When someone has completed a scientific project, it is customary to publish it [‘unpublished science is no science’, someone once told me many years ago]. To do so, he needs to write it up and submit it to a scientific journal. The editor of this journal will then submit it to a process called ‘peer review’.
What does ‘peer review’ entail? Well, it means that 2-3 experts are asked to critically assess the paper in question, make suggestions as to how it can be improved and submit a recommendation as to whether or not the article deserves to be published.
Peer review has many pitfalls but, so far, nobody has come up with a solution that is convincingly better. Many scientists are under pressure to publish [‘publish or perish’], and therefore some people resort to cheating. A most spectacular case of fraudulent peer review has been reported recently in this press release:
London, UK (08 July 2014) – SAGE announces the retraction of 60 articles implicated in a peer review and citation ring at the Journal of Vibration and Control (JVC). The full extent of the peer review ring has been uncovered following a 14 month SAGE-led investigation, and centres on the strongly suspected misconduct of Peter Chen, formerly of National Pingtung University of Education, Taiwan (NPUE) and possibly other authors at this institution.
In 2013 the then Editor-in-Chief of JVC, Professor Ali H. Nayfeh,and SAGE became aware of a potential peer review ring involving assumed and fabricated identities used to manipulate the online submission system SAGE Track powered by ScholarOne Manuscripts™. Immediate action was taken to prevent JVC from being exploited further, and a complex investigation throughout 2013 and 2014 was undertaken with the full cooperation of Professor Nayfeh and subsequently NPUE.
In total 60 articles have been retracted from JVC after evidence led to at least one author or reviewer being implicated in the peer review ring. Now that the investigation is complete, and the authors have been notified of the findings, we are in a position to make this statement.
While investigating the JVC papers submitted and reviewed by Peter Chen, it was discovered that the author had created various aliases on SAGE Track, providing different email addresses to set up more than one account. Consequently, SAGE scrutinised further the co-authors of and reviewers selected for Peter Chen’s papers, these names appeared to form part of a peer review ring. The investigation also revealed that on at least one occasion, the author Peter Chen reviewed his own paper under one of the aliases he had created.
Unbelievable? Perhaps, but sadly it is true; some scientists seem to be criminally ingenious when it comes to getting their dodgy articles into peer-reviewed journals.
And what does this have to do with ALTERNATIVE MEDICINE, you may well ask. The Journal of Vibration and Control is not even medical and certainly would never consider publishing articles on alternative medicine. Such papers go to one of the many [I estimate more that 1000] journals that cover either alternative medicine in general or any of the modalities that fall under this wide umbrella. Most of these journals, of course, pride themselves with being peer-reviewed – and, at least nominally, that is correct.
I have been on the editorial board of most of the more important journals in alternative medicine, and I cannot help thinking that their peer review process is not all that dissimilar from the fraudulent scheme set up by Peter Chen and disclosed above. What happens in alternative medicine is roughly as follows:
- a researcher submits a paper for publication,
- the editor sends it out for peer review,
- the peer reviewers are either those suggested by the original author or members of the editorial board of the journal,
- in either case, the reviewers are more than likely to be uncritical and recommend publication,
- in the end, peer review turns out to be a farcical window dressing exercise with no consequence,
- thus even very poor research and pseudo-research are being published abundantly.
The editorial boards of journals of alternative medicine tend to be devoid of experts who are critical about the subject at hand. If you think that I am exaggerating, have a look at the editorial board members of ‘HOMEOPATHY’ (or any other journal of alternative medicine) and tell me who might qualify as a critic of homeopathy. When the editor, Peter Fisher, recently fired me from his board because he felt I had tarnished the image of homeopathy, this panel lost the only person who understood the subject matter and, at the same time, was critical about it (the fact that the website still lists me as an editorial board member is merely a reflection of how slow things are in the world of homeopathy: Fisher fired me more than a year ago).
The point I am trying to make is simple: peer review is never a perfect method but when it is set up to be deliberately uncritical, it cannot possibly fulfil its function to prevent the publication of dodgy research. In this case, the quality of the science will be inadequate and generate false-positive messages that mislead the public.
Reiki is a Japanese technique which, according to a proponent, … is administered by “laying on hands” and is based on the idea that an unseen “life force energy” flows through us and is what causes us to be alive. If one’s “life force energy” is low, then we are more likely to get sick or feel stress, and if it is high, we are more capable of being happy and healthy…
A treatment feels like a wonderful glowing radiance that flows through and around you. Reiki treats the whole person including body, emotions, mind and spirit creating many beneficial effects that include relaxation and feelings of peace, security and wellbeing. Many have reported miraculous results.
Reiki is a simple, natural and safe method of spiritual healing and self-improvement that everyone can use. It has been effective in helping virtually every known illness and malady and always creates a beneficial effect. It also works in conjunction with all other medical or therapeutic techniques to relieve side effects and promote recovery [my emphasis].
Many websites give much more specific information about the health effects of Reiki:
- Creates deep relaxation and aids the body to release stress and tension,
- It accelerates the body’s self-healing abilities,
- Aids better sleep,
- Reduces blood pressure
- Can help with acute (injuries) and chronic problems (asthma, eczema, headaches, etc.) and aides the breaking of addictions,
- Helps relieve pain,
- Removes energy blockages, adjusts the energy flow of the endocrine system bringing the body into balance and harmony,
- Assists the body in cleaning itself from toxins,
- Reduces some of the side effects of drugs and helps the body to recover from drug therapy after surgery and chemotherapy,
- Supports the immune system,
- Increases vitality and postpones the aging process,
- Raises the vibrational frequency of the body,
- Helps spiritual growth and emotional clearing.
With such remarkable claims being made, I had to look into this extraordinary treatment.
