MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

critical thinking

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This systematic review aimed to identify and explore published studies on the health, wellbeing and economic impact of retreat experiences. Three electronic databases were searched for residential retreat studies published in English. Studies were included, if they involved an intervention program in a residential setting of one or more nights, and included before-and-after data related to the health of participants.

A total of 23 studies including 8 randomised controlled trials, 6 non-randomised controlled trials and 9 longitudinal cohort studies met the inclusion criteria. These studies included a total of 2592 participants from diverse geographical and demographic populations and a great heterogeneity of outcome measures, with 7 studies examining objective outcomes such as blood pressure or biological makers of disease, and 16 studies examining subjective outcomes that mostly involved self-reported questionnaires on psychological and spiritual measures.

All studies reported post-retreat health benefits ranging from immediately after to five-years post-retreat. Study populations varied widely and most studies had small sample sizes, poorly described methodology and little follow-up data, and no studies reported on health economic outcomes or adverse effects, making it difficult to make definite conclusions about specific conditions, safety or return on investment.

The authors concluded that health retreat experiences appear to have health benefits that include benefits for people with chronic diseases such as multiple sclerosis, various cancers, HIV/AIDS, heart conditions and mental health. Future research with larger numbers of subjects and longer follow-up periods are needed to investigate the health impact of different retreat experiences and the clinical populations most likely to benefit. Further studies are also needed to determine the economic benefits of retreat experiences for individuals, as well as for businesses, health insurers and policy makers.

In the article, the authors also state that the findings from the reviewed studies suggest there are many positive health benefits from retreat experiences that includes improvements in both subjective and objective measures… The results from the most rigorous studies that used randomized controlled designs were consistent with less rigorous studies and suggest that retreat experiences can produce benefits that include positive changes in metabolic and neurological pathways, loss of weight, blood pressure and abdominal girth, reduction in health symptoms and improvements in quality of life and subjective wellbeing.

As it happens, we have discussed one of their ‘most rigorous’ RCTs on this blog. Here is what I wrote about it when it was first published:

The ‘study‘ in question allegedly examined the effects of a comprehensive residential mind–body program on well-being. The authors describe it as “a quasi-randomized trial comparing the effects of participation in a 6-day Ayurvedic system of medicine-based comprehensive residential program with a 6-day residential vacation at the same retreat location.” They included 69 healthy women and men who received the Ayurvedic intervention addressing physical and emotional well-being through group meditation and yoga, massage, diet, adaptogenic herbs, lectures, and journaling. Key components of the program include physical cleansing through ingestion of herbs, fiber, and oils that support the body’s natural detoxification pathways and facilitate healthy elimination; two Ayurvedic meals daily (breakfast and lunch) that provide a light plant-based diet; daily Ayurvedic oil massage treatments; and heating treatments through the use of sauna and/or steam. The program includes lectures on Ayurvedic principles and lifestyle as well as lectures on meditation and yoga philosophy. The study group also participated in twice-daily group meditation and daily yoga and practiced breathing exercises (pranayama) as well as emotional expression through a process of journaling and emotional support. During the program, participants received a 1-hour integrative medical consultation with a physician and follow-up with an Ayurvedic health educator.

The control group simply had a vacation without any of the above therapies in the same resort. They were asked to do what they would normally do on a resort vacation with the additional following restrictions: they were asked not to engage in more exercise than they would in their normal lifestyle and to refrain from using La Costa Resort spa services. They were also asked not to drink ginger tea or take Gingko biloba during the 2 days before and during the study week.

Recruitment was via email announcements on the University of California San Diego faculty and staff and Chopra Center for Wellbeing list-servers. Study flyers stated that the week-long Self-Directed Biological Transformation Initiative (SBTI) study would be conducted at the Chopra Center for Wellbeing, located at the La Costa Resort in Carlsbad, California, in order to learn more about the psychosocial and physiologic effects of the 6-day Perfect Health (PH) Program compared with a 6-day stay at the La Costa Resort. The study participants were not blinded, and site investigators and study personnel knew to which group participants were assigned.

Participants in the Ayurvedic program showed significant and sustained increases in ratings of spirituality and gratitude compared with the vacation group, which showed no change. The Ayurvedic participants also showed increased ratings for self-compassion as well as less anxiety at the 1-month follow-up.

The authors arrived at the following conclusion: Findings suggest that a short-term intensive program providing holistic instruction and experience in mind–body healing practices can lead to significant and sustained increases in perceived well-being and that relaxation alone is not enough to improve certain aspects of well-being.

This ‘study’ had ethical approval from the University of California San Diego and was supported by the Fred Foundation, the MCJ Amelior Foundation, the National Philanthropic Trust, the Walton Family Foundation, and the Chopra Foundation. The paper’s first author is director of research at the Chopra Foundation… Just for the record, let me formulate a short conclusion that actually fits the data from this ‘study’: Lots of TLC, attention and empathy does make some people feel better… 

END OF QUOTE FROM MY OWN POST

The subject of health retreats could be relevant and important. Educating people and teaching them the essentials about healthy life-styles is potentially a good thing. It could well turn out that health retreats benefit many individuals, while saving money for society.

Yet, do we need all sorts of quackery for achieving this aim?

No, we don’t!

