were noted in time to recovery, somatic cell count, risk of clinical cure within 14 d after disease occurrence, mastitis recurrence risk, or culling risk.
The authors concluded that the results indicated no additional effect of homeopathic treatment compared with placebo.
The question is HOW MUCH MORE EVIDENCE IS NEEDED BEFORE HOMEOPATHS ABANDON THEIR BOGUS CLAIM?
“Millions of people have adverse drug reactions to prescribed medicine; it is ranked as the third leading causes of death. In the US, health-care spending reached $1.6 trillion in 2003. Considering this enormous expenditure, we should have the best medicine in the world. But we don’t. Bottom line, people are suffering. The public is calling out for a reform in mainstream medicine.” These seem to be the conclusions of a new film about homeopathy entitled JUST ONE DROP. It was shown recently for the first time in London, and we already have a fascinating comment about it.
“This professional, eight-year effort attempted to be quite even-handed, while featuring many compelling and documented success stories”, states “The World’s No. 1 Authority on Intention, Spirituality and the New Science”, Lynne Mc Taggart. An ‘even-handed’ effort is worth pursuing, I thought, and so I read on.
When I reached the point where Lynne writes “The greatest revelation had to do with the dirty pool employed by the Australian government’s National Health and Medical Research Council (NHMRC), when it decided to assess the effectiveness of homeopathy by reviewing all research that had been done to date”, I got a little suspicious. We discussed the NHMRC report here and here and I had an entirely different impression of it.
Lynne also elaborated at length on the infamous ‘Swiss report’: “The Swiss team had comprehensively reviewed all the major evidence for homeopathy, everything from preclinical research to double-blind, placebo-controlled studies and meta-analyses. After assessing all the available data, the Swiss team concluded that the high-quality investigations of preclinical basic research proved that homeopathic high-potency remedies induce “regulative and specific changes in cells or living organisms”. Of the systematic reviews of human research, said the report, 20 out of 22 detected “at least a trend in favor of homeopathy”, and five showed “clear evidence for homeopathic therapy”. The report found particularly strong evidence for the use of homeopathy for upper respiratory tract infections and allergic reactions. Perhaps most significantly, the report concluded that the effectiveness of homeopathy “can be supported by clinical evidence” and “regarded as safe”.(Forsch Komple-mentmed, 2006; 13 Suppl 2: 19–29).”
This report has been evaluated by many experts (see for instance here). One expert even called it ‘research misconduct’ and concluded that “…the authors of this report adopted a very unusual strategy in what should have been an impartial evidence appraisal. It appears that their goal was not to provide an independent assessment but to choose criteria that would lead to their chosen conclusion that homeopathy is effective. To this end, they chose to adopt a highly questionable criterion of “real-world” effectiveness, ignore negative findings concerning homeopathy in favour of implausible reinterpretation of results, and attack RCTs. This use of a unique and suspect methodology in an appraisal designed to assess healthcare objectively gives cause for particular concern; one imagines that the Swiss government wanted homeopathy to be judged against existing standards rather than new ones created specially for the evaluation. In doing so the authors have distorted the evidence and misled the public; these actions, combined with their conflicts of interest, strongly suggest that they are guilty of research misconduct. It is extremely unfortunate that the Swiss government lent legitimacy to this report by attaching its name to it, and also unfair that the English-language text is not available free of charge to the public when it is being widely misrepresented all over the world as proof of the efficacy of homeopathy. It remains possible that homeopathy is effective, but the authors of this report do the practice a grave disservice.”
Could it be that Lynne does not know all this?
Or is she not interested in an ‘even-handed’ approach?
For me, the last drop arrived when Lynne started writing about my friend “Simon Singh, the self-appointed attack dog on all things alternative”, as she calls him. This is where I began to feel nauseous, so much so that I had to reach for my Nux Vomica C30. Alas, it did not help – Lynne’s writing was too overpoweringly sickening, particularly when she tried to motivate her readers to defend charities that endanger public health by promoting bogus treatments for life-threatening conditions: “If you value alternative medicine, here’s what to write the CC before the deadline: Tell them to read the Swiss report on homeopathy, the most contentious of alternative therapies, which shows very good evidence for it. Demand a level playing field. If they are going to challenge charities for alternative medicine based on scientific evidence, then they need to evaluate Cancer Research UK, Arthritis Research UK and every other charity partly or wholly funded by pharmaceutical companies, an estimated 75 percent of whose research is massaged, manipulated or fabricated.”
My only hope now is that the film JUST ONE DROP is less bonkers than Lynne’s comment about it!
