MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

Healing Touch

Daniel P Wirth used to be THE star amongst researchers and proponents of paranormal healing. About 15 years ago, there was nobody who had published more studies of it than Wirth. The extraordinary phenomenon was not just the number of studies, but also the fact that these trials all reported positive findings.

At the time, this puzzled me a lot. I had conducted two trials of paranormal healing myself; and, in both, cases the results had turned out to be negative (see here and here). Thus I made several attempts to contact Wirth or his co-authors hoping to better understand the phenomenon. Yet I never received a reply and became increasingly suspicious of their research.

In 2004, it was announced that Wirth together with one of his co-workers had been arrested and later imprisoned for fraud. Several of his 20 papers published in various journals were subsequently withdrawn. I remember writing to several journal editors myself urging them to follow suit so that, in future, the literature would not be polluted with dubious studies. Eventually, we all forgot about the whole story.

Recently, I took a renewed interest in paranormal healing. To my surprise, I found that several of Wirth’s papers are still listed on Medline:

1 Does prayer influence the success of in vitro fertilization-embryo transfer? Report of a masked, randomized trial.

Cha KY, Wirth DP.

J Reprod Med. 2001 Sep;46(9):781-7. Erratum in: J Reprod Med. 2004 Oct;49(10):100A. Lobo, RA [removed].

PMID: 11584476

2 Multisite electromyographic analysis of therapeutic touch and qigong therapy.

Wirth DP, Cram JR, Chang RJ.

J Altern Complement Med. 1997 Summer;3(2):109-18.

PMID: 9395700

3 Multisite surface electromyography and complementary healing intervention: a comparative analysis.

Wirth DP, Cram JR.

J Altern Complement Med. 1997 Winter;3(4):355-64.

PMID: 9449057

4 Wound healing and complementary therapies: a review.

Wirth DP, Richardson JT, Eidelman WS.

J Altern Complement Med. 1996 Winter;2(4):493-502. Review.

PMID: 9395679

5 The significance of belief and expectancy within the spiritual healing encounter.

Wirth DP.

Soc Sci Med. 1995 Jul;41(2):249-60.

PMID: 7667686

6 Complementary healing intervention and dermal wound reepithelialization: an overview.

Wirth DP.

Int J Psychosom. 1995;42(1-4):48-53.

PMID: 8582812

7 The psychophysiology of nontraditional prayer.

Wirth DP, Cram JR.

Int J Psychosom. 1994;41(1-4):68-75.

PMID: 7843870

8 Complementary healing therapies.

Wirth DP, Barrett MJ.

Int J Psychosom. 1994;41(1-4):61-7.

PMID: 7843869

Multi-site electromyographic analysis of non-contact therapeutic touch.

Wirth DP, Cram JR.

Int J Psychosom. 1993;40(1-4):47-55.

PMID: 8070986

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Of these 9 papers, only the first one in the list carries a note indicating that the paper has been removed. In other words, 8 of Wirth’s articles are still available as though they are fine and proper.

The situation is even worse on ‘Research Gate’. Here we find all of the following articles with no indication of any suspicion of fraud:

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Article: Does Prayer Influence the Success of in Vitro Fertilization-Embryo Transfer? Report of a Masked, Randomized Trial

KY Cha · Daniel P. Wirth · RA Lobo

Abstract: To assess the potential effect of intercessory prayer (IP) on pregnancy rates in women being treated with in vitro fertilization-embryo transfer (IVF-ET). Prospective, double-blind, randomized clinical trial in which patients and providers were not informed about the intervention. Statisticians and investigators were masked until all the data had been collected and clinical outcomes were known. The setting was an IVF-ET program at Cha Hospital, Seoul, Korea. IP was carried out by prayer…

Article · Oct 2001 · The Journal of reproductive medicine

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Article: Exploring Further Menstruation and Spiritual Healing

Daniel P. Wirth

Article · Apr 1997 · Alternative and Complementary Therapies

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Article: Multisite Surface Electromyography and Complementary Healing Intervention: A Comparative Analysis

Daniel P. Wirth · Jeffrey R. Cram

Abstract: A comparative analysis was conducted on a series of three experimental studies that examined the effect of various local and nonlocal (distant) complementary healing methods on multisite surface electromyographic (sEMG) and autonomic measures. The series concentrated sEMG electrode placement on specific neuromuscular paraspinal centers (cervical [C4], thoracic [T6], and lumbar [L3]), along with the frontalis region, due to the fact that these sites corresponded to the location of individual…