A rational programme would need to teach and motivate people about diet, weight control, smoking cessation, regular sleep, relaxation, exercise, etc. It could prevent disease and save funds. This approach has existed in Europe long before the US ‘New Agers’ with their flimflam jumped on this bandwagon. Health education is a good idea, but it does not require the use of alternative therapies or luxury retreats.

As it turns out, the new systematic review is a disappointment. It fails to stress that no firm conclusions can be drawn from flimsy data and degenerates into little more than an embarrassing advertisement for Deepak Chopra’s and similar entrepreneurs’ money-making retreats. It totally ignores the sizable body of Non-English literature on the subject, and is focussed on promoting fashionable retreats and wellness centres in the US and Australia.

To be fair to the authors, they almost admit as much when they state: “Competing interests: MC is a board member of the Global Wellness Summit and has previously been a paid presenter at the Gwinganna Health Retreat. RMIT University has received donations from Danubius Hotel Group, Lapinha, Sunswept Resorts, Sheenjoy and The Golden Door for ongoing retreat research.”

I rest my case.

How often have we heard this? YOU ARE WRONG! MY TREATMENT DOES WORK!!! ONLY THE OTHER DAY, I HAD A PATIENT WHO WAS CURED BY IT.

Take for instance this tweet I got yesterday:

F SThomas‏ @spenthomf

You go too far @EdzardErnst. In fact I was consulted about a child who hadn’t grown after an accident. She responded well to homoeopathy and grew. How much are you being paid for your attempts to deny people’s health choices?

The tweet refers to my last post where I exposed homeopathic child abuse. Having thought about Thomas’ tweet, I must say that I find it too to be abusive – even abusive on 4 different levels.

  1. First, the tweet is obviously a personal attack suggesting that I am bribed into doing what I do. I have stated it many times, and I do so again: I receive no payment from anyone for my work. How then do I survive? I have a pension and savings (not that this is anyone’s business).
  2. Second, it is abusive because it claims that children who suffer from a pathological growth retardation can benefit from homeopathy. There is no evidence for that at all, and making false claims of this nature is unethical and, in this case, even abusive.
  3. Third, if Thomas really did make the observation she suggests in her tweet and is convinced that her homeopathic treatment was the cause of the child’s improvement, she has an ethical duty to do something more about it than just shooting off a flippant tweet. She could, for instance, run a clinical trial to find out whether her observation was correct. I admit this might be beyond her means. So alternatively, she could write up the case in full detail and publish it for all of us to scrutinise her findings. This is the very minimum a responsible clinician ought to do when she comes across a novel and potentially important result. Anything else is my view unethical and hinders progress.

I do, of course, sympathise with lay people who fail to fully understand the concept of causality. But surely, healthcare professionals who pride themselves of taking charge of patients ought to have some comprehension of it. They should know that clinical improvements after a treatment is not necessarily the same as clinical improvement because of the treatment. Is it really too much to ask of them to know the criteria for causality? There is plenty of easy-reading on the subject; even Wikipedia has a good article on it:

In 1965, the English statistician Sir Austin Bradford Hill proposed a set of nine criteria to provide epidemiologic evidence of a causal relationship between a presumed cause and an observed effect. (For example, he demonstrated the connection between cigarette smoking and lung cancer.) The list of the criteria is as follows:

  1. Strength (effect size): A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal.
  2. Consistency (reproducibility): Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect.
  3. Specificity: Causation is likely if there is a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship.
  4. Temporality: The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay).
  5. Biological gradient: Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence.
  6. Plausibility: A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge).
  7. Coherence: Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that “… lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations”.
  8. Experiment: “Occasionally it is possible to appeal to experimental evidence”.
  9. Analogy: The effect of similar factors may be considered.

And this brings me to my 4th and last level of abuse in relation to the above tweet and most other claims of this nature: being ill-informed and stupid while insisting to make a nonsensical point is, in my view, offensive – so much so that it can reach the level of abuse.

UK farmers are being taught how to treat their livestock with homeopathy “by kind permission of His Royal Highness, The Prince Of Wales”. This website explains:

The Homeopathy at Wellie Level (HAWL) Course has been developed specifically for those who tend livestock by the School of Agricultural Homeopathy, and is taught by homeopathic vets and qualified homeopaths – all with farm experience.  This is the ONLY course in the UK to provide qualified teaching aimed at empowering farmers and smallholders to use homeopathy for their animals with both confidence and understanding. We have been operational since 2001 and over the years have gathered literally hundreds of positive feedback comments and course testimonials…

HAWL is funded largely by donations, relies heavily on the generosity of supporters and volunteers, and makes no profit. We subsidise our courses, and our post-course support groups, in order to make them affordable to all; many of our farmers and smallholders run their farms single-handedly or with family members. Our aim is to educate, inform and support those who seek to reduce the burden of antibiotics, chemical wormers, and other drugs in the food chain and on the environment…

END OF QUOTE

Today, Oliver Kamm, a Times business columnist and leader writer, sates in THE TIMES that part of the blame for the persistence of fake medicine lies with, of all people, the heir to the throne. In a new book titled More Harm than Good?, Professor Edzard Ernst says that, as the most prominent advocate of homeopathy, the Prince of Wales is engaged in “foolish and immoral” support for unproven remedies for serious illness. You can say that again.

Yes, let’s say that again: foolish and immoral!

