MD, PhD, FMedSci, FSB, FRCP, FRCPEd

survey

Yes, I admit it: over the years, I had formed a vague impression that homeopaths lack humour. Certainly, many comments on this blog seemed to confirm the notion. But now I changed my mind: some homeopaths are intensely funny.

Yesterday, I found a tweet which read: “NCH and homeopathy to be highlighted at the 2016 American Public Health Association’s conference in Denver”. The tweet provided a link which took me to an abstract authored by Alison Teitelbaum from the US National Center for Homeopathy (on their website, this organization tell us that they “inform legislators and work to secure homeopathy’s place in the U.S health care system while working to ensure that homeopathy is accurately represented in the media”).

The abstract in question summarized a presentation for the up-coming APHA-meeting in Denver. It is so hilariously comical that I simply have to share it with you (for those readers are homeopaths, I have added [in square brackets] a few footnotes explaining the humorous side of it):

Background: Over the last 25 years there has been a marked increase in consumer demand for information about complimentary [1] and alternative medicine, including homeopathy. Anecdotal data [2] suggest that homeopathic consumers are very satisfied with homeopathic medicines, and use them to treat acute, self-limiting conditions, however very little data exists in the published literature examining either topic [3]. Therefore, the purpose of this project was to evaluate homeopathic consumers’ use and satisfaction with homeopathic medicines.

Methods: Survey of nearly 20,000 consumers [4] who had purchased at least 1 over-the-counter (OTC) homeopathic medicine in the past 2 years.

Results: [5] More than 95% of respondents indicated they were very or extremely satisfied with the most recent OTC homeopathic medicine they had purchased and used [6]. More than 96% of respondents indicated they were very or extremely satisfied with the results of OTC homeopathic medicines that they had used in general [7]. Over 98% of respondents reported that they were very likely to purchase OTC homeopathic medicines again in the future [8]. More than 97% of respondents indicated that they were very likely to recommend homeopathic medicines to others [9]. Finally, more than 80% of respondents indicated using OTC homeopathic medicines for acute, self-limiting conditions, such as aches and pains; cold and flu symptoms; and digestive upset [10].

Conclusion: These results support anecdotal evidence [11] that homeopathic consumers are satisfied with OTC homeopathic medicines [12], and are using them to treat acute, self-limiting conditions [13]. Additional research is needed to further explore the use of OTC homeopathic medicine in the US for trends, access, and overall awareness about homeopathy [14].

[1] complimentary medicine = healthcare that costs nothing; complementary medicine = healthcare that complements real medicine; homeopathy should belong to the former category because it contains nothing.

[2] please note how ‘anecdotal data’ becomes ‘anecdotal evidence’ by the time we reach the conclusion; little does the author know that THE PLURAL OF ANECDOTE IS NOT ‘DATA’ BUT ‘ANECDOTES’!!!

[3] this statement implies that the author cannot cope with a Medline search, because there are plenty of articles on this subject.

[4] ‘nearly 20 000’ perfectly reflects the scientific rigor of this project (is it really too demanding to provide the exact figure?)

[5] how come we do not learn anything about the response rate of this survey (did ‘nearly’ everyone reply? or did ‘nearly’ everyone not reply?)?

[6] considering that only homeopathy-fans were included, this figure should be 100%!

[7] considering that only homeopathy-fans were included, this figure should be 100%!

[8] considering that only homeopathy-fans were included, this figure should be 100%!

[9] considering that only homeopathy-fans were included, this figure should be 100%!

[10] ‘more than 80%’ of an unknown rate of responders is about as much as a tin of peas. But I am nevertheless relieved that the majority used placebos merely for self-limiting conditions; the 20% who might have used it for life-threatening conditions are probably all dead – sad!

[11] see footnote number 2

[12] this is like doing a survey in a hamburger joint concluding that all consumers love to eat hamburgers.

[13] except, of course, the unknown percentage of non-responders who might all be dead.

[14] I would re-phrase this last sentence as follows: MORE SUCH PRESENTATIONS ARE NEEDED TO PROVIDE COMIC RELIEF TO OTHERWISE DRY AND BORING MEETINGS ON PUBLIC HEALTH.

Yes, yes, yes, I know: we have too few women in our ‘ALT MED HALL OF FAME’. This is not because I have anything against them (quite the contrary) but, in alternative medicine research, the boys by far outnumber the girls, I am afraid.