Article · Feb 1997 · The Journal of Alternative and Complementary Medicine

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Article: Multisite Electromyographic Analysis of Therapeutic Touch and Qigong Therapy

Daniel P. Wirth · Jeffrey R. Cram · Richard J. Chang

Abstract: The influence of complementary healing treatment on paraspinal electromagnetic activity at specific neuromuscular sites was examined in an exploratory pilot study that used a multisite surface electromyographic (sEMG) assessment procedure. The study was a replication and extension of previous research that indicated that complementary healing had a significant effect in normalizing the activity of the “end organ” for the central nervous system (CNS). Multisite sEMG electrodes were placed on…

Article · Feb 1997 · The Journal of Alternative and Complementary Medicine

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Article: Non-contact Therapeutic Touch intervention and full thickness cutaneous wounds: A replication

Daniel P Wirth · Joseph T. Richardson · Robert D. Martinez · William S. Eidelman · Maria E.L. Lopez

Abstract: The study described here utilized a randomized double-blind methodological protocol in order to examine the effect of non-contact therapeutic touch (NCTT) on the healing rate of full-thickness human dermal wounds. This study is the fifth experiment in a series of extensions based on the original research design, and is an exact methodological replication of the second study in the series. Thirty-two healthy subjects were randomly divided into treatment and control groups and biopsies were…

Article · Oct 1996 · Complementary Therapies in Medicine

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Article: Wound Healing and Complementary Therapies: A Review

Daniel P. Wirth · Joseph T. Richardson · William S. Eidelman

Abstract: A series of five innovative experiments conducted by Wirth et al. which examined the effect of various complementary healing interventions on the reepithelialization rate of full thickness human dermal wounds was assessed as to specific methodological and related factors. The treatment interventions utilized in the series included experimental derivatives of the Therapeutic Touch (TT), Reiki, LeShan, and Intercessory Prayer techniques. The results of the series indicated statistical…

Article · Feb 1996 · The Journal of Alternative and Complementary Medicine

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Article: Haematological indicators of complementary healing intervention

Daniel P. Wirth · Richard J. Chang · William S. Eidelman · Joanne B. Paxton

Abstract: The effect of Therapeutic Touch, Reiki, LeShan, and Qigong Therapy in combination on haematological measures was examined in an exploratory pilot study utilizing a randomized, double-blind, within-subject, crossover design. Fourteen subjects were randomly assigned to treatment and control conditions for two one-hour evaluation sessions separated by a 24-hour period. Six blood samples were taken from each subject — three during the treatment condition and three during the control condition —…

Article · Jan 1996 · Complementary Therapies in Medicine

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Article: The significance of belief and expectancy within the spiritual healing encounter

Daniel P. Wirth

Abstract: Historically, traditional cultures recognized the importance of belief and expectancy within the healing encounter and created complex rituals and ceremonies designed to elicit or foster the expectancy and participation of both the healer and patient, as well as the community as a whole. This holistic approach to health care was a fundamental component in the spiritual healing rituals of virtually all traditional native cultures. The focus of the current study was to assess the impact of…

Article · Aug 1995 · Social Science & Medicine

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Article: Non-contact Therapeutic Touch and wound re-epithelialization: An extension of previous research

Daniel P. Wirth · Margaret J Barrett · William S. Eidelman

Abstract: The results demonstrated a non-significant effect for the treatment versus control groups. Several factors may have contributed to the non-significance, including: the ineffectiveness of the healers, the inhibitive or dampening effect of plastic, the use of self-regulatory techniques, the dependent variable examined, the type of dressing utilized, the influence of distance, and the healers’ belief as to the effect of distance. Future studies would benefit by examining the methodological…

Article · Oct 1994 · Complementary Therapies in Medicine

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Article: The effect of complementary healing therapy on postoperative pain after surgical removal of impacted third molar teeth

Daniel P. Wirth · David R. Brenlan · Richard J. Levine · Christine M. Rodriguez

Abstract: This study utilized a randomized, double-blind, within subject, crossover design to examine the effect of Reiki and LeShan healing in combination on iatrogenic pain experienced after unilateral operative extraction of the lower third molar. Two separate operations were performed on 21 patients with bilateral, asymptomatic, impacted lower third molar teeth. The patients were randomly assigned to the treatment or control condition prior to the first operation. For the second operation,…

