MD, PhD, FMedSci, FSB, FRCP, FRCPEd

critical thinking

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The Committees of Advertising Practice (CAP) write and maintain the UK Advertising Codes, which are administered by the Advertising Standards Authority. On their website, the CAP recently published an updated advertising code for naturopathy. As we have regularly discussed the fact that the public is being frequently misled in this area, I consider the code important in the context of this blog. I therefore take the liberty of repeating it here – not least in the hope that this helps preventing misinformation in the future [the numbers in square brackets refer to me footnotes below].

START OF QUOTE

What is Naturopathy?

Naturopathy is a holistic [1] approach to healthcare that uses a combination of one or more different disciplines (for example herbal medicine or hydrotherapy) and a healthy lifestyle [2] in order to gain and maintain a healthy body [3].

What claims are likely to be acceptable?

The promotion of a healthy [4] lifestyle is likely to acceptable as are claims that go no further than those commonly accepted for healthy [4] eating, sleeping well, taking exercise and the like.

What claims are likely to be problematic?

The ASA and CAP have not yet been provided with evidence which demonstrates that Naturopathy can be used to treat medical conditions (Rule 12.1).  Therefore, any claims that go beyond accepted claims for a healthy [4] lifestyle are likely to be problematic [5] unless they are supported by a robust body of evidence.  In 2013, the ASA ruled against claims on a marketer’s website which said that Naturopathy could be used to treat acute and chronic illness and disease because the marketer had not provided any evidence in support of their claims (CNM The College of Naturopathic Medicine Ltd, 13 March 2013).

What about serious medical conditions?

Claims to offer treatment on conditions for which medical supervision should be sought [6] are likely to be considered to discourage essential treatment unless that treatment is carried out under the supervision of a suitably qualified health professional (Rule 12.2).

END OF QUOTE

Naturopathy has been the subject of my posts before – see for instance here, here, here, here and here. Naturopathy can be dangerous to the point where it can kill the patient – see for instance here and here. Therefore it is important that advertising gets regulated. To make it very clear: the above statement by the CAP is, in my view, a step in the right direction, and I encourage alternative practitioners to look up the equivalent CAP documents for their specific therapy.

Having said that, I still feel the need to make a few comments:

  1. It is misleading to call naturopathy ‘holistic’. This is often factually incorrect and also gives the impression that conventional medicine is not holistic – see also here.
  2. Are we sure that all lifestyles promoted by naturopaths are, in fact, healthy?
  3. Maintaining a healthy body is naturopathy speak for DISEASE PREVENTION. Who decides what is effective prevention? On what evidence? How come many naturopaths are against the most effective means of prevention of all times – vaccination?
  4. Who decides what is ‘healthy’? On what evidence?
  5. Why ‘problematic’? Are they not wrong or bogus or false or fraudulent or criminal?
  6. Are there conditions for which medical supervision should not be sought? Which are they?

Whenever a level-headed person discloses that a specific alternative therapy is not based on good evidence, you can bet your last shirt that a proponent of the said treatment responds by claiming that conventional medicine is not much better.

There are several variations to this theme. Today I want to focus on just one of them, namely the counter-claim that, only a short while ago, conventional medicine was not much better than the said alternative therapy (the implication is that it must be unfair to demand evidence from alternative medicine, while accepting a similar state of affairs in conventional medicine). The argument has recently been formulated by one commentator on this blog as follows:

“Trepanation, leeches for UTI’s, and bloodletting are all historical treatments of medical doctors…It’s hypocritical… to impute mainstream chiropractice to the profession’s beginnings and yet not admit that medicine’s founding and evolution was inbued with consistently scientific rigor.”

Sadly, some people seem to be convinced by such words, and this is why they are being repeated ad nauseam by interested parties. Yet the argument is fallacious for a range of reasons.

  • Firstly, it is based on the classical ‘tu quoque’ fallacy (appeal to hypocrisy).
  • Secondly – unless we happen to be historians – it is not the healthcare of the past that is relevant to our discussions. The question cannot be what this or that group of clinicians used to do; the question is HOW DO THEY TREAT THEIR PATIENTS TODAY?

As soon as we focus on this issue, it is impossible to deny that conventional medicine has made lots of progress and moved light years away from treatments such as trepanation, leeches, bloodletting and many others.

Why?

Why did we make such huge progress?

Because research showed that many of the traditional treatments were ineffective, unsafe and/or implausible (thus demonstrating that hundreds of years of experience – which alternative therapists rate so very highly – is of more than dubious value), and because we consequently developed and tested new therapies and subsequently used those treatments that passed these tests and were proven to do more good than harm.

By contrast, in the last decades, centuries and millennia, homeopathy, chiropractic, acupuncture, paranormal healing etc. did make no (or very little) progress. So much so that Hahnemann, for instance, would pass any exam for  homeopathy today. (If you disagree with this statement, please post a list of those treatments that have been given up by alternative therapists in the last 100 years or so.) Come to think of it, it is a hallmark of alternative medicine that it does not progress in the way conventional medicine does. It is almost completely static, a fact, that renders it akin to a dogma or a cult.

