MD, PhD, FMedSci, FSB, FRCP, FRCPEd

evidence

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Some osteopaths – similar to their chiropractic, naturopathic, homeopathic, etc. colleagues – claim they can treat almost any condition under the sun. Even gynaecological ones? Sure! But is the claim true? Let’s find out.

The aim of this recent review was to evaluate the effects of the osteopathic manipulative treatment (OMT) on women with gynaecological and obstetric disorders. An extensive search from inception to April 2014 was conducted on MEDLINE, Embase, the Cochrane library using MeSH and free terms. Clinical studies investigating the effect of OMT in gynaecologic and obstetric conditions were included as well as unpublished works. Reviews and personal contributions were excluded. Studies were screened for population, outcome, results and adverse effects by two independent reviewers using an ad-hoc data extraction form. The high heterogeneity of the studies led to a narrative review.

In total, 24 studies were included. They addressed the following conditions: back pain and low back functioning in pregnancy, pain and drug use during labor and delivery, infertility and subfertility, dysmenorrhea, symptoms of (peri)menopause and pelvic pain. Overall, OMT was considered to be effective for pregnancy related back pain. For all other gynaecological and obstetrical conditions the evidence was considered to be uncertain. Only three studies mentioned adverse events after OMT.

The authors concluded that, although positive effects were found, the heterogeneity of study designs, the low number of studies and the high risk of bias of included trials prevented any indication on the effect of osteopathic care. Further investigation with more pragmatic methodology, better and detailed description of interventions and systematic reporting of adverse events are recommended in order to obtain solid and generalizable results.

Given the fact that the lead authors of this review come from the “Accademia Italiana Osteopatia Tradizionale, Pescara, Italy, we can probably answer the question in the title of this blog with a straight NO. I see no reason why OMT should work for gynaecological conditions, and I am not in the least surprised to read that there is no clinical evidence for this notion. Sadly, this is unlikely to stop osteopaths to claim otherwise and continue to prey on the desperate and the gullible.

One might thus say that this review is totally unremarkable – but I would beg to differ: it highlights yet again one very important finding, namely the fact that trials of alternative therapies far too often fail to report adverse effects. I have stated this often already, but I will say it again: THIS OMISSION IS A VIOLATION OF RESEARCH ETHICS WHICH GIVES US A FALSE POSITIVE OVERALL PICTURE OF THE RISKS ASSOCIATED WITH ALTERNATIVE MEDICINE.

According to Wikipedia, Swiss state insurance funding of homeopathy and four other alternative therapies had been withdrawn after a review in 2005, and a 2009 referendum vote called for state backed health insurance to once more pay for these therapies. In 2012 the Swiss government reinstated them for a trial period until 2017, pending an independent investigation of the efficacy and cost-effectiveness of the therapies. The rules for the registration of homeopathic remedies without a concrete field of application are more liberal in Switzerland than they are in member countries of the EU. For homeopathic medicines based on well-known low-risk substances, Swissmedic, the regulatory authority, offers inexpensive registration by means of a simplified electronic registration procedure.

Several weeks ago, I have commented on the remarkable position of alternative medicine in Switzerland. Now this website offers further information specifically on homeopathy in Switzerland:

According to a report jointly issued by the Swiss Federal Health Office and the Swiss State Secretariat for Economic Affairs (SECO), the annual expenses for homeopathic treatments and medications in Switzerland amount to roughly CHF 50 million and CHF 31 million, respectively. These numbers seem impressive, particularly if we consider how little each homeopathic remedy costs and how ineffective it is.

But the argument that homeopathy somehow defies scientific testing does not seem to die. For instance, SantéSuisse, the umbrella organisation of health insurers, argues that standardised methods used to test conventional treatments cannot be applied to homeopathy. “It would be unfair to homeopathy if we borrowed the methodologies from conventional therapeutic options when evaluating its effectiveness. The potential risk is that these systematic and internationally accepted methods of biomedical science go against the underlying principles of homeopathy,” said SantéSuisse spokesman Christophe Kämpf. I am afraid, he is talking complete tosh – and he should, of course, know better.

