Here are 3 more short pieces of alternative medicine satire. if you like them, please consider to send me your own short articles.
AT FAP No 7 (sent in by ‘Ex-Acupuncturist’)
Heroin junkies are now putting another type of needle in their body to get high… Acupuncture needles! Acupuncturists have long theorized that an endorphin release is part of the clinical effect of acupuncture. Endorphins are the body’s own painkillers. They are in a group of chemicals called endogenous opioids. While sceptics have pointed out that endorphin release is also a key part of the placebo effect, it seems that ancient Chinese wisdom wins this round of the battle.
“The key is to twirl the needle in the correct direction for each individual,” one experienced user reported. “In general, men get clockwise, women counter-clockwise, but it reverses depending on the phase of the moon and whether the kidney pulse on the wrist is floating or deep. It may sound strange, but once you hit the right point and twirl the right way, you’re talking to the rabbit on the moon for hours.”
Apparently, heroin-like effects aren’t the only drugs acupuncture can mimic. Homeless researcher William S. Burrows reports point combinations which replicate cannabis, magic mushrooms, and even methamphetamines. “We confirmed this with a double-blind test down in the park. I drew the point combinations and labelled them with codes, then taught a few volunteers how to do the needling without telling them what combinations mimic each drug. Then I hit the bar while they rolled dice and randomly did these combinations on hundreds of homeless addicts, who then were observed and interviewed by different volunteers who didn’t know what group they had been randomized to. The differences between the meth points and the horse points were pretty obvious by behaviour, but we also gathered more objective data such as blood pressure, pupil size, and pre- and post- treatment urinalysis results. Most of our volunteers are users of real drugs, but when you get the acupuncture right it the metabolites show up in urine.”
Science journal editor Dr. Edward Ernest was impressed. “This acupuncture research carried out by homeless drug addicts, literally under a bridge, is better and more convincing than all previous acupuncture research combined. What’s more impressive is that it’s being replicated as we speak in addicted populations around the world, all through grassroots efforts.”
When asked why his research was so well structured and recorded compared to previous acupuncture research, Burrows said, “I’m not sure, but it may have something to do with how important getting high is to addicts. Regular acupuncturists are just telling people they can treat normal pain and diseases, and many of those go away on their own. We are dealing with serious drug habits here, it’s not something to mess around with. Regular people can be fooled with post hoc reasoning, regression to the mean, and a good bedside manner. Junkies in withdrawal have a higher standard of evidence.”
While getting high with acupuncture is safer and less expensive than using black market drugs, public health officials are already warning users that familiar communicable disease dangers exist if needles are shared. “We are discussing setting up a free acupuncture needle exchange to reduce the risk of hepatitis and HIV transmission.”
AT FAP No 8 (by Edzard Ernst)
THE END OF EBM and the arrival of VBM
Inspired by a recent popular vote in Scotland on the need of having homeopathy free on the NHS, top-ranking health politicians from across the UK have met to discuss the implications of this intriguing and ground-breaking development. The politicians were taken by the idea of replacing evidence with a popular vote. They felt that they were much more familiar with the various ways to influence voters than with the often fiendishly complex issues of scientific evidence. “Everything becomes understandable and transparent with one single stroke”, one senior official commented, “what could be more logical than finally democratising health care? It was time anyway to break the dictatorship of science; as politicians, we cannot tolerate to be told by scientists what is right and wrong.”
The panel drew up plans to have all major health care decisions decided by popular vote. Pilot projects that followed this courageous move have already generated most encouraging results: diabetics voted to have free chocolate, claudicants opted for cheaper cigarettes, addicts wanted to legalise hard drugs and the entire population of Totness was in favour of replacing conventional by alternative medicine.
On the basis of these findings, the secretary for health issued a press release pointing out that innovations of this nature might look counter-intuitive to notoriously short-sighted medics but from a more realistic perspective, they do make a lot of sense: patients deserve to be given a choice; if many to the most desperately ill diabetics die early as a consequence, it might even be humane to let them end their suffering quickly and with dignity - and from a societal point of view, early fatalities mean significant cost-savings which will certainly free funds to improve the health of the rest of the nation. “I am sure that this innovation will win us votes”, one Tory health politician was quoted saying. A white paper was drawn up which suggests the nationwide implementation of these progressive concepts, and well-informed circles at Westminster indicate that David Cameron views the new ‘Vote-Based Medicine’ (VBM) as a possible solution to steer the NHS out of its current crisis.
AT FAP No 9 (by Edzard Ernst)
A bitter row has broken out in the US-based ‘Palmer Institute of Straight Chiropractic’ (PISC) over the interpretation of the results generated by the largest long-term study of chiropractic that has ever been initiated. The study in question, which had been funded by the NIH and several chiropractic bodies across the world, started recruiting in the 1970. Its was aimed at testing the effects of chiropractic maintenance treatment. Based on D D Palmer’s , the father of chiropractic, axiom that all diseases are caused by ‘subluxations of the spine’, chiropractic maintenance care is a method of regularly adjusting subluxations of healthy people before they can do any significant damage to health and well-being. Top officials of PICS had therefore concluded that regular adjustments would prevent illness and prolong life. The project was thus to administer maintenance care to 1000 volunteers for their entire life time and compare the mortality and morbidity of this cohort with the data from the US population at large.
So far, the findings of this study had been kept under tight wraps; the protocol foresaw that the first analysis should only be at the 40-year follow-up. Last months, however, the first preliminary analysis emerged at a closed meeting of the PISC in Devonport, US. A leaked note shows that, despite the large sample size and the sizable number of morbidity and mortality outcomes in the study cohort, the comparison with the general population did not demonstrate any significant differences; if anything, the incidence of neurological problems, e.g. stroke, in the experimental group seems unusually high.