But why? Why is there no real progress in alternative medicine?

Don’t tell me that there is no research, research funding, etc. There are now hundreds of studies of homeopathy or chiropractic, thousands of acupuncture, and dozens of paranormal healing, for instance. The trouble is not the paucity of such research but its findings! The totality of the evidence in each of these areas fails to show that the therapy in question is efficacious.

And there we have, I think, another hallmark of alternative medicine: it is an area where research is only acted upon, if its findings are in line with the preconceptions and aspirations of its proponents.

I find this interesting!

It means, amongst other things, that research into alternative medicine tends not to be used for finding the truth or establishing new knowledge; it is mainly employed for the promotion of the therapy in question, regardless of what the truth about it might be (this would disqualify this exercise from being research and qualify it as PSEUDO-RESEARCH). If the research findings are such that they cannot be used for promotion, they are simply ignored or defamed as inadequate.

This new RCT was embargoed until today; so, I had to wait until I was able to publish my comments. Here are the essentials of the study:

The Swedish investigators compared the effect of two types of acupuncture versus no acupuncture in infants with colic in public child health centres (CHCs). The study was designed as a multicentre, randomised controlled, single-blind, three-armed trial (ACU-COL) comparing two styles of acupuncture with no acupuncture, as an adjunct to standard care. Among 426 infants whose parents sought help for colic and registered their child’s fussing/crying in a diary, 157 fulfilled the criteria for colic and 147 started the intervention.

Parallel to usual care, study participants visited the study CHC twice a week for 2 weeks. Thus, all infants received usual care plus 4 extra visits to a CHC, during which parents met a nurse for 20–30 min and were able to discuss their infant’s symptoms. Together these were considered to represent gold standard care. The nurse listened, and gave evidence-based advice and calming reassurance. Breastfeeding mothers were encouraged to continue breastfeeding. At each visit, the study nurse carried the infant to a separate treatment room where they were left alone with the acupuncturist for 5 min.

The acupuncturist treated the baby according to group allocation and recorded the treatment procedures and any adverse events. Disposable stainless steel 0.20×13 mm Vinco needles (Helio, Jiangsu Province, China) were used. Infants allocated to group A received standardised MA at LI4. One needle was inserted to a depth of approximately 3 mm unilaterally for 2–5 s and then withdrawn without stimulation. Infants allocated to group B received semi-standardised individualised acupuncture, mimicking clinical TCM practice. Following a manual, the acupuncturists were able to choose one point, or any combination of Sifeng, LI4 and ST36, depending on the infant’s symptoms, as reported in the diary. A maximum of five insertions were allowed per treatment. Needling at Sifeng consisted of 4 insertions, each to a depth of approximately 1 mm for 1 s. At LI4 and ST36, needles were inserted to a depth of approximately 3 mm, uni- or bilaterally. Needles could be retained for 30 seconds. De qi was not sought, therefore stimulation was similarly minimal in groups A and B. Infants in group C spent 5 min alone with the acupuncturist without receiving acupuncture.

The effect of the two types of acupuncture was similar and both were superior to gold standard care alone. Relative to baseline, there was a greater relative reduction in time spent crying and colicky crying by the second intervention week (p=0.050) and follow-up period (p=0.031), respectively, in infants receiving either type of acupuncture. More infants receiving acupuncture cried <3 hours/day, and thereby no longer fulfilled criteria for colic, in the first (p=0.040) and second (p=0.006) intervention weeks. No serious adverse events were reported.

The authors concluded that acupuncture appears to reduce crying in infants with colic safely.

Notice that the investigators are cautious and state in the abstract that “acupuncture appears to reduce crying…” Their conclusions from the actual article are, however, quite different; here they state the following:

Among those initially experiencing excessive infant crying, the majority of parents reported normal values once the infant’s crying had been evaluated in a diary and a diet free of cow’s milk had been introduced. Therefore, objective measurement of crying and exclusion of cow’s milk protein are recommended as first steps, to avoid unnecessary treatment. For those infants that continue to cry >3 hours/day, acupuncture may be an effective treatment option. The two styles of MA tested in ACU-COL had similar effects; both reduced crying in infants with colic and had no serious side effects. However, there is a need for further research to find the optimal needling locations, stimulation and treatment intervals.

Such phraseology is much more assertive and seems to assume acupuncture caused specific therapeutic effects. Yet, I think, this assumption is not warranted.

In fact, I believe, the study shows almost the opposite of what the authors conclude. Both minimal and TCM acupuncture seemed to reduce the symptoms of colic compared to no acupuncture at all. I think, this confirms previous research showing that acupuncture is a ‘theatrical placebo’. The study was designed without an adequate placebo group. It would have been easy to use some form of sham acupuncture in the control group. Why did the authors not do that? Heaven knows, but one might speculate that they were aiming for a positive result – and what better way to ensure it than with a ‘no treatment’ control group?