The Swiss Federal Health Office admitted in its press release at the end of March that “no evidence has so far been found to prove that complementary and alternative therapies”, including homeopathy, meet the standard criteria for “effectiveness, appropriateness, and costs.” And a Swiss health office spokesman, Daniel Dauwalder, explained that the decision “reflected the will of the people” in a 2009 referendum. “The health insurance system will cover the cost of alternative therapies according to the principle of trust,” Dauwalder explained. He added that, if the standards of effectiveness, suitability and economy are called into question, SantéSuisse have the right to deny payment.

The core of the issue centres on the questions

  • How to ensure that the physical conditions of patients will not be compromised by unqualified, self-proclaimed clinicians?
  • How can health insurers deal with the potential challenges?

The truth is, alternative treatments will not be unconditionally covered by the basic insurance policies which every Swiss resident must have. Only the costs of treatments administered by certified medical doctors will be considered. Otherwise, the costs incurred can only be reimbursed, if the person insured has purchased supplementary health coverage.

END OF QUOTE

That, however, does not mean that only doctors can practice homeopathy in Switzerland. Lay-homeopaths do exist in the form of Heilpraktiker. While it is true that the national health insurance only covers the treatment by medical doctors, some private health insurances also cover homeopathy by Heilpraktiker.

All this is very different from what some enthusiasts report about homeopathy in Switzerland. Probably the best example for someone obscuring the truth is (yet again) Dana Ullman who stated that “the Swiss government has determined that the very small doses commonly used in homeopathic medicine are both effective and cost-effective.” Little wonder, I might add, because Dana Ullman also keeps on referring to “a remarkable report on homeopathic medicine conducted by and for the government of Switzerland”. He does so despite having been told over and over again that the report in question is firstly utterly unreliable and secondly not by the Swiss government.

Why this odd insistence on disseminating wrong information? Is it because it is good for business, or because homeopaths are not capable of learning (otherwise they would not be homeopaths), or both?

We have become used to bogus claims made by homeopaths – far too much so, I would argue. Therefore, we let the vast majority of their bogus claims pass without serious objections. Yet exposing bogus claims would be an important task, particularly when they relate to serious conditions. Doing this might even save lives!

According to the website of the ‘HOMEOPATHIC DOCTOR’, homeopathy is mild in nature and tends to modify the body’s natural immunity. It is the responsibility of the immune system of the body to protect it from all sorts of damage, whether from bacteria or viruses or from any other disease. It also helps in repairing any damage that may occur at any time. Homeopathic medicines help strengthen the natural immunity of the body so that it can perform its natural functions in a more efficient manner.

5 Best Homeopathic remedies for Ulcerative Colitis

In my experience, homeopathic medicines like Merc Sol, Baptisia, Nux Vomica, Arsenic Album and Phosphorus have been found to be quite effective in the treatment of Ulcerative Colitis…

Merc Sol- One of the best homeopathic medicines for ulcerative colitis with blood and tenesmus

When there is too much bleeding with tenesmus and other symptoms, Merc Sol is one of the best homeopathic medicines for ulcerative colitis. There are frequent stools with blood being discharged almost every time. The patient is a sweaty sort of patient who keeps on sweating most of the time. Creeping sort of chilliness may be felt in the back.

Nux Vomica- One of the best homeopathic remedies for ulcerative colitis due to high life

When the problem has occurred from living a high life, Nux Vomica is one of the best homeopathic remedies for ulcerative colitis. Excess of alcohol, stimulants like tea and coffee, late night partying and other habits incident to modern lifestyle can contribute to such a problem. The patient is usually a chilly sort of patient who cannot tolerate cold. He is unusually angry and that too at trifles.

Arsenic Album – One of the best homeopathic medicines for ulcerative colitis with anxiety and restlesness

When the predominant symptoms are the mental symptoms of anxiety and restlessness, Arsenic Album is one of the best homeopathic medicines for ulcerative colitis. The patient gets anxious, worried and restless for no rhyme or reason. There may be weakness which may be disproportionately more than the problem. There is increased thirst for water, though the patient takes a small quantity or a sip at a time.

Baptisia – One of the best homeopathic remedy for ulcerative colitis with low grade fever

When there is low grade fever present along with other symptoms, Baptisia is one of the best homeopathic remedy for ulcerative colitis. The patient has great muscular soreness all over the body as if bruised and beaten. Appetite is reduced or next to nil. At the same time, there is constant desire for water. Stools are very offensive, thin and watery.