Tui Na is a massage technique that is based on the Taoist principles of TCM. It involves a range of manipulations usually performed by an operator’s finger, hand, elbow, knee, or foot applied to muscle or soft tissue at specific parts of the body. According to one website of TCM-proponents “Tui Na makes use of various hand techniques in combination with acupuncture and other manipulation techniques. To enhance the healing process, the practitioner may recommend the use of Chinese herbs. Many of the techniques used in this massage resemble that of a western massage like gliding, kneading, vibration, tapping, friction, pulling, rolling, pressing and shaking. In Tui Na massage, the muscles and tendons are massaged with the help of hands, and an acupressure technique is applied to directly affect the flow of Qi at different acupressure points of the body, thus facilitating the healing process. It removes the blockages and keeps the energy moving through the meridians as well as the muscles. A typical session of Tui Na massage may vary from thirty minutes to an hour. The session timings may vary depending on the patient’s needs and condition. The best part of the therapy is that it relaxes as well as energizes the person. The main benefit of Tui Na massage is that it focuses on the specific problem, whether it is an acute or a chronic pain associated with the joints, muscles or a skeletal system. This technique is very beneficial in reducing the pain of neck, shoulders, hips, back, arms, highs, legs and ankle disorders. It is a very effective therapy for arthritis, pain, sciatica and muscle spasms. Other benefits of this massage therapy include alleviation of the stress related disorders like insomnia, constipation, headaches and other disorders related to digestive, respiratory and reproductive systems. The greatest advantage of Tui Na is that it focuses on maintaining overall balance with both physical and mental health. Any one who wants to avoid the side effects of drugs or a chemical based treatment can adopt this effective massage technique to alleviate their pain. Tui Na massage therapy is now becoming a more common therapy method due to its focus on specific problems rather than providing a general treatment.”
This clearly begs the question IS IT EFFECTIVE?
This systematic review assessed the evidence of Tui Na for cervical radiculopathy. Seven databases were searched. Randomised controlled trials (RCTs) incorporating Tui Na alone or Tui Na combined with conventional treatment were included. Five studies involving 448 patients were found. The pooled analysis from the 3 trials indicated that Tui Na alone showed a significant lowering immediate effects on pain score with moderate heterogeneity compared to cervical traction. The meta-analysis from 2 trials revealed significant immediate effects of Tui Na plus cervical traction in improving pain score with no heterogeneity compared to cervical traction alone. None of the RCTs mentioned adverse effects. There was very low quality or low quality evidence to support the results.
The authors concluded that “Tui Na alone or Tui Na plus cervical traction may be helpful to cervical radiculopathy patients, but supportive evidence seems generally weak. Future clinical studies with low risk of bias and adequate follow-up design are recommended.”
In my view, this is a misleading conclusion. A correct one would have been: THE CURRENT EVIDENCE IS INSUFFICIENT TO DRAW ANY CONCLUSIONS ABOUT THE EFFECTIVENESS OF TUI NA.
Here are some of the most obvious reasons:
- there are far too few studies for a firm conclusion,
- the included RCTs lack scientific rigour,
- all trials originate from China where reliability seems to be a serious problem,
- traction is not a useful therapy for radiculopathy,
- the primary studies violate research ethics by not reporting adverse effects.
Personally, I am getting very tired of conclusions stating ‘…XY MAY BE EFFECTIVE/HELPFUL/USEFUL/WORTH A TRY…’ It is obvious that the therapy in question MAY be effective, otherwise one would surely not conduct a systematic review. If a review fails to produce good evidence, it is the authors’ ethical, moral and scientific obligation to state this clearly. If they don’t, they simply misuse science for promotion and mislead the public. Strictly speaking, this amounts to scientific misconduct.
Drug and alcohol dependencies are notoriously difficult to treat effectively. Patients and their families are often desperate and willing to try anything. This seems like an ideal ground for acupuncturists who are, in my experience, experts in putting up smokescreens hiding the true value of their treatment.
The best way to determine the value of any intervention is probably conducting a systematic review of the evidence from rigorous clinical trials. Today we are in the fortunate position to have not just one of those articles; but do they really tell us the truth?
This brand-new systematic review investigated the effects of acupuncture on alcohol-related symptoms and behaviors in patients with this disorder. The PubMed database was searched until 23 August 2016, and reference lists from review studies were also reviewed. The inclusion criteria were the following: (1) being published in a peer-reviewed English-language journal, (2) use of randomized controlled trials (RCTs), (3) assessing the effects of acupuncture on psychological variables in individuals with a primary alcohol problem, and (4) reporting statistics that could be converted to effect sizes.