There are, of course, numerous other flaws. For instance, Prof David Colquhoun FRS, Professor of Pharmacology at University College London, criticised the study because of its lousy statistics:

START OF QUOTE

“It is truly astonishing that, in the 21st century, the BMJ still publishes a journal devoted to a form of pre-scientific medicine which after more than 3000 trials has still not been able to produce convincing evidence of efficacy1. Like most forms of alternative medicine, acupuncture has been advocated for a vast range of problems, and there is little evidence that it works for any of them. Colic has not been prominent in these claims. What parent would think that sticking needles into their baby would stop it crying? The idea sounds bizarre. It is. This paper certainly doesn’t show that it works.

“The statistical analysis in the paper is incompetent. This should have been detected by the referees, but wasn’t.  For a start, the opening statement, ‘A two-sided P value ≤0.05 was considered statistically significant’ is simply unacceptable in the light of all recent work about reproducibility.  Still worse, Table 1 uses the description ‘statistical tendency towards significance (p=0.051–0.1)’.

“Worst of all, Table 1 reports 24 different P values, of which three are (just) below 0.05. Yet no correction has been used for multiple comparisons. This is very bad practice. It’s highly unlikely that, if the proper correction had been done, any of the results would have given a type 1 error rate below 5%.

“Even were it not for this, most of the ‘significant’ P values are marginal (only slightly less than 0.05).  It is now well known that the type 1 error rate gives an optimistic view. What matters is the false positive rate – the chance that a ‘significant’ result is a false positive.  A p-value close to 0.05 implies that there is at least a 30% chance that they are false positives.  If one thought, a priori, that the chance of colic being cured by sticking needles into a baby was less than 50%, the false positive rate could easily be greater than 80%2.  It is now recognised that this misinterpretation of p-values is a major contributor to the crisis of reproducibility.

“Other problems concern the power calculation.  A priori calculations of power are well-known to be overoptimistic, because small trials usually overestimate the effect size.  In this case the initial estimated sample size was not attained, and a rather mysterious recalculation of power was used.

“Another small problem: the discussion points out that ‘the majority of infants in this cohort did not have colic’.

“The nature of the control group is not very clear. An appropriate control might have been to cuddle the baby – this was used in a study in which another implausible treatment, chiropractic, was shown not to work.  This appears not to have been done.

“Lastly, p-values are reported in the text without mention of effect sizes. This is contrary to all statistical advice.

“In conclusion, the design of the trial is reasonable (apart from the control group) but the statistical analysis is appalling.  It’s very likely that there aren’t any real effects of acupuncture at all. This paper serves more to muddy the waters than to add useful information. It’s a model for the sort of mistakes that have led to the crisis in reproducibility.  The BMJ should not be publishing this sort of stuff, and the referees seem to have no understanding of statistics.”

END OF QUOTE

Despite these rather obvious – some would say fatal – flaws, the editor of ACUPUNCTURE IN MEDICINE (AIM) thought this trial to be so impressively rigorous that he issued a press-release about it. This, I think, is particularly telling, perhaps even humorous: it shows what kind of a journal AIM is, and also provides an insight into the state of acupuncture research in general.

The long and short of it is that conclusions about specific therapeutic effects of acupuncture are not permissible. We know that colicky babies respond even to minimal attention, and this trial confirms that even a little additional TLC in the form of acupuncture will generate an effect. The observed outcome is most likely unrelated to acupuncture.

Originally, I had meant this blog to discuss all types of alternative therapies – well, perhaps not all (there are simply too many of them), but at least the most popular ones. And so far, I have omitted one that seems certainly quite wide-spread: CRYSTAL HEALING.

What the Dickens is crystal healing, you ask? It is the attempt to bring about healing with the power of crystals, of course. And how is it supposed to work? This is where things get quite nebulous; this website, for instance tells us that the repeating chemical structure of crystals is said to invest them with a kind of memory. This means that crystals have the power to hold energies. You may hold a quartz crystal with the intention of filling it with your love. This is what is meant by programming a crystal. You do not need any wires or a special connection with God – all you need is intention and focus. The crystal will remember your love, which will then permeate any environment in which the crystal is placed. Crystals can remember negative as well as positive energies and so will sometimes need to be cleansed. For instance, an amethyst will actually help to cleanse a room of negative energies (eg. anger) but this means that the amethyst, which will retain an element of that negative energy, will itself occasionally require cleansing.

Most crystal healers make fairly specific claims about the healing power of specific crystals. This website explains it in some detail. The following text is an extract of several key (only marginally altered) passages from much longer instructions about the use of different crystals for healing purposes:

Crystal healing specialists generally agree that garnet promotes rapid general healing and regeneration in users. Garnet also has a positive effect on disorders such as acid reflux, blood-related illnesses, and physical strength.

Rose quartz is considered, by practitioners of alternative medicine, to be the stone of love—in this case, love of the self, in the form of self-esteem and self-worth. Rose quartz is simply brimming with happiness, and is a very positive stone that can help bring out forgiveness, compassion, and tolerance in users.