Phosphorus – One of the best homeopathic medicine for ulcerative colitis with increased thirst for cold water

When there is intense thirst for cold water, Phosphorus is one of the best homeopathic medicine for ulcerative colitis. The patient is usually tall and thin. The diarrhoea is copious. Stool is watery and profuse bleeding may be present. Patient feels too weak and more so after passing a stool.

The ‘HOMEOPATHIC DOCTOR’s first statement was ‘in my experience…’? Unfortunately most patients will not understand what this expression truly means when written by a homeopath. It means THERE IS NOT A JOT OF EVIDENCE FOR ANY OF THIS. Had he stated this clearly, it would probably have been the only correct sentence in the whole article.

People who understand medicine a bit might laugh at such deluded clinicians and their weird, unethical recommendations. However, patients who are chronically ill and therefore desperate might take them seriously and follow their advice. Patients who suffer from potentially life-threatening diseases like ulcerative colitis might then cause serious damage to themselves or even die.

And this is precisely the reason why I will continue to expose these charlatans for what they are: irresponsible, unethical, uninformed, dangerous quacks

This recent report is worth a mention, I think:

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is aware that some chiropractors are advertising and attempting to turn breech babies in utero using the “Webster Technique”.

On 7 March 2016, the Chiropractic Board of Australia released the following statement in relation to chiropractic care of pregnant women and their unborn child:

“Care of pregnant patients

Chiropractors are not trained to apply any direct treatment to an unborn child and should not deliver any treatment to the unborn child. Chiropractic care must not be represented or provided as treatment to the unborn child as an obstetric breech correction technique.

RANZCOG supports the Chiropractic Board of Australia in its clear position that chiropractic care must not be represented or provided as a treatment to the unborn child as an obstetric breech correction technique. Chiropractors should not be using the “Webster Technique” or any other inappropriate breech correction technique to facilitate breech version as there is insufficient scientific evidence to support this practice.

In addition, RANZCOG does not support chiropractors treating pregnant women to reduce their risk of caesarean delivery. There is insufficient evidence to make any claims to consumers regarding the benefits of chiropractic treatment to reduce the risk of caesarean delivery. We commend the Chiropractic Board on their statement that:

“Advertisers must ensure that any statements and claims made in relation to chiropractic care are not false, misleading or deceptive or create an unreasonable expectation of beneficial treatment.”1

Recommendations for the management of a breech baby at term are outlined in the RANZCOG statement, Management of breech presentation at term

External Cephalic Version (ECV) is a procedure where a care provider puts his or her hands on the outside of the mother’s belly and attempts to turn the baby from breech to cephalic presentation. It is recommended that women with a breech presentation at or near term should be informed about external cephalic version (ECV) and offered it if clinically appropriate. Attempting cephalic version at term reduces the chance of non-cephalic presentation at birth, vaginal cephalic birth not achieved and caesarean section. There is not enough evidence from randomised trials to assess complications of ECV at term. Large observational studies suggest that complications are rare. ECV should only be performed by suitably trained health professionals where there is facility for emergency caesarean section. Each institution should have its own documented protocol for offering and performing ECVs.

This communiqué highlights the need for patients to be adequately informed when making health care choices.

END OF QUOTE

These are clear and badly needed words. As we have discussed often on this blog, chiropractors make all sorts of bogus claims. Those directed at children and unborn babies are perhaps the most nonsensical of them all. I applaud the College for their clear statements and hope that other institutions follow this example.

After > 200 years of existence, homeopathy still remains unproven – in fact, most rational thinkers would call it disproven. Today only homeopaths doubt this statement; they work hard to find a water-tight proof that might show the doubters to be wrong.

What is better suited for this purpose than a few rigorous animal experiments?

Engystol® is a popular homeopathic product promoted as an anti-viral agent manufactured by Heel GmbH, Baden-Baden, Germany. In several in vivo and in vitro studies, it apparently affected an immune response. This new study was to “evaluate the innate and adaptive immuno-modulatory effects of oral Engystol® (1 or 10 tablets/L water consumed), prior to and post antigenic challenge in a mouse model with a well-characterized and clinically measureable immune system.”

