MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

risk/benefit

1 2 3 9

This overview by researchers from that Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, UK, was aimed at summarising the current best evidence on treatment options for 5 common musculoskeletal pain presentations: back, neck, shoulder, knee and multi-site pain. Reviews and studies of treatments were considered of the following therapeutic options: self-management advice and education, exercise therapy, manual therapy, pharmacological interventions (oral and topical analgesics, local injections), aids and devices, other treatments (ultrasound, TENS, laser, acupuncture, ice / hot packs) and psychosocial interventions (such as cognitive-behavioural therapy and pain-coping skills).

Here are the findings for those treatments most relevant in alternative medicine (it is interesting that most alternative medicines were not even considered because of lack of evidence and that the team of researchers can hardly be accused of an anti-alternative medicine bias, since its senior author has a track record of publishing results favourable to alternative medicine):

EXERCISE

Current evidence shows significant positive effects in favour of exercise on pain, function, quality of life and work related outcomes in the short and long-term for all the musculoskeletal pain presentations (compared to no exercise or other control) but the evidence regarding optimal content or delivery of exercise in each case is inconclusive.

ACUPUNCTURE

The evidence from a good quality individual patient data meta-analysis suggests that acupuncture may be effective for short-term relief of back pain and knee pain with medium summary effect sizes respectively compared with usual care or no acupuncture. However, effects on function were reported to be minimal and not maintained at longer-term follow-up. Similarly for neck and shoulder pain, acupuncture was only found to be effective for short-term (immediately post-treatment and at short-term follow-up) symptom relief compared to placebo.

MANUAL THERAPY

Current evidence regarding manual therapy is beset by heterogeneity. Due to paucity of high quality evidence, it is uncertain whether the efficacy of manual therapy might be different for different patient subgroups or influenced by the type and experience of professional delivering the therapy. On the whole, the available evidence suggests that manual therapy may offer some beneficial effects on pain and function, but it may not be superior to other non-pharmacological treatments (e.g. exercise) for patients with acute or chronic musculoskeletal pain.

Overall. the authors concluded that the best available evidence shows that patients with musculoskeletal pain problems in primary care can be managed effectively with non-pharmacological treatments such as self-management advice, exercise therapy, and psychosocial interventions. Pharmacological interventions such as corticosteroid injections (for knee and shoulder pain) were shown to be effective treatment options for the short-term relief of musculoskeletal pain and may be used in addition to non-pharmacological treatments. NSAIDs and opioids also offer short-term benefit for musculoskeletal pain, but the potential for adverse effects must be considered. Furthermore, the optimal treatment intensity, methods of application, amount of clinical contact, and type of provider or setting, are unclear for most treatment options.

These findings confirm what we have pointed out many times before on this blog. There is very little that alternative therapies have to offer for musculoskeletal pain. Whenever it is possible, I would recommend exercise therapy initiated by a physiotherapist; it is inexpensive, safe, and at least as effective as acupuncture or chiropractic or osteopathy.

Practitioners of alternative medicine will, of course, not like this solution.

Acupuncturists may not be that bothered by such evidence: their focus is not necessarily on musculoskeletal but on a range of other conditions (with usually little evidence, I hasten to add).

But for chiropractors and osteopaths, this is much more serious, in my view. Of course, some of them also claim to be able to treat a plethora of non-musculoskeletal conditions (but there the evidence is even worse than for musculoskeletal pain, and therefore this type of practice is clearly unethical). And those who see themselves as musculoskeletal specialists have to either accept the evidence that shows little benefit and considerable risk of spinal manipulation, or go in a state of denial.

In the former case, the logical conclusion is to look for another job.

In the latter case, the only conclusion is that their practice is not ethical.

This is a fascinating new review of upper neck manipulation. It raises many concerns that we, on this blog, have been struggling with for years. I take the liberty of quoting a few passages which I feel are important and encourage everyone to study the report in full:

The Minister of Health, Seniors and Active Living gave direction to the Health Professions Advisory Council (“the Council”) to undertake a review related to high neck manipulation.

Specifically, the Minister directed the Council to undertake:

1) A review of the status of the reserved act in other Canadian jurisdictions,

2) A literature review related to the benefits to patients and risks to patient safety associated with the procedure, and

3) A jurisprudence review or a review into the legal issues that have arisen in Canada with respect to the performance of the procedure that touch upon the risk of harm to a patient.