Seventeen studies were identified for a full-text inspection, and seven (243 patients) of these met our inclusion criteria. The outcomes assessed at the last post-treatment point and any available follow-up data were extracted from each of the studies. Five studies treated patients by inserting a needle into several acupoints in each ear. Two studies stimulated body points with or without ear stimulation. Four studies treated control patients with a placebo needle or under a completely different type of intervention, such as relaxation or transdermal stimulation, whereas the remaining studies inserted needles into nonspecific points. The patients were treated for 2 weeks to 3 months, and the treatment duration per session was 15–45 min. The results of the meta-analysis demonstrated that an acupuncture intervention had a stronger effect on reducing alcohol-related symptoms and behaviours than did the control intervention. A beneficial but weak effect of acupuncture treatment was also found in the follow-up data.
The authors concluded that although our analysis showed a significant difference between acupuncture and the control intervention in patients with alcohol use disorder, this meta-analysis is limited by the small number of studies included. Thus, a larger cohort study is required to provide a firm conclusion.
I am used to reading poor research papers, but this one is like a new dimension. Here are just the most obvious flaws:
- by searching just one database, the likelihood of missing studies is huge,
- by excluding non-English papers, the review automatically becomes non-systematic,
- the included studies differed vastly in many respects and can therefore not be pooled.
As it happens, a further meta-analysis has just been published. Here is its abstract:
Acupuncture has been widely used as a treatment for alcohol dependence. An updated and rigorously conducted systematic review is needed to establish the extent and quality of the evidence on the effectiveness of acupuncture as an intervention for reducing alcohol dependence. This review aimed to ascertain the effectiveness of acupuncture for reducing alcohol dependence as assessed by changes in either craving or withdrawal symptoms.
In this systematic review, a search strategy was designed to identify randomised controlled trials (RCTs) published in either the English or Chinese literature, with a priori eligibility criteria. The following English language databases were searched from inception until June 2015: AMED, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and PubMed; and the following Chinese language databases were similarly searched: CNKI, Sino-med, VIP, and WanFang. Methodological quality of identified RCTs was assessed using the Jadad Scale and the Cochrane Risk of Bias tool.
Fifteen RCTs were included in this review, comprising 1378 participants. The majority of the RCTs were rated as having poor methodological rigour. A statistically significant effect was found in the two primary analyses: acupuncture reduced alcohol craving compared with all controls (SMD = −1.24, 95% CI = −1.96 to −0.51); and acupuncture reduced alcohol withdrawal symptoms compared with all controls (SMD = −0.50, 95% CI = −0.83 to −0.17). In secondary analyses: acupuncture reduced craving compared with sham acupuncture (SMD = −1.00, 95% CI = −1.79 to −0.21); acupuncture reduced craving compared with controls in RCTs conducted in Western countries (SMD = −1.15, 95% CI = −2.12 to −0.18); and acupuncture reduced craving compared with controls in RCTs with only male participants (SMD = −1.68, 95% CI = −2.62 to −0.75).
This study showed that acupuncture was potentially effective in reducing alcohol craving and withdrawal symptoms and could be considered as an additional treatment choice and/or referral option within national healthcare systems.
This Meta-analysis is only a little better than the first, I am afraid. What its conclusions do not sufficiently reflect, in my view, is the fact that the quality of the primary studies was mostly very poor – too poor to draw conclusions from (other than ‘acupuncture research is usually lousy’; see figure below). Therefore, I fail to see how the authors could draw the relatively firm and positive conclusions cited above. In my view, they should have stated something like this: DUE TO THE RISK OF BIAS IN MANY TRIALS, THE EFFECTIVENESS OF ACUPUNCTURE REMAINS UNPROVEN.
The authors of the first meta-analysis open the discussion by proudly declaring that “the present study is the first meta-analysis to examine the effect of acupuncture treatment on patients with alcohol use disorder and to provide data on the magnitude of this effect on alcohol-related clinical symptoms and behaviours.” They discretely overlook this meta-analysis from 2009 (and several others which even their rudimentary search would have identified):
Nineteen electronic databases, including English, Korean, Japanese, and Chinese databases, were systematically searched for RCTs of acupuncture for alcohol dependence up to June 2008 with no language restrictions. The methodological qualities of eligible studies were assessed using the criteria described in the Cochrane Handbook.
Eleven studies, which comprised a total of 1,110 individual cases, were systematically reviewed. Only 2 of 11 trials reported satisfactorily all quality criteria. Four trials comparing acupuncture treatment and sham treatments reported data for alcohol craving. Three studies reported that there were no significant differences. Among 4 trials comparing acupuncture and no acupuncture with conventional therapies, 3 reported significant reductions. No differences between acupuncture and sham treatments were found for completion rates (Risk Ratio = 1.07, 95% confidence interval, CI = 0.91 to 1.25) or acupuncture and no acupuncture (Risk Ratio = 1.15, 95% CI = 0.79 to 1.67). Only 3 RCTs reported acupuncture-related adverse events, which were mostly minimal.