The investigators first evaluated the murine immune response when oral Engystol® was given alone for 28 days. to mice. The animals were then challenged with an antigen-specific H5N1 HA vaccine while on Engystol® for an additional 33 days. Serum and supernatants from cultured splenic lymphocytes were collected and screened with a 32-cytokine panel. Serum vaccine epitope-specific IgG titers plus T cell and B cell phenotypes from splenic tissue were also evaluated.

The results showed that Engystol® alone did not alter immunity. However, upon vaccine challenge, Engystol® decreased CD4+/CD8+ ratios, altered select cytokines/chemokines, and anti-H5N1 HA IgG titers were increased in the group of mice receiving 10 tablet/L.

The authors concluded that “these data suggest that Engystol® can modulate immunity upon antigenic challenge.”

Engystol is being advertised as “a homeopathic preparation which has been scientifically proven to significantly reduce the duration and severity of symptoms during an acute viral infection and help protect from subsequent infections.” I was unable find good evidence for this claim and therefore have to assume that it is bogus. The only human trial I was able to locate was this one:

OBJECTIVE:

To compare the effects of a complex homeopathic preparation (Engystol; Heel GmbH, Baden-Baden, Germany) with those of conventional therapies with antihistamines, antitussives, and nonsteroidal antiinflammatory drugs on upper respiratory symptoms of the common cold in a setting closely related to everyday clinical practice.

DESIGN:

Nonrandomized, observational study over a treatment period of maximally two weeks.

SETTING:

Eighty-five general and homeopathic practices in Germany.

PARTICIPANTS:

Three hundred ninety-seven patients with upper respiratory symptoms of the common cold.

INTERVENTIONS:

Engystol-based therapy or common over-the-counter treatments for the common cold. Patients receiving this homeopathic treatment were allowed other short-term medications, but long-term use of analgesics, antibiotics, and antiinflammatory agents was not permitted. Patients were allowed nonpharmacological therapies such as vitamins, thermotherapies, and others.

MAIN OUTCOME MEASURES:

The effects of treatment were evaluated on the variables fatigue, sensation of illness, chill/tremor, aching joints, overall severity of illness, sum of all clinical variables, temperature, and time to symptomatic improvement.

RESULTS:

Both treatment regimens provided significant symptomatic relief, and this homeopathic treatment was noninferior in a noninferiority analysis. Significantly more patients (P < .05) using Engystol-based therapy reported improvement within 3 days (77.1% vs 61.7% for the control group). No adverse events were reported in any of the treatment groups.

CONCLUSION:

This homeopathic treatment may be a useful component of an integrated symptomatic therapy for the common cold in patients and practitioners choosing an integrative approach to medical care.

Let me comment on the human study first. It is an excellent example of the bias that can be introduced by non-randomization. The patients in the homeopathic group obviously were those who chose to be treated homeopathically. Consequently they had high expectations in this therapy. Consequently they reported better results than the control group. In other words the reported outcomes have nothing to do with the homeopathic remedy.

But what about the animal study? Animals, we hear so often, do not exhibit a placebo response. Does that render this investigation any more reliable?

The answer, I am afraid is no.

The animal study in question had no control group at all. Therefore a myriad of factors could have caused the observed result. This study is very far from a poof of homeopathy!

But even if the findings of the two studies had not been the result of bias and confounding, I would be more than cautious about viewing them as anything near conclusive. The reason lies in the nature of this particular homeopathic remedy.

Engystol® contains Vincetoxicum hirundinaria (D6), Vincetoxicum hirundinaria (D10), Vincetoxicum hirundinaria (D30), sulphur (D4) and sulphur (D10). In other words, it is one of those combination remedies which are not sufficiently dilute to be devoid of active molecules. Sulphur D4, for instance, means that the remedy contains one part of sulphur in 10 000 parts of diluent. It is conceivable, even likely that such a concentration might affect certain immune parameters, I think.

And my conclusion from all this?

The proof of homeopathy – if it ever came – would need to be based on investigations that are more rigorous than these two rather pathetic studies.

At first, I thought this survey would be yet another of those useless and boring articles that currently seem to litter the literature of alternative medicine. It’s abstract seemed to confirm my suspicion: “Fifty-two chiropractors in Victoria, Australia, provided information for up to 100 consecutive encounters. If patients attended more than once during the 100 encounters, only data from their first encounter were included in this study. Where possible patient characteristics were compared with the general Australian population…” But then I saw that the chiropractors were also asked to record their patients’ main complaints. That, I thought, was much more interesting, and I decided to do a post that focusses on this particular point.