In addition, the Minister requested the Council to seek written input on the issue from:

  • Manitoba Chiropractic Stroke Survivors
  • Manitoba Chiropractic Association
  • College of Physiotherapists of Manitoba
  • Manitoba Naturopathic Association
  • College of Physicians and Surgeons of Manitoba
  • other relevant interested parties as determined by the Council

… The review indicated that further research is required to:

  • strengthen evidence for the efficacy of cervical spinal manipulations (CSM) as a treatment for neck pain and headache, “as well as for other indications where evidence currently does not exist (i.e., upper back and should/arm pain, high blood pressure, etc.)”
  • establish safety and efficacy of CSM in infants and children
  • assess the risk versus benefit in consideration of using HVLA cervical spine manipulation, which also involve cost-benefit analyses that compare CSM to other standard treatments.

… the performance of “high neck manipulation” or cervical spine manipulation does present a risk of harm to patients. This risk of harm must be understood by both the patient and the practitioner.

Both the jurisprudence review and the research literature review point to the need for the following actions to mitigate the risk of harm associated with the performance of cervical spine manipulation:

  • Action One: Ensure that the patient provides written informed consent prior to initiating treatment which includes a discussion about the risk associated with cervical spine manipulation.
  • Action Two: Provide patients with information to assist in the early recognition of a serious adverse event.

The British press recently reported that a retired bank manager (John Lawler, aged 80) died after visiting a chiropractor in York. This tragic case was published in multiple articles, most recently in THE SUN. Personally, I find this regrettable – not the fact that the press warns consumers of chiropractic, but the tone and content of the articles.

Let me explain this by citing the one in THE SUN of today. Here is the critical bit that concerns me:

Ezvard Ernst, Emeritus Professor of Complementary Medicine at Exeter University, published a study showing at least 26 people had died as a result. He said: “The evidence is not in favour of chiropractic treatments. Nobody knows how many have suffered severe complications or died.” Edvard Ernst, Professor of Complementary Medicine, says many have suffered complications or died from chiropractors treatments… A study from Exeter University shows at least 26 people have died as a result of treatment.

And what is wrong with this?

The answer is lots:

  • My first name is consistently misspelled (a triviality, I agree).
  • I am once named as Emeritus Professor and once as Professor of Complementary Medicine. The latter is wrong (another triviality, perhaps, but some of my more demented critics have regularly accused me of carrying wrong titles)
  • The mention of 26 deaths after chiropractic treatments is problematic and arguably misleading (see below).
  • Our ‘study’ was not a study but a systematic review (another triviality?).

Now you probably think I am being pedantic, but I feel that the article is regrettable not so much by what it says but by what it fails to say. To understand this better, I will below copy my emails to the journalist who asked for help in researching this article.

  • My email of 17/10 answering all 7 of the journalist’s specific questions:
  • 1. Why are you sceptical of chiropractic?
  • I have researched the subject for more than 2 decades, and I know that the evidence is not in favour of chiropractic
  • 2. How many people do you believe have died in Britain as a result of being treated by a chiropractor? If it’s not possible to say, can you estimate?
  • nobody knows how many patients have suffered severe complications or deaths. there is no system to monitor such events that is comparable to the post-marketing surveillance of conventional medicine. we did some research and found that the under-reporting of cases of severe complications was close to 100% in the UK.
  • 3. What is so dangerous about chiropractic? Is there a particular physical treatment than endangers life?
  • manipulations that involve rotation and over-extension of the upper spine can lead to a vertebral artery breaking up. this causes a stroke which sometimes is fatal.
  • 4. Is the industry well regulated?
  • UK chiropractors are regulated by the General Chiropractic Council. it is debatable whether they are fit for purpose (see here:http://edzardernst.com/2015/02/the-uk-general-chiropractic-council-fit-for-purpose/)
  • 5. Should we be suspicious of claims that chiropractic can cure things like IBS and autism?
  • such claims are not based on good evidence and therefore misleading and unethical. sadly, however, they are prevalent.
  • 6. Who trains chiropractors?
  • there are numerous colleges that specialise in that activity.
  • 7. Is it true Prince Charles is to blame for the rise in popularity/prominence of chiropractic?
  • I am not sure. certainly he has been promoting all sorts of unproven treatments for decades.
  • My email of 18/10 answering 3 further specific questions
  • 1. Would you actively discourage anyone from being treated by a chiropractor?
    yes, anyone I feel responsible for
    2. Are older people particularly at risk or could one wrong move affect anyone?
    older people are at higher risk of bone fractures and might also have more brittle arteries prone to dissection
    3. If someone has, say, a bad back or stiff neck what treatment would you recommend instead of chiropractic?
    I realise every case is different, but you are sceptical of all complementary treatments (as I understand it) so what would you suggest instead?
    I would normally consider therapeutic exercises and recommend seeing a good physio.
  • 3. My email of 23/10 replying to his request for specific UK cases
  • the only thing I can offer is this 2001 paper
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1297923/
  • where we discovered 35 cases seen by UK neurologists within the preceding year. the truly amazing finding here was that NONE of them had been reported anywhere before. this means under-reporting was exactly 100%.