As soon as the results were known to the PISC-officials, dramatically different interpretations of these findings emerged, our reporter was told:
- One group of chiropractors claimed the results were obviously rigged; some were sure that BIG PHARMA had bribed the researchers/statisticians to produce false negative findings. “It stands to reason”, one chiropractor from this camp was quoted saying, “just imagine what would happen, if the effectiveness of chiropractic maintenance care would become general knowledge; nobody would need the pharma-industry any more. It is therefore clear that they did everything in their power to supress the truth”
- The other group of chiropractors claimed that the maintenance treatment implemented in the study was not intensive enough to be effective. On average, every study participant had 1.6 sessions of spinal manipulation per week (the costs of these treatments were estimated at US$ 60 million across the study period). But these chiropractors argued that “subluxations occur much more frequently and need to be treated more regularly; we advocate daily sessions to be on the safe side - besides, this would be ever so good for the profession as a whole.”
So far none of the chiropractors who have commented on the results of this study considered that their original hypothesis was false, i.e. that subluxations might not be the cause of all human disease. When our reporter put this possibility to the president of PISC, the answer was prompt and abrupt: ” You must be kidding! That would mean that D D Plamer was wrong. This is not a realistic possibility at all. Chiropractors are foremost manipulators; we will now manipulate the data until they confirm Palmer’s theory.”
CAM-Cancer is short for a project entitled “Concerted Action for Complementary and Alternative Medicine Assessment in the Cancer Field”. Originally funded by the European Commission, it is now hosted by the National Information Center for Complementary and Alternative Medicine (NIFAB) at the University of Tromsø, Norway.
Our executive Committee is very international and, in my view, fairly balanced; it consists of the following experts:
- Prof Vinjar Fønnebø, The Norwegian National Research Center in CAM
- Prof Thomas Cerny, Kantonsspital St Gallen, Switzerland
- Prof Edzard Ernst, University of Exeter, UK
- Dr Markus Horneber, Department of Oncology/Hematology, Klinikum Nuernberg, Germany
- Dr Christine Paludan-Müller, Danish Cancer Society
Our work consists mainly of conducting and updating systematic reviews of treatments often used by cancer patients and providing them for free via the Internet. To date, we have concluded more than 60 such projects and they are all available for anyone to study. I have previously reported about our results in the area of herbal medicine. Today, I will briefly mention those on mind-body interventions.
The Internet is awash with information on the effectiveness of such treatments which is not always accurate, and even top-journals publish reviews which paint a rather optimistic picture: Mind-body therapies categorized as CAM could potentially serve as a positive platform from which providers could discuss CAM and even link survivor subgroups to services that may, at least, partly address unmet psychosocial needs. This would be especially relevant for survivor subgroups that have a cultural bias toward CAM. The mind-body therapies reviewed in this article have some supportive evidence and a rationale for use in cancer survivors. Although data on efficacy and mechanisms of action of mind-body therapies are incomplete and inconclusive, the potential benefits of using these therapies in survivor care plans warrant consideration.
By contrast, our reviews seem far less positive. Here are the key sentences describing the evidence of the four mind-body therapies that we at ’CAM cancer’ have so far tackled.
- Based on one clinical trial and two pilot studies, it is not possible to draw conclusions about the effectiveness of autogenic therapy for people with cancer
- There is presently a lack of good quality, single-intervention trials, so it is not possible to draw clear conclusions about the efficacy of biofeedback for people with cancer
- Existing evidence suggests that hypnotherapy may reduce cancer therapy related pain, anticipatory nausea and vomiting, and anxiety
- There is insufficient evidence for the effectiveness of PMR for cancer patients suffering from pain, anxiety, depression, sleep disorders and chemotherapy-induced nausea
The question is, what precisely does that mean? I think this evidence is compatible with several interpretations:
- Mind-body therapies are generally over-rated but not really that helpful.
- They are effective, but the research is in its infancy and currently fails to document their value adequately.
- Some mind-body therapies are effective, while others are not.
At present, it is impossible to tell which interpretation is correct. What is clear, however, is the fact that ‘CAM-Cancer’ is a source that tries its utmost to inform people accurately while doing everything possible to minimise bias.
The NHS tells us that our “choices include more than just which GP or hospital to use. You also have choices about your treatment decisions…” In most other countries, similarly confusing statements about PATIENT CHOICE are being made almost on a daily basis, often by politicians who have more ambition to win votes than to understand the complex issues at hand. Consequently, patients and consumers might be forgiven to assume that PATIENT CHOICE means we are all invited to indulge in the therapy we happen to fancy, while society foots the bill. Certainly, proponents of alternative medicine are fond of the notion that the principle of PATIENT CHOICE provides a ‘carte blanche’ for everyone who wants it to have homeopathy, Reiki, Bach Flower Remedies, crystal healing, or other bogus treatments - paid for, of course, by the taxpayer.
Reality is, however, very different. Anyone who has actually tried to choose his/her hospital will know that this is far from easy. And deciding what treatment one might employ for this or that condition is even less straight forward. Choice, it turns out, is a big word, but often it is just that: a word.
Yet politicians love their new mantra of PATIENT CHOICE; it is politically correct as it might give the taxpayer the impression that he/she is firmly installed in the driving seat. Consequently PATIENT CHOICE has become a slogan that is used to score points in public debates but that, in fact, is frequently next to meaningless. More often than not, the illusion of being in control has to serve as a poor substitute for actually being in control.
To imply that patients should be able to choose their treatment has always struck me as a little naïve, particularly in the way this is often understood in the realm of alternative medicine. Imagine you have a serious condition, say cancer: after you have come over the shock of this diagnosis, you begin to read on the Internet and consider your options. Should you have surgery or faith healing, chemotherapy or homeopathy, radiotherapy or a little detox?