You do remember, of course, you has previously been admitted to this austere club of excellence; only two women so far. Here is the current list of members to remind you:

David Peters (osteopathy, homeopathy, UK)

Nicola Robinson (TCM, UK)

Peter Fisher (homeopathy, UK)

Simon Mills (herbal medicine, UK)

Gustav Dobos (various, Germany)

Claudia Witt (homeopathy, Germany and Switzerland)

George Lewith (acupuncture, UK)

John Licciardone (osteopathy, US)

If you study the list carefully, you will also notice that, until now, I have totally ignored the chiropractic profession. This is a truly embarrassing omission! When it comes to excellence in research, who could possibly bypass our friends, the chiropractors?

Today we are going to correct these mistakes. Specifically, we are going to increase the number of women by 50% (adding one more to the previous two) and, at the same time, admit a deserving chiropractor to the ALT MED HALL OF FAME.

Cheryl Hawk is currently the Executive Director of Northwest Center for Lifestyle and Functional Medicine, University of Western States, Portland, USA. Previously she worked as Director of Clinical Research at the Logan University College of Chiropractic, Chesterfield, USA, and prior to that she was employed at various other institutions. Since many years she has been a shining light of chiropractic research. She is certainly not ‘small fry’ when it comes to the promotion of chiropractic.

Cheryl seems to prefer surveys as a research tool over clinical trials, and it was therefore not always easy to identify those of her 67 Medline-listed articles that reported some kind of evaluation of the value of chiropractic. Here are, as always, the 10 most recent papers where I could extract something like a data-based conclusion (in bold) from the abstract.

Best Practices for Chiropractic Care of Children: A Consensus Update.

Hawk C, Schneider MJ, Vallone S, Hewitt EG.

J Manipulative Physiol Ther. 2016 Mar-Apr;39(3):158-68

All of the seed statements in this best practices document achieved a high level of consensus and thus represent a general framework for what constitutes an evidence-based and reasonable approach to the chiropractic management of infants, children, and adolescents.

Clinical Practice Guideline: Chiropractic Care for Low Back Pain.

Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, Whalen WM, Walters S, Kaeser M, Dehen M, Augat T.

J Manipulative Physiol Ther. 2016 Jan;39(1):1-22

The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain disorders.

The Role of Chiropractic Care in the Treatment of Dizziness or Balance Disorders: Analysis of National Health Interview Survey Data.

Ndetan H, Hawk C, Sekhon VK, Chiusano M.

J Evid Based Complementary Altern Med. 2016 Apr;21(2):138-42.

The odds ratio for perceiving being helped by a chiropractor was 4.36 (95% CI, 1.17-16.31) for respondents aged 65 years or older; 9.5 (95% CI, 7.92-11.40) for respondents reporting head or neck trauma; and 13.78 (95% CI, 5.59-33.99) for those reporting neurological or muscular conditions as the cause of their balance or dizziness.

US chiropractors’ attitudes, skills and use of evidence-based practice: A cross-sectional national survey.

Schneider MJ, Evans R, Haas M, Leach M, Hawk C, Long C, Cramer GD, Walters O, Vihstadt C, Terhorst L.

Chiropr Man Therap. 2015 May 4;23:16.

American chiropractors appear similar to chiropractors in other countries, and other health professionals regarding their favorable attitudes towards EBP, while expressing barriers related to EBP skills such as research relevance and lack of time. This suggests that the design of future EBP educational interventions should capitalize on the growing body of EBP implementation research developing in other health disciplines. This will likely include broadening the approach beyond a sole focus on EBP education, and taking a multilevel approach that also targets professional, organizational and health policy domains.

Chiropractic identity, role and future: a survey of North American chiropractic students.

Gliedt JA, Hawk C, Anderson M, Ahmad K, Bunn D, Cambron J, Gleberzon B, Hart J, Kizhakkeveettil A, Perle SM, Ramcharan M, Sullivan S, Zhang L.

Chiropr Man Therap. 2015 Feb 2;23(1):4

The chiropractic students in this study showed a preference for participating in mainstream health care, report an exposure to evidence-based practice, and desire to hold to traditional chiropractic theories and practices. The majority of students would like to see an emphasis on correction of vertebral subluxation, while a larger percent found it is important to learn about evidence-based practice. These two key points may seem contradictory, suggesting cognitive dissonance. Or perhaps some students want to hold on to traditional theory (e.g., subluxation-centered practice) while recognizing the need for further research to fully explore these theories. Further research on this topic is needed.

Do informed consent documents for chiropractic clinical research studies meet readability level recommendations and contain required elements: a descriptive study.

Twist E, Lawrence DJ, Salsbury SA, Hawk C.