In our book, Kevin Smith and I develop the argument that the practice of and education in alternative medicine systematically violates medical ethics. We are sure that our argument holds water. It is not possible, we think, to practice or teach fake medicine within the rules and standards of medical ethics. This means that most of alternative medicine is unethical.

We have not drawn such conclusions lightly and feel that our ethical perspective on alternative medicine deserves serious consideration. It would be good, if the Prince of Wales gave it some thought.

Recently, I was asked about the ‘Dorn Method’. In alternative medicine, it sometimes seems that everyone who manages to write his family name correctly has inaugurated his very own therapy. It is therefore a tall order to aim at blogging about them all. But that’s been my goal all along, and after more than 1 000 posts, I am still far from achieving it.

So, what is the Dorn Method?

A website dedicated to it provides some first-hand information. Here are a few extracts (numbers in brackets were inserted by me and refer to my comments below):

START OF QUOTE

Developed by Dieter Dorn in the 1970’s in the South of Germany, it is now fast becoming the widest used therapy for Back Pain and many Spinal Disorders in Germany (1).

The Dorn Method ist presented under different names like Dornmethod, Dorntherapy, Dorn Spinal Therapy, Dorn-Breuss Method, Dorn-XXname-method and (should) have as ‘core’ the same basic principles.

There are many supporters of the Dorn Method (2) but also Critics (see: Dorn controversy) and because it is a free (3) Method and therefore not bound to clear defined rules and regulations, this issue will not change so quickly.

The Method is featured in numerous books and medical expositions (4), taught to medical students in some universities (5), covered by most private medical insurances (6) and more and more recognized in general (7).

However because it is fairly new and not developed by a Medical Professional it is often still considered an alternative Healing Method and it is meant to stay FREE of becoming a registered trademark, following the wish of the Founder Dieter Dorn (†2011) who did NOT execute his sole right to register this Method as the founder, this Method must become socalled Folk Medicine.

As of now only licensed Therapists, Non Medical Practitioners (in Germany called Heilpraktiker (Healing Practitioners with Government recognition) (8), Physical Therapists or Medical Doctors are authorized to practice with government license, but luckily the Dorn Method is mainly a True Self Help Method therefore all other Dorn Method Practitioners can legally help others by sharing it in this way (9).

What conditions can be treated with the Dorn Method? Every disease, even up to the psychological domain can be treated (positively influenced) unless an illness had already led to irreversible damages at organs (10). The main areas of application are: Muscle-Skeletal Disorders (incl. Back Pain, Sciatica, Scoliosis, Joint-Pain, Muscular Tensions, Migraines etc.)

END OF QUOTE

My brief comments:

  1. This is a gross exaggeration.
  2. Clearly another exaggeration.
  3. Not ‘free’ in the sense of costing nothing, surely!
  4. Yet another exaggeration.
  5. I very much doubt that.
  6. I also have difficulties believing this statement.
  7. I see no evidence for this.
  8. We have repeatedly discussed the Heilpraktiker on this blog, see for instance here, here and here.
  9. Sorry, but I fail to understand the meaning of this statement.
  10. I am always sceptical of claims of this nature.

By now, we all are keen to know what evidence there might be to suggest that the Dorn Method works. The website of the Dorn Method claims that there are 4 different strands of evidence:

START OF QUOTE

1. A new form of manual therapy and self help method which is basically unknown in conventional medicine until now, with absolutely revolutionary new knowledge. It concerns for example the manual adjustment of a difference in length of legs as a consequence of a combination of subluxation of the hip-joint (subluxation=partly luxated=misaligned) and a subluxation of the joints of sacrum (Ilio-sacral joint) and possible knee and ankle joints. The longer leg is considered the ‘problem’-leg and Not the shorter leg as believed in classical medicine and chiropractic.

2. The osteopathic knowledge that there is a connection of each vertebra and its appropriate  spinal segment to certain inner organs. That means that when there are damages at these structures, disturbances of organic functions are the consequence, which again are the base for the arising of diseases.

3. The knowledge of the Chinese medicine, especially of acupuncture and meridian science that the organic functions are stirred and leveled, also among each other, via the vegetative nervous system

4. The natural-scientific  knowledge of anatomy, physiology, physics, chemistry and other domains.

END OF QUOTE

One does not need to be a master in critical thinking to realise that these 4 strands amount to precisely NOTHING in terms of evidence for the Dorn Method. I therefore conducted several searches and have to report that, to the best of my knowledge, there is not a jot of evidence to suggest that the Dorm Method is more than hocus-pocus.

In case you wonder what actually happens when a patient – unaware of this lack of evidence – consults a clinician using the Dorn Method, the above website provides us with some interesting details:

START OF QUOTE

First the patients leg length is controlled and if necessary corrected in a laying position. The hip joint is brought to a (more or less) 90 degree position and the leg is then brought back to its straight position while guiding the bones back into its original place with gentle pressure.

picture link to dorn therapy pictures

This can be done by the patient and it is absolutely safe, easy and painless!

The treatment of Knees and Ankles should then follow with the same principals: Gentle pressure towards the Joint while moving it from a bended to a more straight position.

After the legs the pelvis is checked for misalignment and also corrected if necessary in standing position.

Followed by the lumbar vertebrae and lower thoracic columns, also while standing upright.