Fluorite is of mental order and clarity, and can be used to help alleviate instability, paving the way for a more balanced view of life. Feeling tossed about on a sea of restless emotions? Try carrying fluorite with you throughout the day—it helps cleanse and detoxify the centers of emotion. Fluorite is also the stone of learning, and can improve concentration and focus, while simultaneously reducing the anxiety that can sometimes make retaining information difficult. If you’re a student, learning a new instrument, or facing a complex new job, fluorite may be the stone you’ll want to keep on your person.

Lapis lazuli is beneficial to the throat, vocal cords, and larynx, and can help to regulate endocrine and thyroid issues. This is one of the most effective stones to meditate with, as lapis lazuli is the stone of higher awareness, able to bring information to the mind in images rather than words. This is an especially great boon to those who have creative jobs, as their next big inspiration can come from this.

If you suffer from anxiety, hematite is for you. A heavy, calming stone, hematite is very grounding—it leaves the user feeling comfortable and “in the moment,” rather than being lost in memory or worry. This disconnection from the present—which many of us suffer from—is the cause of much discomfort. But by practicing mindfulness through meditation with hematite, you can reconnect with what’s currently going on in your life.

Alternative medicine practitioners consider jade to be the stone of the heart, and as such, affects this organ in a positive way, promoting heart health. Not only does jade promote physical heart health, but heals emotionally, as well. Focusing energies on the emotional heart, jade helps regulate what we embrace and what we resist, giving us better self-control, as well as a better picture of our own wants and needs.

Turquoise is powerful, giving peace to the spirit and well-being to the body. This stone induces a sense of serenity, keeping physically harmful stress and inflammation at bay. Holding turquoise can bring back focus and restore vitality. Turquoise is also a stabilizer, and can calm the nerves when working on a difficult problem, or when performing or speaking in public. It is known for its effectiveness in alleviating the fear of flying.

Obsidian is a protective stone, able to remove and guard against negativity. If you are trying to release issues from your past, including emotions such as anger, resentment, and fear, handling obsidian can help by allowing you to see them for what they are so that they can be dealt with. Physically, obsidian is said to benefit good health in muscle tissue and the digestive system, and can help rid the body of infection. It helps to reduce the pain of arthritis, joint problems, and cramps.

Citrine holds the power of granting energy and stamina and supporting proper metabolism. Especially beneficial for those suffering from chronic fatigue syndrome, this stone can bring back some much-needed vitality, and can even alleviate nausea and vomiting for those suffering from morning sickness. This gem also aids in keeping the nails, skin, and hair healthy, and is effective in relieving skin irritation of any kind. Emotionally, citrine is the gem of joy, helping the subconscious mind to accept happiness in life, releasing anger and negativity. This is the most effective gem for those suffering from depression—combined with the skills of a trained counselor, meditation with citrine can help channel happiness through you, imbuing you with real joy.

Whether you believe in the healing power of crystals or not, they are worth trying alongside your normal health regimen. At best, you’ll find a spiritual support for your physical and mental health goals. And at worst? You’ll be in possession of a few beautiful stones that make great meditative focal points. So do a little research and go try out a few of your favorite stones!

END OF QUOTES

Recently, I promised to be more respectful in my criticism of quackery, but when it comes to things like crystal healing this is a difficult task indeed. It goes almost without saying that there is not a jot of evidence for any of the therapeutic claims made in the above quotes or other promotional texts on crystal healing.

Who publishes this sort of nonsense? The above excerpts come from ‘BELIEFNET‘, the “leading lifestyle site dedicated to faith and inspiration. Beliefnet helps people find and walk a spiritual path that instills comfort, hope, strength and happiness. It is through this discovery that our readers are empowered to live a more meaningful life.”

Say no more!

Trump says he never mocked a disabled journalist.

YET THE WHOLE WORLD SAW HIM DO IT!

UK Brexit politicians such as Boris Johnson claim they never promised £ 350 million per week of EU funds for the NHS.

BUT WE ALL SAW THE PICTURES OF THE CAMPAIGN BUS!

These are just two of the numerous, obvious and highly significant lies that we have been told in recent months. In fact, we have heard so many lies recently that some of us seem to be getting used to them. We even have a new term for the phenomenon: the ‘post-truth society’.

Personally I don’t like the word at all: it seems to reflect a tacit acceptance of lies and their legitimisation.

I find it dangerous to put up with falsehoods in that way. And I think the truth is far too valuable to abandon it without a fight. I will therefore continue to call a lie a lie!

And, by Jove, in alternative medicine, we have no shortage of them:

  • Homeopaths claiming to be able to treat any condition with their ‘high potency remedies’.
  • Chiropractors who claim that spinal manipulation improves health.
  • Healers who state that their paranormal healing affects symptoms.
  • Alternative practitioners who claim that they treat the root cause of diseases.
  • Naturopaths who pretend they can treat childhood conditions.
  • Acupuncturists who say that rebalancing yin and yang affects health.
  • Alternative practitioners who insist they can detox our bodies.
  • Politicians who claim that TCM save lives.
  • Slapping therapists who say they can cure diabetes.
  • Journalists who publish that Paleo-diet can cure inflammatory bowel diseases.
  • Entrepreneurs who promote their unproven products as diabetes cures.
  • Academics who teach homeopathy to medical students.
  • Homeopaths who claim that their remedies are effective alternatives for vaccinations.

