MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

evidence

The UK ‘Society of Homeopaths’ (SoH) is the largest professional organisation of UK non-doctor, so-called lay- homeopaths. On their website, the SoH made very specific claims about homeopathy; in particular, they listed conditions for which homeopathy had allegedly been proven to be effective. These claims have now thoroughly been debunked, and the evidence the SoH produced in support of their claims has been shown to be misleading, cherry-picked or misinterpreted.

I have no idea who conducted the above-named investigation and made a youtube video of it, but I think it is essentially correct and well worth watching. My own experiences with the SoH relate mainly to two encounters.

The first was a complaint I made about one of their high-ranking officers, Ralf Jeutter. He had been promotiong homeopathic vaccinations on his website (needless to stress, I think, that there is no evidence to support the notion that homeopathic vaccinations are effective). As I felt that the SoH dragged their feet pursuing my complaint, I had to send several reminders. Eventually, they considered it and concluded that Reuter had done nothing wrong. This, presumably, is the reason why, even today, he can state on his website that Homeopathy is used to help individuals in dealing better with kinds of infections such as leptospirosis, meningitis and cholera. All is fine, it seems as long as a disclaimer is added: Any information obtained here is not to be construed as medical OR legal advice. The decision to vaccinate and how you implement that decision is yours and yours alone. The evidence for the efficacy of homeopathic immunisation is ‘anecdotal’. That means it is based on individuals’ reports past and present.

My second encounter with the SoH relates to my 2010 analysis of the SoH code of ethics and their adherence to it. The code demanded that:

 

  • ‘all speculative theories will be stated as such and clearly distinguished’
  • ‘no advertising may be used which expressly or implicitly claims to cure named diseases’
  • ‘Advertising shall not be false, fraudulent, misleading, deceptive, extravagant or sensational.’

Encouraged by these assurances, I decided to study the websites of some members of the SoH, and soon discovered numerous and very obvious violations of the above-mentioned imperatives. In an attempt to find the root of these transgressions, I scrutinised the SoH’s own website where I found a multitude violations on all levels of the SoH’s own code of ethics. Many of the violations related to claims which were not supported by evidence. In other words, the largest professional UK organisation of lay- homeopaths misled the public in several rather devious ways:

  • they pretended to adhere to a code of ethics which forbids members to mislead the public
  • SoH -members nevertheless did mislead the public in ways that public health at risk
  • and they did so not least because the SoH followed exactly the same strategy
  • thus the SoH violated its own code of ethics to the detriment of public health.

My analysis was conducted a while ago, and some might hope that the SoH has stopped systematically misleading the public. This hope, however, is harshly disappointed when you watch the brand-new video entitled TESTING HOMEOPATHY mentioned above. As the SoH is about to celebrate 35 years of wisdom, courage, knowledge and prosperity, I do wonder whether this should not be 35 years of dangerously misleading the public.

What do you think?

 

 

A lengthy article posted by THE HOMEOPATHIC COLLEGE recently advocated treating cancer with homeopathy. Since I doubt that many readers access this publication, I take the liberty of reproducing here their (also fairly lengthy) CONCLUSIONS in full:

Laboratory studies in vitro and in vivo show that homeopathic drugs, in addition to having the capacity to reduce the size of tumors and to induce apoptosis, can induce protective and restorative effects. Additionally homeopathic treatment has shown effects when used as a complementary therapy for the effects of conventional cancer treatment. This confirms observations from our own clinical experience as well as that of others that when suitable remedies are selected according to individual indications as well as according to pathology and to cell-line indications and administered in the appropriate doses according to the standard principles of homeopathic posology, homeopathic treatment of cancer can be a highly effective therapy for all kinds of cancers and leukemia as well as for the harmful side effects of conventional treatment. More research is needed to corroborate these clinical observations.

Homeopathy over almost two decades of its existence has developed more than four hundred remedies for cancer treatment. Only a small fraction have been subjected to scientific study so far. More homeopathic remedies need to be studied to establish if they have any significant action in cancer. Undoubtedly the next big step in homeopathic cancer research must be multiple comprehensive double-blinded, placebo-controlled, randomized clinical trials. To assess the effect of homeopathic treatment in clinical settings, volunteer adult patients who prefer to try homeopathic treatment instead of conventional therapy could be recruited, especially in cases for which no conventional therapy has been shown to be effective.