END OF QUOTES
I think that makes it quite obvious that much relevant information never made it into the final article. I also know that several other experts provided even more information than I did which never appeared.

The most important issues, I think, are firstly the lack of a monitoring system for adverse events, secondly the level of under-reporting and thirdly the 50% rate of mild to moderate adverse-effects. Without making these issues amply clear, lay readers cannot possibly make any sense of the 26 deaths. More importantly, chiropractors will now be able to respond by claiming: 26 deaths compare very favourably with the millions of fatalities caused by conventional medicine. In the end, the message that will remain in the heads of many consumers is this: CONVENTIONAL MEDICINE IS MUCH MORE DANGEROUS THAN CHIROPRACTIC!!! (The 1st comment making this erroneous point has already been published: Don’t be stupid Andy. You wanna discuss how many deaths occur due to medication side effects and drug interactions? There is a reason chiros have the lowest malpractice rates.)

Don’t get me wrong, I am not accusing the author of the SUN-article. For all I know, he has filed a very thoughtful and complete piece. It might have been shortened by the editor who may also have been the one adding the picture of the US starlet with her silicone boobs. But I am accusing THE SUN of missing a chance to publish something that might have had the chance of being a meaningful contribution to public health.

Perhaps you still think this is all quite trivial. Yet, after having experienced this sort of thing dozens, if not hundreds of times, I disagree.

This is the question asked by the American Chiropractic Association. And this is their answer [the numbers in square brackets were inserted by me and refer to my comments below]:

Chiropractic is widely recognized [1] as one of the safest drug-free, non-invasive therapies available for the treatment of neuromusculoskeletal complaints [2]. Although chiropractic has an excellent safety record [3], no health treatment is completely free of potential adverse effects. The risks associated with chiropractic, however, are very small [4]. Many patients feel immediate relief following chiropractic treatment [5], but some may experience mild soreness, stiffness or aching, just as they do after some forms of exercise [6]. Current research shows that minor discomfort or soreness following spinal manipulation typically fades within 24 hours [7]…

Some reports have associated high-velocity upper neck manipulation with a certain rare kind of stroke, or vertebral artery dissection [8]. However, evidence suggests that this type of arterial injury often takes place spontaneously in patients who have pre-existing arterial disease [9]. These dissections have been associated with everyday activities such as turning the head while driving, swimming, or having a shampoo in a hair salon [10]. Patients with this condition may experience neck pain and headache that leads them to seek professional care—often at the office of a doctor of chiropractic or family physician—but that care is not the cause of the injury. The best evidence indicates that the incidence of artery injuries associated with high-velocity upper neck manipulation is extremely rare—about one to three cases in 100,000 patients who get treated with a course of care [11]. This is similar to the incidence of this type of stroke among the general population [12]…

When discussing the risks of any health care procedure, it is important to look at that risk in comparison to other treatments available for the same condition [13]. In this regard, the risks of serious complications from spinal manipulation for conditions such as neck pain and headache compare very favorably with even the most conservative care options. For example, the risks associated with some of the most common treatments for musculoskeletal pain—over-the-counter or prescription nonsteroidal anti-inflammatory drugs (NSAIDS) and prescription painkillers—are significantly greater than those of chiropractic manipulation [14]…

Doctors of chiropractic are well trained professionals who provide patients with safe, effective care for a variety of common conditions. Their extensive education has prepared them to identify patients who have special risk factors [15] and to get those patients the most appropriate care, even if that requires referral to a medical specialist [16].

END OF QUOTE

  1. Appeal to tradition = fallacy
  2. and every other condition that brings in cash.
  3. Not true.
  4. Probably not true.
  5. The plural of anecdote is anecdotes, not evidence.
  6. Not true, the adverse effects of spinal manipulation are different and more severe.
  7. Not true, they last 1-3 days.
  8. Not just ‘some reports’ but a few hundred.
  9. Which does not mean that spinal manipulation cannot provoke such events.
  10. True, but this does not mean that spinal manipulation cannot provoke such events.
  11. There are other estimates that gives much higher figures; without a proper monitoring system, nobody can provide an accurate incidence figure.
  12. Not true, see above.
  13. ‘Available’ is meaningless – ‘effective’ is what we need here.
  14. The difference between different treatments is not merely their safety but also their effectiveness; in the end it is the risk/benefit balance that determines their value.
  15. Not true, there are no good predictors to identify at-risk populations.
  16. Chiropractors are notoriously bad at referring to other healthcare professionals; they have a huge conflict of interest in keeping up their cash-flow.

So, is chiropractic a safe treatment?

My advice here is not to ask chiropractors but independent experts.