Do I need to go on?

These are not ‘post-truths’ – these are just lies, pure and simple.

We must not be lulled into complacency or false tolerance. Lies are lies, and they are wrong and unethical. In many instances they can even kill. To ignore or accept a steady stream of lies is not a solution; on the contrary, it can easily become part of the problem.

So, let’s continue to call them by their proper name – no matter whether they originate from the dizzy heights of world politics or the low lands of quackery.

At a recent conference in Montréal (October 2016), the WFC (World Federation of Chiropractic) and the ACC (Association of Chiropractic Colleges) reached a consensus on education. Consequently, recommendations were produced that offer 12 key ‘take away messages’. I take the liberty of reproducing these statements entitled ‘Training Tomorrow’s Spine Care Experts’ (the square brackets were inserted by me and refer to brief comments I made below).

START OF QUOTE

1. Chiropractic educational institutions have a  responsibility to equip students with the skills and  attributes necessary to become future spinal health care experts. This includes a commitment to astute diagnostic ability, a comprehensive knowledge of spine-related disorders [1], appreciation for the contributions of other health professionals and a commitment to collaborative, patient-centered and evidence-informed care [2].

2. Technological advances [3] provide an opportunity for the chiropractic profession to enhance, evolve and standardize core education and practice. This is relevant to the teaching of chiropractic skills, sharing of learning resources and assessment of performance. Emerging technologies that support the development of clinically-competent practitioners should be embedded within chiropractic programs.

3. The teaching and learning of specialized manual assessment and treatment skills should remain a key distinguishing element of chiropractic curricula.

4. Surveys of the public have a demonstrated a desire for consistency in the provision of chiropractic services. Such consistency need not compromise the identities of individual institutions but will cultivate public trust and cultural authority [4].

5. Globally consistent educational and practice standards will facilitate international portability [5] and promote greater health equity in the delivery of spine care.

6. Chiropractic programs should espouse innovation and leadership in the context of ethical [6], sustainable business [7] practices.

7. Chiropractic educational curricula should reflect current evidence [8] and high quality guidelines [9], and be subjected to regular review to ensure that students are prepared to work in collaborative health care environments.

8. The training of tomorrow’ s spine care experts should incorporate current best practices in education.

9. Interdisciplinary collaboration and strategic partnerships present opportunities to position chiropractors as leaders [10] and integral team players in global spine care.

10. Chiropractic educational institutions should champion the integration of evidence informed clinical practice [11], including clinical practice guidelines, in order to optimize patient outcomes. This will in turn foster principles of lifelong learning and willingness to adapt practice methods in the light of emerging evidence [12].

11. Students, faculty, staff and administrators must all contribute to a learning environment that fosters cultural diversity, critical thinking [13], academic responsibility and scholarly activity.

12. Resources should be dedicated to embed and promote educational research activity in all chiropractic institutions.

END OF QUOTE

And here are my brief comments:

[1] Some chiropractors believe that all or most human conditions are ‘spine-related disorders’. We would need a clear statement here whether the WFC/ACC do support or reject this notion and what conditions we are actually talking about.

[2] ‘Evidence-informed’??? I have come across this term before; it is used more and more by quacks of all types. It is clearly not synonymous with ‘evidence-based’, but aims at providing a veneer of respectability by creation an association with EBM. In concrete terms, asthma, for instance, might, in the eyes of some chiropractors, be an evidence-informed indication for chiropractic. In other words, ‘evidence-informed’ is merely a card blanch for promoting all sorts of nonsense.

[3] It would be good to know which technical advances they are thinking of.

[4] Public trust is best cultivated by demonstrating that chiropractic is doing more good than harm; by itself, this point sounds a bit like PR for maximising income. Sorry, I am not sure what they mean by ‘cultural authority’ – chiropractic as a cult?

[5] ‘International portability’ – nice term, but what does it mean?

[6] I get the impression that many chiropractors do not know what is meant by the term ‘ethics’.

[7] But they certainly know much about business!

[8] That is, I think, the most relevant statement in the entire text – see below.

[9] Like those by NICE which no longer recommend chiropractic for back pain? No? They are not ‘high quality’? I see, only those that recommend chiropractic fulfil this criterion!

[10] Chiropractors as leaders? Really? With their (largely ineffective) manipulations as the main contribution to the field? You have to be a chiropractor to find this realistic, I guess.

[11] Again ‘evidence-informed’ instead of ‘evidence-based’ – who are they trying to kid?

[12] The evidence that has been emerging since many years is that chiropractic manipulations fail to generate more good than harm.

[13] In the past, I got the impression that critical thinking and chiropractic are a bit like fire and water.