Chiropr Man Therap. 2014 Dec 10;22(1):40

These results strongly suggest that chiropractic clinical researchers are not developing ICDs at a readability level congruent with the national average acceptable level. The low number of elements in some of the informed consent documents raises concern that not all research participants were fully informed when given the informed consent, and it may suggest that some documents may not be in compliance with federal requirements. Risk varies among institutions and even within institutions for the same intervention.

Feasibility of using a standardized patient encounter for training chiropractic students in tobacco cessation counseling.

Hawk C, Kaeser MA, Beavers DV.

J Chiropr Educ. 2013 Fall;27(2):135-40.

This active learning exercise appeared to be a feasible way to introduce tobacco counseling into the curriculum.

Consensus process to develop a best-practice document on the role of chiropractic care in health promotion, disease prevention, and wellness.

Hawk C, Schneider M, Evans MW Jr, Redwood D.

J Manipulative Physiol Ther. 2012 Sep;35(7):556-67

This living document provides a general framework for an evidence-based approach to chiropractic wellness care.

Chiropractic or osteopathic manipulation for children in the United States: an analysis of data from the 2007 National Health Interview Survey.

Ndetan H, Evans MW Jr, Hawk C, Walker C.

J Altern Complement Med. 2012 Apr;18(4):347-53.

C/OM is primarily used for back and neck pain, which is increasing in prevalence in children. Teens are more likely to use it than are younger children.

The role of chiropractic care in older adults.

Dougherty PE, Hawk C, Weiner DK, Gleberzon B, Andrew K, Killinger L.

Chiropr Man Therap. 2012 Feb 21;20(1):3.

Given the utilization of chiropractic services by the older adult, it is imperative that providers be familiar with the evidence for and the prudent use of different management strategies for older adults.

I am pleased to say that Prof Hawk gave me no problems at all; her case is clear: she is a champion of using research as a means for promoting chiropractic, has published many papers in this vein, clearly prefers the journals of chiropractic that nobody other than chiropractors ever access, and has an impeccable track record when it comes to avoiding negative conclusions which could harm chiropractic in any way.

Very well done indeed!

WELCOME, PROF HAWK, TO THE ‘ALT MED HALL OF FAME’.

 

I have previously reported about the issue of homeopathy on the NHS in Liverpool here. Since then, the NHS Liverpool Clinical Commissioning Group (CCG) has conducted a consultation on whether to continue funding. Personally, I think such polls are a daft waste of resources.

Why?

I will explain in a moment; first read the (slightly shortened) summary:

In November 2015, NHS Liverpool CCG Governing Body stated a preference to decommission the homeopathy service and commenced the consultation exercise with the intent to ascertain how the public felt about it. This report was written by the Centre for Public Health, Liverpool John Moores University, and includes independent analysis of the consultation activities.

The consultation ran from 13th November – 22nd December 2015. The two main methods used were 1) a survey available online and in paper format. It was completed by 743 individual respondents and, of those who provided a valid postcode, 68% (323 individuals) lived within the Liverpool CCG area, 2) a small consultation event held on 4th December 2015 facilitated by Liverpool John Moores University. The event was attended by 29 individuals, the majority of whom were patients and staff from the Liverpool Medical Homeopathic Service. Eighteen of the participants at this event resided in Liverpool.

Two thirds of survey respondents (66%; 380 respondents) said they would never use homeopathy services in the future. The reasons for this included the lack of evidence and scientific basis of homeopathy; negative personal experiences of homeopathy; and believing it was an inappropriate use of NHS funding. Those who would be likely to use it in the future (28%) felt they wanted to be able to choose an alternative to conventional medicine; felt it was value for money for the NHS; appreciated the time, care and holistic consultation; and discussed their own positive experiences. Sixty six per cent of survey respondents (111) who had used homeopathy in the past reported an excellent or good experience. Those who reported a positive experience (66%) felt that homeopathy had improved their health where conventional medicine had not, and participants valued that the homeopathic practitioner had treated their emotional as well as their physical needs. Those who reported a below average or poor experience (31%) felt homeopathy had not improved their medical condition and some felt they had been misled and had not been told the remedy contained no active ingredients.

At the consultation event, the majority of the 29 participants were homeopathy service users and they described a positive experience of homeopathy and the ability to choose ‘holistic’ and non-pharmaceutical treatment. Participants also questioned what services they could use if they were unable to access homeopathy on the NHS and were concerned and angry about the service potentially being decommissioned. A small number of participants at this event agreed with the view that there is a lack of evidence regarding efficacy and felt it was an inappropriate use of NHS funds that would be better spent on other, more effective services.

Of the survey respondents, 73% (541 individuals) chose the option to stop funding all homeopathy services; when including only Liverpool residents in the analysis this decreased to 64%.  Twenty three per cent of survey respondents (170 individuals) wanted to continue to fund homeopathy services in Liverpool (either at current levels or to increase the budget); when only including Liverpool residents this proportion increased slightly to 30%. At the end of the consultation event the participants in the room (29 individuals) were asked to vote on their preferred funding option; twenty two participants (76%) wanted to continue the service and increase the maximum funding limit; three participants (14%) wanted to stay with the current situation and three participants (10%) wanted to stop funding the service.

There was some tension in what those in the consultation saw as acceptable and appropriate evidence about the effectiveness of homeopathy. Many participants in the survey and at the event reported their positive experience or anecdotal evidence as “proof” that homeopathy is effective.  There was a low understanding about how scientific research is conducted or evaluated. The NHS try to base funding decisions on rigorous, high-quality, unbiased, peer-reviewed research, however, the CCG is required to account of all evidence, including patient experience, when funding or discontinuing services.

Across the survey and the consultation event there was some confusion about what types of treatment come under the heading of “homeopathy”, with participants making reference to a range of herbal remedies and supplements. Iscador (a mistletoe extract) may be, in some cases, provided as a complementary treatment for patients with cancer, however, this is not a homeopathic remedy. There was also discussion (in the event and in the survey responses) about other herbal remedies and supplements.

END OF SUMMARY

So, why do I not think highly about exercises of this kind?

In general, surveys are tricky and often very dodgy research tools. Particularly in alternative medicine, they are as popular as they are useless. The potential problems arise from the way the methodology is often applied. For instance, sampling is crucial. If, like in the present case, no rigorous sampling techniques are applied, the results will inevitably be unreliable in reflecting the views of a population.

The findings of the survey above could easily be little more than a reflection of which camp had a better PR. Homeopaths usually are very good on such occasions at persuading others for homeopathy. In this case, the results show that, despite their best efforts, the overall vote was not positive for homeopathy. What we don’t know is whether this is a reflection on the ‘will of the people’. It could be that the public is much more against funding nonsense than this poll suggests.

I would also argue that letting people vote about the availability of medical interventions is nonsensical. The value of healthcare technologies is not determined by such ‘beauty contests’; the value depends on the scientific evidence, and that is not readily evaluated by non-experts. Imagine: next we might vote for or against bone-marrow transplants; who has the expertise to cast such a vote?

Oh yes, and the ‘small consultation’ – what was that supposed to be. Probably just an exercise in political correctness. Nobody in their right mind can have expected any meaningful insight coming from it.

Finally, I dispute that ‘patients’ experience’ is the same as ‘evidence’, as the summary above seems to claim. This is just nonsense. evidence is something entirely different from experience.

But politicians will disregard all this. They will say ‘the public has decided’ and will stop funding homeopathy on the NHS in Liverpool. More by coincidence than by design, this survey went into the right direction. Now one can only hope that the rest of the country will follow suit – on evidence, not on dodgy pseudo-evidence from surveys.

Over the years, I had to get used to some abominably poor research in alternative medicine, particularly homeopathy. This new paper takes the biscuit, in my fairly well-informed opinion.

The article in question reports a survey investigating the management of paediatric tonsillopharyngitis, with a focus on natural remedies. For that purpose, 138 paediatricians, general practitioners and ear-nose-throat (ENT) specialists from 7 countries were sent a self-made, non-validated questionnaire.

The results indicate that a rapid strept test (RST) to diagnose acute tonsillopharyngitis was routinely used by 41% of the respondents. The use of RST allowed 200 diagnosis/year compared with 125 diagnosis/year for clinicians who did not use this tool. Homeopathic remedies were prescribed as a supportive therapy by 62% of participants. Among different homeopathic remedies, SilAtro-5-90 was the most frequently prescribed. In the chronic setting, homeopathy was suggested as a supportive therapy by 59% of all participants, phytotherapy by 28% and vitamins/nutritional supplementation by 37%.

The authors of this paper concluded from these results that the management of tonsillopharyngitis in paediatric patients still remains empiric. Natural remedies, and homeopathy in particular, are used in the management of URTIs. An integrative approach to these infections may help reduce excessive antibiotic prescription.

No wonder that homeopathy and research into it are the laughing stock of the scientific community!

A survey of this nature is already a fairly daft idea. What could it possibly show? That health care professionals who like homeopathy answer, while the vast majority don’t!

But the pinnacle of silliness must be the conclusions drawn from such ‘research’. Let’s take them step by step:

  1. the management of tonsillopharyngitis in paediatric patients still remains empiric – this is not true nor is it borne out by the data generated.
  2. Natural remedies, and homeopathy in particular, are used in the management of URTIs – this may be true, but it has been known before; we therefore do not need to waste time and effort to re-state it.
  3. An integrative approach to these infections may help reduce excessive antibiotic prescription – this is not supported by the data and it also seems nonsensical: if it truly successful in reducing antibiotic prescribing, it is arguably no longer integrative but alternative.

So?

Say no more!

Hurray, I can hear the Champagne corks popping: this month is ‘National Chiropractic Months’ in the USA – a whole month! This has depleted my stock of the delicious fizz already in the first three days.

Now that my bottles are empty (is there a chiropractic cure for a hang-over?), I must find other ways to celebrate. How about a more sober look at what has been published in the medical literature on chiropractic during the last few days?

A quick look into Medline identifies several articles of interest. The very first one is a case-report:

Spinal epidural hematoma (SEH) occurring after chiropractic spinal manipulation therapy (CSMT) is a rare clinical phenomenon. Our case is unique because the patient had an undiagnosed cervical spinal arteriovenous malformation (AVM) discovered on pathological analysis of the evacuated hematoma. Although the spinal manipulation likely contributed to the rupture of the AVM, there was no radiographic evidence of the use of excessive force, which was seen in another reported case. As such, patients with a known AVM who have not undergone surgical intervention should be cautioned against symptomatic treatment with CSMT, even if performed properly. Regardless of etiology, SEH is a surgical emergency and its favorable neurological recovery correlates inversely with time to surgical evacuation.

This is important, I think, in more than one way. Many chiropractors simply deny that their manipulations cause serious complications of this nature. Yet such cases are being reported with depressing regularity. Other chiropractors claim that excessive force is necessary to cause the damage. This paper seems to refute this notion quite well, I think.

But let’s not be inelegant and dwell on this unpleasant subject; it might upset chiros during their month of celebration.

The next article fresh from the press is a survey – chiropractors are very fond of this research tool, it seems. It produced a lot of intensely boring data – except for one item that caught my eye: the authors found that ‘virtually all Danish chiropractors working in the primary sector made use of manipulation as one of their treatment modalities.’

Why is that interesting? Whenever I point out that there is no good evidence that chiropractic manipulations generate more good than harm, chiropractors tend to point out that they do so much more than that. Manipulations are not administered to all their patients, they say. This survey is a reminder (there is plenty more evidence on this issue) of the fact that the argument is not very convincing.

Another survey which has just been published in time for the ‘celebratory month’ is worth mentioning. It reports the responses of patients to questions about chiropractic by providing the ‘positive angle’, e.g.: ‘Most (61.4%) respondents believed that chiropractic care was effective at treating neck and back pain…’ Just for the fun of it, I thought it might be worth doing the opposite: 39% did not believe that chiropractic care was effective at treating neck and back pain… If we use this approach, the new survey also indicates that about half of the respondents did not think chiropractors were trustworthy, and 86% have not consulted a chiropractor within the last year.

Oh, so sorry – I did not mean to spoil the celebrations! Better move on then!

A third survey assessed the attitudes of Canadian obstetricians towards chiropractic. Overall, 70% of respondents did not hold a positive views toward chiropractic, 74% did not agree that chiropractic had a role in treatment of non-musculoskeletal conditions, 60% did not refer at least some patients for chiropractic care each year, and comments of the obstetricians revealed concerns regarding safety of spinal manipulation and variability among chiropractors.

And now I better let you get on with your well-deserved celebrations and look for another bottle!

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The question why patients turn to homeopathy – or indeed any other disproven treatment – has puzzled many people. There has been a flurry of research into these issues. Here is the abstract of a paper that I find very remarkable and truly fascinating:

Interviews with 100 homeopathic patients in the San Francisco Bay Area show that for the most part the patients are young, white and well-educated, and have white-collar jobs; most had previously tried mainstream medical care and found it unsatisfactory. Among the reasons for their dissatisfaction were instances of negative side effects from medication, lack of nutritional or preventive medical counseling, and lack of health education. Experiences with conventional physicians were almost evenly divided: nearly half of the subjects reported poor experiences, slightly fewer reported good experiences. Three quarters of the patients suffered from chronic illness and about half considered their progress to be good under homeopathic care. The majority were simultaneously involved in other nontraditional health care activities.

If you read the full article, you will see that the authors make further important points:

  • Patients who use alternative treatments are by no means ignorant or unsophisticated.
  • Most of these patients use other treatments in parallel – but they seem to attribute any improvements in their condition to homeopathy.
  • Dissatisfaction with conventional medicine seems the prime motivation to turn to homeopathy. In particular, patients need more time with their clinician and want to share the responsibility for their own health – and these needs are met by homeopaths better than by conventional doctors.
  • Most homeopaths (63%) adhere to Hahnemann’s dictum that homeopathic remedies must never be combined with other treatments. This renders then potentially dangerous in many situations.

At this point you might say BUT WE KNEW ALL THIS BEFORE! True! Why then do I find this paper so remarkable?

It is remarkable mostly because of its publication date: 1978! In fact, it may well be the very first of hundreds of similar surveys that followed in the years since.

The questions I ask myself are these:

  • IF WE KNEW ALL THIS SINCE ALMOST 40 YEARS, WHY HAVE WE NOT DONE MORE ABOUT IT?
  • WHY ARE WE SO UNSUCCESSFUL IN GETTING THE FACTS THROUGH TO OUR PATIENTS?
  • WHY HAVE WE NOT MANAGED TO IMPROVE CONVENTIONAL MEDICINE SUCH THAT PATIENTS STOP CONSULTING QUACKS?
  • WHY ARE WE STILL CONDUCTING SURVEY AFTER SURVEY WHEN THE EMBARRASSING FACTS ARE PLAIN TO SEE?

Homeopathy is very popular in India – at least this is what we are being told over and over again. The notion goes as far as some sources assuming that homeopathy is quintessential Indian (see below). One Website, informs us that homeopathy is the third most popular method of treatment in India, after Allopathy and Ayurveda. It is estimated that there are about quarter million homeopaths in India. Nearly 10,000 new ones add to this number every year. The legal status of homeopathy in India is very much at par with the conventional medicine.

Another website currently advises the Indian population as well as heath tourists from abroad about homeopathy in the following terms:

Homeopathic medicines have various benefits. Some of them are as follows:

  • Such medicines can be given to infants, children, pregnant or nursing woman
  • If by chance, wrong medication is prescribed, it is not going to have any ill-effect
  • These medicines can be taken along with other medications
  • Homeopathic treatment can be used by anyone
  • The medicines work on the eradication of the symptoms so that illness never comes back
  • These medicines can be stored for a longer span of time and are inexpensive as well
  • Homeopathy has a holistic approach and deals with mind, body and emotions
  • These medicines are non-invasive and extremely effective
  • These medicines can be administered easily
  • Homeopathy useful in a number of health problems

Homeopathic Remedies, for Diseases and Conditions

  • Asthma
  • Arthritis
  • Cancer
  • Acute fevers
  • Sore throats
  • Toothache
  • Eczema
  • Mild depression
  • Fatigue
  • Anxiety
  • Cataract
  • Fractures
  • Injuries with blunt objects
  • Loss of appetite

But is it really true that so many Indian consumers swear by homeopathy, or is that just one of the many myths from the realm of quackery that stubbornly refuse to disappear ?

survey recently conducted by Indian National Sample Survey Office might provide some answers. It revealed that 90 per cent of the Indian population rely on conventional medicine. Merely 6% trusted what the investigators chose to call ‘Indian systems of medicine’, e. g. ayurveda, unani and siddha, homeopathy and yoga and naturopathy.

Odd? Not really! There are several plausible explanations for this apparent contradiction:

  1. The popularity of homeopathy in India could be a myth promoted by apologists.
  2. The figures could be correct, and many Indian patients could use homeopathy not because they believe in it but because they cannot afford effective treatments.
  3. The claim of homeopathy’s popularity could refer to the past, while the recent survey clearly relates to the present.

Whatever the true answer might be, I think this little news story is an instructive example for the fact that the ‘argumentum ad populum’ is a fallacy that easily can mislead us.

I will state my position up front: THERE IS NO CHILDHOOD CONDITION FOR WHICH CHIROPRACTIC SPINAL MANIPULATION GENERATES MORE GOOD THAN HARM. What is more, I have published evidence (published herehere, here, and here, for instance) to support this statement. If you disagree with it, this is the place and time to do so – and please don’t forget to cite the evidence that supports your statements.

Given that there is very little reliable evidence in this area, I find it surprising that so many chiropractors continue to treat kids. Not true! I hear some chiropractors shout, we do not often treat children. Who is correct? Clearly, we need data to answer this question.

The objective of a new paper was to investigate characteristics of clinical chiropractic practice, including the age of pediatric patients, the number of reports of negative side effects (NSEs), the opinions of doctors of chiropractic on treatment options by patient age groups, the conditions seen and the number of treatment sessions delivered by conditions and by patient age.

An Internet cross-sectional survey was conducted in 20 European countries with 4109 chiropractors invited to reply. The 19 national associations belonging to the European Chiropractic Union and the Danish Chiropractic Association were asked to participate. Respondents were asked to self-report characteristics of their practices.

Of the 956 (23.3%) participating chiropractors, 921 reported 19821 pediatric patients per month. Children represented 8.1% of chiropractors’ total patient load over the last year. A total of 557 (534 mild, 23 moderate, and 0 severe) negative (adverse) side effects were reported for an estimated incidence of 0.23%. On the given treatment statements, chiropractors reported varying agreement and disagreement rates based on patient age. The 8309 answers on conditions were grouped into skeletal (57.0%), neurologic (23.7%), gastrointestinal (12.4%), infection (3.5%), genitourinary (1.5%), immune (1.4%), and miscellaneous conditions (0.5%). The number of treatment sessions delivered varied according to the condition and the patient age.

The authors of this survey concluded that this study showed that European chiropractors are active in the care of pediatric patients. Reported conditions were mainly skeletal and neurologic complaints. In this survey, no severe NSEs were reported, and mild NSEs were infrequent.

In my view, a more appropriate conclusion might be that MANY EUROPEAN CHIROPRACTORS ARE ACTIVE IN QUACKERY.

Recently, I was sent an interesting press release; here it is in full:

A new study has shed light on how cancer patients’ attitudes and beliefs drive the use of complementary and alternative medicine. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings may help hospitals develop more effective and accessible integrative oncology services for patients.

Although many cancer patients use complementary and alternative medicine, what drives this usage is unclear. To investigate, a team led by Jun Mao, MD and Joshua Bauml, MD, of the Abramson Cancer Center at the University of Pennsylvania’s Perelman School of Medicine, conducted a survey-based study in their institution’s thoracic, breast, and gastrointestinal medical oncology clinics.

Among 969 participants surveyed between June 2010 and September 2011, patients who were younger, those who were female, and those who had a college education tended to expect greater benefits from complementary and alternative medicine. Nonwhite patients reported more perceived barriers to the use of complementary and alternative medicine compared with white patients, but their expectations concerning the medicine’s benefits were similar. Attitudes and beliefs about complementary and alternative medicine were much more likely to affect patients’ use than clinical and demographic characteristics.

“We found that specific attitudes and beliefs — such as expectation of therapeutic benefits, patient-perceived barriers regarding cost and access, and opinions of patients’ physician and family members — may predict patients’ use of complementary and alternative medicine following cancer diagnoses,” said Dr. Mao. “We also found that these beliefs and attitudes varied by key socio-demographic factors such as sex, race, and education, which highlights the need for a more individualized approach when clinically integrating complementary and alternative medicine into conventional cancer care.”

The researchers noted that as therapies such as acupuncture and yoga continue to demonstrate clinical benefits for reducing pain, fatigue, and psychological distress, the field of integrative oncology is emerging to bring complementary and alternative medicine together with conventional care to improve patient outcomes. “Our findings emphasize the importance of patients’ attitudes and beliefs about complementary and alternative medicine as we seek to develop integrative oncology programs in academic medical centers and community hospitals,” said Dr. Bauml. “By aligning with patients’ expectations, removing unnecessary structural barriers, and engaging patients’ social and support networks, we can develop patient-centered clinical programs that better serve diverse groups of cancer patients regardless of sex, race, and education levels.”

And here is the abstract of the actual article:

BACKGROUND:

Complementary and alternative medicine (CAM) incorporates treatments used by cancer survivors in an attempt to improve their quality of life. Although population studies have identified factors associated with its use, to the best of the authors knowledge, assessment of why patients use CAM or the barriers against its use have not been examined to date.

METHODS:

The authors conducted a cross-sectional survey study in the thoracic, breast, and gastrointestinal medical oncology clinics at an academic cancer center. Clinical and demographic variables were collected by self-report and chart abstraction. Attitudes and beliefs were measured using the validated Attitudes and Beliefs about CAM (ABCAM) instrument. This instrument divides attitudes and beliefs into 3 domains: expected benefits, perceived barriers, and subjective norms.

RESULTS:

Among 969 participants (response rate, 82.7%) surveyed between June 2010 and September 2011, patient age ≤65 years, female sex, and college education were associated with a significantly greater expected benefit from CAM (P<.0001 for all). Nonwhite patients reported more perceived barriers to CAM use compared with white patients (P<.0001), but had a similar degree of expected benefit (P = .76). In a multivariate logistic regression analysis, all domains of the ABCAM instrument were found to be significantly associated with CAM use (P<.01 for all) among patients with cancer. Attitudes and beliefs regarding CAM explained much more variance in CAM use than clinical and demographic variables alone.

CONCLUSIONS:

Attitudes and beliefs varied by key clinical and demographic characteristics, and predicted CAM use. By developing CAM programs based upon attitudes and beliefs, barriers among underserved patient populations may be removed and more patient centered care may be provided.

Why do I find this remarkable?

The article was published in the Journal CANCER, one of the very best publications in oncology. One would therefore expect that it contributes meaningfully to our knowledge. Remarkably, it doesn’t! Virtually every finding from this survey had been known or is so obvious that it does not require research, in my view. The article is an orgy of platitudes, and the press release is even worse.

But this is not what irritates me most with this paper. The aspect that I find seriously bad about it is its general attitude: it seems to accept that alternative therapies are a good thing for cancer patients which we should all welcome with open arms. The press release even states that, as therapies such as acupuncture and yoga continue to demonstrate clinical benefits for reducing pain, fatigue, and psychological distress, the field of integrative oncology is emerging to bring complementary and alternative medicine together with conventional care to improve patient outcomes.

I might be a bit old-fashioned, but I would have thought that, before we accept treatments into clinical routine, we ought to demonstrate that they generate more good than harm. Should we not actually show beyond reasonable doubt that patients’ outcomes are improved before we waffle about the notion? Is it not our ethical duty to analyse and think critically? If we fail to do that, we are, I think, nothing other than charlatans!

This article might be a mere triviality – if it were not symptomatic of what we are currently witnessing on a truly grand scale in this area. Integrative oncology seems fast to deteriorate into a paradise for pseudoscience and quacks.

Not much is known about the interactions of real doctors (by this I mean people who have been to medical school) and chiropractors who like to call themselves ‘doctors’ or ‘DCs’ but have never been to medical school. Therefore this recent article is of particular interest, in my view.

The purpose of this paper was to identify characteristics of Canadian chiropractors (DCs) associated with the number of patients referred by medical doctors (MDs). For this purpose, secondary data analyses were performed on the 2011 cross-sectional survey of the Canadian Chiropractic Resources Databank survey which included 81 questions about the practice of DCs. Of the 6533 mailed questionnaires, 2529 (38.7%) were returned and 489 did not meet our inclusion criteria. In total, the analysed sample included 2040 respondents.

The results show that, on average, DCs reported receiving 15.6 (SD 31.3) patient referrals from MDs per year. Nearly one-third of the respondents did not receive any. The type of clinic (multidisciplinary with MD), the province of practice (Atlantic provinces), the number of treatments provided per week, the number of practicing hours, rehabilitation and sports injuries as the main sector of activity, prescription of exercises, use of heat packs and ultrasound, and the percentage of patients referred to other health care providers were associated with a higher number of MD referrals to DCs. The percentage of patients with somatovisceral conditions, using a particular chiropractic technique (hole in one and Thompson), taking own radiographs, being the client of a chiropractic management service, and considering maintenance/wellness care as a main sector of activity were associated with fewer MD referrals.

The authors concluded that Canadian DCs who interacted with other health care workers and who focus their practice on musculoskeletal conditions reported more referrals from MDs.

One could criticise this survey for a number of reasons, for instance:

  • the response rate was low,
  • the sample was small,
  • the data are now 4 years old and might be obsolete.

Despite these flaws, the paper does seem to reveal some relevant things. What I find especially interesting is that:

  • the level of referrals from doctors to chiropractors seems exceedingly low,
  • dubious chiropractic activities such as maintenance therapy or treatment of non-spinal conditions led to even less referrals.

To me, that implies that Canadian doctors are, on the one hand, willing to co-operate with chiropractors. On the other hand, they remain cautious about the high level of quackery in this profession.

All this means really is that Canadian doctors are responsible and aim to adhere to evidence-based practice…in contrast to many chiropractors, I hasten to add.

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