The results of the included studies were equivocal, and the poor methodological quality and the limited number of the trials do not allow any conclusion about the efficacy of acupuncture for treatment of alcohol dependence. More research and well-designed, rigorous, and large clinical trials are necessary to address these issues.
One does not need to be an expert in interpreting meta-analyses, I think, to see that this paper is more rigorous than the new ones (which incidentally were published in the very dubious journals). And this is why I trust the conclusions of this last-named meta-analysis more than those of the new one: the efficacy of acupuncture remains unproven. And this means that we should not employ or promote it for routine care.
THE TELEGRAPH reported that “homeopathic medicines will escape an NHS prescribing ban even though the Chief Medical Officer Dame Sally Davies has dismissed the treatments as ‘rubbish’ and a waste of taxpayers money.”
This sounds insane!
Sorry, I do not know the answer either, but below I offer 10 possible options – so bear with me, please.
The NHS spends around £4 million a year on homeopathic remedies, the article claimed. Sandra Gidley, chairwoman of the Royal Pharmaceutical Society, said: “We are surprised that homeopathy, which has no scientific evidence of effectiveness, is not on the list for review. We are in agreement with NHS England that products with low or no clinical evidence of effectiveness should be reviewed with urgency.”
The NHS Clinical Commissioners, the body which was asked to review which medications should no longer be prescribed for NHS England, said it had included drugs with ‘little or no clinical value’, yet could not offer an explanation why homeopathic medicines had escaped the cut. Julie Wood, Chief Executive, NHS Clinical Commissioners said: “Clinical commissioners have always had to make difficult choices about prioritising how they spend their budget on services, but the finance and demand challenges we face at the moment are unprecedented. Clinical Commissioning Groups have been looking at their medicines spend, and many are already implementing policies to reduce spending on those prescribeable items that have little or no clinical value for patients, and are therefore not an effective use of the NHS pound.”
Under the new rules, NHS doctors will be banned from routinely prescribing items that are cheaply available in chemists. The list includes heartburn pills, paracetamol, hayfever tablets, sun cream, muscle rubs, Omega 3 fish oils, medicine for coughs and colds and travel vaccinations. Coeliacs will also be forced to buy their own gluten-free food.
So, why are homeopathic remedies excluded from this new cost-saving exercise?
I am puzzled!
Is it because:
- The NHS has recently found out that homeopathy is effective after all?
- The officials have forgotten to put homeopathics on the list?
- In times of Brexit, the government cannot be bothered about reason, science and all that?
- The NHS does not need the money?
- Homeopathic globuli look so pretty?
- Our Health Secretary is in love with homeopathy?
- Experts are no longer needed for decision-making?
- EBM has suddenly gone out of fashion?
- Placebos are now all the rage?
- Some influential person called Charles is against it?
Sorry, no prizes for the winner of this quiz!
Therapeutic Touch is a therapy mostly popular with nurses. We have discussed it before, for instance here, here, here and here. To call it implausible would be an understatement. But what does the clinical evidence tell us? Does it work?
This literature review by Iranian authors was aimed at critically evaluating the data from clinical trials examining the clinical efficacy of therapeutic touch as a supportive care modality in adult patients with cancer.
Four electronic databases were searched from the year 1990 to 2015 to locate potentially relevant peer-reviewed articles using the key words therapeutic touch, touch therapy, neoplasm, cancer, and CAM. Additionally, relevant journals and references of all the located articles were manually searched for other potentially relevant studies.
The number of 334 articles was found on the basis of the key words, of which 17 articles related to the clinical trial were examined in accordance with the objectives of the study. A total of 6 articles were in the final dataset in which several examples of the positive effects of healing touch on pain, nausea, anxiety and fatigue, and life quality and also on biochemical parameters were observed.
The authors concluded that, based on the results of this study, an affirmation can be made regarding the use of TT, as a non-invasive intervention for improving the health status in patients with cancer. Moreover, therapeutic touch was proved to be a useful strategy for adult patients with cancer.
This review is badly designed and poorly reported. Crucially, its conclusions are not credible. Contrary to what the authors stated when formulating their aims, the methods lack any attempt of critically evaluating the primary data.
A systematic review is more than a process of ‘pea counting’. It requires a rigorous assessment of the risk of bias of the included studies. If that crucial step is absent, the article is next to worthless and the review degenerates into a promotional excercise. Sadly, this is the case with the present review.
You may think that this is relatively trivial (“Who cares what a few feeble-minded nurses do?”), but I would disagree: if the medical literature continues to be polluted by such irresponsible trash, many people (nurses, journalists, healthcare decision makers, researchers) who may not be in a position to see the fatal flaws of such pseudo-reviews will arrive at the wrong conclusions and make wrong decisions. This will inevitably contribute to a hindrance of progress and, in certain circumstances, must endanger the well-being or even the life of vulnerable patients.