Clearly PATIENT CHOICE, as paid for by society, cannot be about choosing between a realistic option and an unrealistic one. It must be confined to treatments which have all been shown to be effective. Using scarce public funds for ineffective treatments is nothing short of unethical. If, for a certain condition, there happen to be 10 different, equally effective and safe options, we may indeed have a choice. Alas, this is not often the case. Often, there is just one effective treatment, and in such instances the only realistic choice is between accepting or rejecting it.
And, anyway, how would we know that 10 different treatments are equally effective and safe? After going on the Internet and reading a bit about them, we might convince ourselves that we know but, in fact, very few patients have sufficient knowledge for making complex decisions of this nature. We usually need an expert to help us. In other words, we require our doctor to guide us through this jungle of proven benefits and potential risks.
Once we accept this to be true, we have arrived at a reasonable concept of what PATIENT CHOICE really means in relation to deciding between two or more treatments: the principle of shared decision making. And this is a fundamentally different concept from the naïve view of those alternative medicine enthusiasts who promote the idea that PATIENT CHOICE opens the door to opting for any unproven or disproven pseudo-therapy.
To be meaningful, ethical and responsible, choice needs to be guided by sound evidence - if not, it degenerates into irresponsible arbitrariness, and health care deteriorates into some kind of Russian roulette. To claim, as some fans of alternative medicine do, that the principle of PATIENT CHOICE gives everyone the right to use unproven treatments at the expense of the taxpayer is pure nonsense. But some extreme proponents of quackery go even further; they claim that the discontinuation of payment for treatments that have been identified as ineffective amounts to a dangerous curtailment of patients’ rights. This, I think, is simply a cynical attempt to mislead the public for the selfish purpose of profit.
Postoperative ileus (POI), the phenomenon that after an operation the intestines tend to be inactive for a few days, can cause intense pain and thus contributes significantly to human suffering. It also prolongs hospital stay and increases the risks of post-operative complications. There is no known effective treatment for POI.
In China, POI is often treated with acupuncture, and due to this fact acupuncture became known in the West: James Reston, a journalist who accompanied Nixon on his first trip to China, had to have an appendectomy in a Beijing hospital, he subsequently suffered from POI, was treated with acupuncture and moxibustion, experienced symptom-relief, and subsequently wrote about it in the New York Times. This was the beginning of the present acupuncture-boom.
Since then, thousands of acupuncture trials have been published but, intriguingly, very few have tested the effectiveness of acupuncture for POI. Now researchers from the Sloan Kettering Cancer Center in New York have conducted a randomized, sham-controlled trial to test whether acupuncture reduces POI more effectively than sham acupuncture.
Ninety colon cancer patients undergoing elective colectomy were randomized to receive 30 min of true or sham acupuncture twice daily during their first three postoperative days. GI-3 (the later of the following two events: time that the patient first tolerated solid food, AND time that the patient first passed flatus OR a bowel movement) and GI-2 (the later of the following two events: time patient first tolerated solid food AND time patient first passed a bowel movement) were determined. Pain, nausea, vomiting, and use of pain medications were evaluated daily for the first three postoperative days. Eighty-one patients received the allocated intervention: 39 the true acupuncture and 42 the sham acupuncture. The mean time to GI-3 was 149 hours and 146 hours for the acupuncture group and the sham acupuncture group. No significant differences were found between groups for secondary endpoints.
The authors’ conclusion was clear: True acupuncture as provided in this study did not reduce POI more significantly than sham acupuncture.
So, did a mere misunderstanding start the present acupuncture boom? POI inevitably normalises with time. Did the journalist just imagine that acupuncture helped, while nature cured the condition? It would seem so, according to this study. But perhaps things are not just black or white. Almost at the same time as the New York trial, another study was emerged.
Researchers from Hong Kong conducted an RCT with 165 patients undergoing elective laparoscopic surgery for colonic and upper rectal cancer. Patients were assigned randomly to receive electroacupuncture (n = 55) or sham acupuncture (n = 55), once daily from postoperative days 1-4, or no acupuncture (n = 55). The primary outcome was time to defecation. Secondary outcomes included postoperative analgesic requirement, time to ambulation, and length of hospital stay. The results showed that patients who received electroacupuncture had a shorter time to defecation than patients who received no acupuncture (85.9 ± 36.1 vs 122.1 ± 53.5 h) and length of hospital stay (6.5 ± 2.2 vs 8.5 ± 4.8 days). Patients who received electroacupuncture also had a shorter time to defecation than patients who received sham acupuncture (85.9 ± 36.1 vs 107.5 ± 46.2 h). Electroacupuncture was more effective than no or sham acupuncture in reducing postoperative analgesic requirement and time to ambulation.
The Chinese researchers’ conclusion is equally clear: electroacupuncture reduced the duration of postoperative ileus, time to ambulation, and postoperative analgesic requirement, compared with no or sham acupuncture, after laparoscopic surgery for colorectal cancer.
The only other trial I know in this area failed to show that acupuncture shortens POI. What should we make of these data? A systematic review would be nice, of course, but, to the best of my knowledge, none is currently available.
Is this a question of everyone being able to pick and chose the evidence they like? Is it a question of who we trust, the researchers in New York or those in China? Is it a question of where the treatment was done authentically? Is it a question of critically analysing which study had the higher risks of bias? Or is it a question of simply saying that two negative studies are more than one positive trial?
Confused? Me too, a little!
Whatever answers we chose, several things seems fairly certain to me. It would be wrong to say that there is good evidence for acupuncture as a treatment of POI. And the acupuncture-boom that ensued after Reston’s article was to a very large degree built on a simple misunderstanding: POI is a condition that resolves literally into thin air whether we treat it or not.
Tai Chi, as we know it in the West, is said to promote the smooth flow of “energy” throughout the body by performing postures, slow meditative movements and controlled breathing. Tai Chi is also supposed to help increasing flexibility, suppleness, balance and coordination. According to enthusiasts, the smooth, gentle movements of Tai Chi aid relaxation and help to keep the mind calm and focused.