MY CONCLUSION FROM ALL THIS

What we have here is, in my view, little more than a mixture between politically correct drivel and wishful thinking. If chiropractors truly want chiropractic educational curricula to “reflect current evidence”, they need to teach the following main tenets:

  • Chiropractic manipulations have not been shown to be effective for any of the conditions they are currently used for.
  • Other forms of treatment are invariably preferable.
  • Subluxation, as defined by chiropractors, is a myth.
  • Spine-related disorders, as taught in many chiropractic colleges, are a myth.
  • ‘Evidence-informed’ is a term that has no meaning; the proper word is ‘evidence-based’ – and evidence-based chiropractic is a contradiction in terms.

Finally, chiropractors need to be aware of the fact that any curriculum for future clinicians must include the core elements of critical assessment and medical ethics. The two combined would automatically discontinue the worst excesses of chiropractic abuse, such as the promotion of bogus claims or the financial exploitation of the public.

But, of course, none of this is ever going to happen! Why? Because it would mean teaching students that they need to find a different profession. And this is why I feel that statements like the above are politically correct drivel which can serve only one purpose: to distract everyone from the fundamental problems in that profession.

If you want to scientifically investigate this question, it might be a good idea NOT to start with the following sentence: “Auricular acupuncture (AA) is effective in the treatment of preoperative anxiety”. Yet, this is exactly what the authors did in their recent publication.

The aim of this new study was to investigate whether AA can reduce exam anxiety as compared to placebo and no intervention. Forty-four medical students were randomized to receive AA, placebo, or no intervention in a crossover manner. Subsequently they completed three comparable oral anatomy exams with an interval of one month between the exams/interventions.

A licensed acupuncturist with more than five years of experience with this technique applied AA at the acupuncture points MA-IC1 (Lung), MA-TF1 (ear Shenmen), MA-SC (Kidney), MA-AT1 (Subcortex) and MA-TG (Adrenal gland) bilaterally. Indwelling fixed ‘New Pyonex’ needles embedded in a skin-coloured adhesive tape were used for AA. The participants were instructed by the acupuncturist to stimulate the auricular needles for 3–5 minutes, if they felt anxious. For the placebo procedure, ‘New Pyonex’ placebo needles were attached to five sites on the helix of the auricle bilaterally. ‘New Pyonex’ placebo needles have the same appearance as AA needles but consist of self-adhesive tape only. In order to avoid potential physiologic effects of acupressure, the participants were not instructed to stimulate the attached ‘New Pyonex’ placebo needles. AA and placebo needles were left in situ until the next day and were removed out of sight of the participants after the exam by the investigator, who was not involved in acupuncture procedure

Levels of anxiety were measured using a visual analogue scale before and after each intervention as well as before each exam. Additional measures included the State-Trait-Anxiety Inventory, duration of sleep at night, blood pressure, heart rate and the extent of participant blinding.

All included participants finished the study. Anxiety levels were reduced after AA and placebo intervention compared to baseline and the no intervention condition (p < 0.003). Moreover, AA was also better at reducing anxiety than placebo in the evening before the exam (p = 0.018). Participants were able to distinguish between AA and placebo intervention.

The authors concluded that both auricular acupuncture and placebo procedure were shown to be effective in reducing levels of exam anxiety in medical students. The superiority of verum AA over placebo AA and no intervention is considered to be due to stimulation of cranial nerves, but may have been increased in effect by insufficient participant blinding.

Here are just three of the major concerns I have about this study:

  • The trial design seems odd: a crossover study can only work well, if there is a stable baseline. This may not be the case with three consecutive exams; the anxiety experienced by students is bound to get less as time goes by. I think anyone who has passed a series of exams will confirm that there is a large degree of habituation.
  • It seems inadequate to employ just one acupuncturist; it means that the trial might end up testing not acupuncture per se but the skills of the therapist.
  • The placebo used for this study cannot possibly have fooled anyone into believing that it was real AA; volunteers were not even instructed to ‘stimulate’ the placebo devices. The difference to the ‘real thing’ must have been very clear to all involved. This means that the control for placebo-effects was woefully incomplete. In turn, this means that the observed outcomes are most likely due to residual bias.

In view of these concerns, allow me to re-phrase the authors’ conclusions:

THE RESULTS OF THIS POORLY-DESIGNED STUDY ARE DIFFICULT TO INTERPRET. MOST LIKELY THEY SHOW THAT ACUPUNCTURE IS NOT EFFECTIVE BUT MERELY WORKS THROUGH A PLACEBO-RESPONSE.

Can intercessory prayer improve the symptoms of sick people?

Why should it? It’s utterly implausible!

Because the clinical evidence says so?

No, the current Cochrane review concluded that [the] findings are equivocal and, although some of the results of individual studies suggest a positive effect of intercessory prayer, the majority do not and the evidence does not support a recommendation either in favour or against the use of intercessory prayer. We are not convinced that further trials of this intervention should be undertaken and would prefer to see any resources available for such a trial used to investigate other questions in health care.

Yet, not all seem to agree with this; and some even continue to investigate prayer as a medical therpy.