 

The European Academies Science Advisory Council (EASAC) is an umbrella organization representing 29 national and international scientific academies in Europe, including the Royal Society (UK) and Royal Swedish Academy of Sciences. One of its aims is to influence policy and regulations across the European Union. Now, the EASAC has issued an important and long-awaited verdict on homeopathy:

The EASAC is publishing this Statement to build on recent work by its member academies to reinforce criticism of the health and scientific claims made for homeopathic products. The analysis and conclusions are based on the excellent science-based assessments already published by authoritative and impartial bodies. The fundamental importance of allowing and supporting consumer choice requires that consumers and patients are supplied with evidence-based, accurate and clear information. It is, therefore, essential to implement a standardised, knowledge-based regulatory framework to cover product efficacy, safety and quality, and accurate advertising practices, across the European Union (EU). Our Statement examines the following issues:

  • Scientific mechanisms of action—where we conclude that the claims for homeopathy are implausible and inconsistent with established scientific concepts.
  • Clinical efficacy—we acknowledge that a placebo effect may appear in individual patients but we agree with previous extensive evaluations concluding that there are no known diseases for which there is robust, reproducible evidence that homeopathy is effective beyond the placebo effect.

There are related concerns for patient-informed consent and for safety, the latter associated with poor quality control in preparing homeopathic remedies. Promotion of homeopathy—we note that this may pose significant harm to the patient if incurring delay in seeking evidence-based medical care and that there is a more general risk of undermining public confidence in the nature and value of scientific evidence. Veterinary practice—we conclude similarly that there is no rigorous evidence to
substantiate the use of homeopathy in veterinary medicine and it is particularly worrying when such products are used in preference to evidence-based medicinal products to treat livestock infections. We make the following recommendations.

1. There should be consistent regulatory requirements to demonstrate efficacy, safety and quality of all products for human and veterinary medicine, to be based on verifiable and objective evidence, commensurate with the nature of the claims being made. In the absence of this evidence, a product should be neither approvable nor registrable by national regulatory agencies for the designation medicinal product.

2. Evidence-based public health systems should not reimburse homeopathic products and practices unless they are demonstrated to be efficacious and safe by rigorous testing.

3. The composition of homeopathic remedies should be labelled in a similar way to other health products available: that is, there should be an accurate, clear and simple description of the ingredients and their amounts present in the formulation.

4. Advertising and marketing of homeopathic products and services must conform to established standards of accuracy and clarity. Promotional claims for efficacy, safety and quality should not be made without demonstrable and reproducible evidence.

END OF QUOTE

No comment needed!!!

I just came across a new article entitled ” Vaccinated children four times more likely to suffer from ADHD, autism“. It was published in WDDTY, my favourite source of misleading information. Here it is:

Vaccinated children are nearly four times more likely to suffer from learning disabilities, ADHD and autism, a major new study has discovered—and they are six times more likely to suffer from one of these neuro-developmental problems if they were also born prematurely.

The vaccinated child is also more likely to suffer from otitis media, the ear infection, and nearly six times more likely to contract pneumonia.

But the standard childhood vaccines do at least do their job: the vaccinated child is nearly eight times less likely than the unvaccinated to develop chicken pox, and also less likely to suffer from whooping cough (pertussis).

Researchers from Jackson State University are some of the first to look at the long-term effects of vaccination. They monitored the health of 666 children for six years from the time they were six—when the full vaccination programme had been completed—until they were 12. All the children were being home-schooled because it was one of the few communities where researchers could find enough unvaccinated children for comparison; 261 of the children hadn’t been vaccinated and 208 hadn’t had all their vaccinations, while 197 had received the full 48-dose course.

The vaccinated were more likely to suffer from allergic rhinitis, such as hay fever, eczema and atopic dermatitis, learning disability, ADHD (attention-deficit, hyperactive disorder), and autism. The risk was lower among the children who had been partially vaccinated.

Vaccinated children were also more likely to have taken medication, such as an antibiotic, or treatment for allergies or for a fever, than the unvaccinated.

END OF QUOTE

I looked up the original study to check and found several surprises.

The first surprise was that the study was called a ‘pilot’ by its authors, even in the title of the paper: “Pilot comparative study on the health of vaccinated and unvaccinated 6- to 12-year-old U.S. children.”