Tai Chi has become popular in Western countries and is being considered for a surprisingly wide range of conditions. The patient/consumer is taught to perform postures, slow meditative movements and controlled breathing. The concepts underlying Tai Chi are strange, but that does not necessarily mean that the treatment is not effective for certain illnesses or symptoms.
There has been a surprising amount of research in this area, and some studies have generated encouraging results. A recent study which is unfortunately not available electronically ( Wu, WF; Muheremu, A; Chen, CH; Liu, WG; Sun, L. Effectiveness of Tai Chi Practice for Non-Specific Chronic Low Back Pain on Retired Athletes: A Randomized Controlled Study. JOURNAL OF MUSCULOSKELETAL PAIN 2013, 21:1, p.37-45) tested the effectiveness of Tai Chi for chronic back pain. Specifically, the researchers wanted to determine whether regular Tai Chi practice is superior to other means of sports rehabilitation in relieving non-specific chronic low back pain [LBP] in a younger population. They randomized 320 former athletes suffering from chronic LBP into a treatment [tai chi practice] and several control groups [regular sessions with swimming, backward walking or jogging, or no such interventions]. At the beginning, middle, and end of a six-month intervention, patients from all groups completed questionnaires assessing the intensity of LBP; in addition, a physical examination was conducted.
After 3 and 6 months, no statistically significant difference in the intensity of LBP was demonstrated between the Tai Chi and swimming. However, significant differences were demonstrated between the Tai Chi and backward walking, jogging, and no exercise groups.
The authors’ concluded that “Tai chi has better efficacy than certain other sports on the treatment of non-specific chronic LBP.”
This is only the second RCT of Tai chi for back pain. The first such study consisted of 160 volunteers between ages 18 and 70 years with persistent nonspecific low back pain. The experimental group (n = 80) had 18 Tai Chi sessions over a 10-week period. The waitlist control group continued with their usual health care. Bothersomeness of symptoms was the primary outcome, and secondary outcomes included pain intensity and pain-related disability. Tai Chi reduced bothersomeness of back symptoms by 1.7 points on a 0-10 scale, reduced pain intensity by 1.3 points on a 0-10 scale, and improved self-report disability by 2.6 points on the 0-24 Roland-Morris Disability Questionnaire scale. The authors of this RCT concluded that a 10-week Tai Chi program improved pain and disability outcomes and can be considered a safe and effective intervention for those experiencing long-term low back pain symptoms.
My own team have conducted their fair share of Tai Chi research. Specifically,we have published several systematic reviews of Tai Chi as an adjunctive or supportive treatment of various conditions, and the conclusions (in italics) have been mixed.
DIABETES: The existing evidence does not suggest that tai chi is an effective therapy for type 2 diabetes.
HYPERTENSION: The evidence for tai chi in reducing blood pressure in the elderly individuals is limited.
BREAST CANCER: the existing trial evidence does not show convincingly that tai chi is effective for supportive breast cancer care.
IMPROVEMENT OF AEROBIC EXCERCISE CAPACITY: the existing evidence does not suggest that regular tai chi is an effective way of increasing aerobic capacity.
PARKINSON’S DISEASE: the evidence is insufficient to suggest tai chi is an effective intervention for Parkinson’s Disease.
OSTEOPOROSIS: The evidence for tai chi in the prevention or treatment of osteoporosis is not convincing.
OSTEOARTHRITIS: there is some encouraging evidence suggesting that tai chi may be effective for pain control in patients with knee OA.
RHEUMATOID ARTHRITIS: Collectively this evidence is not convincing enough to suggest that tai chi is an effective treatment for RA.
Finally, an overview over all systematic reviews of Tai Chi suggested that the only area where the evidence is convincing is the prevention of falls in the elderly.
I think, this indicates that we should not pin our hopes too high as to the therapeutic value of Tai Chi. In particular, for back pain, the evidence might be optimistically judged as encouraging, but it is by no means convincing; the effect size seems to be small and two studies are not enough to issue general recommendations. On the other hand, considering that there is so little to offer to back pain patients, I concede that this is an area that should be studied further. Meanwhile, one could argue that Tai Chi can be fun and is devoid of risks – so, why not give it a try?
The vexing question whether the acupuncture needle is as safe as most acupuncturists seem to believe has been raised several times before on this blog. Here is a new case-report by Japanese authors which sheds an interesting light on this issue.
A 62-year-old man was admitted to A+E complaining of dizziness and diaphoresis. He had received an acupuncture treatment in the sub-xyphoid area (lower 2 cm and left 1 cm point from the lower xyphoid process border) only about one hour ago. He had a history of cerebral infarction and atrial fibrillation, and the latter condition was treated with 2 mg warfarin per day. On admission, the acupuncture needle was still sticking in his sub-sternum.
His blood pressure was 80/50 mm Hg, and tachycardia with 110 beats/min was noted. The acupuncture-needle was duly removed, but the patient went into cardiac arrest and had to be resuscitated. Because his international normalized ratio was 1.99, 2 pints of fresh frozen plasma and 5 mg of vitamin K were administered at that stage. A transthoracic echocardiography revealed pericardial effusion with early diastolic collapse of the right ventricle. Emergency pericardiocentesis using a sub-costal approach was performed. After drainage of 500 mL of sanguineous effusion, the patient seemed to stabilize.
Two hours later, the drainage of pericardial effusion amounted to around 1000 mL, and cardiac arrest re-developed. After another resuscitation, an operation was performed under cardiopulmonary bypass (CPB). A median sternotomy allowed visualization of huge hematomas over the right atrium and ventricle. After the hematomas had been evacuated, pulsating blood loss from the marginal branch of the right coronary artery was identified. The vessel had been torn into pieces, and it was ligated which stopped the bleeding. Thereafter, the patient remained hemodynamically stable. Subsequently the patient made an uneventful recovery and, eventually, he was discharged without further complications.