Then the upper thoracic vertebrae are checked, corrected if necessary, and finally the cervical vertebrae, usually in a sitting position.

The treatment often is continued by the controlling and correction of other joints like the shoulders, elbow, hands and others like the jaw or collarbone.

END OF QUOTE

Even if we disregard the poor English used throughout the text, we cannot possibly escape the conclusion that the Dorn Method is pure nonsense. So, why do some practitioners practice it?

The answer to this question is, of course, simple: There is money in it!

“Average fees for Dorn Therapy sessions range from about 40€ to 100€ or more…  Average fees for Dorn Method Seminars range from about 180€ to 400€ in most developed countries for a two day basic or review or advanced training.”

SAY NO MORE!

 

 

 

This announcement caught my eye:

START OF 1st QUOTE

Dr Patrick Vickers of the Northern Baja Gerson Centre, Mexico will deliver a two hour riveting lecture of ‘The American Experience of Dr Max Gerson, M.D.’

The lecture will present the indisputable science supporting the Gerson Therapy and its ability to reverse advanced disease.

Dr Vickers will explain the history and the politics of both medical and governmental authorities and their relentless attempts to surpress this information, keeping it from the world.

‘Dr Max Gerson, Censored for Curing Cancer’

“I see in Dr Max Gerson, one of the most eminent geniuses in medical history” Nobel Prize Laureate, Dr Albert Schweitzer.

END OF 1st QUOTE

Who is this man, Dr Patrik Vickers, I asked myself. And soon I found a CV in his own words:

START OF 2nd QUOTE

Dr. Patrick Vickers is the Director and Founder of the Northern Baja Gerson Clinic. His mission is to provide patients with the highest quality and standard of care available in the world today for the treatment of advanced (and non-advanced) degenerative disease. His dedication and commitment to the development of advanced protocols has led to the realization of exponentially greater results in healing disease. Dr. Vickers, along with his highly trained staff, provides patients with the education, support, and resources to achieve optimal health.

Dr. Patrick was born and raised outside of Milwaukee, Wisconsin. At the age of 11 years old, after witnessing a miraculous recovery from a chiropractic adjustment, Dr. Patrick’s passion for natural medicine was born.

Giving up careers in professional golf and entertainment, Dr. Patrick obtained his undergraduate degrees from the University of Wisconsin-Madison and Life University before going on to receive his doctorate in Chiropractic from New York Chiropractic College in 1997.

While a student at New York Chiropractic College(NYCC), Dr. Patrick befriended Charlotte Gerson, the last living daughter of Dr. Max Gerson, M.D. who Nobel Peace Prize Winner, Dr. Albert Schweitzer called, ” One of the most eminent geniuses in medical history. “

Dr. Gerson, murdered in 1959, remains the most censured doctor in the history of medicine as he was reversing virtually every degenerative disease known to man, including TERMINAL cancer…

END OF 2nd QUOTE

I have to admit, I find all this quite upsetting!

Not because the ticket for the lecture costs just over £27.

Not because exploitation of vulnerable patients by quacks always annoys me.

Not even because the announcement is probably unlawful, according to the UK ‘cancer act’.

I find it upsetting because there is simply no good evidence that the Gerson therapy does anything to cancer patients other than making them die earlier, poorer and more miserable (the fact that Prince Charles is a fan makes it only worse). And I do not believe that the lecture will present indisputable evidence to the contrary – lectures almost never do. Evidence has to be presented in peer-reviewed publications, independently confirmed and scrutinised. And, as far as I can see, Vickers has not authored a single peer-reviewed article [however, he thrives on anecdotal stories via youtube (worth watching, if you want to hear pure BS)].

But mostly I find it upsetting because it is almost inevitable that some desperate cancer patients will believe ‘Dr’ Vickers. And if they do, they will have to pay a very high price.

This blog is almost entirely about critical thinking as it applies to the realm of alternative medicine, and I have written about it more often than I care to remember. For instance, in one post I concluded that criticism  in alternative medicine is directed almost exclusively towards those who are outside the realm. Criticism from the inside is as good as non-existent.

The consequences of this situation are easy to see for everyone, and they can be dramatic:

  • The journals of alternative medicine publish nothing that could be perceived to be negative for the practice of alternative medicine.
  • Self-critical thinking has no tradition and has remained an almost alien concept.
  • The very few people from the ‘inside’ who dare to criticise alternative practices are ousted and/or declared to be incompetent or worse.
  • No action is taken to initiate change.
  • The assumptions of alternative medicine remain unaltered for centuries.
  • Progress is all but absent.

But what exactly is critical thinking? The ‘Foundation of Critical Thinking‘ defines it as follows: Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness.

In an article in the Scientific American Heather butler recently provided further clarification. Here is a short extract from this most commendable paper:

START OF QUOTE

Though often confused with intelligence, critical thinking is not intelligence. Critical thinking is a collection of cognitive skills that allow us to think rationally in a goal-orientated fashion, and a disposition to use those skills when appropriate. Critical thinkers are amiable skeptics. They are flexible thinkers who require evidence to support their beliefs and recognize fallacious attempts to persuade them. Critical thinking means overcoming all sorts of cognitive biases (e.g., hindsight bias, confirmation bias).