The second surprise was that even the authors admit to important limitations of their research:

We did not set out to test a specific hypothesis about the association between vaccination and health. The aim of the study was to determine whether the health outcomes of vaccinated children differed from those of unvaccinated homeschool children, given that vaccines have nonspecific effects on morbidity and mortality in addition to protecting against targeted pathogens [11]. Comparisons were based on mothers’ reports of pregnancy-related factors, birth histories, vaccinations, physician-diagnosed illnesses, medications, and the use of health services. We tested the null hypothesis of no difference in outcomes using chi-square tests, and then used Odds Ratios and 96% Confidence Intervals to determine the strength and significance of the association…

What credence can be given to the findings? This study was not intended to be based on a representative sample of homeschool children but on a convenience sample of sufficient size to test for significant differences in outcomes. Homeschoolers were targeted for the study because their vaccination completion rates are lower than those of children in the general population. In this respect our pilot survey was successful, since data were available on 261 unvaccinated children…

Mothers’ reports could not be validated by clinical records because the survey was designed to be anonymous. However, self-reports about significant events provide a valid proxy for official records when medical records and administrative data are unavailable [70]. Had mothers been asked to provide copies of their children’s medical records it would no longer have been an anonymous study and would have resulted in few completed questionnaires. We were advised by homeschool leaders that recruitment efforts would have been unsuccessful had we insisted on obtaining the children’s medical records as a requirement for participating in the study.

A further potential limitation is under-ascertainment of disease in unvaccinated children. Could the unvaccinated have artificially reduced rates of illness because they are seen less often by physicians and would therefore have been less likely to be diagnosed with a disease? The vaccinated were indeed more likely to have seen a doctor for a routine checkup in the past 12 months (57.5% vs. 37.1%, p < 0.001; OR 2.3, 95% CI: 1.7, 3.1). Such visits usually involve vaccinations, which nonvaccinating families would be expected to refuse. However, fewer visits to physicians would not necessarily mean that unvaccinated children are less likely to be seen by a physician if their condition warranted it. In fact, since unvaccinated children were more likely to be diagnosed with chickenpox and whooping cough, which would have involved a visit to the pediatrician, differences in health outcomes are unlikely to be due to under-ascertainment.

The third surprise was that the authors were not at all as certain as WDDTY in their conclusions: “the study findings should be interpreted with caution. First, additional research is needed to replicate the findings in studies with larger samples and stronger research designs. Second, subject to replication, potentially detrimental factors associated with the vaccination schedule should be identified and addressed and underlying mechanisms better understood. Such studies are essential in order to optimize the impact of vaccination of children’s health.”

The fourth surprise was to find the sponsors of this research:

Generation Rescue is, according to Wikipedia, a nonprofit organization that advocates the incorrect view that autism and related disorders are primarily caused by environmental factors, particularly vaccines. These claims are biologically implausible and are disproven by scientific evidence. The organization was established in 2005 by Lisa and J.B. Handley. They have gained attention through use of a media campaign, including full page ads in the New York Times and USA Today. Today, Generation Rescue is known as a platform for Jenny McCarthy‘s autism and anti-vaccine advocacy.

The Children’s Medical Safety Research Institute (CMSRI) was, according to Vaxopedia, created by and is funded by the Dwoskin Family Foundation. It provides grants to folks who will do research on “vaccine induced brain and immune dysfunction” and on what they believe are other “gaps in our knowledge about vaccines and vaccine safety”, including:

While they claim that they are not an anti-vaccine organization, it should be noted that  Claire Dwoskin once said that “Vaccines are a holocaust of poison on our children’s brains and immune systems.”

Did I say SURPRISE?

I take it back!

When it comes to WDDTY, nothing does surprise me.

We have repeatedly discussed on this blog the fact that many alternative practitioners are advising their patients against vaccinations, e. g.:

There is little doubt that this phenomenon contributes to low immunisation rates. This, in turn, is a contributing factor to outbreaks of measles and other infectious diseases. The website of the European Centre for Disease Prevention and Control has recently published data on measles outbreaks in Europe:

Bulgaria: There is an increase by three cases since 21 July 2017. Since the beginning of 2017 and as of 16 July, Bulgaria reported 166 cases. During the same time period in 2016 Bulgaria reported one case.

France: On 27 July 2017 media quoting the French Minister of Health reported the death of a 16-year-old unvaccinated girl. She had fallen sick in Nice and died on 27 June 2017 in Marseille.

Germany: There is an increase by four cases since the last report on 21 July 2017. Since the beginning of 2017 and as of 26 July, Germany reported 801 cases. During the same time period in 2016 Germany reported 187 cases.

Italy: There is an increase by 170 cases since 21 July 2017. Since the beginning of 2017 and as of 25 July, Italy reported 3 842 cases, including three deaths. Among the cases, 271 are healthcare workers. The median age is 27 years, 89% of the cases were not vaccinated and 6% received only one dose of vaccine.