For this new study (published in EBCAM), the Iranian investigators randomly assigned 92 patients in 2 groups to receive either 40 mg of propranolol twice a day for 2 month (group “A”) or 40 mg of propranolol twice a day for 2 months with prayer (group “B”). At the beginning of study and 3 months after intervention, patients’ pain was measured using the visual analogue scale.

All patients who participate in present study were Muslim. At the beginning of study and before intervention, the mean score of pain in patients in groups A and B were 5.7 ± 1.6 and 6.5 ± 1.9, respectively. According to results of independent t test, mean score of pain intensity at the beginning of study were similar between patients in 2 groups (P > .05). Three month after intervention, mean score of pain intensity decreased in patients in both groups. At this time, the mean scores of pain intensity were 5.4 ± 1.1 and 4.2 ± 2.3 in patients in groups A and B, respectively. This difference between groups was statistically significant (P < .001).

figure

The above figure shows the pain score in patients before and after the intervention.

The authors concluded that the present study revealed that prayer can be used as a nonpharmacologic pain coping strategy in addition to pharmacologic intervention for this group of patients.

Extraordinary claims require extraordinary proof. This study is, in fact, extraordinary – but only in the sense of being extraordinarily poor, or at least it is extraordinary in its quality of reporting. For instance, all we learn in the full text article about the two treatments applied to the patient groups is this: “The prayer group participated in an 8-week, weekly, intercessory prayer program with each session lasting 45 minutes. Pain reduction was measured at baseline and after 3 months, by registered nurses who were specialist in pain management and did not know which patients were in which groups (control or intervention), using a visual analogue scale.”

Intercessory prayer is the act of praying on behalf of others. This mans that the patients receiving prayer might have been unaware of being ‘treated’. In this case, the patients could have been adequately blinded. But this is not made clear in the article.

More importantly perhaps, the authors fail to provide any numeric results. All that we are given is the above figure. It is not possible therefore to run any type of check on the data. We are simply asked to believe what the authors have written. I for one have great difficulties in doing so. All I do believe in relation to this article is that

  • the journal EBCAM is utter trash,
  • constantly publishing rubbish is unethical and a disservice to everyone,
  • prayer does not need further research of this nature,
  • and poor studies often generate false-positive findings.

Is acupuncture a pseudoscience? An interesting question! It was used as the title of a recent article. Knowing who authored it, the question unfortunately promised to be rhetorical. Dr Mike Cummings is (or was?) the ‘Medical Director at British Medical Acupuncture Society’ – hardly a source of critical or sceptical thinking about acupuncture, I’d say. The vast majority of his recent publications are in ‘ACUPUNCTURE IN MEDICINE’ and his blog post too is for that journal. Nevertheless, his thoughts might be worth considering, and therefore I present the essence of his post below [the footnotes refer to my comments following Cummings’ article]:

…Wikipedia has branded acupuncture as pseudoscience and its benefits as placebo [1]. ‘Acupuncture’ is clearly is not pseudoscience; however, the way in which it is used or portrayed by some may on occasion meet that definition. Acupuncture is a technique that predates the development of the scientific method [2] … so it is hardly fair to classify this ancient medical technique within that framework [3]. It would be better to use a less pejorative classification within the bracket of history when referring to acupuncture and other ancient East Asian medical techniques [4]. The contemporary use of acupuncture within modern healthcare is another matter entirely, and the fact that it can be associated with pre-scientific medicine does not make it a pseudoscience.

The Wikipedia acupuncture page is extensive and currently runs to 302 references. But how do we judge the quality or reliability of a text or its references? … I would generally look down on blogs, such as this, because they lack … hurdles prior to publication [5]. Open peer review was introduced relatively recently associated with immediate publication. But all this involves researchers and senior academics publishing and reviewing within their own fields of expertise. Wikipedia has a slightly different model built on five pillars. The second of those pillars reads:


Wikipedia is written from a neutral point of view: We strive for articles that document and explain major points of view, giving due weight with respect to their prominence in an impartial tone. We avoid advocacy and we characterize information and issues rather than debate them. In some areas there may be just one well-recognized point of view; in others, we describe multiple points of view, presenting each accurately and in context rather than as “the truth” or “the best view”. All articles must strive for verifiable accuracy, citing reliable, authoritative sources, especially when the topic is controversial or is on living persons. Editors’ personal experiences, interpretations, or opinions do not belong.


Experts within a field may be seen to have a certain POV (point of view), and are discouraged from editing pages directly because they cannot have the desired NPOV (neutral POV). This is a rather unique publication model in my experience, although the editing and comments are all visible and traceable, so there is no hiding… apart from the fact that editors are allowed to be entirely anonymous. Have a look at the talk page behind the main acupuncture page on Wikipedia. You may be shocked by the tone of much of the commentary. It certainly does not seem to comply with the fourth of the five pillars, which urges respect and civility, and in my opinion results primarily from the security of anonymity. I object to the latter, but there is always a balance to be found between freedom of expression (enhanced for some by the safety of anonymity) and cyber bullying (almost certainly fuelled in part by anonymity). That balance requires good moderation, and whilst there was some evidence of moderation on the talk page, it was inadequate to my mind… I might move to drop anonymity from Wikipedia if moderation is wanting.