Critical thinking predicts a wide range of life events. In a series of studies, conducted in the U.S. and abroad, my colleagues and I have found that critical thinkers experience fewer bad things in life. We asked people to complete an inventory of life events and take a critical thinking assessment (the Halpern Critical Thinking Assessment). The critical thinking assessment measures five components of critical thinking skills including verbal reasoning, argument analysis, hypothesis testing, probability and uncertainty, decision-making, and problem-solving. The inventory of negative life events captures different domains of life such as academic (e.g., I forgot about an exam), health (e.g., I contracted a sexually transmitted infection because I did not wear a condom), legal (e.g., I was arrested for driving under the influence), interpersonal (e.g., I cheated on my romantic partner who I had been with for over a year), financial (e.g., I have over $5,000 of credit card debt), etc. Repeatedly, we found that critical thinkers experience fewer negative life events. This is an important finding because there is plenty of evidence that critical thinking can be taught and improved.

Is it better to be a critical thinker or to be intelligent? My latest research pitted critical thinking and intelligence against each other to see which was associated with fewer negative life events. People who were strong on either intelligence or critical thinking experienced fewer negative events, but critical thinkers did better.

Intelligence and improving intelligence are hot topics that receive a lot of attention. It is time for critical thinking to receive a little more of that attention. Keith Stanovich wrote an entire book about What Intelligence Tests Miss. Reasoning and rationality more closely resemble what we mean when we say a person is smart than spatial skills and math ability. Furthermore, improving intelligence is difficult. Intelligence is largely determined by genetics. Critical thinking, though, can improve with training and the benefits have been shown to persist over time. Anyone can improve their critical thinking skills: Doing so, we can say with certainty, is a smart thing to do.

END OF QUOTE

We cannot learn to be intelligent, but we can learn how to think critically. If my blog helps some readers to achieve this aim, I would consider the effort worthwhile.

Can conventional therapy (CT) be combined with herbal therapy (CT + H) in the management of Alzheimer’s disease (AD) to the benefit of patients? This was the question investigated by Chinese researchers in a recent retrospective cohort study funded by grants from China Ministry of Education, National Natural Science Foundation of China, Beijing Municipal Science and Technology Commission, and Beijing Municipal Commission of Health and Family Planning.

In total, 344 outpatients diagnosed as probable dementia due to AD were collected, who had received either CT + H or CT alone. The GRAPE formula was prescribed for AD patients after every visit according to TCM theory. It consisted mainly (what does ‘mainly’ mean as a description of a trial intervention?) of Ren shen (Panax ginseng, 10 g/d), Di huang (Rehmannia glutinosa, 30 g/d), Cang pu (Acorus tatarinowii, 10 g/d), Yuan zhi (Polygala tenuifolia, 10 g/d), Yin yanghuo (Epimedium brevicornu, 10 g/d), Shan zhuyu (Cornus officinalis, 10 g/d), Rou congrong (Cistanche deserticola, 10 g/d), Yu jin (Curcuma aromatica, 10 g/d), Dan shen (Salvia miltiorrhiza, 10 g/d), Dang gui (Angelica sinensis, 10 g/d), Tian ma (Gastrodia elata, 10 g/d), and Huang lian (Coptis chinensis, 10 g/d), supplied by Beijing Tcmages Pharmaceutical Co., LTD. Daily dose was taken twice and dissolved in 150 ml hot water each time. Cognitive function was quantified by the mini-mental state examination (MMSE) every 3 months for 24 months.

The results show that most of the patients were initially diagnosed with mild (MMSE = 21-26, n = 177) and moderate (MMSE = 10-20, n = 137) dementia. At 18 months, CT+ H patients scored on average 1.76 (P = 0.002) better than CT patients, and at 24 months, patients scored on average 2.52 (P < 0.001) better. At 24 months, the patients with improved cognitive function (△MMSE ≥ 0) in CT + H was more than CT alone (33.33% vs 7.69%, P = 0.020). Interestingly, patients with mild AD received the most robust benefit from CT + H therapy. The deterioration of the cognitive function was largely prevented at 24 months (ΔMMSE = -0.06), a significant improvement from CT alone (ΔMMSE = -2.66, P = 0.005).

 

The authors concluded that, compared to CT alone, CT + H significantly benefited AD patients. A symptomatic effect of CT + H was more pronounced with time. Cognitive decline was substantially decelerated in patients with moderate severity, while the cognitive function was largely stabilized in patients with mild severity over two years. These results imply that Chinese herbal medicines may provide an alternative and additive treatment for AD.

Conclusions like these render me speechless – well, almost speechless. This was nothing more than a retrospective chart analysis. It is not possible to draw causal conclusions from such data.

Why?

Because of a whole host of reasons. Most crucially, the CT+H patients were almost certainly a different and therefore non-comparable population to the CT patients. This flaw is so elementary that I need to ask, who are the reviewers letting such utter nonsense pass, and which journal would publish such rubbish? In fact, I can be used for teaching students why randomisation is essential, if we aim to find out about cause and effect.

Ahhh, it’s the ! I think the funders, editors, reviewers, and authors of this paper should all go and hide in shame.

The title of this post is a statement recently made in an article by Mike Adams in ‘Alternative Medicine News’:

The cancer industry goes to great lengths to deny patients access to any information that they might use to prevent, treat or cure cancer without requiring expensive (and highly toxic) medical interventions. That’s what makes the BMJ documentation of this curcumin cancer cure so astonishing: In years past, the BMJ never would have even tolerated the publishing of such a scientific assessment. So what changed? In truth, the evidence of natural cures for cancer is now so overwhelming that even the BMJ cannot remain in a state of denial without appearing to be hopelessly out of touch with scientific reality.