Romania: There is an increase by 229 cases, including one additional death, since 21 July 2017. Since 1 January 2016 and as of 21 July 2017, Romania reported 8 246 cases, including 32 deaths. Cases are either laboratory-confirmed or have an epidemiological link to a laboratory-confirmed case. Infants and young children are the most affected groups. Timis, in the western part of the country closest to the border with Serbia, is the most affected district with 1 215 cases. Vaccination activities are ongoing in order to cover communities with suboptimal vaccination coverage.

Spain: There is an increase by seven cases since 14 July 2017. Since the beginning of 2017 and as of 25 July, Spain reported 145  measles cases.

United Kingdom: Public Health Wales reported two additional cases related to the outbreak in Newport and Torfaen, bringing the total to ten cases related to this outbreak. In England and Wales there is an increase by 76 cases since 21 July 2017. Since the beginning of 2017 and as of 23 July 2017, England and Wales reported 922 cases. In the same time period in 2016, they reported 946 cases.

In addition to the updates listed above ECDC produces a monthly measles and rubella monitoring report with surveillance data provided by the member states through TESSy. The last report was published on 11 July 2017 with data up to 31 May 2017.

Measles outbreaks continue to occur in EU/EEA countries. There is a risk of spread and sustained transmission in areas with susceptible populations. The national vaccination coverage remains less than 95% for the second dose of MMR in the majority of EU/EEA countries. The progress towards elimination of measles in the WHO European Region is assessed by the European Regional Verification Commission for Measles and Rubella Elimination (RVC). Member States of the WHO European Region are making steady progress towards the elimination of measles. At the fifth meeting of the RVC for Measles and Rubella in October 2016, of 53 countries in the WHO European Region, 24 (15 of which are in the EU/EEA) were declared to have reached the elimination goal for measles, and 13 countries (nine in the EU/EEA) were deemed to have interrupted endemic transmission for between 12 and 36 months, meaning they are on their way to achieving the elimination goal. However, six EU/EEA countries were judged to still have endemic transmission: Belgium, France, Germany, Italy, Poland and Romania. More information on strain sequences would allow further insight into the epidemiological investigation.

All EU/EEA countries report measles cases on a monthly basis to ECDC and these data are published every month. Since 10 March 2017, ECDC has been reporting measles outbreaks in Europe on a weekly basis and monitoring worldwide outbreaks on a monthly basis through epidemic intelligence activities. ECDC published a rapid risk assessment on 6 March.

END OF QUOTE

Personally, I believe that it is high time to stop the rhetoric and actions of the anti-vaccination movements. This includes educating alternative practitioners and their patients. If necessary, we need regulation that prohibits their dangerous and unethical activities.

On this blog, we have often discussed the risks of spinal manipulation. As I see it, the information we have at present suggests that

  • mild to moderate adverse effects are extremely frequent and occur in about half of all patients;
  • serious adverse effects are being reported regularly;
  • the occur usually with chiropractic manipulations of the neck (which are not of proven efficacy for any condition) and often relate to vascular accidents;
  • the consequences can be permanent neurological deficits and even deaths;
  • under-reporting of such cases might be considerable and therefore precise incidence figures are not available;
  • there is no system to accurately monitor the risks;
  • chiropractors are in denial of these problems.

Considering the seriousness of these issues, it is important to do more rigorous research. Therefore, any new paper published on this subject is welcome. A recent article might shed new light on the topic.

The objective of this systematic review was to identify characteristics of 1) patients, 2) practitioners, 3) treatment process and 4) adverse events (AE) occurring after cervical spinal manipulation (CSM) or cervical mobilization. A systematic searches were performed in 6 electronic databases up to December 2014. Of the initial 1043 articles thus located, 144 were included, containing 227 cases. 117 cases described male patients with a mean age of 45 and a mean age of 39 for females. Most patients were treated by chiropractors (66%). Manipulation was reported in 95% of the cases, and neck pain was the most frequent indication for the treatment. Cervical arterial dissection (CAD) was reported in 57%  of the cases and 45.8% had immediate onset symptoms. The overall distribution of gender for CAD was 55% for female. Patient characteristics were described poorly. No clear patient profile, related to the risk of AE after CSM, could be extracted, except that women seemed more at risk for CAD. The authors of this review concluded that there seems to be under-reporting of cases. Further research should focus on a more uniform and complete registration of AE using standardized terminology.

This article provides little new information; but it does confirm what I have been saying since many years: NECK MANIPULATIONS ARE ASSOCIATED WITH SERIOUS RISKS AND SHOULD THEREFORE BE AVOIDED.

In my previous post, I reported that the NHS has included homeopathy and herbal medicine on the list of medications that might no longer get reimbursed. The news was reported by most newspapers in the UK. All of the papers correctly quote NHS England giving their reasons for black-listing homeopathy and herbal remedies. Some papers also quote critics of homeopathy providing short ‘sound bites’ and opinions. None of the articles bother to explain in any detail why homeopathy is so ridiculously implausible or how strong the evidence against it has become. In this post, I intend to analyse some of this press coverage by copying those excerpts from the newspaper articles which I find odd or misleading and by adding short comments by myself.