In 2008, I had a co-worker in my team who was (still is, I think) a Reiki healer. He also happened to be a decent scientist, and we thus decided to conduct a systematic review summarising the evidence for the effectiveness of Reiki. We searched the literature using 23 databases from their respective inceptions through to November 2007 (search again 23 January 2008) without language restrictions. Methodological quality was assessed using the Jadad score. The searches identified 205 potentially relevant studies. Nine randomised clinical trials (RCTs) met our inclusion criteria. Two RCTs suggested beneficial effects of Reiki compared with sham control on depression, while one RCT did not report intergroup differences. For pain and anxiety, one RCT showed intergroup differences compared with sham control. For stress and hopelessness, a further RCT reported effects of Reiki and distant Reiki compared with distant sham control. For functional recovery after ischaemic stroke there were no intergroup differences compared with sham. There was also no difference for anxiety between groups of pregnant women undergoing amniocentesis. For diabetic neuropathy there were no effects of reiki on pain. A further RCT failed to show the effects of Reiki for anxiety and depression in women undergoing breast biopsy compared with conventional care.
Overall, the trial data for any one condition were scarce and independent replications were not available for any condition. Most trials suffered from methodological flaws such as small sample size, inadequate study design and poor reporting. We therefore concluded that the evidence is insufficient to suggest that Reiki is an effective treatment for any condition. Therefore the value of Reiki remains unproven.
But this was in 2008! In the meantime, the evidence might have changed. Here are two recent publications which, I think, are worth having a look at:
The first article is a case-report of a nine-year-old female patient with a history of perinatal stroke, seizures, and type-I diabetes was treated for six weeks with Reiki. At the end of this treatment period, there was a decrease in stress in both the child and the mother, as measured by a modified Perceived Stress Scale and a Perceived Stress Scale, respectively. No change was noted in the child’s overall sense of well-being, as measured by a global questionnaire. However, there was a positive change in sleep patterns on 33.3% of the nights as reported on a sleep log kept by the mother. The child and the Reiki Master (a Reiki practitioner who has completed all three levels of Reiki certification training, trains and certifies individuals in the practice of Reiki, and provides Reiki to individuals) experienced warmth and tingling sensations on the same area of the child during the Reiki 7 minutes of each session. There were no reports of seizures during the study period.
The author concluded that Reiki is a useful adjunct for children with increased stress levels and sleep disturbances secondary to their medical condition. Further research is warranted to evaluate the use of Reiki in children, particularly with a large sample size, and to evaluate the long-term use of Reiki and its effects on adequate sleep.
In my view, this article is relevant because it typifies the type of research that is being done in this area and the conclusions that are being drawn from it. It should be clear to anyone who has the slightest ability of critical thinking that a case report of this nature tells us as good as nothing about the effectiveness of a therapy. Considering that Reiki is just about the least plausible intervention anyone can think of, the child’s condition in all likelihood improved not because of the Reiki healing but because of a myriad of unrelated factors; just think of placebo-effects, regression towards the mean, natural history of the condition, concomitant treatments, etc.
The plausibility of energy/biofield/spiritual healing such as Reiki is also the focus of the second remarkable article that was just published. It reports a systematic review of studies designed to examine whether bio-field therapists undergo physiological changes as they enter the healing state (remember: the Reiki healer in the above study experienced ‘warmth and tingling sensations’ during therapies). If reproducible changes could be identified, the authors argue, they might serve as markers to reveal events that correlate with the healing process.
Databases were searched for controlled or non-controlled studies of bio-field therapies in which physiological measurements were made on practitioners in a healing state. Design and reporting criteria, developed in part to reflect the pilot nature of the included studies, were applied using a yes (1.0), partial (0.5), or no (0) scoring system.
Of 67 identified studies, the inclusion criteria were met by 22, 10 of which involved human patients. Overall, the studies were of moderate to poor quality and many omitted information about the training and experience of the healer. The most frequently measured biomarkers were electroencephalography (EEG) and heart rate variability (HRV). EEG changes were inconsistent and not specific to bio-field therapies. HRV results suggest an aroused physiology for Reconnective Healing, Bruyere healing, and Hawaiian healing, but no changes were detected for Reiki or Therapeutic Touch.
The authors of this paper concluded that despite a decades-long research interest in identifying healing-related biomarkers in bio-field healers, little robust evidence of unique physiological changes has emerged to define the healers׳ state.
Now, let me guess why this is so. One does not need to be a rocket scientist to come up with the suggestion that no robust evidence for Reiki and all the other nonsensical forms of healing can be found for one disarmingly simple reason: NO SUCH EFFECTS EXIST.
In the US, the scope of practice of health care professionals is a matter for each state to decide. Only the one of doctors is regulated nationwide. Other health care professions’ scope of practice can vary considerably within the US. This means that a chiropractor in one state of the US might be allowed to do more (or less) than in the next state. But what exactly are US chiropractors legally allowed to do?
A recent paper was aimed at answering this very question. Its authors assessed the current status of chiropractic practice laws in the US.
A cross-sectional survey of licensure officials from the Federation of Chiropractic Licensing Boards e-mail list was conducted in 2011 requesting information about chiropractic practice laws and 97 diagnostic, evaluation, and management procedures. To evaluate content validity, the survey was distributed in draft form at the fall 2010 Federation of Chiropractic Licensing Boards regional meeting to regulatory board members and feedback was requested. Comments were reviewed and incorporated into the final survey.
Partial or complete responses were received from 96% (n = 51) of the jurisdictions. The states with the highest number of services that could be performed were Missouri (n = 92), New Mexico (n = 91), Kansas (n = 89), Utah (n = 89), Oklahoma (n = 88), Illinois (n = 87), and Alabama (n = 86). The states with the highest number of services that cannot be performed are New Hampshire (n = 49), Hawaii (n = 47), Michigan (n = 42), New Jersey (n = 39), Mississippi (n = 39), and Texas (n = 30).