The article informs us that 72 chiropractors agreed to participate (46 % response rate of eligible chiropractors approached). During the study, 20 (28 %) of these chiropractors withdrew and did not provide any data. Fifty two chiropractors (72 % of those enrolled) completed the study, providing information for 4464 chiropractor-patient encounters. Of these, 1123 (25 %) encounters were identified as repeat patient encounters during the recording period and were removed from further analyses, leaving 3287 unique patients.

The results that I want to focus on indicated that chiropractors give the following reasons for treating patients:

  • maintenance: 39%
  • spinal problems: 33%
  • neck problems: 18%
  • shoulder problems: 6%
  • headache: 6%
  • hip problems: 3%
  • leg problems: 3%
  • muscle problems: 3%
  • knee problems: 2%

(the percentage figures refer to the percentages of patients with the indicated problem)

Yes, I know, there is lots to be criticised about the methodology used for this survey. But let’s forget about this for the moment and focus on the list of reasons or indications which these chiropractors give for treating patients. For which of these is there enough evidence to justify this decision and the fees asked for the interventions? Here is my very quick run-down of the evidence:

  • maintenance: no good evidence.
  • spinal problems: if they mean back pain by this nebulous term, an optimist might grant that there is some promising but by no means conclusive evidence.
  • neck problems: again some promising but by no means conclusive evidence.
  • shoulder problems: no good evidence.
  • headache: again some promising but by no means conclusive evidence
  • hip problems: no good evidence.
  • leg problems: no good evidence.
  • muscle problems: no good evidence.
  • knee problems: no good evidence.

As I said, this is merely a very quick assessment. I imagine that many chiropractors will disagree with it – and I invite them to present their evidence in the comments section below. However, if I am correct (or at least not totally off the mark), this new survey seems to show that most of the things these chiropractors do is not supported by good evidence. One could be more blunt and phrase this differently:

  • these chiropractors are misleading their patients;
  • they are not behaving ethically;
  • they are not adhering to EBP.

Yes, we (I mean rationalists who know about EBM) did suspect this all along – but now we can back it up with quite nice data from a recent survey done by chiropractors themselves.

I have moaned about the JACM several times on this blog (for instance here). It is a very poor journal, in my view, but it nevertheless is important because it is the one with the highest impact factor in this field. Despite all this I missed something important that recently happened to the JACM: a few months ago, it got a new editor in chief: John Weeks.

Had I been more attentive, I would have known this already in May when Weeks wrote in the HuffPo this: “I was asked a month ago, out of the blue, if I would like to become editor-in-chief of the first peer-reviewed, indexed journal in what is now the “integrative health and medicine” field. The journal was born 20 years ago when — as my father would have put it — “integrative medicine” was hardly a gleam in anyone’s eye. The publication is the Journal of Alternative and Complementary Medicine.”

I have a vague memory of meeting him once at a conference and sitting next to him during a dinner. For those who haven’t heard of him, here is how he once described himself:

I have been involved as an organizer-writer in the emerging fields of complementary, alternative and integrative medicine since 1983. Happily, I have learned some things. I was once called an “expert in alternative medicine” by Medical Economics and later an “alternative care (integration) expert” by Modern Healthcare. The name-calling was proud-making, even if I was so-dubbed by reporters who were on their first forays into the field.

Both anointed me before I went on sabbatical in Costa Rica and later Nicaragua with my family in 2002. Part of the reason for sabbatical was that whatever expertise I may have developed often ran frustratingly short of being able to offer robust, successful business models with readers and clients. More than once I counseled people against the initiatives they planned. Trends taught me to recognize the invisible handwriting of a sure failure event behind the bubbling enthusiasm of an initiate. I needed a break from the work. My family and I took it!