Many of the researchers conducting studies — cited here but not discussed — on the growing interest in homeopathic cancer treatment have observed that patients are driving the demand for access to homeopathic and other alternative modes of cancer treatment. So long as existing cancer treatment is fraught with danger and low efficacy, it is urgent that the research on and the provision of quality homeopathic cancer treatment be made available for those who wish to try it.

When I report about nonsense like that, I find it hard not to go into a fuming rage. But doing that would not be very constructive – so let me instead highlight (in random order) eight simple techniques that seem to be so common when unsubstantiated claims are being promoted for alternative treatments:

1) cherry pick the data

2) use all sorts of ‘evidence’ regardless how flimsy or irrelevant it might be

3) give yourself the flair of being highly scientific and totally impartial

4) point out how dangerous and ineffective all the conventional treatments are

5) do not shy away from overt lies

6) do not forget to stress that the science is in full agreement with your exhaustive clinical experience

7) stress that patients want what you are offering

8) ignore the biological plausibility of the underlying concepts

Provided we adhere to these simple rules, we can convince the unsuspecting public of just about anything – even of the notion that homeopathy is a cure for cancer!

A single, tiny mosquito can make my life a misery. It can rob me of a night’s sleep and turn me into a frantic lunatic. But now there is a remedy that, according to its manufacturer, makes my mosquito-phobia a distant memory. Mosquito-maniacs like myself can finally breathe a sigh of relief!

According to the manufacturer’s web-site, Mozi-Q is formula to reduce the frequency of bites as well as the reactions that people have to bites. No more itching and big red bumps! No more smelly sprays or stinky coils…what a great ally for camping, golfing, hiking, biking. This could revolutionize the whole outdoor experience! Some of the product’s features include:

  • It works within 30 minutes of taking it.
  • There are no side effects.
  • It works on other bugs aside from mosquitoes like ticks and head lice.
  • Product can be taken every 3-5 hours starting right before you go outside.
  • There are no contraindications.
  • Homeopathic medicine is by definition non-toxic…

Mozi-Q is a formula containing five homeopathic remedies:

  • Staphysagria
  • Ledum palustre
  • Urtica urens
  • Cedron 
  • Grindelia

They are in low C and D potencies, thereby acting at the physical level for their common indication, to reduce the frequency and severity of insect bites….

I am sure that most readers will, by now, ask themselves: is there any good evidence for these claims? The manufacturer’s site is pretty affirmative:

In the ’60s a homeopath by the name of HR. Trexler studied Staphysagria for its effectiveness at preventing mosquito bites. In a study of 421 subjects over a 4 year period, he found this remedy to be 90% effective…We have tested this remedy in our clinic over four mosquito seasons and found the response from the public confirmatory of Trexler’s findings.

Sounds great? Yes, but it turns out that the Trexler trial did not test the mixture contained in Mozi-Q at all; it used just one of its ingredients. Moreover, it seemed to have lacked a control group and therefore constitutes no reliable evidence. And the manufacturer’s own tests? I don’t know, they tell us nothing about them.

At this stage, the mosquito-phobe is disappointed. It seems to me that this product is not supported by sound evidence – more trick than treatment.

And why would this important? Because some people like me might lose a bit of sleep? No! It is important because mosquitos, ticks and other insects transmit diseases, some of which can be deadly. If someone claims that there is a preparation which protects us from insect-bites, some consumers will inevitably trust this claim. And this would not just be unfortunate; it could be life-threatening.

Swiss chiropractors have just published a clinical trial to investigate outcomes of patients with radiculopathy due to cervical disk herniation (CDH). All patients had neck pain and dermatomal arm pain; sensory, motor, or reflex changes corresponding to the involved nerve root and at least one positive orthopaedic test for cervical radiculopathy were included. CDH was confirmed by magnetic resonance imaging. All patients received regular neck manipulations.

Baseline data included two pain numeric rating scales (NRSs), for neck and arm, and the Neck Disability Index (NDI). At two, four and twelve weeks after the initial consultation, patients were contacted by telephone, and the data for NDI, NRSs, and patient’s global impression of change were collected. High-velocity, low-amplitude thrusts were administered by experienced chiropractors. The proportion of patients reporting to feel “better” or “much better” on the patient’s global impression of change scale was calculated. Pre-treatment and post-treatment NRSs and NDIs were analysed.