Anyway my impression, for what it’s worth, is that the acupuncture page on Wikipedia is not written from an NPOV, but rather it appears to be controlled by semi professional anti-CAM pseudosceptics [6]. I have come across these characters [6] regularly since I was introduced to the value of needling in military general practice. I have a stereotypical mental image: plain or scary looking bespectacled geeks and science nuts [6], the worst are often particle physicists … Interacting with them is at first intense, but rapidly becomes tedious as they know little of the subject detail [6], fall back on the same rather simplistic arguments [6] and ultimately appear to be motivated by eristic discourse rather than the truth [6].

I am not surprised that they prefer to close the comments, because I imagine that some people might object rather strongly to many of the statements made in this text.

Here are my short comments:

[1] I should perhaps stress that I am not the author of nor a contributor to this Wiki (or any other) page.

[2] Is this an attempt to employ the ‘appeal to tradition’ fallacy?

[3] The Wiki page does by no means classify the ancient history of acupuncture as pseudoscience.

[4] I have always felt that classification of science or medicine according to geography is nonsensical; they should not be classified as Western or Asian but as sound or not, effective or not, etc.

[5] As we have often seen on this blog, the ‘hurdles’ (peer-review) are often laughable, particularly in the realm of alternative medicine.

[6] This article is essentially trying to show that the Wiki page is biased. Yet it ends with a bonanza of insults which essentially reveal the profound bias of the author.

IS ACUPUNCTURE PSEUDOSCIENCE? Cummings’ article promised to address this question. Sadly it did nothing of the sort. It  turned out to be an incompetent rant about a Wiki page. If anything, Cummings contributed to the neutral reader of his text getting convinced that, indeed, acupuncture IS a pseudoscience! At least Wiki used facts, arguments, evidence etc. and it went a lot further in finding a rational answer to this intriguing question.

With well over 800 articles, this blog has become somewhat of a reference library for subjects related to alternative medicine (I know that some journalists already employ it in this way [if you want to use it in this way, try the search box on the right top of the page]). To review the year 2016 in alternative medicine, I will now use it for exactly this purpose. In other words, I will highlight those posts from 2016 which, in my view, have taught us something potentially valuable or are otherwise remarkable.

Here we go!

19 January 2016: What are the competencies of a paediatric chiropractor? Chiropractors disagree, of course, but I think they should be foremost to realise that chiropractors must not treat children.

29 January 2016: Is the Internet a good source of information for cancer patients? No, in the realm of alternative medicine, the Internet can be very dangerous indeed.

15 February 2016: Alternative practitioners employ a multitude of diagnostic techniques. These methods are not validated and run an unacceptably high risk of false-positive or false-negative results.

22 March 2016: The career-path to becoming a convinced homeopath … may be less far puzzling than you think.

24 March 2016: Even the most respected medical journals are now beginning to publish very weak, borderline fraudulent studies of alternative medicine.

26 March 2016: Alternative practitioners seem to never protest even against the most outrageous quackery within their ranks.

28 March 2016: NICE might finally start being a little more critical about the value of alternative therapies.

02 April 2016: The ability to think critically seems extremely rare amongst alternative practitioners.

13 April 2016: Many, if not most, of the ‘research’ papers published in alternative medicine seem to have little to do with science but turn out to be exercises in promotion.

16 April 2016: There is no epidemic that does not bring some dangerously delusional homeopaths to the fore.

29 April 2016: Most alternative practitioners have little idea about medical ethics (see also here).

01 May 2016: Some, one could even say most CAM journals are not worth the paper they are printed on (see also here).

23 May 2016: Integrative medicine is one of the most colossal deceptions in healthcare today.

24 May 2016: Some CAM researcher are too good to be true.

10 June 2016: Pharmacists who sell quackery are probably quacks.

22 July 2016: Far too many TCM products are of lamentably poor quality.

19 August 2016: The German ‘HEILPRAKTIKER’ is a relic from the Nazis that continues to endanger public health.

03 September 2016: Homeoprophylaxis is a criminally bad idea; it has the potential to endanger public health.

04 September 2016: Quackery can kill people – and sadly, it does so with depressing regularity.

06 September 2016: Research into alternative medicine is scarce and usually of deplorably poor quality.

26 September 2016: Holistic dentistry is a con – just like holistic medicine; the term ‘holistic’ has degenerated into an advertising gimmick.

04 October 2016: Data fabrication in China is rife and further undermines the trustworthiness of TCM studies.

21 October 2016: Most (if not all) of the money spent on chiropractic is wasted.

10 December 2016: When sceptics criticise homeopathy, they are often wrong.

19 December 2016: Charlatans‘ income crucially relies on advertising lies.

22 December 2016: Homeopathy is not just useless for humans, it also does not work in animals.

HAPPY NEW YEAR EVERYONE!

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