The authors of this case-report conclude as follows: To our best knowledge, this appears to be the first case of an acupuncture-related coronary artery injury. The important causes of this unfortunate adverse event are a lack of anatomic knowledge and an incorrect application of the procedure. It can be avoided that acupuncture leads to cardiac tamponade like most serious complications….every acupuncturist should be aware of the possible and life-threatening adverse events and be adequately trained to prevent them.
In 2011, we published a review of all cases of cardiac tamponade after acupuncture. At the time, we found a total of 26 such incidences. In 14 patients, the complications were fatal. In most reports, there was little doubt about causality. We concluded that cardiac tamponade is a serious, often fatal complication after acupuncture. As it is theoretically avoidable, acupuncturists should be trained to minimize the risk.
Acupuncture-fans will, of course, claim (as before) that it is alarmist to go on about risks of acupuncture or alternative medicine which are so minute that they are dwarfed by those of conventional health care. And I will counter (as before) that it is never the absolute risk that counts, but that it is the risk benefit balance which defines the value of any therapeutic intervention. As long as we have no solid proof that acupuncture is more than a “theatrical placebo“, even a tiny risk weighs heavily and seems unacceptable.
But the true significance of this case-report lies elsewhere, in my view: risks of this nature can and should be avoided. The only way to achieve this aim is to train and educate acupuncturists properly. At present this does not seem to be the case, particularly in Asian countries where acupuncture is most popular. It is up to the acupuncture communities across the globe to get their act together.
A stroke is a condition where brain cells get irreversibly damaged either by a haemorrhage in the brain or by a blood clot cutting off oxygen supply. This process leaves most patients with neurological deficits such as difficulties in moving, speaking, concentrating etc. As other parts of the brain learn to take over, these problems can partly or completely resolve themselves over time, but many patients are left with permanent handicaps. Stroke-rehabilitation can minimise these problems, and there is a long-standing debate as to which measures are most effective. Acupuncture has been discussed as a method to improve the results of stroke-rehabilitation, but the evidence is hotly disputed. This is why a new study in this area is an important contribution to our existing knowledge.
The aim of this randomised trial was to test the effectiveness of acupuncture in promoting the recovery of patients with ischaemic stroke and to determine whether the outcomes of combined physiotherapy and acupuncture are superior to those with physiotherapy alone. The Chinese investigators recruited 120 patients who received one of three daily treatments: 1) acupuncture, 2) physiotherapy, 3) physiotherapy combined with acupuncture. Motor function in the limbs was measured with the Fugl-Meyer assessment (FMA); the modified Barthel index (MBI) was used to rate activities of daily living; both of these measures are validated and well-established. All evaluations were performed by assessors blinded to treatment allocation.
At baseline, FMA and MBI scores did not significantly differ among the treatment groups. Compared with baseline, on day 28 of therapy, the mean FMA scores of the physiotherapy, acupuncture, and combined treatment groups had increased by 65.6%, 57.7%, and 67.2%, respectively; on day 56, FMA scores had increased by 88.1%, 64.5%, and 88.6%, respectively. The respective MBI scores in the three groups had increased by 85.2%, 60.4%, and 63.4% at day 28 and by 108.0%, 71.2%, and 86.2% at day 56, respectively. However, FMA scores did not significantly differ between the three treatment groups on the 28th day. By the day 56, the FMA and MBI scores of the physiotherapy group were 46.1% and 33.2% greater, respectively, than those in the acupuncture group. No significant differences were seen between the combined treatment group and the other groups. The FMA subscores for the upper extremities did not show significant improvements in any group on day 56.
The authors draw the following conclusion: “Acupuncture is less effective for the outcome measures studied than is physiotherapy. Moreover, the therapeutic effect of combining acupuncture with physiotherapy was not superior to that of physiotherapy alone. A larger-scale clinical trial is necessary to confirm these finding.”
Our own study arrived at similarly disappointing conclusions: “Acupuncture is not superior to sham treatment for recovery in activities of daily living and health-related quality of life after stroke, although there may be a limited effect on leg function in more severely affected patients“. Our review of all 10 sham-controlled RCTs in this area is also in line with the results of this new study: “Our meta-analyses of data from rigorous randomized sham-controlled trials did not show a positive effect of acupuncture as a treatment for functional recovery after stroke”
I am quite sure that some acupuncture-enthusiasts will dispute this evidence. They might argue that I am too critical, the trials were not done optimally, that acupuncturists have seen plenty of good results in their clinical practice, that acupuncture is a complex intervention that does not fit into the straight jacket of an RCT, that this or that “prestigious” organisation recommends acupuncture for stroke patients, that it would be wrong not to give acupuncture a try etc. etc. I would counter that the reliable evidence available to date is sufficiently conclusive to stop claiming that acupuncture is effective and thus give false hope to severely suffering, vulnerable patients. Moreover, I would advocate using the sparse available resources to help stroke victims with treatments that demonstrably work.
Many people who have arrived at a certain age have knee osteoarthritis and most of them suffer pain, lack of mobility etc. because of it. There are many effective treatments for this condition, of course, but some have serious side-effects, others are tedious to follow and therefore not popular, and none of the existing options totally cure the problem. In many cases, surgery is the best solution; a knee-endoprosthesis can restore everything almost back to normal. But surgery carries risks and will cause considerable pain and rehabilitation-effort. This is perhaps why we are still looking for a treatment that is both effective and risk-free. Personally, I doubt that such a therapy will ever be found, but that does, of course, not stop alternative medicine enthusiasts from claiming that this or that treatment is what the world has been waiting for. The newest kid on this block is leech therapy. Did I just write “newest”? Leeches are not new at all; they are a treatment from the dark ages of medicine – but are they about to experience a come-back?