Article · Jul 1993 · Complementary Therapies in Medicine

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Article: Full thickness dermal wounds treated with non-contact Therapeutic Touch: a replication and extension

Daniel P. Wirth · Joseph T. Richardson · William S. Eidelman · Alice C. O’Malley

Abstract: The effect of non-contact Therapeutic Touch (NCTT) therapy on the healing rate of full thickness human dermal wounds was examined in a double-blind, placebo controlled study. Punch biopsies were performed on the lateral deltoid in 24 healthy subjects who were randomly assigned to treatment and control groups. Active and control treatments were comprised of daily sessions of 5 min of exposure to a hidden NCTT practitioner or control exposure. Placebo effects and the possible influences of…

Article · Jul 1993 · Complementary Therapies in Medicine

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Article: The Effect of Alternative Healing Therapy on the Regeneration Rate of Salamander Forelimbs

DANIEL P. WIRTH · CATHY A. JOHNSON · JOSEPH S. HORVATH

Article · Jan 1992

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Article: Complementary Healing Therapy For Patients With Type I Diabetes Mellitus

DANIEL P. WIRTH · BARBARA J. MITCHELL

Abstract: The effect of Noncontact Therapeutic Touch (NCTT) therapy and Intercessory Prayer (IP) on patient determined insulin dosage was exam- ined in an exploratory pilot study which utilized a randomized, double-blind, within subject, crossover design. Sixteen type I diabetes mellitus patients were examined and treated daily by NCTT and IP healers for a duration of two weeks. Each patient underwent two separate sessions-one in the treat- ment condition and one in the control condition-with the…

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What is even worse, Wirth’s papers continue to get cited. In other words, Wirth’s research lives on regardless of the fact that it is highly dubious.

In my view, it is long over-due for all journal-editors to fully and completely delete Wirth’s dubious papers. This is particularly true since several experts have alerted them to the problem. Furthermore, I submit that failing to take action  amounts to unethical behaviour which is quite simply unacceptable.

Therapeutic Touch is a therapy mostly popular with nurses. We have discussed it before, for instance here, here, here and here. To call it implausible would be an understatement. But what does the clinical evidence tell us? Does it work?

This literature review by Iranian authors was aimed at critically evaluating the data from clinical trials examining the clinical efficacy of therapeutic touch as a supportive care modality in adult patients with cancer.

Four electronic databases were searched from the year 1990 to 2015 to locate potentially relevant peer-reviewed articles using the key words therapeutic touch, touch therapy, neoplasm, cancer, and CAM. Additionally, relevant journals and references of all the located articles were manually searched for other potentially relevant studies.

The number of 334 articles was found on the basis of the key words, of which 17 articles related to the clinical trial were examined in accordance with the objectives of the study. A total of 6 articles were in the final dataset in which several examples of the positive effects of healing touch on pain, nausea, anxiety and fatigue, and life quality and also on biochemical parameters were observed.

The authors concluded that, based on the results of this study, an affirmation can be made regarding the use of TT, as a non-invasive intervention for improving the health status in patients with cancer. Moreover, therapeutic touch was proved to be a useful strategy for adult patients with cancer.

This review is badly designed and poorly reported. Crucially, its conclusions are not credible. Contrary to what the authors stated when formulating their aims, the methods lack any attempt of critically evaluating the primary data.

A systematic review is more than a process of ‘pea counting’. It requires a rigorous assessment of the risk of bias of the included studies. If that crucial step is absent, the article is next to worthless and the review degenerates into a promotional excercise. Sadly, this is the case with the present review.

You may think that this is relatively trivial (“Who cares what a few feeble-minded nurses do?”), but I would disagree: if the medical literature continues to be polluted by such irresponsible trash, many people (nurses, journalists, healthcare decision makers, researchers) who may not be in a position to see the fatal flaws of such pseudo-reviews will arrive at the wrong conclusions and make wrong decisions. This will inevitably contribute to a hindrance of progress and, in certain circumstances, must endanger the well-being or even the life of vulnerable patients.

Distant healing is one of the most bizarre yet popular forms of alternative medicine. Healers claim they can transmit ‘healing energy’ towards patients to enable them to heal themselves. There have been many trials testing the effectiveness of the method, and the general consensus amongst critical thinkers is that all variations of ‘energy healing’ rely entirely on a placebo response. A recent and widely publicised paper seems to challenge this view.

This article has, according to its authors, two aims. Firstly it reviews healing studies that involved biological systems other than ‘whole’ humans (e.g., studies of plants or cell cultures) that were less susceptible to placebo-like effects. Secondly, it presents a systematic review of clinical trials on human patients receiving distant healing.

All the included studies examined the effects upon a biological system of the explicit intention to improve the wellbeing of that target; 49 non-whole human studies and 57 whole human studies were included.

The combined weighted effect size for non-whole human studies yielded a highly significant (r = 0.258) result in favour of distant healing. However, outcomes were heterogeneous and correlated with blind ratings of study quality; 22 studies that met minimum quality thresholds gave a reduced but still significant weighted r of 0.115.

Whole human studies yielded a small but significant effect size of r = .203. Outcomes were again heterogeneous, and correlated with methodological quality ratings; 27 studies that met threshold quality levels gave an r = .224.

From these findings, the authors drew the following conclusions: Results suggest that subjects in the active condition exhibit a significant improvement in wellbeing relative to control subjects under circumstances that do not seem to be susceptible to placebo and expectancy effects. Findings with the whole human database suggests that the effect is not dependent upon the previous inclusion of suspect studies and is robust enough to accommodate some high profile failures to replicate. Both databases show problems with heterogeneity and with study quality and recommendations are made for necessary standards for future replication attempts.

In a press release, the authors warned: the data need to be treated with some caution in view of the poor quality of many studies and the negative publishing bias; however, our results do show a significant effect of healing intention on both human and non-human living systems (where expectation and placebo effects cannot be the cause), indicating that healing intention can be of value.

My thoughts on this article are not very complimentary, I am afraid. The problems are, it seems to me, too numerous to discuss in detail:

  • The article is written such that it is exceedingly difficult to make sense of it.
  • It was published in a journal which is not exactly known for its cutting edge science; this may seem a petty point but I think it is nevertheless important: if distant healing works, we are confronted with a revolution in the understanding of nature – and surely such a finding should not be buried in a journal that hardly anyone reads.
  • The authors seem embarrassingly inexperienced in conducting and publishing systematic reviews.
  • There is very little (self-) critical input in the write-up.
  • A critical attitude is necessary, as the primary studies tend to be by evangelic believers in and amateur enthusiasts of healing.
  • The article has no data table where the reader might learn the details about the primary studies included in the review.
  • It also has no table to inform us in sufficient detail about the quality assessment of the included trials.
  • It seems to me that some published studies of distant healing are missing.
  • The authors ignored all studies that were not published in English.
  • The method section lacks detail, and it would therefore be impossible to conduct an independent replication.
  • Even if one ignored all the above problems, the effect sizes are small and would not be clinically important.
  • The research was sponsored by the ‘Confederation of Healing Organisations’ and some of the comments look as though the sponsor had a strong influence on the phraseology of the article.

Given these reservations, my conclusion from an analysis of the primary studies of distant healing would be dramatically different from the one published by the authors: DESPITE A SIZABLE AMOUNT OF PRIMARY STUDIES ON THE SUBJECT, THE EFFECTIVENESS OF DISTANT HEALING REMAINS UNPROVEN. AS THIS THERAPY IS BAR OF ANY BIOLOGICAL PLAUSIBILITY, FURTHER RESEARCH IN THIS AREA SEEMS NOT WARRANTED.

There are many terms for this type of treatment: energy healing, Therapeutic Touch, Reiki, spiritual healing and para-normal healing are just some of the better-known ones. These interventions are based of the belief that some sort of ‘energy’ can be channelled by the healer into the body of the patient to assist its capacity for self-healing. Needless to say that their biological plausibility is suspiciously close to zero.

This new study was aimed at testing the effectiveness of energy healing on the well-being of patients and at assessing the influence on the results of participating in a randomized controlled trial. A total of 247 colorectal cancer patients were included in the trial. One half of them were randomized to either:

  • healing (RH) or
  • control (RC)

The other half of the patients was not randomized and had either:

  • self-selected healing (SH) or
  • self-selected control condition (SC)

All patients completed questionnaires assessing well-being Quality of Life (QoL), depressive symptoms, mood, and sleep quality), attitude toward complementary and alternative medicine (CAM), and faith/spirituality at baseline, 1 week, and 2 months post-intervention. Patients were also asked to indicate, at baseline, whether they considered QoL, depressive symptoms, mood, and sleep quality as important outcomes.

Compared with controls, no overall effect of healing were noted on QoL, depressive symptoms, mood, or sleep quality in the intervention groups (RH, SH). Effects of healing on mood were only found for patients who initially had a positive attitude toward CAM and considered the outcome in question as important.

The authors of this study arrived at the following conclusions: Whereas it is generally assumed that CAMs such as healing have beneficial effects on well-being, our results indicated no overall effectiveness of energy healing on QoL, depressive symptoms, mood, and sleep quality in colorectal cancer patients. Effectiveness of healing on well-being was, however, related to factors such as self-selection and a positive attitude toward the treatment.

Survey after survey shows that ‘energy healing’ is popular amongst cancer patients. But medicine is no popularity contest, and the existing clinical trials have mostly failed to show that these treatments work beyond a sometimes remarkably strong placebo-effect. Consequently, several systematic reviews have arrived at conclusions that were far from positive:

There is no robust evidence that Therapeutic Touch promotes healing of acute wounds

We found inconclusive evidence that interventions with spiritual or religious components for adults in the terminal phase of a disease may or may not enhance well-being

The serious methodological and reporting limitations of limited existing Reiki studies preclude a definitive conclusion on its effectiveness

…the majority do not and the evidence does not support a recommendation either in favour or against the use of intercessory prayer

 …the evidence is insufficient to suggest that reiki is an effective treatment for any condition. Therefore the value of reiki remains unproven

Since the publication of our previous systematic review in 2000, several rigorous new studies have emerged. Collectively they shift the weight of the evidence against the notion that distant healing is more than a placebo

This new and fairly rigorous trial clearly points in the same direction. Thus we a faced with the fact that these treatments are:

  1. utterly implausible
  2. not supported by good clinical evidence

What follows seems as simple as it is indisputable: energy healing is nonsense and does not merit further research.

Therapeutic Touch is an alternative therapy which is based on the notion of ‘energy healing’; it is thus akin to Reiki and other forms of spiritual healing. A recent survey from Canada suggested that such treatments are incredibly popular: over 50% of the families that were asked admitted using them for kids suffering from cancer.

The therapists using Therapeutic Touch, mostly nurses, believe to be able to channel ‘healing energy’ into the body of the patient which, in turn, is thought to stimulate the patient’s self-healing potential. Proponents of Therapeutic Touch claim that it is effective for a very wide range of conditions. Here is what one typical website by advocates states: As a healing modality Therapeutic Touch has been shown to be very effective in decreasing anxiety, decreasing stress, evoking the relaxation response, decreasing pain, and promoting wound healing. Therapeutic Touch as a method of healing is used by both professionals in the health field and laymen in the community.

There is a surprising amount of research on Therapeutic Touch. Unfortunately most of it is fatally flawed. It is therefore refreshing to see a new clinical study with a rigorous and straight forward design.

The objective of this trial was to determine whether Therapeutic Touch is efficacious in decreasing pain in preterm neonates. Fifty-five infants < 30 weeks’ gestational age participated in a randomized control trial in two neonatal intensive care units. Immediately before and after a painful heel lance procedure, the therapist performed non-tactile Therapeutic Touch with the infant behind curtains. In the sham condition, the therapist stood by the incubator without performing Therapeutic Touch. The Premature Infant Pain Profile was used for measuring pain and time for heart rate to return to baseline during recovery. Heart rate variability and stress response were secondary outcomes.

The results showed no group differences in any of the outcome measures. Mean Premature Infant Pain Profile scores across 2 minutes of heel lance procedure in 30-second blocks ranged from 7.92 to 8.98 in the Therapeutic Touch group and 7.64 to 8.46 in the sham group. The authors concluded that Therapeutic Touch given immediately before and after heel lance has no comforting effect in preterm neonates. Other effective strategies involving actual touch should be considered.

These findings are hardly surprising considering the implausibility of the ‘principles’ that underlie Therapeutic Touch. Nobody has so far been able to measure the mystical ‘energy’ that is the basis of this treatment. The only Cochrane review failed to show that Therapeutic touch works beyond placebo: There is no robust evidence that TT promotes healing of acute wounds.

Why then is Therapeutic Touch so popular? Part of the answer to this question might lie here: New Age spiritualism has co-opted some of the language of physics, including the language of quantum mechanics, in its quest to make ancient metaphysics sound like respectable science. The New Age preaches enhancing your vital energy, tapping into the subtle energy of the universe,or manipulating your biofield so that you can be happy, fulfilled, successful, and lovable, and so life can be meaningful, significant, and endless. The New Age promises you the power to heal the sick and create reality according to your will, as if you were a god.

The ‘Samueli Institute’ might be known to many readers of this blog; it is a wealthy institution that is almost entirely dedicated to promoting the more implausible fringe of alternative medicine. The official aim is “to create a flourishing society through the scientific exploration of wellness and whole-person healing“. Much of its activity seems to be focused on military medical research. Its co-workers include Harald Walach who recently was awarded a rare distinction for his relentless efforts in introducing esoteric pseudo-science into academia.

Now researchers from the Californian branch of the Samueli Institute have published an articles whic, in my view, is another landmark in nonsense.

Jain and colleagues conducted a randomized controlled trial to determine whether Healing Touch with Guided Imagery [HT+GI] reduced post-traumatic stress disorder (PTSD) compared to treatment as usual (TAU) in “returning combat-exposed active duty military with significant PTSD symptoms“. HT is a popular form of para-normal healing where the therapist channels “energy” into the patient’s body; GI is a self-hypnotic from of relaxation-therapy. While the latter approach might be seen as plausible and, at least to some degree, evidence-based, the former cannot.

123 soldiers were randomized to 6 sessions of HT+GI, while the control group had no such therapies. All patients also received standard conventional therapies, and the treatment period was three weeks. The results showed significant reductions in PTSD symptoms as well as depression for HT+GI compared to controls. HT+GI also showed significant improvements in mental quality of life and cynicism.

The authors concluded that HT+GI resulted in a clinically significant reduction in PTSD and related symptoms, and that further investigations of biofield therapies for mitigating PTSD in military populations are warranted.

The Samueli Institute claims to “support science grounded in observation, investigation, and analysis, and [to have] the courage to ask challenging questions within a framework of systematic, high-quality, research methods and the peer-review process“. I do not think that the above-named paper lives up to these standards.

As discussed in some detail in a previous post, this type of study-design is next to useless for determining whether any intervention does any good at all: A+B is always more than B alone! Moreover, if we test HT+GI as a package, how can we conclude about the effectiveness of one of the two interventions? Thus this trial tells us next to nothing about the effectiveness of HT, nor about the effectiveness of HT+GI.

Previously, I have argued that conducting a trial for which the result is already clear before the first patient has been recruited, is not ethical. Samueli Institute, however, claims that it “acts with the highest respect for the public it serves by ensuring transparency, responsible management and ethical practices from discovery to policy and application“. Am I the only one who senses a contradiction here?

Perhaps other research in this area might be more informative? Even the most superficial Medline-search brings to light a flurry of articles on HT and other biofield therapies that are relevant.

Several trials have indeed produces promissing evidence suggesting positive effects of such treatments on anxiety and other symptoms. But the data are far from uniform, and most investigations are wide open to bias. The more rigorous studies seem to suggest that these interventions are not effective beyond placebo. Our review demonstrated that “the evidence is insufficient” to suggest that reiki, another biofield therapy, is an effective treatment for any condition.

Another study showed that tactile touch led to significantly lower levels of anxiety. Conventional massage may even be better than HT, according to some trials. The conclusion from this body of evidence is, I think, fairly obvious: touch can be helpful (most clinicians knew that anyway) but this has nothing to do with energy, biofields, healing energy or any of the other implausible assumptions these treatments are based on.

I therefore disagree with the authors’ conclusion that “further investigation into biofield therapies… is warranted“. If we really want to help patients, let’s find out more about the benefits of touch and let’s not mislead the public about some mystical energies and implausible quackery. And if we truly want to improve heath care, as the Samueli Institute claims, let’s use our limited resources for research which meaningfully contributes to our knowledge.

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