I was away from the United States for three years. I had my hand back in things for the last 2.5 years. I assisted a philanthropist on her integrative medicine investments in community clinics, CAM schools and academic health centers. From early 2004 forward, and out of home offices in Monteverde, Costa Rica, and then Granada, Nicaragua, I helped organize and direct the National Education Dialogue to Advance Integrated Health Care: Creating Common Ground

END OF QUOTE

Is Weeks going to be a good editor who throws out all the trash that JACM has been publishing on a far too regular basis? Well, the good news, I suppose, is that he cannot possibly be worse than his predecessor. Perhaps we should see for ourselves what the new man thinks and writes. Here is an excerpt from his recent editorial on the question of medical errors in conventional medicine and the role of integrative medicine in this difficult issue:

[A] whole-system solution to medical errors suggests many roles for traditional, alternative, complementary, and integrative approaches and practices. First, better use of these new therapies and provider types expands the tools and strategies for keeping the locus of care out in communities instead of in the problematic hospital environment. One of the commentators at Medscape for instance pointed out that when it comes to “errors” that lead to death, the most significant culprits are the errors individuals make in living the standard U.S. life-style. A starting place in limiting medical deaths is for us to take better care of ourselves. We’ll be less likely to need treatment or to be admitted if we do. The across-the-board engagement by multiple integrative and traditional medicine practitioners with life-style medicine, there are clearly important roles for integrative and traditional practices and practitioners.

More evidence that integrative practice keeps people healthy and out of hospitals would be useful. Our research needs to capture these life-changing outcomes better. The values movement is toward primary care and community medicine. Outpatient care offers a home-field advantage for traditional medical systems and licensed integrative health practitioners, from yoga and massage therapists to acupuncture and Oriental medicine specialists and integrative, chiropractic, and naturopathic doctors. And when people are admitted to hospitals, broader integrative teams need to be available to catch, hold, and treat the whole person and help keep them from being biomedically reduced. Such efforts would be served by research data that measure quadruple-aim outcomes. Think patient experience, enhancing life-style skills, faster healing times, diminished hospital stays, and more pleasure of practitioners in their caregiving. Some have begun gathering these outcomes. We need bushels more. We’ll also have a growing need for reports that delineate processes and obstacles overcome in highly functioning integrative care teams.

The whole-system response to medical deaths is opening minds and doors to integrative practices and to leadership from the integrative community. In one remarkable example, the state of Oregon is seeking to reduce the morbidity and mortality associated with opioids through prioritizing the care of chiropractors, acupuncturists, and massage and yoga therapists. To maximize our effectiveness as agents of change in helping create health in those we serve, more of us need to study up on the emerging language, goals, and methods of the value-based movement, then match up to these aims in our study designs and selections of outcomes. Advancing whole-person care and linking to the emerging values appear to be our best opportunities to help shape the path away from death and toward safety and health.

END OF QUOTE

Impressed? Me neither!

In my view, this reads like an accumulation of platitudes, wishful thinking and uncritical waffling. The passage that I found positively worrying was this one: More evidence that integrative practice keeps people healthy and out of hospitals would be useful. Our research needs to capture these life-changing outcomes better. The editor of a medical journal should, I think, know that research is not for confirming beliefs but for testing hypotheses. In all this verbose rambling, I really cannot find a good reason why integrative medicine might have a role in reducing medical errors. More worrying still, I cannot find a trace of critical thinking.

As I was writing this, I remembered more about the only personal encounter I had with Weeks years ago. For some reason we talked about THE ‘textbook’ of naturopaths, entitled THE TEXTBOOK OF NATURAL MEDICINE. I remember explaining to Weeks that it contained a lot of factual errors and outright nonsense. He very much disputed my view, seemed to take it personally, and even got quite stroppy. In the end, we agreed to disagree.

Neither this episode nor indeed the editorial are all that important – we will simply have to wait and see how the JACM does under its new editor.

This article in THE DAILY MAIL caught my eye. It’s about ear-candles, a subject we have discussed before on this blog. Apparently, the ‘TV doctor’ Dawn Harper was had to apologise after recommending ear candling for clearing ears of wax. This prompted various protests from listeners of her programme one of whom even called Dr Harper a ‘dangerous quack’. Dr  Harper apologised to listeners by saying: ‘It was recommended to me by an ENT surgeon but seems to have fallen from favour. I’ll discuss next week.’

One would think that this is a non-story, but not for THE DAILY MAIL. The paper continues by citing my article published in 2004:

Edzard Ernst, an expert in the study of alternative medicine and former professor at the University of Exeter, has published an article entitled ‘Ear candles: a triumph of ignorance over science’ and said there is no evidence they work.