A recent systematic review and meta-analysis evaluated the effectiveness of medical leech therapy for osteoarthritis of the knee. Five electronic databases were screened to identify randomized (RCTs) and non randomized controlled clinical trials (CCTs) comparing leech therapy to any type of control condition. The main outcome measures were pain, functional impairment, and joint stiffness. Three RCTs and 1 CCT with a total of 237 patients with osteoarthritis were included. Three trials had, according to the review-authors, a low risk of bias. They claimed to have found strong evidence for immediate and short-term pain reduction, immediate improvement in patients’ physical function, and both immediate and long-term improvement in their joint stiffness. Moderate evidence was found for leech therapy’s short-term effects on physical function and long-term effects on pain. Leech therapy was not associated with any serious adverse events. The authors reached the following conclusion: “ Given the low number of reported adverse events, leech therapy may be a useful approach in treating this condition. Further high-quality RCTs are required for the conclusive judgment of its effectiveness and safety.”
When, about 35 years ago, I worked as a young doctor in the homeopathic hospital in Munich, I was taught how to apply leeches to my patients. We got the animals from a specialised supplier, put them on the patient’s skin and waited until they had bitten a little hole and started sucking the patient’s blood. Once they were full they spontaneously fell off and were then disposed off. Many patients were too disgusted with the prospect of leech therapy to agree to this intervention. Those who did were very impressed with the procedure; it occurred to me then that this therapy must be associated with an enormous placebo-effect simply because it is exotic, impressive and a treatment that no patient will ever forget.
The bite of the leech is not normally painful because the leech has a local anaesthetic which it applies in order to suck blood without being noticed. The leech furthermore injects a powerful anticoagulant into its victim’s body which is necessary for preventing the blood from clotting. Through the injection of these pharmacologically active substances, leeches can clearly be therapeutic and they are thus not entirely unknown in conventional medicine; in plastic surgery, for instance, they are sometimes being used to generate optimal results for micro surgical wounds. Their anticoagulant has long been identified and is sometimes being used therapeutically. The use of leeches for the management of osteoarthritis, however, is not a conventional concept. So, how convincing are the above data? Should we agree with the authors’ conclusion that “leech therapy may be a useful approach in treating this condition“? I think not, and here is why:
1) The collective evidence for efficacy is far from convincing. The few studies which were summarised in this systematic review are mostly those of the research group that also authored the review. Critical thinkers would insist on an independent assessment of those trials. Moreover, none of the trials was patient-blind (which would not be all that difficult to do), and thus the enormous placebo-effect of applying a leech might be the cause of all or most of the observed effect.
2) The authors claim that the treatment is safe. On the basis of just 250 patients treated under highly controlled conditions, this claim has almost no evidential basis.
3) As already mentioned above, there are many treatments which are more effective for improving pain and function than leeches.
4) Leech therapy is time-consuming, relatively expensive and quite unpractical as a regular, long-term therapy.
5) In my experience, patients will run a mile to avoid having something as ‘disgusting’ as leeches sucking blood from their body.
6) The animals need to be destroyed after the treatment to avoid infections.
7) As multiple leeches applied regularly will suck a significant volume of blood, the treatment might lead to anaemia and would be contra-indicated in patients with low haemoglobin levels.
8) Like most other treatments for osteoarthritis, leech therapy would not be curative but might just alleviate the symptoms temporarily.
On balance therefore, I very much doubt that the leech will have a come-back in the realm of osteoarthritis therapy. In fact, I think that, in this particular context, leeches are just a chapter from the dark ages of medicine. Their re-introduction into osteoarthritis care seems like a significant step into the wrong direction.
Many cancer patients will suffer from severe, debilitating fatigue during the course of their illness. The exact cause of this common symptom is not entirely clear. Most likely it is due to a combination of the cancer and the treatments used to cure it. Managing cancer-related fatigue (CRF) is thus an important part of the palliative and supportive care of cancer patients. Acupuncture is often advocated for this purpose and many centres use it routinely. The question therefore is, does it work?
The most recent trial on this subject was aimed at assessing the effectiveness of maintenance acupuncture in the management of CRF; acupuncture or self-acupuncture/self-needling was compared with no such treatment. Breast cancer patients who previously had received acupuncture were randomized to have 4 acupuncturist-delivered weekly sessions, 4 self-administered weekly acupuncture sessions (self-needling); or no acupuncture at all. The primary outcome-measure was general fatigue, while mood, quality of life and safety served as secondary endpoints. In total, 197 patients were randomized: 65 to therapist-delivered sessions, 67 to self-acupuncture/self-needling and 65 to no further acupuncture. The results failed to demonstrate significant inter-group differences in any of the parameters evaluated. The authors concluded that “maintenance acupuncture did not yield important improvements beyond those observed after an initial clinic-based course of acupuncture“.
But this is just one single of several available studies. Acupuncture-fans might suspect me of cherry-picking a largely negative study. If we want a fair verdict, we must consider the totality of the evidence. The aim of our systematic review was therefore to critically evaluate the effectiveness of acupuncture (AT) for CRF based on all the trial data available to us.
Fourteen databases were searched from their respective inception to November 2012. Randomized clinical trials (RCTs) of AT for the treatment of CRF were considered for inclusion. The risk of bias/methodological quality was assessed using the method suggested by the Cochrane Collaboration. Seven RCTs met the eligibility criteria. Most were small pilot studies with serious methodological flaws. Four of them showed effectiveness of AT or AT in addition to usual care (UC) over sham AT, UC, enhanced UC, or no intervention for alleviating CRF. Three RCTs failed to demonstrate an effect of AT over sham treatment.