Fifty patients were included. At two weeks, 55.3% were “improved,” 68.9% at four and 85.7% at twelve weeks. Statistically significant decreases in neck pain, arm pain, and NDI scores were noted at 1 and 3 months compared with baseline scores. 76.2% of all sub-acute/chronic patients were improved at 3 months.

The authors concluded that most patients in this study, including sub-acute/chronic patients, with symptomatic magnetic resonance imaging-confirmed CDH treated with spinal manipulative therapy, reported significant improvement with no adverse events.

In the presence of disc herniation, chiropractic manipulations have been described to cause serious complications. Some experts therefore believe that CDH is a contra-indication for spinal manipulation. The authors of this study imply, however, that it is not – on the contrary, they think it is an effective intervention for CDH.

One does not need to be a sceptic to notice that the basis for this assumption is less than solid. The study had no control group. This means that the observed effect could have been due to:

a placebo response,

the regression towards the mean,

the natural history of the condition,

concomitant treatments,

social desirability,

or other factors which have nothing to do with the chiropractic intervention per se.

And what about the interesting finding that no adverse-effects were noted? Does that mean that the treatment is safe? Sorry, but it most certainly does not! In order to generate reliable results about possibly rare complications, the study would have needed to include not 50 but well over 50 000 patients.

So what does the study really tell us? I have pondered over this question for some time and arrived at the following answer: NOTHING!

Is that a bit harsh? Well, perhaps yes. And I will revise my verdict slightly: the study does tell us something, after all – chiropractors tend to confuse research with the promotion of very doubtful concepts at the expense of their patients. I think, there is a name for this phenomenon: PSEUDO-SCIENCE.

Australian researchers wanted to know whether acupuncture is effective for alleviating the symptoms of fibromyalgia, a common painful condition for which no universally accepted treatment exists. For this purpose, they conducted a Cochrane review. After extensive literature searches, they identified 9 RCTs, extracted their data and assessed risk of bias.

The results show that all studies except one were at low risk of selection bias; five were at risk of selective reporting bias; two were subject to attrition bias (favouring acupuncture); three were subject to performance bias (favouring acupuncture) and one to detection bias (favouring acupuncture).

Three studies utilised electro-acupuncture (EA) and the remainder manual acupuncture (MA) without electrical stimulation.

Low quality evidence from one study (13 participants) showed EA improved symptoms with no adverse events at one month following treatment.

Moderate quality evidence from six studies (286 participants) indicated that acupuncture (EA or MA) was no better than sham acupuncture, except for less stiffness at one month. Subgroup analysis of two studies (104 participants) indicated benefits of EA. Mean pain was 70 points on 0 to 100 point scale with sham treatment; EA reduced pain by 13% (5% to 22%).

Low-quality evidence from one study suggested that MA resulted in poorer physical function: mean function in the sham group was 28 points (100 point scale); treatment worsened function by a mean of 6 points.

Moderate quality evidence from one study (58 participants) found that, compared with standard therapy alone (antidepressants and exercise), adjunct acupuncture therapy reduced pain at one month after treatment.

Low quality evidence from one study (38 participants) showed a short-term benefit of acupuncture over antidepressants in pain relief.

Moderate-quality evidence from one study (41 participants) indicated that deep needling with or without deqi did not differ in pain, fatigue, function or adverse events.

Four studies reported no differences between acupuncture and control or other treatments described at six to seven months follow-up.

No serious adverse events were reported, but there were insufficient adverse events to be certain of the risks.

The authors draw the following conclusions: There is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia. There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being. EA is probably better than MA for pain and stiffness reduction and improvement of global well-being, sleep and fatigue. The effect lasts up to one month, but is not maintained at six months follow-up. MA probably does not improve pain or physical functioning. Acupuncture appears safe. People with fibromyalgia may consider using EA alone or with exercise and medication. The small sample size, scarcity of studies for each comparison, lack of an ideal sham acupuncture weaken the level of evidence and its clinical implications. Larger studies are warranted.

What does all that mean? In my view, it means that there is no sound evidence base for acupuncture as a treatment of fibromyalgia – or as we expressed it in our own systematic review of 2007: The notion that acupuncture is an effective symptomatic treatment for fibromyaligia is not supported by the results from rigorous clinical trials. On the basis of this evidence, acupuncture cannot be recommended for fibromyalgia.

In a recent comment, US chiropractors stated that there is a growing recognition within the profession that the practicing chiropractor must be able to do the following: formulate a searchable clinical question, rapidly access the best evidence available, assess the quality of that evidence, determine if it is applicable to a particular patient or group of patients, and decide if and how to incorporate the evidence into the care being offered. In a word, they believe, that evidence-based chiropractic is possible, perhaps even (almost) a reality. For evidence-based practice to penetrate and transform a profession, the penetration must occur at two levels, they explain. One level is the degree to which individual practitioners possess the willingness and basic skills to search and assess the literature.

The second level, the authors explain, relates to whether the therapeutic interventions commonly employed by a particular health care discipline are supported by clinical research. The authors believe that a growing body of randomized controlled trials provides evidence of the effectiveness and safety of manual therapies. Is this really true, I wonder.

In support of these fairly bold statements, they cite a paper by Bronfort et al which, in their view, is currently the most comprehensive review of the evidence for the efficacy of manual therapies. According to these authors, the ‘Bronfort-report’ stated that evidence is inconclusive for pneumonia, stage 1 hypertension, pre-menstrual syndrome, nocturnal enuresis, and otitis media. The authors also believe that it is unlikely manipulation of the neck is causally related to stroke.

When I read this article, I could not stop myself from giggling. It seems to me that it provides pretty good evidence for the fact that the chiropractic profession is nowhere near reaching the stage where anyone could reasonably claim that chiropractors practice evidence-based medicine – not even the authors themselves seem to abide by the rules of evidence-based medicine! If they had truly been able to access the best evidence available and assess the quality of that evidence surely they would not have (mis-) quoted the ‘Bronfort-report’.

Bronfort’s overview was commissioned by the General Chiropractic Council, it was hastily compiled by ardent believers of chiropractic, published in a journal that non-chiropractors would not touch with a barge pole, and crucially it lacks some of the most important qualities of an unbiased systematic review. In my view, it is nothing short of a white-wash and not worth the paper it was printed on. Conclusions, such as the evidence regarding pneumonia, bed-wetting and otitis is inconclusive are just embarrassing; the correct conclusion is that the evidence fails to be positive for these and most other indications.

Similarly, if the authors had really studied and quoted the best evidence, how on earth could they have stated that manipulation of the neck cannot cause a stroke? The evidence for that is fairly overwhelming, and the only open question here is, how often do such complications occur? And even the biased ‘Bronfort-report’ states: Adverse events associated with manual treatment can be classified into two categories: 1) benign, minor or non-serious and 2) serious. Generally those that are benign are transient, mild to moderate in intensity, have little effect on activities, and are short lasting. Most commonly, these involve pain or discomfort to the musculoskeletal system. Less commonly, nausea, dizziness or tiredness are reported. Serious adverse events are disabling, require hospitalization and may be life-threatening. The most documented and discussed serious adverse event associated with spinal manipulation (specifically to the cervical spine) is vertebrobasilar artery (VBA) stroke. Less commonly reported are serious adverse events associated with lumbar spine manipulation, including lumbar disc herniation and cauda equina syndrome.

Evidence-based practice? Who are these chiropractors kidding? This article very neatly reflects the exact opposite. It ignores hundreds of peer-reviewed papers which are critical of chiropractic. The best one can do with this paper, I think, is to use it as a hilarious bit of involuntary humour or as a classic example of cherry-picking.

Come to think of it, chiropractic and evidence-based practice are contradictions in terms. Either a therapist claims to adjust mystical subluxations, in which case he/she does not practice evidence-based medicine. Or he/she practices evidence-based medicine, in which case adjusting mystical subluxations cannot be part of their therapeutic repertoire.

Towards the end of the article, we learn further fascinating things: the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article – oh, really?!?! Furthermore, we are told that this ‘research’ was funded by the ‘National Center of Complementary and Alternative Medicine’ (NCCAM) of the National Institutes of Health.

Can it be true? Does the otherwise most respectable NIH really give its name for such overt nonsense? Yes, it is true, and it is by no means the first time. In fact, our analysis shows that, when it comes to chiropractic, this organisation has sponsored almost nothing but utter rubbish, and our conclusion was blunt: the criticism repeatedly aimed at NCCAM seems justified, as far as their RCTs of chiropractic is concerned. It seems questionable whether such research is worthwhile.

The NHS tells us that our “choices include more than just which GP or hospital to use. You also have choices about your treatment decisions…”  In most other countries, similarly confusing statements about PATIENT CHOICE are being made almost on a daily basis, often by politicians who have more ambition to win votes than to understand the complex issues at hand. Consequently, patients and consumers might be forgiven to assume that PATIENT CHOICE means we are all invited to indulge in the therapy we happen to fancy, while society foots the bill. Certainly, proponents of alternative medicine are fond of the notion that the principle of PATIENT CHOICE provides a ‘carte blanche’ for everyone who wants it to have homeopathy, Reiki, Bach Flower Remedies, crystal healing, or other bogus treatments – paid for, of course, by the taxpayer.

Reality is, however, very different. Anyone who has actually tried to choose his/her hospital will know that this is far from easy. And deciding what treatment one might employ for this or that condition is even less straight forward. Choice, it turns out, is a big word, but often it is just that: a word.

Yet politicians love their new mantra of PATIENT CHOICE; it is politically correct as it might give the taxpayer the impression that he/she is firmly installed in the driving seat. Consequently PATIENT CHOICE has become a slogan that is used to score points in public debates but that, in fact, is frequently next to meaningless. More often than not, the illusion of being in control has to serve as a poor substitute for actually being in control.

To imply that patients should be able to choose their treatment has always struck me as a little naïve, particularly in the way this is often understood in the realm of alternative medicine. Imagine you have a serious condition, say cancer: after you have come over the shock of this diagnosis, you begin to read on the Internet and consider your options. Should you have surgery or faith healing, chemotherapy or homeopathy, radiotherapy or a little detox?

Clearly PATIENT CHOICE, as paid for by society, cannot be about choosing between a realistic option and an unrealistic one. It must be confined to treatments which have all been shown to be effective. Using scarce public funds for ineffective treatments is nothing short of unethical. If, for a certain condition, there happen to be 10 different, equally effective and safe options, we may indeed have a choice. Alas, this is not often the case. Often, there is just one effective treatment, and in such instances the only realistic choice is between accepting or rejecting it.

And, anyway, how would we know that 10 different treatments are equally effective and safe? After going on the Internet and reading a bit about them, we might convince ourselves that we know but, in fact, very few patients have sufficient knowledge for making complex decisions of this nature. We usually need an expert to help us. In other words, we require our doctor to guide us through this jungle of proven benefits and potential risks.

Once we accept this to be true, we have arrived at a reasonable concept of what PATIENT CHOICE really means in relation to deciding between two or more treatments: the principle of shared decision making. And this  is a  fundamentally different concept from the naïve view of those alternative medicine enthusiasts who promote the idea that PATIENT CHOICE opens the door to opting for any unproven or disproven pseudo-therapy.

To be meaningful, ethical and responsible, choice needs to be guided by sound evidence – if not, it degenerates into irresponsible arbitrariness, and health care deteriorates into some kind of Russian roulette. To claim, as some fans of alternative medicine do, that the principle of PATIENT CHOICE gives everyone the right to use unproven treatments at the expense of the taxpayer is pure nonsense. But some extreme proponents of quackery go even further; they claim that the discontinuation of payment for treatments that have been identified as ineffective amounts to a dangerous curtailment of patients’ rights. This, I think, is simply a cynical attempt to mislead the public for the selfish purpose of profit.

A cult can be defined not just in a religious context, but also as a” usually nonscientific method or regimen claimed by its originator to have exclusive or exceptional power in curing a particular disease.” After ~20 years of researching this area, I have come to suspect that much of alternative medicine resembles a cult – a bold statement, so I better explain.

One characteristic of a cult is the unquestioning commitment of its members to the bizarre ideas of their iconic leader. This, I think, chimes with several forms alternative medicine. Homeopaths, for instance, very rarely question the implausible doctrines of Hahnemann who, to them, is some sort of a semi-god. Similarly, few chiropractors doubt even the most ridiculous assumptions of their founding father, D D Palmer who, despite of having been a somewhat pathetic figure, is uncritically worshipped. By definition, a cult-leader is idealised and thus not accountable to anyone; he (yes, it is almost invariably a male person) cannot be proven wrong by logic arguments nor by scientific facts. He is quite simply immune to any form of scrutiny. Those who dare to disagree with his dogma are expelled, punished, defamed or all of the above.