The story is based on one single patient who apparently was cured of cancer using curcumin (turmeric). The case was also recently (3/1/18) featured on BBC’s ‘YOU AND YOURS’ (http://www.bbc.co.uk/programmes/b09k0ng7) in a similarly uncritical way: no expert was asked to provide an evidence-based assessment and bring some reason into the discussion. Even the DAILY FAIL reported about the story, and predictably, critical assessment had to make way for sensationalism.

So what?

We hear about such nonsense almost every day!

True, but this case is different; it is based on a publication in the highly-respected BMJ (well, actually, it was the ‘BMJ CASE REPORTS’ and not the BMJ, as reported). Here is the article:

START OF QUOTE

A woman aged 57 years was initially diagnosed with monoclonal gammopathy of undetermined significance (MGUS) in 2007 following an incidental finding of M-protein (18 g/L) during investigation for hypertension.

Within 15 months, the patient had rapidly progressed to ISS stage 3 myeloma with M-protein 49 g/L, urinary protein 1.3 g/24-hour, Bence-Jones protein 1.0 g/24-hour, Hb 9.7 g/dL and increasing back pain. She initially declined antimyeloma treatment but 6 months later, following vertebral collapse at T5 and T12, started cyclophosphamide, thalidomide and dexamethasone (CTD) treatment. However, after a week, the patient was admitted with idiosyncratic syndrome including hyponatraemia, a fall in albumin and worsening of blood counts. She received red cell transfusion and her electrolyte abnormalities were carefully corrected.

Although there was evidence of a response to CTD (M-protein 34 g/L), bortezomib and dexamethasone treatment was initiated as an alternative, but this was discontinued after three cycles due to progressive disease (M-protein 49 g/L). The patient was then treated with lenalidomide and dexamethasone with the aim of reducing disease burden prior to high-dose therapy and autologous stem cell transplantation. Treatment was frequently interrupted and dose adjusted to account for neutropenia and despite a minor response after six cycles (starting M-protein 47 g/L, finishing M-protein 34 g/L), in October 2009, she proceeded with stem cell mobilisation. However, neither cyclophosphamide nor plerixafor/GCSF priming were successful. A bone marrow biopsy revealed 50% myeloma cells and a course of CTD was restarted with cautious titration of thalidomide.

The patient achieved a partial response with CTD retreatment over the course of 17 cycles (M-protein 13 g/L) with no further episodes of idiosyncratic syndrome. However, attempts to harvest stem cells in February 2011 and again there months later, both failed. By then, her M-protein had risen to 24 g/L and the patient was too neutropenic to be considered for a clinical trial.

At this point, the patient began a daily regime of oral curcumin complexed with bioperine (to aid absorption), as a single dose of 8 g each evening on an empty stomach. A few months later, she also embarked on a once-weekly course of hyperbaric oxygen therapy (90 min at 2 ATA) which she has maintained ever since. Her paraprotein levels gradually declined to a nadir of 13 g/L, her blood counts steadily improved and there was no evidence of further progressive lytic bone disease.

Outcome and follow-up

The patient continues to take oral curcumin 8 g daily without further antimyeloma treatment. Over the last 60 months, her myeloma has remained stable with minimal fluctuation in paraprotein level, her blood counts lie within the normal range and she has maintained good quality of life throughout this period. Repeat bone imaging in 2014 identified multiple lucencies <1 cm in the right hip and degenerative changes in both hips, but these were attributed to osteoarthritis rather than the myeloma. Recent cytogenetic analysis revealed she had no abnormal cytogenetics by fluorescent in situ hybridisation.

Discussion

A small but significant number of myeloma patients consume dietary supplements in conjunction with conventional treatment primarily to help cope with the side effects of treatment, manage symptoms and enhance general well-being. Few, if any, use dietary supplementation as an alternative to standard antimyeloma therapy. Here, we describe a case in which curcumin has maintained long-term disease control in a multiply-relapsed myeloma patient. To the best of our knowledge, this is the first report in which curcumin has demonstrated an objective response in progressive disease in the absence of conventional treatment.

Curcumin is a polyphenol derived from the perennial herb Curcuma longa (turmeric) and has, for centuries, been used as a traditional Indian medicine. Several reports published over the two decades have claimed various health benefits of curcumin and this has led to its increasing popularity as a dietary supplement to prevent or treat a number of different diseases.

The biological activity of curcumin is indeed remarkable. It is a highly pleiotropic molecule which possesses natural antioxidant, anti-inflammatory, antiseptic and analgesic properties. More recently, it has demonstrated antiproliferative effects in a wide variety of tumour cells including myeloma cells and exerts its antiproliferative effects through multiple cellular targets that regulate cell growth and survival.

In vitro, curcumin prevents myeloma cell proliferation through inhibition of IL-6-induced STAT-3 phosphorylation and through modulation of the expression of NF-kB-associated proteins such as IkB〈,Bcl-2, Bcl-xL, cyclin D1 and IL-6 and apoptosis-related molecules including p53 and Bax. In other studies, curcumin was shown to circumvent resistance to dexamethasone, doxorubicin and melphalan as well as potentiate the effects of bortezomib, thalidomide and lenalidomide. Furthermore, curcumin-induced cell death was not influenced by myeloma molecular heterogeneity.