THE DAILY MAIL claimed that homeopathic remedies are treatments using heavily diluted forms of plants, herbs and minerals. This is factually incorrect; think of remedies like X-ray! The Mail also quoted Don Redding, director of policy at National Voices, stating: ‘Whilst some treatments are available to purchase over the counter, that does not mean that everyone can afford them. There will be distinct categories of people who rely on NHS funding for prescriptions of remedies that are otherwise available over the counter. Stopping such prescriptions would break with the principle of an NHS “free at the point of use” and would create a system where access to treatments is based on a person’s ability to pay.’  This argument might apply to medicines that are proven to work; it does, however, not apply to homeopathy.

THE INDEPENDENT cited Professor Helen Stokes-Lampard, chair of the Royal College of GPs, who said: “If patients are in a position that they can afford to buy over the counter medicines and products, then we would encourage them to do so rather than request a prescription – but imposing blanket policies on GPs, that don’t take into account demographic differences across the country, or that don’t allow for flexibility for a patient’s individual circumstances, risks alienating the most vulnerable in society.” Again, this argument might apply to medicines that are proven to work; it does, however, not apply to homeopathy.

THE DAILY TELEGRAPH also reported the quote from Don Redding, Director of Policy at National Voices which I cited above.

THE DAILY MIRROR quoted The Royal Pharmaceutical Society claiming that such a move raised “serious concerns” for poorer Brits. RPS England Board Chair Sandra Gidley said: “A blanket ban on prescribing of items available to buy will not improve individual quality of life or health outcomes in England. “Those on low incomes will be disproportionately affected.” THE MIRROR also reported what had to say and added that the NHS constitution states that: “Access to NHS services is based on clinical need, not an individual’s ability to pay; NHS services are free of charge, except in limited circumstances sanctioned by parliament.”

THE NEWS & STAR repeated the above quote from The Royal Pharmaceutical Society.

THE GUERNSEY PRESS repeated what RPS England board chair Sandra Gidley said: “We would encourage people with minor health problems to self-care with the support of a pharmacist and to buy medicines where appropriate and affordable to the individual. However, expecting everyone to pay for medicines for common conditions will further increase health inequalities and worsen the health of patients who cannot afford them. A blanket ban on prescribing of items available to buy will not improve individual quality of life or health outcomes in England. Those on low incomes will be disproportionately affected. They should not be denied treatment because of an inability to pay.”

THE TIMES also quoted the RPS and Don Redding misleadingly (see above and below) and concluded their article by citing Cristal Summer, chief executive of the British Homeopathic Association saying: Patients will be prescribed more expensive conventional drugs in place of homeopathy, which defeats the object of the exercise. The NHS also claims it wants to reduce the amount of prescription drugs patients take, then stops offering complementary therapies which can help achieve this. This clearly ignores the fact that ‘the object of the exercise’ for any health service must be to provide effective treatments and avoid placebo therapies like homeopathy. 

THE SUN quoted The Royal Pharmaceutical Society saying such a move raised “serious concerns” for poorer Brits. But it said banning NHS-funded homeopathy was long overdue. THE SUN continued by citing John O’Connell, Chief Executive of the TaxPayers’ Alliance: “The NHS are absolutely right to look at removing homeopathy from their approved prescription list and it’s astonishing that it hasn’t happened sooner.”

METRO pointed out that actress Gwyneth Paltrow, ex-Beatle Paul McCartney and world record sprinter Usain Bolt are all known to swear by homeopathic remedies.

Generally speaking, the newspaper coverage was not bad, in my view. The exception evidently is THE TIMES (see above). Several other articles also have a slight whiff of false balance, introducing seemingly rational counter-arguments where none exist. Even though the headlines invariably focus on homeopathy, some of the quotes used by the papers are clearly about other medicines black-listed. This seems particularly obvious with the quotes by the RPS. Many readers might thus be misled into thinking that there is opposition by reputable organisations to the ban on homeopathy. None of the articles that I read quoted a homeopath at the end saying something like  WE KNOW OF MANY PATIENTS WHOSE LIVES WERE SAVED BY HOMEOPATHY. JUST BECAUSE WE DON’T UNDERSTAND HOW IT WORKS DOES NOT MEAN IT DOES NOT WORK. A BAN WOULD PUT PUBLIC HEALTH AT RISK.

Only a few years ago, this type of conclusion to an article on homeopathy would have been inevitable! Could it be that UK journalists (with the exception of those at THE TIMES?) are slowly learning?