Our conclusion had to be cautious: “Overall, the quantity and quality of RCTs included in the analysis were too low to draw meaningful conclusions. Even in the positive trials, it remained unclear whether the observed outcome was due to specific effects of AT or nonspecific effects of care. Further research is required to investigate whether AT demonstrates specific effects on CRF”
There will, of course, be those who claim that no trial evidence is needed in this case; if a cancer-patient benefits from the treatment, she should have it regardless of whether it works as a placebo or has effects beyond that. I do sympathize with this attitude but should point out that there are a number of points to consider when making it:
2) There are other treatments against CRF; if we blindly advocate acupuncture, we might not offer the best option to our patients.
3) If we spend our limited resources on acupuncture, we might not afford treatments which are more effective.
4) If we are happy using acupuncture because it conveys a sizable placebo-effect, how will we make progress in finding treatments that are more effective?
It is therefore difficult to decide whether or not to recommend acupuncture for CRF. There are some arguments for both sides. Skeptics or critical thinkers or clinicians adhering to the principles of evidence-based medicine are unlikely to condone it, and some people might accuse them for cruelly and heartlessly denying severely ill patients help which they so badly need. Personally, I fail to see what is cruel or heartless in insisting that these patients receive the treatment which demonstrably works best – and that does not seem to be acupuncture.
Five years ago to the day, Simon Singh and I published an article in The Daily Mail to promote our book TRICK OR TREATMENT… which was then about to be launched. We recently learnt that our short article prompted a “confidential” message by the BRITISH CHIROPRACTIC ASSOCIATION to all its members. “Confidential” needs to be put in inverted commas because it is readily available on the Internet. I find it fascinating and of sufficient public interest to reproduce it here in full. I have not altered a thing in the following text, except putting it in italics and putting the section where the BCA quote our text in bold for clarity.
CONFIDENTIAL FOR BCA MEMBERS ONLY
Information for BCA members regarding an article in the Daily Mail – April 8th 2008
A double page spread appeared in the edition of the Daily Mail April 8th 2008 on page 46 and 47 and titled ‘Alternative Medicine The Verdict’.
The article was written by Simon Singh and Edzard Ernst and is a publicity prelude to a book they have written called ‘Trick or Treatment? Alternative Medicine on Trial’, which will be published later this month.
The article covers Alexander Technique, Aromatherapy, Flower Remedy, Chiropractic, Hypnotherapy, Magnet Therapy and Osteopathy.
The coverage of Chiropractic follows a familiar pattern for E Ernst. The treatment is oversimplified in explanation, with a heavy emphasis on words like thrust, strong and aggressive. There is tacit acknowledgement that chiropractic works for back pain, but then there is a long section about caution regarding neck manipulation. The article concludes by advising people not to have their neck manipulated and not to allow children to be treated.
WHAT IS IT? Chiropractors use spinal manipulation to realign the spine to restore mobility. Initial examination often includes X-ray images or MRI scans.
Spinal manipulation can be a fairly aggressive technique, which pushes the spinal joint slightly beyond what it is ordinarily capable of achieving, using a technique called high-velocity, low-amplitude thrust – exerting a relatively strong force in order to move the joint at speed, but the extent of the motion needs to be limited to prevent damage to the joint and its surrounding structures.
Although spinal manipulation is often associated with a cracking sound, this is not a result of the bones crunching or a sign that bones are being put back; the noise is caused by the release and popping of gas bubbles, generated when the fluid in the joint space is put under severe stress.
Some chiropractors claim to treat everything from digestive disorders to ear infections, others will treat only back problems.
DOES IT WORK? There is no evidence to suggest that spinal manipulation is effective for anything but back pain and even then conventional approaches (such as regular exercise and ibuprofen) are just as likely to be effective and are cheaper.
Neck manipulation has been linked to neurological complications such as strokes – in 1998, a 20-year-old Canadian woman died after neck manipulation caused a blood clot which led to stroke. We would strongly recommend physiotherapy exercises and osteopathy ahead of chiropractic therapy because they are at least effective and much safer.
If you do decide to visit a chiropractor despite our concerns and warnings, we very strongly recommend you confirm your chiropractor won’t manipulate your neck. The dangers of chiropractic therapy to children are particularly worrying because a chiropractor would be manipulating an immature spine.
Daily Mail 2008 April 8th.
As we are aware that patients or potential patients of our members will be confronted with questions regarding this article, we have put together some comment and Q&As to assist you.
• Please consider this information as strictly confidential and for your use only.
• Only use this if a patient asks about these specific issues; there is nothing to be gained from releasing any information not asked for.
• Do not duplicate these patient notes and hand out direct to the patient or the media; these are designed for you to use when in direct conversation with a patient.
The BCA will be very carefully considering any questions or approaches we may receive from the press and will respond to them using specially briefed spokespeople. We would strongly advise our members not to speak directly to the press on any of the issues raised as a result of this coverage.
Please note that In the event of you receiving queries from the media, please refer these direct to BCA (0118 950 5950 – Anne Barlow or Sue Wakefield) or Publicasity (0207 632 2400 – Julie Doyle or Sara Bailey).
The following points should assist you in answering questions that patients may ask with regard to the safety and effectiveness of chiropractic care. Potential questions are detailed along with the desired ‘BCA response’:
o “The Daily Mail article seems to suggest chiropractic treatment is not that effective”
Nothing could be further from the truth. The authors have had to concede that chiropractic treatment works for back pain as there is overwhelming evidence to support this. The authors also contest that pain killers and exercises can do the job just as well. What they fail to mention is that research has shown that this might be the case for some patients, but the amount of time it may take to recover is a lot longer and the chance of re-occurrence of the problem is higher. This means that chiropractic treatment works, gets results more quickly and helps prevent re-occurrence of the problem. Chiropractic is the third largest healthcare profession in the world and in the UK is recognised and regulated by the UK Government.
o “The treatment is described as aggressive, can you explain?”
It is important to say that the authors of the article clearly have no direct experience of chiropractic treatment, nor have they bothered to properly research the training and techniques. Chiropractic treatment can take many forms, depending on the nature of the problem, the particular patient’s age and medical history and other factors. The training chiropractors receive is overseen by the government appointed regulator and the content of training is absolutely designed to ensure that an individual chiropractor understands exactly which treatment types are required in each individual patient scenario. Gentle technique, massage and exercise are just some of the techniques available in the chiropractor’s ‘toolkit’. It is a gross generalisation and a demonstration of lack of knowledge of chiropractic to characterise it the way it appeared in the article.
o “The article talked about ‘claims’ of success with other problems”
There is a large and undeniable body of evidence regarding the effectiveness of chiropractic treatment for musculoskeletal problems such as back pain. There is also growing evidence that chiropractic treatment can help many patients with other problems; persistent headaches for example. There is also anecdotal evidence and positive patient experience to show that other kinds of problems have been helped by chiropractic treatment. For many of these kinds of problems, the formal research is just beginning and a chiropractor would never propose their treatment as a substitute for other, ongoing treatments.
o “Am I at risk of having a stroke if I have a chiropractic treatment?”
What is important to understand is that any association between neck manipulation and stroke is extremely rare. Chiropractic is a very safe form of treatment.
Another important point to understand is that the treatments employed by chiropractors are statistically safer than many other conservative treatment options (such as ibuprofen and other pain killers with side effects such as gastric bleeding) for mechanical low back or neck pain conditions.
A research study in the UK, published just last year studied the neck manipulations received by nearly 20,000 chiropractic patients. NO SERIOUS ADVERSE SIDE EFFECTS WERE IDENTIFIED AT ALL. In another piece of research, published in February this year, stroke was found to be a very rare event and the risk associated with a visit to a chiropractor appeared to be no different from the risk of a stroke following a visit to a GP.
Other recent research shows that such an association with stroke may occur once in every 5.85 million adjustments.
To put this in context, a ‘significant risk’ for any therapeutic intervention (such as pain medication) is defined as 1 in 10,000.
Additional info: Stroke is a natural occurring phenomenon, and evidence dictates that a number of key risk factors increase the likelihood of an individual suffering a stroke. Smoking, high blood pressure, high cholesterol and family medical histories can all contribute; rarely does a stroke occur in isolation from these factors. Also, stroke symptoms can be similar to that of upper neck pains, stiffness or headaches, conditions for which patients may seek chiropractic treatment. BCA chiropractors are trained to recognise and diagnose these symptoms and advise appropriate mainstream medical care.
o “Can you tell if I am at risk from stroke?”
As a BCA chiropractor I am trained to identify risk factors and would not proceed with treatment if there was any doubt as to the patient’s suitability. Potential risks may come to light during the taking of a case history, which may include: smoking, high cholesterol, contraceptive pill, Blood clotting problems/blood thinning meds, heart problems, trauma to the head etc and on physical examination e.g. high blood pressure, severe osteoarthritis of the neck, history of rheumatoid arthritis
o “Do you ever tell patients if they are at risk?”
Yes, I would always discuss risks with patients and treatment will not proceed without informed consent.
o “Is it safe for my child to be treated by a chiropractor”
It is a shame that the article so generalises the treatment provided by a chiropractor, that it makes such outrageous claims. My training in anatomy, physiology and diagnosis means that I absolutely understand the demands and needs of spines from the newborn baby to the very elderly patient. The techniques and treatments I might use on a 25 year old are not the same as those I would employ on a 5 year old. I see a lot of children as patients at this clinic and am able to offer help with a variety of problems with the back, joints and muscles. I examine every patient very thoroughly, understand their medical history and discuss my findings with them and their parents before undertaking any treatment.
- Chiropractic is a mature profession and numerous studies clearly demonstrate that chiropractic treatment, including manipulative and spinal adjustment, is both safe and effective.
- Thousands of patients are treated by me and my fellow chiropractors every day in the UK. Chiropractic is a healthcare profession that is growing purely because our patients see the results and GPs refer patients to us because they know we get results!
This article is to promote a book and a controversial one at that. Certainly, in the case of the comments about chiropractic, there is much evidence and research that has formed part of guidelines developed by the Royal Society of General Practitioners, NICE and other NHS/Government agencies, has been conveniently ignored. The statements about chiropractic treatment and technique demonstrate that there has clearly been no research into the actual education that chiropractors in the UK receive – in my case a four year full-time degree course that meets stringent educational standards set down by the government appointed regulator.
Shortly after the article in The Daily Mail, our book was published and turned out to be much appreciated by critical thinkers across the globe — not, however, by chiropractors.
At the time, I did, of course, not know about the above “strictly confidential” message to BCA members, yet I strongly suspected that chiropractors would do everything in their power to dispute our central argument, namely that most of the therapeutic claims by chiropractors were not supported by sufficient evidence. I also knew that our evidence for it was rock solid; after all, I had researched the evidence for or against chiropractic in full depth and minute detail and published dozens of articles on the subject in the medical literature.
When, one and a half weeks after our piece in the Mail, Simon published his now famous Guardian comment stating that the BCA “happily promote bogus treatments”, he was sued for libel by the BCA. I think the above “strictly confidential” message already reveals the BCA’s determination and their conviction to be on firm ground. As it turned out, they were wrong. Not only did they lose their libel suit, but they also dragged chiropractic into a deep crisis.
The “strictly confidential” message is intriguing in several more ways - I will leave it to my readers to pick out some of the many gems hidden in this text. Personally, I find the most remarkable aspect that the BCA seems to attempt to silence its own members regarding the controversy about the value of their treatments. Instead they proscribe answers (should I say doctrines?) of highly debatable accuracy for them, almost as though chiropractors were unable to speak for themselves. To me, this smells of cult-like behaviour, and is by no means indicative of a mature profession – despite their affirmations to the contrary.