The antimyeloma effects of curcumin in the clinical setting however are less clear. Only one phase I/II study has evaluated curcumin treatment in myeloma patients. These patients were either asymptomatic, relapsed or had plateau phase disease. Treatment with curcumin downregulated the expression of NFkB, COX-2 and STAT3 in peripheral blood mononuclear cells, but no objective responses were observed in any subgroup of patients. This may be as a result of small sample size in this study, follow-up was limited to 3 months and clinical responses may have been observed with longer follow-up. However, downregulation of NFkB, COX-2 and STAT3 expression may not correlate with the clinical activity of curcumin and there may be further mechanisms of action that remain unclear, possibly through the modulation of another target. We would not be able to identify any patient-specific mechanisms of activity in this case study, as the patient has been taking curcumin for some time now and baseline bone marrow or peripheral blood samples are not available. However, in the setting of a clinical trial, it may be possible to use next-generation sequencing to help identify a mutation that may be a potential target for curcumin.

Another study examined its effects in preventing the progression of MGUS and smouldering myeloma to myeloma. The results showed that curcumin exerted a trace of biological activity with modest decreases in free light chain and paraprotein levels and a reduction in a marker of bone resorption with curcumin treatment, suggesting the therapeutic potential of curcumin in MGUS and smouldering myeloma. However, more studies are needed to address this further.

Whether such effects are observed in patients with active disease remains to be seen. The fact that our patient, who had advanced stage disease and was effectively salvaged while exclusively on curcumin, suggests a potential antimyeloma effect of curcumin. She continues to take daily curcumin and remains in a very satisfactory condition with good quality of life. This case provides further evidence of the potential benefit for curcumin in myeloma. We would recommend further evaluation of curcumin in myeloma patients in the context of a clinical trial.

END OF QUOTE

What should we make of this?

I think that much of the reporting around the story was grossly irresponsible. It is simply not possible to conclude that curcumin was the cause of the remission. It could be due to a whole host of other factors. And a case report is just an anecdote; it never can prove anything and can only be used to stimulate further research.

I fully agree with the authors of the case report: curcumin seems worthy of further investigation. But recommending it to patients for self-medication is vastly premature and quite simply dangerous, unethical and naïve bordering on stupid.

And, of course, the above-cited drivel of Mike Adams is just beyond the pale – the evidence for ‘alternative cancer cures‘ is very, very far from ‘overwhelming’; and the ‘cancer industry’ is doing what they can to determine whether turmeric or any other natural remedy can be used to treat cancer and other diseases.

If they are ever successful, the Adams of this world will shout ‘EXPLOITATION!!!’

If their endeavours are not successful, they will complain ‘CONSPIRACY!!!’

Yesterday, I heard my ‘good friend’ Dr Michael Dixon (see here, here and here, for example) talk on the BBC about the “new thing” in healthcare: social prescribing. He explained, for instance, that social prescribing could mean treating a diabetic not with medication but with auto-hypnosis and other alternative therapies. At that moment, I wasn’t even entirely sure what the term ‘social prescribing’ meant, I have to admit – so I did some reading.

What is social prescribing?

The UK ‘Social Prescribing Network‘ defines it thus:

Social Prescribing is a means of enabling GPs and other frontline healthcare professionals to refer patients to a link worker – to provide them with a face to face conversation during which they can learn about the possibilities and design their own personalised solutions, i.e. ‘co-produce’ their ‘social prescription’- so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary and community sector. It is an innovative and growing movement, with the potential to reduce the financial burden on the NHS and particularly on primary care.

Does social prescribing work?

The UK King’s Fund is mildly optimistic:

There is emerging evidence that social prescribing can lead to a range of positive health and well-being outcomes. Studies have pointed to improvements in areas such as quality of life and emotional wellbeing, mental and general wellbeing, and levels of depression and anxiety. For example, a study into a social prescribing project in Bristol found improvements in anxiety levels and in feelings about general health and quality of life. In general, social prescribing schemes appear to result in high levels of satisfaction from participants, primary care professionals and commissioners.

Social prescribing schemes may also lead to a reduction in the use of NHS services. A study of a scheme in Rotherham (a liaison service helping patients access support from more than 20 voluntary and community sector organisations), showed that for more than 8 in 10 patients referred to the scheme who were followed up three to four months later, there were reductions in NHS use in terms of accident and emergency (A&E) attendance, outpatient appointments and inpatient admissions. The Bristol study also showed reductions in general practice attendance rates for most people who had received the social prescription.

However, robust and systematic evidence on the effectiveness of social prescribing is very limited. Many studies are small scale, do not have a control group, focus on progress rather than outcomes, or relate to individual interventions rather than the social prescribing model. Much of the evidence available is qualitative, and relies on self-reported outcomes. Researchers have also highlighted the challenges of measuring the outcomes of complex interventions, or making meaningful comparisons between very different schemes.

Determining the cost, resource implications and cost effectiveness of social prescribing is particularly difficult. The Bristol study found that positive health and wellbeing outcomes came at a higher cost than routine GP care over the period of a year, but other research has highlighted the importance of looking at cost effectiveness over a longer period of time. Exploratory economic analysis of the Rotherham scheme, for example, suggested that the scheme could pay for itself over 18–24 months in terms of reduced NHS use….

END OF QUOTES

Is there no harder evidence at all?

The only Medline-listed controlled study seems to have been omitted by the King’s Fund – I wonder why. Perhaps because it fails to share the optimism? Here is its abstract:

Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use. We used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use. At 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent. Changes in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.

So, there is a lack of evidence for social prescribing. Yet, this is not why I feel uneasy about the promotion of this “new thing”. The more i think about it, the more I realise that social prescribing is just good care and decent medicine. It is what I was taught at med school 40 years ago. It therefore seems like a fancy name for something that should be obvious.

But why my unease?

The way I see it, it will be (and perhaps already is) used to smuggle bogus alternative therapies into the mainstream. In this way, it could turn out to serve the same purpose as did the boom in integrative/integrated medicine/healthcare: a smokescreen to incorporate treatments into medical routine which otherwise would not pass muster. If advocates of this approach, like Michael Dixon, subscribe to it, the danger of this happening is hard to deny.

The disservice to patients (and medical ethics) would then be obvious: diabetics unquestionably can benefit from a change of life-style (and to encourage them is part of good conventional medicine), but I very much doubt that they should replace their anti-diabetic medications with auto-hypnosis or other alternative therapies.

The question whether chiropractic is a truly valuable option for people suffering from back pain has been addressed repeatedly on this blog. My answer was usually negative, but proponents of chiropractic tended to argue that I am biased. Therefore I find it constructive to see what an organisation that hardly can be accused of bias says on this topic. An article by ‘SHOW ME THE EVIDENCE’ has recently provided a comprehensive overview of treatments for back pain. This is what they wrote about chiropractic:

START OF QUOTE

Spinal manipulation, the cranking and tweaking on offer when you visit a traditional chiropractor, is among the most popular approaches to back pain. Practitioners lay their hands on the patient and move their joints to or beyond their range of motion — a technique that’s often accompanied by a pop or crack.

There is some evidence the approach can help people with chronic back pain — but not any more than over-the-counter painkillers or exercise, and you need to take precautions when seeking out a chiropractor.

First, a quick look at the evidence. There are two recent Cochrane reviews on spinal manipulation for low back pain: one focused on people with acute (again, episodic/short duration) pain and the other on chronic pain. The 2011 review on chronic low back pain found that spinal manipulation had small, short-term effects on reducing pain and improving the patient’s functional status — but this effect was about the same as other common therapies for chronic low back pain, such as exercise. That review was published in 2011; UpToDate reviewed the randomized trials that have come out since — and also found that spinal manipulation delivered modest, short-term benefits for chronic back pain sufferers.

The Cochrane review on acute pain found that spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor.

“Based on the evidence,” University of Amsterdam assistant professor Sidney Rubinstein, who is the lead author on the Cochrane reviews, told me, “it would appear [spinal manipulation] works as well as other accepted conservative therapies for chronic low back pain, such as non-prescription medication or exercise, but less well for patients with acute low back pain.”

As a chiropractor himself, he had some advice for patients: They should avoid chiropractors who routinely make X-rays or do advanced diagnostics for low back pain because this adds nothing to the clinical picture, particularly in the case of nonspecific low back pain. Patients should also beware chiropractors who put them on extended programs of care.

“Patients who respond to chiropractic care traditionally respond rather quickly,” he said. “My advice is those patients who have not responded to a short course of chiropractic care or manipulation should consider another type of therapy.”

While the risks of serious side effects from spinal manipulation for back pain are rare — about one in 10 million — the risks associated with chiropractic therapy for neck pain tend to be slightly higher: 1.46 strokes for every million neck adjustments.

The issue is the vertebral artery, which travels from the neck down through the vertebrae. Manipulating the neck can put patients at a higher risk of arterial problems, including stroke or vertebral artery dissection, or the tearing of the vertebral artery (though Rubinstein noted that people in the initial stages of stroke or dissection may also seek out care for their symptoms, such as neck pain, which makes it difficult to untangle how many of health emergencies are brought on by the adjustments).

END OF QUOTE

This all seems fairly reasonable to me – except for the following not entirely unimportant points:

  • I am not sure where the evidence about risks of spinal manipulation comes from. In my view, it is not entirely correct: as there is no effective post-marketing surveillance, we cannot possibly name the incidence figures.
  • Neck manipulations are clearly more risky than manipulations lower down. But this does not necessarily mean that back patients are safer than those with neck pain. Chiropractors view the spine as a whole organ and will regularly manipulate the neck (if they sense ‘subluxations’ in this area), even if the patient comes with low back pain.
  • There are also indirect risks with consulting a chiropractor; for instance, they often give incompetent advice about healthcare. This can include discouraging immunisations or treating serious diseases, such as asthma, colic etc., with chiropractic.
  • I think the article should point out that exercise is not just as effective (or as ineffective) as chiropractic, but it is much safer and less expensive.
  • What Rubinstein says about responders is debatable, in my view. In particular, most chiropractors will convince their patients to continue treatment, even if they do not ‘respond’. And ‘responding’ might be simply the natural history of the condition and therefore totally unrelated to the therapy.

The bottom line: Chiropractic is not the best treatment for back pain!

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