The authors conclude that the scope of chiropractic practice in the United States has a high degree of variability. Scope of practice is dynamic, and gray areas are subject to interpretation by ever-changing board members. Although statutes may not address specific procedures, upon challenge, there may be a possibility of sanctions depending on interpretation.
For me, the most surprising aspect of this article was to realise how many ‘non-chiropractic’ activities chiropractors are legally permitted in some US states. Here are some of the items that amazed me most:
- birth certificates
- death certificates
- premarital certificates
- recto-vaginal exam
- i.v. injections
- prostatic exam
- genital exam
- ear irrigation
- colonic irrigation
- oral and i.v. chelation therapy
- hyperbaric chamber
I have to admit that I did not even know what a PREMARITAL CERTIFICATE’ is; so I looked it up. The first one I found on the internet was entitled “PURITY COVENANT” and committed the couple “to abstain from fornication and remain sincere to the Lord Jesus Christ and to each other”
I have to further admit that many other of the items on this list leave me equally speechless. For example, how can chiropractors with their training focussed on the musculoskeletal system responsibly complete a death certificate? Why are they allowed in some states to examine the genitalia of their patients?
I suspect the perceived need of chiropractors to do all these things must be closely related to their long-standing ambition to become primary care physicians. Just to be clear: a primary care physician is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. I have always been more than just a bit perplexed how chiropractors, who state that they are musculoskeletal specialists, might even consider being competent primary care providers.
But regardless of common sense, they do! The US ‘Council of Chiropractic Education’ accreditation process, for instance, requires schools to educate and train students to become a “competent doctor of chiropractic who will provide quality patient care and serve as a primary care physician” and the chiro-literature is awash with statements such as this one: “The primary care chiropractic physician is a viable and important part of the primary health care delivery system, with many chiropractic physicians currently prepared to participate effectively and competently in primary care.” Moreover, the phenomenon is by no means limited to the US: “chiropractors in the UK view their role as one of a primary contact healthcare practitioner and that this view is held irrespective of the country in which they were educated or the length of time in practice.”
As far as I am concerned, chiropractors might view their role as whatever they want. The fact is that, even if they add many more items to the list of their ‘services’, they are very far from being competent primary care physicians. Being able to provide the first contact as well as continuous care of medical conditions, not limited by cause, organ system, or diagnosis is not a matter of wishful thinking.
There is some (albeit not compelling) evidence to suggest that chiropractic spinal manipulation might be effective for treating non-specific back pain. But what about specific back pain, such as the one caused by a herniated disc? Some experts believe that, in patients suffering from such a condition, manipulations are contra-indicated (because the latter can cause the former), while others think that manipulation might be an effective treatment option (although the evidence is far from compelling). Who is correct? The issue can only be resolved with data from well-designed clinical investigations. A new trial might therefore enlighten us.
The stated purposes of this study were:
- to evaluate patients with low-back pain (LBP) and leg pain due to magnetic resonance imaging-confirmed disc herniation treated with high-velocity, low-amplitude spinal manipulation in terms of their short-, medium-, and long-term outcomes of self-reported global impression of change and pain levels
- to determine if outcomes differ between acute and chronic patients using.
The researchers conducted a ‘prospective cohort outcomes study‘ with 148 patients with LBP, leg pain, and physical examination abnormalities with concordant lumbar disc herniations. Baseline numerical rating scale (NRS) data for LBP, leg pain, and the Oswestry questionnaire were obtained. The specific lumbar spinal manipulation was dependent upon whether the disc herniation was intraforaminal or paramedian as seen on the magnetic resonance images and was performed by a chiropractor. Outcomes included the patient’s global impression of change scale for overall improvement, the NRS for LBP, leg pain, and the Oswestry questionnaire at 2 weeks, 1, 3, and 6 months, and 1 year. The proportion of patients reporting “improvement” on the patient’s global impression of change scale was calculated for all patients and for acute vs chronic patients. Pre-treatment and post-treatment NRS scores were compared using the paired t test. Baseline and follow-up Oswestry scores were compared using the Wilcoxon test. Numerical rating scale and Oswestry scores for acute vs chronic patients were compared using the unpaired t test for NRS scores and the Mann-Whitney U test for Oswestry scores.
Significant improvements for all outcomes at all time points were reported. At 3 months, 91% of patients were “improved”, and 88% were “improved” after 1 year. Acute patients improved faster by 3 months than did chronic patients. 81.8% of chronic patients 89.2% felt “improved” at 1 year. No adverse events were reported.
The researchers concluded that a large percentage of acute and importantly chronic lumbar disc herniation patients treated with chiropractic spinal manipulation reported clinically relevant improvement.
Does this new study meaningfully contribute to our knowledge about the effectiveness of chiropractic manipulation for back pain caused by herniated discs? The short answer to this question is NO.
A longer answer might be that the report does tell us something relevant about the quality of this research project. We know from countless studies that ~50% of patients experience adverse effects after spinal manipulations by a chiropractor. This means that any report claiming that NO ADVERSE EFFECTS WERE REPORTED is puzzling to a degree that we have to seriously question its quality or even honesty. In this context, it is relevant to mention that a recent review of the evidence concluded that a cause-effect relationship exists between the manipulative treatment and the development of disc herniation.
The positive outcomes reported in this new study could, of course, be due to a range of factors which are unrelated to the manipulations administered by the chiropractors:
- natural history of disc herniation
- regression towards the mean
- other treatments employed by the patients
- social desirability
To be able to say with any degree of certainty that the manipulations had anything to do with the observed positive outcomes would require an entirely different study-design. Should we assume that this is not known in the world of chiropractic? Or should we consider that chiropractors shy away from rigorous research because they fear its results?
The term prospective cohort outcomes study, seems to be a chiropractic invention (cohort studies are by definition prospective, and observational studies are usually prospective). It seems that, behind this long and impressive word, one can easily hide the fact that this study design fails to make the slightest attempt of controlling for non-specific effects; the term sounds scientific – but when we analyse what it means, we discover that this methodology is little more than a self-serving consumer survey. Most scientists would call such an investigation quite simply an OBSERVATIONAL STUDY.
I think it is time that chiropractors start doing proper research which actually does answer some of the many open questions regarding spinal manipulation.
Many posts on this blog have highlighted the fact that homeopathic remedies, when tested in rigorous RCTs, are demonstrably nothing more than pure placebos. Homeopaths, of course, negate this fact but here is a surprising bit of new evidence that further confirms it – and it comes from the highest authority in homeopathy: from Samuel Hahnemann himself!
A well known psychic has been in contact with the great doctor who consequently has dictated a letter to her. Here it is (it came in German, but I took the liberty of translating it into English):
TO ALL HOMEOPATHS OF THE WORLD
I have been watching what you have been doing with my noble healing art for some time now, and I cannot hold back any longer. Enough is enough. You are all fools, bloody fools!
Sceptics and scientists and anyone else who can read the research that has been done with those ‘randomised trials’ that the allopaths are currently so fond of should know that homeopathic medicines, as you monumental idiots employ them, are ineffective. The results of these studies are perfectly true. Instead of asking yourself what you are doing wrong and how you are disobeying my most explicit orders, you insist on doubting that these modern methods generate the truth. How incredibly stupid you are!
I have provided you with a detailed set of instructions – but does any of you pseudo-homeopaths follow them? No, no, no! You are all traitors and ignorant dilettantes. Read my Organon and follow what I wrote; there is no need to re-invent the rules.
Let me remind you what I said in the Organon; I made it perfectly clear that a person receiving homeopathy must have:
- no coffee
- no spices
- no carbonated drinks
- no use of perfumes
- no smoked meat
- no cheese
- no duck
- no shellfish
- no large amounts of animal fat
- no sausages
- no spicy sauces
- no pastries or cakes
- no radishes
- no celery
- no onions or garlic
- no parsley
- no pepper
- no mustard
- no vanilla
- no bitter almonds
- no cloves
- no cinnamon
- no fennel
- no anise
- no green tea
- no spiced chocolate
- no liquors
- no herbal teas
- no tooth powder
- no excessive labour
- no mental exercise
That is simple enough, isn’t it? Or are you too moronic to follow even the simplest of instructions? As you constantly ignore my orders, how do you think my medicines can work?
Those who insist that the current evidence for homeopathy is negative are entirely correct. It is negative because you have been witless and incompetent! I have said it before and I say it again: HE WHO DOES NOT WALK ON EXACTLY THE SAME LINE WITH ME, WHO DIVERGES, IF IT BE BUT THE BREADTH OF A STRAW, TO THE RIGHT OR TO THE LEFT, IS AN APOSTATE AND A TRAITOR, AND WITH HIM I WILL HAVE NOTHING TO SAY.
Now, instead of finding excuses, go home and contemplate what I am telling you. Then do the right thing, conduct a randomised trial testing my proper method, and you will see.
I am very annoyed with all of you! And I am fast running out of patience.
Do as I say or become an allopath.
At this point, I should admit that the letter was, of course, not written by the inventor of homeopathy but by me, Edzard Ernst. Yet it could have been written by him; historians invariably describe him as intolerant, cantankerous and inflexible. Crucially, the dietary instructions outlined in the letter are those of Hahnemann as outlined in the ‘Organon’, his ‘opus maximus’. If he could send a letter via a psychic, Hahnemann would certainly complain about his followers disobeying his orders and he most likely would do it in a most disgruntled tone (the sentence in capital letters is actually a quote from Hahnemann).
This post is a bit of innocent fun, sure. But it also has some relevance to today’s homeopathy, I hope: modern homeopaths make a big thing out of following Hahnemann’s gospel to the letter. But, if we look carefully, we find that they only follow some of it, while ignoring entire sections of what their ‘über-guru’ told them. They argue that these bits are useless or erroneous or implausible and they want to be seen to be scientific and evidence-based. The obvious truth, however, is that everything Hahnemann has ever written about homeopathy is useless, erroneous and implausible and nothing of it is scientific or evidence-based. Homeopaths should draw the only possible conclusion and ignore the lot!
My 2008 evaluation of chiropractic concluded that the concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt. It also pointed out that the advice of chiropractors often is dangerous and not in the best interest of the patient: many chiropractors have a very disturbed attitude towards immunisation: anti-vaccination attitudes till abound within the chiropractic profession. Despite a growing body of evidence about the safety and efficacy of vaccination, many chiropractors do not believe in vaccination, will not recommend it to their patients, and place emphasis on risk rather than benefit.
In case you wonder where this odd behaviour comes from, you best look into the history of chiropractic. D. D. Palmer, the magnetic healer who ‘invented’ chiropractic about 120 years ago, left no doubt about his profound disgust for immunisation: “It is the very height of absurdity to strive to ‘protect’ any person from smallpox and other malady by inoculating them with a filthy animal poison… No one will ever pollute the blood of any member of my family unless he cares to walk over my dead body… ” (D. D. Palmer, 1910)
D. D. Palmer’s son, B. J. Palmer (after literally walking [actually it was driving] over his father’s body) provided a much more detailed explanation for chiropractors’ rejection of immunisation: “Chiropractors have found in every disease that is supposed to be contagious, a cause in the spine. In the spinal column we will find a subluxation that corresponds to every type of disease… If we had one hundred cases of small-pox, I can prove to you, in one, you will find a subluxation and you will find the same condition in the other ninety-nine. I adjust one and return his function to normal… There is no contagious disease… There is no infection…The idea of poisoning healthy people with vaccine virus… is irrational. People make a great ado if exposed to a contagious disease, but they submit to being inoculated with rotten pus, which if it takes, is warranted to give them a disease” (B. J. Palmer, 1909)
Such sentiments and opinions are still prevalent in the chiropractic profession – but today they are expressed in a far less abrupt, more politically correct language: The International Chiropractors Association recognizes that the use of vaccines is not without risk. The ICA supports each individual’s right to select his or her own health care and to be made aware of the possible adverse effects of vaccines upon a human body. In accordance with such principles and based upon the individual’s right to freedom of choice, the ICA is opposed to compulsory programs which infringe upon such rights. The International Chiropractors Association is supportive of a conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health.
Not all chiropractors share such opinions. The chiropractic profession is currently divided over the issue of immunisation. Some chiropractors now realise that immunisations have been one of the most successful interventions ever for public health. Many others, however, do still vehemently adhere to the gospel of the Palmers. Statements like the following abound:
Vaccines. What are we taught? That vaccines came on the scene just in time to save civilization from the ravages of infectious diseases. That vaccines are scientifically formulated to confer immunity to certain diseases; that they are safe and effective. That if we stop vaccinating, epidemics will return…And then one day you’ll be shocked to discover that … your “medical” point of view is unscientific, according to many of the world’s top researchers and scientists. That many state and national legislatures all over the world are now passing laws to exclude compulsory vaccines….
Our original blood was good enough. What a thing to say about one of the most sublime substances in the universe. Our original professional philosophy was also good enough. What a thing to say about the most evolved healing concept since we crawled out of the ocean. Perhaps we can arrive at a position of profound gratitude if we could finally appreciate the identity, the oneness, the nobility of an uncontaminated unrestricted nervous system and an inviolate bloodstream. In such a place, is not the chiropractic position on vaccines self-evident, crystal clear, and as plain as the sun in the sky?
Yes, I do agree: the position of far too many chiropractors is ‘crystal clear’ – unfortunately it is also dangerously wrong.
Times are hard, also in the strange world of chiropractic, I guess. What is therefore more understandable than the attempt of chiropractors to earn a bit of money from people who want to lose weight? If just some of the millions of obese individuals could be fooled into believing that chiropractic is the solution for their problem, chiropractors across the world could be laughing all the way to the bank.
But how does one get to this point? Easy: one only needs to produce some evidence suggesting that chiropractic care is effective in reducing body weight. An extreme option is the advice by one chiropractor to take 10 drops of a homeopathic human chorionic gonadotropin product under the tongue 5 times daily. But, for many chiropractors, this might be one step too far. It would be preferable to show that their hallmark therapy, spinal adjustment, leads to weight loss.
With this in mind, a team of chiropractors performed a retrospective file analysis of patient files attending their 13-week weight loss program. The program consisted of “chiropractic adjustments/spinal manipulative therapy augmented with diet/nutritional intervention, exercise and one-on-one counselling.”
Sixteen of 30 people enrolled completed the program. At its conclusion, statistically and clinically significant changes were noted in weight and BMI measures based on pre-treatment (average weight = 190.46 lbs. and BMI = 30.94 kg/m(2)) and comparative measurements (average weight = 174.94 lbs. and BMI = 28.50 kg/m(2)).
According to the authors of this paper, “this provides supporting evidence on the effectiveness of a multi-modal approach to weight loss implemented in a chiropractic clinic.”
They do not say so, but we all know it, of course: one could just as well combine knitting or crossword puzzles with diet/nutritional intervention, exercise and one-on-one counselling to create a multi-modal program for weight loss showing that knitting or crossword puzzles are effective.
With this paper, chiropractors are not far from their aim of being able to mislead the public by claiming that CHIROPRACTIC CARE IS A NATURAL, SAFE, DRUG-FREE AND EFFECTIVE OPTION IN THE MANAGEMENT OF OBESITY.
Am I exaggerating? No, of course not. There must be thousands of chiropractors who have already jumped on the ‘weight loss band-waggon’. If you don’t believe me, go on the Internet and have a look for yourself. One of the worst sites I have seen might be ‘DOCTORS GOLDMINE’ (yes, most chiropractors call themselves ‘doctor these days!) where a chiropractor promises his colleagues up to $100 000 per month extra income, if they subscribe to his wonderful weight-loss scheme.
It would be nice to be able to believe those who insist that these money-grabbing chiropractors are but a few rotten apples in a vast basket of honest practitioners. But I have problems with this argument – there seem to be far too many rotten apples and virtually no activity or even ambition to get rid of them.
A remarkable article about homeopathy and immunisation entitled THE IMMUNISATION DILEMMA came to my attention recently. Its abstract promised: “evidence quantifying the effectiveness of vaccination and HP (homeoprophylaxis) will be examined. New international research describing and analysing HP interventions will be reported. An evidence-based conclusion will be reached.”
Sounds interesting? Let’s see what the article really offers. Here is the relevant text:
…evidence does exist to support claims regarding the effectiveness of homeopathic immunisation is undeniable.
I was first invited to visit Cuba in December 2008 to present at an international conference hosted by the Finlay Institute, which is a W. H. O.-accredited vaccine manufacturer. The Cubans described their use of HP to control an outbreak of leptospirosis (Weilʼs syndrome – a potentially fatal, water-born bacterial disease) in 2007 among the residents of the three eastern provinces which were most severely damaged by a severe hurricane – over 2.2 million people . 2008 was an even worse year involving three hurricanes, and the countryʼs food production was only just recovering at the time of the conference. The HP program had been repeated in 2008, but data was not available at the conference regarding that intervention.
I revisited Cuba in 2010 and 2012, each time to work with the leader of the HP interventions, Dr. Bracho, to analyse the data available. Dr. Bracho is not a homeopath; he is a published and internationally recognised expert in the manufacture of vaccine adjuvants. He worked in Australia at Flinders University during 2004 with a team trying to develop an antimalarial vaccine.
In 2012 we accessed the raw leptospirosis surveillance data, comprising weekly reports from 15 provinces over 9 years (2000 to 2008) reporting 21 variables. This yielded a matrix with 147 420 possible entries. This included data concerning possible confounders, such as vaccination and chemoprophylaxis, which allowed a careful examination of possible distorting effects. With the permission of the Cubans, I brought this data back to Australia and it is being examined by mathematicians at an Australian university to see what other information can be extracted. Clearly, there is objective data supporting claims regarding the effectiveness of HP.
The 2008 result was remarkable, and could only be explained by the effectiveness of the HP intervention. Whilst the three hurricanes caused immense damage throughout the country it was again worse in the east, yet the three homeopathically immunised provinces experienced a negligible increase in cases whilst the rest of the country showed significant increases until the dry season in January 2009 .
This is but one example – there are many more. It is cited to show that there is significant data available, and that orthodox scientists and doctors have driven the HP interventions, in the Cuban case. Many people internationally now know this, so once again claims by orthodox authorities that there is no evidence merely serves to show that either the authorities are making uninformed/unscientific statements, or that they are aware but are intentionally withholding information. Either way, confidence is destroyed and leads to groups of people questioning what they are told…
The attacks against homeopathy in general and HP in particular will almost certainly continue. If we can achieve a significant level of agreement then we would be able to answer challenges to HP with a single, cohesive, evidence-based, and generally united response. This would be a significant improvement to the existing situation.
Reference 7 is the following article: Bracho G, Varela E, Fernández R et al. Large-scale application of highly-diluted bacteria for Leptospirosis epidemic control. Homeopathy 2010; 99: 156-166. The crucial bit if this paper are as follows:
A homeoprophylactic formulation was prepared from dilutions of four circulating strains of Leptospirosis. This formulation was administered orally to 2.3 million persons at high risk in an epidemic in a region affected by natural disasters. The data from surveillance were used to measure the impact of the intervention by comparing with historical trends and non-intervention regions.
After the homeoprophylactic intervention a significant decrease of the disease incidence was observed in the intervention regions. No such modifications were observed in non-intervention regions. In the intervention region the incidence of Leptospirosis fell below the historic median. This observation was independent of rainfall.
The homeoprophylactic approach was associated with a large reduction of disease incidence and control of the epidemic. The results suggest the use of HP as a feasible tool for epidemic control, further research is warranted.
The paper thus describes little more than an observational study. It shows that one region was less affected than another. I think it is quite clear that this could have many reasons which are unrelated to the homeopathic immunisation. Even the authors are cautious and speak in their conclusions not of a causal effect but of an “association”.
The 2012 data cited in the text remains unpublished; until it is available for public scrutiny, it is impossible to confirm that it is sound and meaningful.
Reference 8 refers to this article: Golden I, Bracho G. Adaptability of homœoprophylaxis in endemic, epidemic and stable background conditions. Homœopathic Links 2009; 22: 211-213. I have no access to this paper (if someone does, please fill us in) but, judging from both its title and the way it is described in the text, it does not seem to show reliable data about the efficacy of homeopathic immunisation.
So, is it true that “evidence does exist to support claims regarding the effectiveness of homeopathic immunisation”?
I do not think so!
Immunisation is by no means a trivial matter; wrong decisions in this area have the potential to cost the lives of millions. Therefore proofs of efficacy need to be published in peer-reviewed journals of high standing. These findings need then be criticised, replicated and re-criticised and re-replicated. Only when there is a wide consensus about the efficacy/safety or lack of efficacy/safety of a new form of immunisation, can it be generally accepted and implemented into clinical practice.
The current consensus about homeopathic immunisation is that it is nothing less than dangerous phantasy. Those who promote this quackery should be publicly exposed as charlatans of the worst kind.
Yesterday, BBC NEWS published the following interesting text about a BBC4 broadcast entitled ‘THE ROYAL ACTIVIST’ aired on the same day:
Prince Charles has been a well-known supporter of complementary medicine. According to a… former Labour cabinet minister, Peter Hain, it was a topic they shared an interest in.
“He had been constantly frustrated at his inability to persuade any health ministers anywhere that that was a good idea, and so he, as he once described it to me, found me unique from this point of view, in being somebody that actually agreed with him on this, and might want to deliver it.”
Mr Hain added: “When I was Secretary of State for Northern Ireland in 2005-7, he was delighted when I told him that since I was running the place I could more or less do what I wanted to do.***
“I was able to introduce a trial for complementary medicine on the NHS, and it had spectacularly good results, that people’s well-being and health was vastly improved.
“And when he learnt about this he was really enthusiastic and tried to persuade the Welsh government to do the same thing and the government in Whitehall to do the same thing for England, but not successfully,” added Mr Hain.
*** obviously there is no homeopathic remedy for megalomania (but that’s a different story)
SPECTACULARLY GOOD RESULTS?
Let’s have a look at the ‘trial’ and its results. An easily accessible report provides the following details about it:
From February 2007 to February 2008, Get Well UK ran the UK’s first government-backed complementary therapy pilot. Sixteen practitioners provided treatments including acupuncture, osteopathy and aromatherapy, to more than 700 patients at two GP practices in Belfast and Derry.
The BBC made an hour long documentary following our trials and tribulations, which was broadcast on BBC1 NI on 5 May 2008.
Aims and Objectives
The aim of the project was to pilot services integrating complementary medicine into existing primary care services in Northern Ireland. Get Well UK provided this pilot project for the Department for Health, Social Services and Public Safety (DHSSPS) during 2007.
The objectives were:
- To measure the health outcomes of the service and monitor health improvements.
- To redress inequalities in access to complementary medicine by providing therapies through the NHS, allowing access regardless of income.
- To contribute to best practise in the field of delivering complementary therapies through primary care.
- To provide work for suitably skilled and qualified practitioners.
- To increase patient satisfaction with quick access to expert care.
- To help patients learn skills to improve and retain their health.
- To free up GP time to work with other patients.
- To deliver the programme for 700 patients.
The results of the pilot were analysed by Social and Market Research, who produced this report.
The findings can be summarised as follows:
Following the pilot, 80% of patients reported an improvement in their symptoms, 64% took less time off work and 55% reduced their use of painkillers.
In the pilot, 713 patients with a range of ages and demographic backgrounds and either physical or mental health conditions were referred to various complementary and alternative medicine (CAM) therapies via nine GP practices in Belfast and Londonderry. Patients assessed their own health and wellbeing pre and post therapy and GPs and CAM practitioners also rated patients’ responses to treatment and the overall effectiveness of the scheme.
• 81% of patients reported an improvement in their physical health
• 79% reported an improvement in their mental health
• 84% of patients linked an improvement in their health and wellbeing directly to their CAM treatment
• In 65% of patient cases, GPs documented a health improvement, correlating closely to patient-reported improvements
• 94% of patients said they would recommend CAM to another patient with their condition
• 87% of patient indicated a desire to continue with their CAM treatment
Painkillers and medication
• Half of GPs reported prescribing less medication and all reported that patients had indicated to them that they needed less
• 62% of patients reported suffering from less pain
• 55% reported using less painkillers following treatment
• Patients using medication reduced from 75% before treatment to 61% after treatment
• 44% of those taking medication before treatment had reduced their use afterwards
Health service and social benefits
• 24% of patients who used health services prior to treatment (i.e. primary and secondary care, accident and emergency) reported using the services less after treatment
• 65% of GPs reported seeing the patient less following the CAM referral
• Half of GPs said the scheme had reduced their workload and 17% reported a financial saving for their practice
• Half of GPs said their patients were using secondary care services less.
Impressed? Well, in case you are, please consider this:
- there was no control group
- therefore it is not possible to attribute any of the outcomes to the alternative therapies offered
- they could have been due to placebo-effects
- or to the natural history of the disease
- or to regression towards the mean
- or to social desirability
- or to many other factors which are unrelated to the alternative treatments provided
- most outcome measures were not objectively verified
- the patients were self-selected
- they would all have had conventional treatments in parallel
- this ‘trial’ was of such poor quality that its findings were never published in a peer-reviewed journal
- this was not a ‘trial’ but a ‘pilot study’
- pilot studies are not normally for measuring outcomes but for testing the feasibility of a proper trial
- the research expertise of the investigators was close to zero
- the scientific community merely had pitiful smiles for this ‘trial’ when it was published
- neither Northern Ireland nor any other region implemented the programme despite its “spectacularly good results”.
So, is the whole ‘trial’ story an utterly irrelevant old hat?
Certainly not! Its true significance does not lie in the fact that a few amateurs are trying to push bogus treatments into the NHS via the flimsiest pseudo-research of the century. The true significance, I think, is that it shows how Prince Charles, once again, oversteps the boundaries of his constitutional role.
Arnold Relman has died aged 91. He was a great personality, served for many years as editor-in-chief of ‘The New England Journal of Medicine’ and was professor of medicine and social medicine at Harvard Medical School. He also was an brilliantly outspoken critic of alternative medicine, and I therefore believe that he deserves to be remembered here. The following excerpts are from an article he wrote in 1998 about Andrew Weil, America’s foremost guru of alternative medicine; I have taken the liberty of extracting a few paragraphs which deal with alternative medicine in general terms.
Until now, alternative medicine has generally been rejected by medical scientists and educators, and by most practicing physicians. The reasons are many, but the most important reason is the difference in mentality between the alternative practitioners and the medical establishment. The leaders of the establishment believe in the scientific method, and in the rule of evidence, and in the laws of physics, chemistry, and biology upon which the modern view of nature is based. Alternative practitioners either do not seem to care about science or explicitly reject its premises. Their methods are often based on notions totally at odds with science, common sense, and modern conceptions of the structure and the function of the human body. In advancing their claims, they do not appear to recognize the need for objective evidence, asserting that the intuitions and the personal beliefs of patients and healers are all that is needed to validate their methods. One might have expected such thinking to alienate most people in a technologically advanced society such as ours; but the alternative medicine movement, and the popularity of gurus such as Weil, are growing rapidly…
That people usually “get better,” that most relatively minor diseases heal spontaneously or seem to improve with simple common remedies, is hardly news. Every physician, indeed every grandmother, knows that. Yet before we accept Weil’s contention that serious illnesses such as “bone cancer,” “Parkinson’s disease,” or “scleroderma” are similarly curable, or respond to alternative healing methods, we need at least to have some convincing medical evidence that the patients whom he reports in these testimonials did indeed suffer from these diseases, and that they were really improved or healed. The perplexity is not that Weil is using “anecdotes” as proof, but that we don’t know whether the anecdotes are true.
Anecdotal evidence is often used in the conventional medical literature to suggest the effectiveness of treatment that has not yet been tested by formal clinical trials. In fact, much of the mainstream professional literature in medicine consists of case reports — “anecdotes,” of a kind. The crucial difference between those case reports and the testimonials that abound in Weil’s books (and throughout the literature of alternative medicine) is that the case reports in the mainstream literature are almost always meticulously documented with objective data to establish the diagnosis and to verify what happened, whereas the testimonials cited by alternative medicine practitioners usually are not. Weil almost never gives any objective data to support his claims. Almost everything is simply hearsay and personal opinion.
To the best of my knowledge, Weil himself has published nothing in the peer-reviewed medical literature to document objectively his personal experiences with allegedly cured patients or to verify his claims for the effectiveness of any of the unorthodox remedies he uses. He is not alone in this respect. Few proponents of alternative medicine have so far published clinical reports that would stand the rigorous scientific scrutiny given to studies of traditional medical treatments published in the serious medical journals. Alternative medicine is still a field rich in undocumented claims and anecdotes and relatively lacking in credible scientific reports…
… Thus Weil can believe in miraculous cures even while claiming to be rational and scientific, because he thinks that quantum theory supports his views.
Yet the leading physicists of our time do not accept such an interpretation of quantum theory. They do not believe quantum theory says anything about the role of human consciousness in the physical world. They see quantum laws as simply a useful mathematical formulation for describing subatomic phenomena that are not adequately handled by classical physical theory, although the latter remains quite satisfactory for the analysis of physical events at the macro-level. Steven Weinberg has observed that “quantum mechanics has been overwhelmingly important to physics, but I cannot find any messages for human life in quantum mechanics that are different in any important way from those of Newtonian physics.” And overriding all discussions of the meaning of quantum physics is the fundamental fact that quantum theory, like all other scientific law, is only valid to the extent that it predicts and accords with the evidence provided by observation and objective measurement. Richard Feynman said it quite simply: “Observation is the ultimate and final judge of the truth of an idea.” Feynman also pointed out that scientific observations need to be objective, reproducible, and, in a sense, public — that is, available to all interested scientists who wish to check the observations for themselves.
Surely almost all scientists would agree with Feynman that, regardless of what theory of nature we wish to espouse, we cannot escape the obligation to support our claims with objective evidence. All theories must conform to the facts or be discarded. So, if Weil cannot produce credible evidence to validate the miraculous cures that he claims for the healing powers of the mind, and if he does not support with objective data the claims he and others make for the effectiveness of alternative healing methods, he cannot presume to wear the mantle of science, and his appeal to quantum theory cannot help him.
Some apologists for alternative medicine have argued that since their healing methods are based on a “paradigm” different from that of traditional medicine, traditional standards of evidence do not apply. Weil sometimes seems to agree with that view, as when he talks about “stoned thinking” and the “ambivalent” nature of reality, but more recently — as he seeks to integrate alternative with allopathic medicine — he seems to acknowledge the need for objective evidence. This, at least, is how I would interpret one of his most recent and ambitious publishing ventures, the editorship of the new quarterly journal Integrative Medicine***.
Integrative Medicine describes itself as a “peer-reviewed journal … committed to gathering evidence for the safety and efficacy of all approaches to health according to the highest standards of scientific research, while remaining open to new paradigms and honoring the healing power of nature.” The Associate Editors and Editorial Board include prominent names in both alternative medicine and allopathic medicine, who presumably support that mission. Yet the first two issues will disappoint those who were looking for original clinical research based on new, objective data. Perhaps subsequent issues will be different, but in any case it is hard to understand the need for Weil’s new journal if he truly intends to hold manuscripts to accepted scientific standards: there already exist many leading peer-reviewed medical journals that will review research studies of alternative healing methods on their merits. During the past decade or so, only a few such studies have passed rigorous review and have been published in first-rate journals. Recently, more studies have been published, but very few of them report significant clinical effects. And that is pretty much where matters now stand. Despite much avowed interest in research on alternative medicine and increased investment in support of such research, the evidentiary underpinnings of unconventional healing methods are still largely lacking…
The alternative medicine movement has been around for a long time, but it was eclipsed during most of this century by the success of medical science. Now there is growing public disenchantment with the cost and the impersonality of modern medical care, as well as concern about medical mistakes and the complications and side-effects of pharmaceuticals and other forms of medical treatment. For their part, physicians have allowed the public to perceive them as uninterested in personal problems, as inaccessible to their patients except when carrying out technical procedures and surgical operations. The “doctor knows best” attitude, which dominated patient-doctor relations during most of the century, has in recent decades given way to a more activist, consumer-oriented view of the patient’s role. Moreover, many other licensed health-care professionals, such as nurse-practitioners, psychotherapists, pharmacists, and chiropractors, are providing services once exclusively reserved to allopathic physicians.
The net result of all these developments has been a weakening of the hegemony that allopathic medicine once exercised over the health care system, and a growing interest by the public in exploring other healing approaches. The authority of allopathic medicine is also being challenged by a swelling current of mysticism and anti-scientism that runs deep through our culture. Even as the number and the complexity of urgent technological and scientific issues facing contemporary society increase, there seems to be a growing public distrust of the scientific outlook and a reawakening of interest in mysticism and spiritualism.
All this obscurantism has given powerful impetus to the alternative medicine movement, with its emphasis on the power of mind over matter. And so consumer demand for alternative remedies is rising, as is public and private financial support for their study and clinical use. It is no wonder that practicing physicians, the academic medical establishment, and the National Institutes of Health are all finding reasons to pay more attention to the alternative medicine movement. Indeed, it is becoming politically incorrect for the movement’s critics to express their skepticism too strongly in public…
There is no doubt that modern medicine as it is now practiced needs to improve its relations with patients, and that some of the criticisms leveled against it by people such as Weil — and by many more within the medical establishment itself — are valid. There also can be no doubt that a few of the “natural” medicines and healing methods now being used by practitioners of alternative medicine will prove, after testing, to be safe and effective. This, after all, has been the way in which many important therapeutic agents and treatments have found their way into standard medical practice in the past. Mainstream medicine should continue to be open to the testing of selected unconventional treatments. In keeping an open mind, however, the medical establishment in this country must not lose its scientific compass or weaken its commitment to rational thought and the rule of evidence.
There are not two kinds of medicine, one conventional and the other unconventional, that can be practiced jointly in a new kind of “integrative medicine.” Nor, as Andrew Weil and his friends also would have us believe, are there two kinds of thinking, or two ways to find out which treatments work and which do not. In the best kind of medical practice, all proposed treatments must be tested objectively. In the end, there will only be treatments that pass that test and those that do not, those that are proven worthwhile and those that are not. Can there be any reasonable “alternative”?
*** the journal only existed for a short period of time