Cults tend to brain-wash their members into unconditional submission and belief. Likewise, fanatics of alternative medicine tend to be brain-washed, i.e. systematically misinformed to the extend that reality becomes invisible. They unquestioningly believe in what they have been told, in what they have read in their cult-texts, and in what they have learnt from their cult-peers. The effects of this phenomenon can be dramatic: the powers of discrimination of the cult-member are reduced, critical questions are discouraged, and no amount of evidence can dissuade the cult-member from abandoning even the most indefensible concepts. Internal criticism is thus by definition non-existent.

Like religious cults, many forms of alternative medicine promote an elitist concept. Cult-members become convinced of their superiority, based not on rational considerations but on irrational beliefs. This phenomenon has a range of consequences. It leads to the isolation of the cult-member from the rest of the world. By definition, critics of the cult do not belong to the elite; they are viewed as not being able to comprehend the subtleties of the issues at hand and are thus ignored or not taken seriously. For cult-members, external criticism is thus non-existent or invalid.

Cult-members tend to be on a mission, and so are many enthusiasts of alternative medicine. They use any conceivable means to recruit new converts. For instance, they try to convince family, friends and acquaintances of their belief in their particular alternative therapy at every conceivable occasion. They also try to operate on a political level to popularize their cult. They cherry pick data, often argue emotionally rather than rationally, and ignore all arguments which contradict their belief system.

Cult-members, in their isolation from society, tend to be assume that there is little worthy of their consideration outside the cult. Similarly, enthusiasts of alternative medicine tend to think that their treatment is the only true method of healing. Therapies, concepts and facts which are not cult-approved are systematically defamed. An example is the notion of BIG PHARMA which is employed regularly in alternative medicine. No reasonable person assumes that the pharmaceutical industry smells of roses. However, the exaggerated and systematic denunciation of this industry and its achievements is a characteristic of virtually all branches of alternative medicine. Such behaviour usually tells us more about the accuser than the accused.

There are many other parallels between a  cult and alternative medicine, I am sure. In my view, the most striking one must be the fact that any spark of cognitive dissonance in the cult-victim is being extinguished by highly effective and incessant flow of misinformation which often amounts to a form of brain-washing.

A recent post of mine seems to have stimulated a lively discussion about the question IS THERE ANY GOOD EVIDENCE AT ALL FOR OSTEOPATHIC TREATMENTS? By and large, osteopaths commented that they are well aware that their signature interventions for their most frequently treated condition (back pain) lack evidential support and that more research is needed. At the same time, many osteopaths seemed to see little wrong in making unsubstantiated therapeutic claims. I thought this was remarkable and feel encouraged to write another post about a similar topic.

Most osteopaths treat children for a wide range of conditions and claim that their interventions are helpful. They believe that children are prone to structural problems which can be corrected by their interventions. Here is an example from just one of the numerous promotional websites on this topic:

STRUCTURAL  PROBLEMS, such as those affecting the proper mobility and function of the  body’s framework, can lead to a range of problems. These may include:

  • Postural – such as scoliosis
  • Respiratory  – such as asthma
  • Manifestations of brain  injury – such as cerebral palsy and spasticity
  • Developmental  – with delayed physical or intellectual progress, perhaps triggering learning  behaviour difficulties
  • Infections – such  as ear and throat infections or urinary disturbances, which may be recurrent.

OSTEOPATHY can assist in the prevention of health problems, helping children to make a smooth  transition into normal, healthy adult life.

As children cannot give informed consent, this is even more tricky than treating adults with therapies of questionable value. It is therefore important, I think, to ask whether osteopathic treatments of children is based on evidence or just on wishful thinking or the need to maximise income. As it happens, my team just published an article about these issues in one of the highest-ranking paediatrics journal.

The objective of our systematic review was to critically evaluate the effectiveness of osteopathic manipulative treatment (OMT) as a treatment of paediatric conditions. Eleven databases were searched from their respective inceptions to November 2012. Only randomized clinical trials (RCTs) were included, if they tested OMT against any type of control intervention in paediatric patients. The quality of all included RCTs was assessed using the Cochrane criteria.

Seventeen trials met our inclusion criteria. Only 5 RCTs were of high methodological quality. Of those, 1 favoured OMT, whereas 4 revealed no effect compared with various control interventions. Replications by independent researchers were available for two conditions only, and both failed to confirm the findings of the previous studies. Seven RCTs suggested that OMT leads to a significantly greater reduction in the symptoms of asthma, congenital nasolacrimal duct obstruction, daily weight gain and length of hospital stay, dysfunctional voiding, infantile colic, otitis media, or postural asymmetry compared with various control interventions. Seven RCTs indicated that OMT had no effect on the symptoms of asthma, cerebral palsy, idiopathic scoliosis, obstructive apnoea, otitis media, or temporo-mandibular disorders compared with various control interventions. Three RCTs did not report between-group comparisons. The majority of the included RCTs did not report the incidence rates of adverse-effects.

Our conclusion is likely to again dissatisfy many osteopaths: The evidence of the effectiveness of OMT for paediatric conditions remains unproven due to the paucity and low methodological quality of the primary studies.

So, what does this tell us? I am sure osteopaths will disagree, but I think it shows that for no paediatric condition do we have sufficient evidence to show that OMT is effective. The existing RCTs are mostly of low quality. There is a lack of independent replication of the few studies that suggested a positive outcome. And to make matters even worse, osteopaths seem to be violating the most basic rule of medical research by not reporting adverse-effects in their clinical trials.

I rest my case – at least for the moment.

Antioxidant vitamins include vitamin E, beta-carotene, and vitamin C. They are often recommended and widely used for preventing major cardiovascular outcomes. However, the effect of antioxidant vitamins on cardiovascular events remains unclear. There is plenty of evidence but the trouble is that it is not always of high quality and confusingly contradictory. Consequently, it is possible to cherry-pick the studies you prefer in order to come up with the answer you like. That this approach is counter-productive should be obvious to every reader of this blog. Only a rigorous systematic review can provide an answer that is as reliable as possible with the data available to date. Chinese researchers have just published such an assessment.

They searched PubMed, EmBase, the Cochrane Central Register of Controlled Trials, and the proceedings of major conferences for relevant investigations. To be eligible, studies had to be randomized, placebo-controlled trials reporting on the effects of antioxidant vitamins on cardiovascular outcomes. The primary outcome measures were major cardiovascular events, myocardial infarction, stroke, cardiac death, total death, and any adverse events.

The searches identified 293 articles of which 15 RCTs reporting data on 188209 participants met the inclusion criteria. In total, these studies reported 12749 major cardiovascular events, 6699 myocardial infarction, 3749 strokes, 14122 total death, and 5980 cardiac deaths. Overall, antioxidant vitamin supplementation, as compared to placebo, had no effect on major cardiovascular events (RR, 1.00; 95% CI, 0.96-1.03), myocardial infarction (RR, 0.98; 95% CI, 0.92-1.04), stroke (RR, 0.99; 95% CI, 0.93-1.05), total death (RR, 1.03; 95% CI, 0.98-1.07), cardiac death (RR, 1.02; 95% CI, 0.97-1.07), revascularization (RR, 1.00; 95% CI, 0.95-1.05), total CHD (RR, 0.96; 95% CI, 0.87-1.05), angina (RR, 0.98; 95% CI, 0.90-1.07), and congestive heart failure (RR, 1.07; 95% CI, 0.96 to 1.19).

The authors’ conclusion from these data could not be clearer: Antioxidant vitamin supplementation has no effect on the incidence of major cardiovascular events, myocardial infarction, stroke, total death, and cardiac death.

Few subjects in the realm of nutrition have attracted as much research during recent years as did antioxidants, and it is hard to think of a disease for which they are not recommended by this expert or another. Cardiovascular disease used to be the flag ship in this fleet of conditions; not so long ago, even the conventional medical wisdom sympathized with the notion that the regular supplementation of our diet with antioxidant vitamins might reduce the risk of cardiovascular disease and mortality.

Today, the pendulum has swung back, and it now seems to be mostly the alternative scene that still swears by antioxidants for that purpose. Nobody doubts that antioxidants have important biological functions, but this excellent meta-analysis quite clearly and fairly convincingly shows that buying antioxidant supplements is a waste of money. It does not promote cardiovascular health, it merely generates very expensive urine.

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