He said a study of ear candles show that its ‘mode of action is implausible and demonstrably wrong’ while there was ‘no data to suggest that it is effective for any condition’.

He added: ‘The inescapable conclusion is that ear candles do more harm than good. Their use should be discouraged.’

He also points to a number of cases in which patients suffered injuries from the practice, including one woman, from London, who suffered hearing loss and another who burned a hole in her ear.

This seems fairly correct, except the quotes must be straight from my paper, because no MAIL journalist actually talked to me. This means that phraseology like ‘he said’ and ‘he added’ is misleading. But this is not what irritates me about the article (I have had enough contact with journalists to get excited about trivialities); the annoying bit, in my view, is what follows:

Ironically since the publication of Professor Ernst’s paper in 2004 ear candles have become more, not less, popular.

The manager of St James’ Beauty, a clinic that provides the treatment in London, said: ‘Everybody says they do work. Quite a lot comes out of the ears which is amazing.

‘People say their sinuses improve and their senses are better.

‘We don’t have very many, about one a month. But it does have a strong following because it’s been around for such a long time.’

Lynne Hatcher, a complementary health practitioner from Wolverhampton, claims ear candles are ‘a pleasant and non-invasive treatment of the ears, used to treat a variety of conditions’.

Writing on her website she adds: ‘This is an ancient and natural therapy handed down by many civilisations. It is believed that the Ancient Greeks used ear candles, initially probably for cleansing, purifying and healing on a spiritual basis, but much later on a purely physical basis.’

I know, journalists feel the need to create balance, and therefore always quote the ‘other side’. But there are instances where what they perceive as balance is really inappropriately false balance. In the above incidence, the MAIL quoted a total of 3 people they consider to be experts. My paper summarized the known facts. The MAIL then ‘balanced’ them with the opinions of two people who earn their money with ear-candles. Consequently, the article gives the impression that ear-candling is probably quite good after all. In truth, this is not creating balance but introducing bias.

This would, of course, be utterly trivial – if it would be an exception. But it is much more the rule, I am afraid. I have seen this hundreds of times in alternative medicine:

  • a journalist phones me to ask me for a quote,
  • I volunteer a factual quote that is easy to understand for a lay-person,
  • the journalist then phones several quacks who contradict the facts based on their opinions,
  • the quotes are then published such that the quacks have the last word,
  • the resulting article is published and turns out to be a promotion of quackery.

This is maddening, of course, but sometimes, it also has its humorous side: in the above case, THE MAIL starts by repeating the allegation against the TV-doctor being a quack; as the article progresses it becomes clear that the true quack is THE DAILY MAIL.

Since several years, there has been an increasingly vociferous movement within the chiropractic profession to obtain limited prescription rights, that is the right to prescribe drugs for musculoskeletal problems. A recent article by Canadian and Swiss chiropractors is an attempt to sum up the arguments for and against this notion. Here I have tried to distil the essence of the pros and contras into short sentences.

 1) Arguments in favour of prescription rights for chiropractors

1.1 Such privileges would be in line with current evidence-based practice. Currently, most international guidelines recommend, alongside prescription medication, a course of manual therapy and/or exercise as well as education and reassurance as part of a multi-modal approach to managing various spine-related and other MSK conditions.

1.2 Limited medication prescription privileges would be consistent with chiropractors’ general experience and practice behaviour. Many clinicians tend to recommend OTC medications to their patients in practice.

1.3 A more comprehensive treatment approach offered by chiropractors could potentially lead to a reduction in healthcare costs by providing additional specialized health care options for the treatment of MSK conditions. Namely, if patients consult one central practitioner who can effectively address and provide a range of treatment modalities for MSK pain-related matters, the number of visits to providers might be reduced, thereby resulting in better resource allocation.

1.4 Limited medication prescription rights could lead to improved cultural authority for chiropractors and better integration within the healthcare system.

1.5 With these privileges, chiropractors could have a positive influence on public health. For instance, analgesics and NSAIDs are widely used and potentially misused by the general public, and users are often unaware of the potential side effects that such medication may cause.

2) Arguments against prescription rights for chiropractors

2.1 Chiropractors and their governing bodies would start reaching out to politicians and third-party payers to promote the benefits of making such changes to the existing healthcare system.

2.2 Additional research may be needed to better understand the consequences of such changes and provide leverage for discussions with healthcare stakeholders.

2.3 Existing healthcare legislation needs to be amended in order to regulate medication prescription by chiropractors.

2.4 There is a need to focus on the curriculum of chiropractors. Inadequate knowledge and competence can result in harm to patients; therefore, appropriate and robust continuing education and training would be an absolute requirement.

2.5 Another important issue to consider relates to the divisiveness around this topic within the profession. In fact, some have argued that the right to prescribe medication in chiropractic practice is the profession’s most divisive issue. Some have argued that further incorporation of prescription rights into the chiropractic scope of practice will negatively impact the distinct professional brand and identity of chiropractic.

2.6 Such privileges would increase chiropractors’ professional responsibilities. For example, if given limited prescriptive authority, chiropractors would be required to recognize and monitor medication side effects in their patients.

2.7 Prior to medication prescription rights being incorporated into the chiropractic scope of practice worldwide, further discussions need to take place around the breadth of such privileges for the chiropractic profession.

In my view, some of these arguments are clearly spurious, particularly those in favour of prescription rights. Moreover, the list of arguments against this notion seems a little incomplete. Here are a few additional ones that came to my mind:

  • Patients might be put at risk by chiropractors who are less than competent in prescribing medicines.
  • More unnecessary NAISDs would be prescribed.
  • The vast majority of the drugs in question is already available OTC.
  • Healthcare costs would increase (just as plausible as the opposite argument made above, I think).
  • Prescribing rights would give more legitimacy to a profession that arguably does not deserve it.
  • Chiropractors would then continue their lobby work and soon demand the prescription rights to be extended to other classes of drugs.

I am sure there are plenty of further arguments both pro and contra – and I would be keen to hear them; so please post yours in the comments section below.

For some time now, the research activity in and around alternative medicine has been seemingly buoyant. In each of the last 4 years, Medline listed around 2 000 articles is the category of ‘complementary alternative medicine’. This will surely look impressive to many!

Why then did I write ‘seemingly’? To comprehend this a little better, we should have some comparisons. Here are numbers of Medline-listed articles published in 2015 for a few other areas:

  • Surgery: 176 277
  • Psychology: 65 679
  • Internal medicine: 36 998
  • Obstetrics/gynaecology: 13 818
  • Pharmacology: 194 322
  • Paediatrics: 30 646

Now you see, I hope, why the 2 049 Medline-listed articles in the category of ‘complementary alternative medicine’ are only seemingly impressive. But what about specific alternative therapies? Here are numbers of Medline-listed articles published in 2015 for some major alternative treatments:

  • Homeopathy: 181
  • Herbal medicine: 1 572
  • Chiropractic: 314
  • Acupuncture: 1 784
  • Naturopathy: 45
  • Dietary supplements: 5 199

These figures are perhaps interesting but not easy to interpret. They might indicate that certain sections of alternative medicine are more open to scientific scrutiny than others. Or do they show that for some areas there are more research funds and expertise than others? I am not sure I know the answer.

If we look a little closer at the research activity in defined alternative therapies, we are bound to get disappointed. I have recently done this for homeopathy and for acupuncture and reached rather gloomy conclusions.

In the case of homeopathy the were:

  1. The research activity into homeopathy is currently very subdued.
  2. Arguably the main research question of efficacy does not seem to concern researchers of homeopathy all that much.
  3. There is an almost irritating abundance of papers that are data-free and thrive on opinion (my category of ‘other papers’).
  4. Given all this, I find it hard to imagine that this area of investigation is going to generate much relevant new knowledge or clinical progress.

And in the case of acupuncture, I stated:

  • Too little research is focussed on the two big questions: efficacy and safety.
  • In relation to the meagre output in RCTs, there are too many systematic reviews.
  • As long as we cannot be sure that acupuncture is more than a placebo, all these pre-clinical studies seem a bit out of place.
  • The vast majority of the articles were in low or very low impact journals.
  • There was only one paper that I would consider outstanding.

And what about the quality of the research into alternative medicine?

Well, this is a sad and depressing tale! If you doubt it, read my previous post or indeed any of the other ~500 which I have written on this particular subject in the past.

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