 

Dr Gabriella Day is a GP in England who describes herself and her beliefs as follows: “I began training in homeopathy as it is clear that for many conditions conventional treatment options are not effective and can have unwanted side effects. It seemed to me that there must be another way to help people suffering from symptoms such as these… I believe in whole person medicine. No illness exists in isolation. The human body is immensely sophisticated and complicated and we do not understand it fully. Therefore the illness cannot be separated from the person suffering the disease. This may be as simple as stress impairing the immune system to far more complex interactions. Homeopathic treatment seeks to match the underlying disturbance in the system and stimulate the body to correct itself.”

I do not know Dr Day, but she caught my attention recently when she published an article in THE HIPPOCRATIC POST (I had never heard of this publication before!). It is, I think, sufficiently noteworthy to show you some excerpts (the references [in square brackets] were added by me, and they refer to my comments below):

START OF QUOTES

…Homeopathy can be helpful for pretty much any condition [1], whether as the main treatment [1], as a complement to a conventional treatment [2] to speed up the healing process [1], or to lessen the side-effects of a pharmacological medication [1]. It can be helpful in the treatment of emotional problems [1], physical problems [1] and for multi-morbidity patients [1]. I find it an invaluable tool in my GP’s toolbox and regularly see the benefits of homeopathy in the patients I treat [3]…

There are many conditions for which I have found homeopathy to be effective [1]… There are, however, a multitude of symptomatic treatments available to suppress symptoms, both on prescription and over-the-counter. Most symptoms experienced by patients in this context result from the body’s attempt to eliminate the infection. Our immune systems have spent thousands of years refining this response; therefore it seems counter-intuitive to suppress it [4].
For these types of acute conditions homeopathy can work with the body to support it [1]. For instance, homeopathic Arsenicum album (arsenic) is a classic remedy for diarrhoea and vomiting that can be taken alongside essential oral rehydration [1]. And in influenza I’ve found Eupatorium perfoliatum (ague or feverwort) to be very helpful if the patient is suffering with bony pain [3].
…Unless it is clinically imperative for a pharmacological intervention, I will always consider homeopathy first [5] and have successfully prescribed the homeopathic remedy Nux vomica (strychnine) for women suffering from morning sickness [5]. Problems associated with breastfeeding such as mastitis have also responded well to the classic remedies Belladonna (deadly nightshade) and Phytolacca (pokeweed), while I have found Urtica urens (dog nettle) effective in switching off the milk supply to prevent engorgement when the mother stops breastfeeding [3].
…“heart sink” patients are clearly suffering from pain and discomfort, which is blighting their lives. This is understandably frustrating for them, for they know full well something is awry but there is no medical evidence for this… Homeopathy affords me another approach in trying to help these patients [1,3]. It doesn’t work for them all, but I’m frequently surprised at how many it does help [3].

Positive side-effects

The beauty of homeopathy is that it combines mental and emotional symptoms with physical symptoms [3]. When the right remedy is found it appears to stimulate the body to recognise how it is being dysfunctional and corrects this, with no suppression, just a correction of the underlying disturbance [3]. Thus homeopathy not only eliminates unwanted symptoms [1], it dramatically improves a patient’s overall well-being [1].
…homeopathy… enables me to reduce the number of painkillers and other drugs I’m prescribing [1,3]. This is particularly true for older multi-morbidity, polypharmacy patients [1] who are often taking huge amounts of medication.
Contrary to what most homeopaths will tell you, I believe homeopathic treatment does have side-effects – positive side-effects! [1] It fosters an enhanced doctor patient relationship [1]. The process of eliciting the relevant information to select a remedy enables me to better understand the patient’s condition and helps me to get to know them better [3]. And the patient, seeing that the doctor is interested in the idiosyncrasies and detail of their disease, finds themselves heard and understood [3]. In short, since training in homeopathy I enjoy my job as a GP and my relationship with patients so much more [3].
Dr Gabriella Day BSc, MBBS, MRCP, DCH, MRCGP, MFHom

END OF QUOTES

MY COMMENTS:

  1. statement without good evidence,
  2. Hahnemann was vehemently against combining homeopathy with other treatments and called clinicians who disregarded this ‘traitors’,
  3. statement of belief,
  4. wrong assumption,
  5. questionable ethics.

I have recently attempted to slip into the brain of lay-homeopaths and shown how illogical, misguided and wrong the arguments of such enthusiasts really are. Surely, the logic of a doctor homeopath must be better, I then thought. Once you have studied medicine, you have learnt an awful lot of things about the body, disease, therapy, etc., etc., I felt.

Judging from the above article, I might have been wrong.

1 2 3 9

Gravityscan Badge

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories