MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Monthly Archives: May 2016

It has long been argued that chiropractic spinal manipulations are mere placebo interventions. Yet few controlled trials have assessed the efficacy of spinal manipulative therapy (SMT). No high quality trials have been performed to test the efficacy and effectiveness of Graston Technique® (GT), an instrument-assisted soft tissue therapy.

The objective of this trial was to determine the efficacy of SMT and GT compared to sham therapy for the treatment of non-specific thoracic spine pain.

People with non-specific thoracic pain were randomly allocated to one of three groups: SMT, GT, or a placebo (de-tuned ultrasound). GT is a popular soft-tissue technique in the United States and becoming more popular in other developed countries. GT is an instrument-assisted soft-tissue therapy involving the use of hand-held stainless steel instruments. The promoters of the GT claim that the instruments resonate in the clinician’s hands allowing the clinician to isolate soft-tissue “adhesions and restrictions”, and treat them precisely. Each participant received up to 10 supervised treatment sessions at Murdoch University chiropractic student clinic over a 4 week period.

The two outcome measures were self-administered instruments. Participants were given blank questionnaires in a package by a research assistant following their first treatment. Participants were instructed to complete the instruments at each assessment time point. After completion of the forms the participant posted them back to the Murdoch University Chiropractic Clinic. Research assistants remained blind to the outcome data for the entire study period. The participants and treatment providers were not blinded to the treatment allocation as it was clear that the groups were receiving different treatments. Participants in the placebo group were blinded to their placebo allocation until follow-up was complete at 12 months. Participants were surveyed for the adequacy of the placebo blinding at the end of the study.

Treatment outcomes were measured at baseline, 1 week, and at one, three, six and 12 months. Primary outcome measures included a modified Oswestry Disability Index, and the Visual Analogue Scale (VAS). Treatment effects were estimated with intention to treat analysis and linear mixed models.

One hundred and forty three participants were randomly allocated to the three groups (SMT = 36, GT = 63 and Placebo = 44). Baseline data for the three groups did not show any meaningful differences. Results of the intention to treat analyses revealed no time by group interactions, indicating no statistically significant between-group differences in pain or disability at 1 week, 1 month, 3 months, 6 months, or 12 months. There were significant main effects of time (p < 0.01) indicating improvements in pain and disability from baseline among all participants regardless of intervention. No significant adverse events were reported.

 

12998_2016_96_Fig3_HTMLThe authors concluded that this study indicates that there is no difference in outcome at any time point for pain or disability when comparing SMT, Graston Technique® or sham therapy for thoracic spine pain, however all groups improved with time. These results constitute the first from a fully powered randomised controlled trial comparing SMT, Graston technique® and a placebo.

Some people claim that there is little wrong with placebo therapy, as long as it helps patients. This is not what I think, but even the proponents of this argument would agree that the placebo used in this way has to be safe. As SMT is by no means free of adverse effects, the argument cannot be applied here.

Other people will argue that this is about SMT and not chiropractic implying that I am conducting a vendetta against the poor chiropractors. I would disagree: we have just learnt that 93% of chiropractors consider SMT as their primary treatment. Yes, osteopaths and physiotherapists also use SMT but certainly not to this extent. Thus this discussion is mostly about chiropractic, and the onus is on chiropractors to demonstrate beyond doubt that SMT does more good than harm.

The true significance of this study is, I think, that the chiropractic profession now must convince us that spinal manipulation has any usefulness at all. They will have to conduct rigorous trials along the lines of this study to test for which condition these interventions generate outcomes that are significantly better than those achievable by sham.

Until such data are available, it would be wise, I think, to consider all therapeutic claims made for chiropractic unproven and bogus.

WATCH THIS SPACE!

Ad hominem attacks, I have previously pointed out, are victories of reason over unreason. And they are used frequently by supporters of alternative medicine!

If you doubt it, see for yourself.

I recently posted a comment on new Nice guidelines. It generated lots of comments, and mostly they were rational discussions of the issues involved. This changed abruptly when, on 16 May, Mel’s comment started a new, concerted wave of discussion at a time when the usual debate had already subsided. In the course of this new and heated debate, I was repeatedly accused of being rude.

As I have stated repeatedly on this blog, I try to keep rudeness out of the comments as much as I can. Therefore, the claim surprised me and today I reviewed the entire comment section selecting all potential ad hominem attacks. Here are the results:

ACTUAL OR POTENTIAL AD HOMINEM ATTACKS AGAINST ME

Peter Deadman on Tuesday 17 May 2016 at 12:55 Edward Ernst, I always thought you were a bully and a fraud. You’re very macho when it comes to slapping down people who may have experiential reasons for supporting acupuncture and other therapies but don’t have the skill to challenge you on the clinical evidence. Now as soon as somebody does, you back off, cry ‘enough’, say you can’t possibly comment till some undetermined future date and generally act like a wuss. I say put up or shut up. I’d prefer the former because it would be good to see you eat crow but I lean towards the latter because of the substantial harm you are causing and the beautiful silence that would ensue if you did indeed go quiet.

tonto on Tuesday 17 May 2016 at 13:19 You appear as weak in your arguments, as some pendulum swinging, new age dowser, who vainly holds sticks to their guns, not because they can back their position up with scientific evidence, but because it is what they “believe”.

Jill Onyett on Tuesday 17 May 2016 at 14:29 …an unfortunate creature too keen on the sound of his own voice.

Tracey Phillips on Tuesday 17 May 2016 at 13:16 …to date you have been fairly opinionated …

Peter Deadman on Tuesday 17 May 2016 at 16:34  I made an ad hominem response because your blog is all about you as a person. You are constantly rude to others and bypass or ignore responses that you don’t like. It’s you who makes it hominem.

Peter Deadman on Tuesday 17 May 2016 at 16:52 You are hyper-emotional, extremely biased, hostile and contemptuous of anyone you think ‘beneath you’. You gloat over people’s real or imagined inconsistencies and generally come across as a nasty piece of work.

Peter Deadman on Tuesday 17 May 2016 at 19:30 How can such a childish provocateur remain in his post. It demeans the University and it’s time they let him go.

Kylee Junghans on Wednesday 18 May 2016 at 08:42 …you, kind Sir, with your rhetoric and tantrums, are exhibiting a prime example of confirmation bias.

Peter Deadman on Wednesday 18 May 2016 at 08:48 [Ernst] professes a scholarly detachment, a commitment to evidence and an open mind, but in fact is deeply biased… He clearly loves his childish provocative stance and is as far from a disinterested observer as it’s possible to be. I wouldn’t waste my time or breath on him if he didn’t have an influence that far exceeds his worth.

Carol Cooke on Wednesday 18 May 2016 at 09:27 I have followed this discussion with interest. Some of the rudest and most discourteous posts I can see are from Mr Ernst himself. But I get that, I imagine you seek to maintain a bold and authoritative tone simply by dismissing others. Being a bit controversial in your discourse has obviously served you well in that you have built a media profile on it.

ACTUAL OR POTENTIAL AD HOMINEM ATTACKS BY MYSELF

Edzard on Wednesday 18 May 2016 at 09:18 “it is also difficult to get a man to read something, when he is foaming from his mouth”.

I know, this is not really ‘ad hominem’ but I could not find anything more dramatic. Surely, some will disagree this me here, and I do invite them to cite my rudeness from this threat, if they spot it. You are more than welcome!

CONCLUSION

You may think this is a bit trivial, but I disagree. The main reason I did this little exercise is to demonstrate a point which I think is important and carries a relevant lesson for future comments and discussions:

  • WHEN I OR ANYONE ELSE DEFENDING RATIONALITY GET AGGRESSED, WE NATURALLY TEND TO RESPOND SLIGHTLY MORE FORCEFULLY.
  • SUBSEQUENTLY, THE OTHER SIDE OFTEN REACTS BY ATTACKING US PERSONALLY.
  • THIS OFTEN LEADS TO AN ESCALATION OF TONE.
  • EVENTUALLY THE OTHER SIDE CLAIMS WITH INDIGNATION THAT WE ARE THE ONES DOING THE PERSONAL ATTACKS.
  • IT IS A TACTIC THAT IS EFFECTIVE BUT DISHONEST, IN MY VIEW.
  • THE LESSON IS SIMPLE: DO NOT LET YOURSELF GET PROVOKED INTO ISSUING AD HOMINEM ATTACKS, BE POLITE AND PATIENT.

I know this sounds simpler than it is, and I am far from being immune to the problem, but we owe it to reason to give it a try.

 

Anyone who really wants to get an insight into the ‘homeopathic mind-set’ should read the regular newsletter ‘HOMEOPATHY 4 EVERYONE’. Its current issue is focussed on cardiology. An article on coronary heart disease, a condition that kills about 40% of the population, informs us how homeopaths tackle this killer-disease:

If anything permanent is to be accomplished by treatment, a most careful examination of the individual case must be made. Not the attack alone, but the habits of the patient, his family history and environments must all be studied in every possible light. In the management, each case must be considered separately and the causes that excite an attack sought after. Many of these patients already have recognized the cause in their own case and often it is some irregularity of diet, exercise or mental condition. Many times it is not an easy matter to control the mental state, as the worry and strain of business life presses upon many of these patients, and is responsible for many cases of arterial degeneration that give rise to apoplexy, Bright ‘s disease, aneurysm or angina pectoris. The age and occupation of the patient, and the condition of the vascular system should be taken into consideration.

Following an attack the condition of the heart may require absolute rest, from a day to a week or more; this is especially true if the attacks are precipitated by a slight degree of exercise, which shows that the heart is not able to propel the blood under anything but normal conditions. Under no condition should quick movements and strong emotions be associated. Steady quiet exercise as walking upon level ground is beneficial. If the cardiac weakness is such as to forbid this, massage, or the resistance exercise of the Schott’s method may be tried. This exercise should not follow immediately after a meal.

But this is not all. There are plenty more papers on life-threatening cardiac conditions. Take the article on pericarditis for instance. This is how homeopaths are told how to treat this medical emergency:

Remedies that may be indicated are as follows: If traumatic, Arnica. For the inflammatory outset, Aconite or Vera- trum viride. The anguish of Aconite distinguishes its inflammation from that attending the stupor of Veratrum. For the pain Bryonia or Spigelia. They may be indicated in this order, Bryonia for the first stage and Spigelia for the subsequent myalgia. In these cases there may be met with indications for Belladonna (its flushed face), Arsenicum (dyspnoea on lying down), Digitalis (its weak pulse), Cactus (severe myalgia) or Kali carb (stitching pains). General symptoms may call for Colchicum, Aesculus, Kali iod., Cimicifuga, Kahnia, Squilla

A further article tackles diseases of the blood vessels. The article on thrombosis informs the homeopath that

Thrombosis is a blocking of the local circulation either spontaneously, after injuries or from slow and imperfect circulation forming a clot. In thrombosis the part becomes pale and edematous. The remedies are Aconite for first stage. Hamamelis, Lachesis or Lycopodium may be indicated. If suppuration threatens Sulphur or Hepar.  Rest and a supporting diet.

The same article also tells us how to treat aneurysms:

Select the remedy carefully. Lycopodium 12 has cured aneurism of the carotid (Hughes). If the attack is due to a sudden strain or injury, Arnica; if from fear or fright, Aconite; if from syphilis, Mercurius, Kali hydr. or Nitric acid; if from alcoholism, Arsenicum or Nux vomica; if from fatty degeneration, Phosphorus; if from fibrous inflammation and degeneration, Bryonia; if there is great arterial excitement and delirium, Veratrum viride; if circulation sluggish, Digitalis. Secale has cured aneurism. Consult Carbo veg., Spigelia. See Heart Therapeutics.

After reading the entire issue, I was not sure whether this wasn’t a hoax. Are we supposed to laugh or to cry? Personally I did giggle a lot while reading this. But if I imagine for a minute that some homeopaths might take this seriously, I am not far from crying.

While over on my post about the new NICE GUIDELINES on acupuncture for back pain, the acupuncturists’ assassination attempts of my character, competence, integrity and personality are in full swing, I have decided to employ my time more fruitfully and briefly comment on a new piece of acupuncture research.

This new Italian study was to determine the effectiveness of acupuncture for the management of hot flashes in women with breast cancer.

A total of 190 women with breast cancer were randomly assigned to two groups. Random assignment was performed with stratification for hormonal therapy; the allocation ratio was 1:1. Both groups received a booklet with information about climacteric syndrome and its management to be followed for at least 12 weeks. In addition, the acupuncture group received 10 traditional acupuncture treatment sessions involving needling of predefined acupoints.

The primary outcome was hot flash score at the end of treatment (week 12), calculated as the frequency multiplied by the average severity of hot flashes. The secondary outcomes were climacteric symptoms and quality of life, measured by the Greene Climacteric and Menopause Quality of Life scales. Health outcomes were measured for up to 6 months after treatment. Expectation and satisfaction of treatment effect and safety were also evaluated. We used intention-to-treat analyses.

Of the participants, 105 were randomly assigned to enhanced self-care and 85 to acupuncture plus enhanced self-care. Acupuncture plus enhanced self-care was associated with a significantly lower hot flash score than enhanced self-care at the end of treatment (P < .001) and at 3- and 6-month post-treatment follow-up visits (P = .0028 and .001, respectively). Acupuncture was also associated with fewer climacteric symptoms and higher quality of life in the vasomotor, physical, and psychosocial dimensions (P < .05).

The authors concluded that acupuncture in association with enhanced self-care is an effective integrative intervention for managing hot flashes and improving quality of life in women with breast cancer.

This hardly needs a comment, as I have been going on about this study design many times before: the ‘A+B versus B’ design can only produce positive findings. Any such study concluding that ‘acupuncture (or whatever other intervention) is effective’ can therefore not be a legitimate test of a hypothesis and ought to be categorised as pseudo-science. Sadly, this problem seems more the rule than the exception in the realm of acupuncture research. That’s a pity really… because, if there is potential in acupuncture at all, this sort of thing can only distract from it.

I think the JOURNAL OF CLINICAL ONCOLOGY, its editors and reviewers, should be ashamed of having published such misleading rubbish.

Yes, I think he does deserve to join this fast-expanding club which, so far, consists of the following people:

Simon Mills

Gustav Dobos

Claudia Witt

George Lewith

John Licciardone

They have been admitted mostly because they have demonstrated that they exclusively or mostly publish positive results about alternative medicine. Therefore, their ‘TRUSTWORTHYNESS INDEX’ is remarkable.

With Peter Fisher, things are a little different, and in a way much more convincing. He also has a remarkable publication record, of course. As the Queen’s homeopath, he is a stark defender of homeopathy. He has just under 100 Medline-listed articles in this area, and, if I am not mistaken, only one of them cast any doubt on the effectiveness of homeopathy.

Peter is also the long-term editor of the journal HOMEOPATHY, and he used this position to fire me from its editorial board. Furthermore, he has been shown to have an unusual attitude towards telling the truth. But the decider for his admission to THE ALT MED HALL OF FAME was the following recent interview for NATURALLYSAVVY where he shows himself as a fierce defender of science, evidence-based medicine and critical thinking:

Andrea Donsky: I understand you arrived yesterday from England. I’m curious what you take for jetlag?

Peter Fisher: We have a traditional combination that we use for jetlag, which is arnica montana, and cocculus indicus. So arnica is something that is traditionally used for bruises, and cocculus is used for sleep problems. So arnica and cocculus combined, 6CH every hour or two, helps with jetlag.

Andrea Donsky: I read about the incredible work you do as an Integrative Medicine Doctor so I thought we would start today’s interview with having you explain what that means.

Peter Fisher: Simply put, it means the best of both worlds: the best of conventional, and the best of complementary medicine. There is also a much longer and more complicated definition, but essentially it’s integrating complementary medicine in care packages to avoid some of the worst excesses of conventional medicines, like over-drugging, and excess use of medication.

Andrea Donsky: I know you don’t see patients with the common cold or flu, but if you did, what would be your protocol?

Peter Fisher: I’ve done quite a lot of research on the flu. It’s quite clear that conventional treatments don’t work all that well, and may even prolong the flu. Most of the conventional treatments push the symptoms down [suppress them] and actually prolong the illness.

Andrea Donsky: So something like Oscillococcinum would be a perfect thing to recommend to people.

Peter Fisher: Yes, and other homeopathic combinations that can speed up the resolution, relieve the symptoms, and make the flu go away quicker.

Andrea Donsky: Tell me a little bit about the European way of practicing medicine. I remember hearing that in Europe doctors prescribe homeopathy alongside medication. Is this true?

Peter Fisher: It varies widely between countries. In France, Germany, and increasingly in Spain, it is the case, but not so much in the UK. A lot of doctors do incorporate it in their practice and they integrate homeopathy when it seems appropriate, but they also use antibiotics and other drugs when they feel it is appropriate.

Andrea Donsky: Do you often approach these skeptics and say: “Listen, you are wrong because there is research behind it!”

Peter Fisher: I will debate with anybody, anytime. The trouble is, skeptics don’t like that because they always lose. I’ve been involved in a series of debates with “so called” skeptics. But many well-known skeptics avoid me because they lose the debate. What they prefer to do is to blog, or tweet, so they can make nasty sneering public remarks and you can’t come back at them. If it’s a proper debate, I say my piece, you say your piece, there’s somebody there to make sure that it’s fair play, and that could be in a journal, it could be in a lower court, I don’t care. There was a big court case in the U.S. that was resolved in September where that happened. An allegation was made that false claims were being made for homeopathic medicines and they lost the case…homeopathy won!

Andrea Donsky: Tell us how you came to be a physician to Her Majesty the Queen.

Peter Fisher: There’s a long tradition of the Royal Family having a homeopathic physician. It actually goes back 150 years to Queen Victoria and her beloved Prince Albert. The founder of our hospital was Prince Albert’s father’s doctor. There has been an official homeopathic physician treating the Royal Family since the 1930s. It’s been me since 2001.

Andrea Donsky: It is nice to hear that the Royal Family is open to integrative medicine. Do you just treat the Queen, or the whole family? I read that Prince Charles eats organic and has an organic garden so I am assuming he is quite open to it as well.

Peter Fisher: I treat the entire family. I think Kate and Will are too young and healthy so they don’t need medicine. But the Prince of Wales, Prince Charles, is very friendly, and he is more than willing to stick his neck out to actually say things. He has spoken at the World Health Assembly, which is the AGN of the World Health Organization. So he’s really quite fond of integrative medicine.

Andrea Donsky: I think that’s incredible. As a conventionally trained physician, how did you become interested in homeopathy?

Peter Fisher: At the end of the Cultural Revolution I went to visit China. I was a medical student at the time, and I remember the moment when it became clear to me. I was in the operating room of a small Chinese provincial town and there was a woman lying on the operating table with her entire abdomen open, fully conscious talking to the anesthetist with three needles in her left ear.

Andrea Donsky: Acupuncture needles?

Peter Fisher: Yes.

Andrea Donsky: That’s amazing.

Peter Fisher: The needles were connected to a little electrical box. I thought, “That doesn’t happen. They didn’t tell us about this at Cambridge.” I went to the best medical school, Cambridge, a very elite medical school, and I just thought, “This can’t happen. This doesn’t happen.” That experience is what made me think that there was more to medicine than what we were taught in medical school. Then a few years later, I became ill myself. I was still a medical student so I went to see a very distinguished professor at my medical school who made a precise diagnosis and said, “Tough, nothing can be done.” So my friends suggested I try homeopathy, and I did, and it helped. So it snowballed from there.

Andrea Donsky: Oftentimes we need to see things for ourselves and/or experience it to believe it.

Peter Fisher: Yes. I got almost obsessed by it, you know. In many ways as a scientific thing it shouldn’t work. I mean I do understand to that extent where the skeptics are coming from. There does appear to be a good reason why it can’t possibly work, and yet it does.

Andrea Donsky: Can you define what homeopathy is and how it works?

Peter Fisher: Homeopathy is based on the idea of like curing like. So you give a very small dose of something that could cause a similar illness if given an enlarged dose. Some people say it’s like holding a mirror up to nature. You’re saying to the body, “OK, this is what your problem is, this is what the disease is.” The idea is that the body has very strong self-healing capabilities; it is strong, but sometimes it can be stupid like when it comes to autoimmune diseases. In that case it is actually the body’s defensive mechanism being misdirected.

Andrea Donsky: Can you explain the difference between a single remedy and a combination?

Peter Fisher: A single remedy is one remedy and a combination is multiple. Broadly speaking, there are two kinds of homeopathy. One is the so-called “keynote prescribing way,” where you prescribe for one or two keynote symptoms like a cold, sore throat, or runny nose.Then there is “constitutional medicine” where you are not so much treating the disease, but rather the person. So for example, if someone has insomnia, muscular aches and pains or even a cold and/or flu, they can take a combination of two, three, four, or even five different homeopathic medicines, which will likely cover the symptoms. This is more for self-treatment, rather than doctor prescribed.

Andrea Donsky: That makes sense. I like that there is a role in homeopathy for both self (like for the common cold) and expert prescribing.

Peter Fisher: Yes. It is one thing if someone has a short-term health issue, but it is another thing if they have a chronic complicated, multi-faceted issue. I mean one of the interesting things about homeopathy is the idea of treating the person, and not the disease

I AM CONFIDENT THAT THE MAJORITY OF MY READERS AGREE TO ADMIT DR FISHER TO THE ALT MED HALL OF FAME.

Polycystic ovarian syndrome (PCOS) is a common condition characterised by oligo-amenorrhoea, infertility and hirsutism. Conventional treatment of PCOS includes a range of oral pharmacological agents, lifestyle changes and surgical modalities. Some studies have suggested that acupuncture might be helpful but the evidence is often flawed and the results are mixed. What is needed in such a situation is, of course, a systematic review.

The aim of this new Cochrane review was to assess the effectiveness and safety of acupuncture treatment of oligo/anovulatory women with polycystic ovarian syndrome (PCOS). The authors identified relevant studies from databases including the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, EMBASE, PsycINFO, CNKI and trial registries. The data are current to 19 October 2015.

They included randomised controlled trials (RCTs) that studied the efficacy of acupuncture treatment for oligo/anovulatory women with PCOS. We excluded quasi- or pseudo-RCTs. Primary outcomes were live birth and ovulation (primary outcomes), and secondary outcomes were clinical pregnancy, restoration of menstruation, multiple pregnancy, miscarriage and adverse events. We assessed the quality of the evidence using GRADE methods.

Two review authors independently selected the studies, extracted data and assessed risk of bias. They calculated Mantel-Haenszel odds ratios (ORs) and mean difference (MD) and 95% confidence intervals (CIs).

Five RCTs with 413 women were included. They compared true acupuncture versus sham acupuncture (two RCTs), true acupuncture versus relaxation (one RCT), true acupuncture versus clomiphene (one RCT) and electroacupuncture versus physical exercise (one RCT). Four of the studies were at high risk of bias in at least one domain. No study reported live birth rate. Two studies reported clinical pregnancy and found no evidence of a difference between true acupuncture and sham acupuncture (OR 2.72, 95% CI 0.69 to 10.77, two RCTs, 191 women, very low quality evidence). Three studies reported ovulation. One RCT reported number of women who had three ovulations during three months of treatment but not ovulation rate. One RCT found no evidence of a difference in mean ovulation rate between true and sham acupuncture (MD -0.03, 95% CI -0.14 to 0.08, one RCT, 84 women, very low quality evidence). However, one other RCT reported very low quality evidence to suggest that true acupuncture might be associated with higher ovulation frequency than relaxation (MD 0.35, 95% CI 0.14 to 0.56, one RCT, 28 women). Two studies reported menstrual frequency. One RCT reported true acupuncture reduced days between menstruation more than sham acupuncture (MD 220.35, 95% CI 252.85 to 187.85, 146 women). One RCT reported electroacupuncture increased menstrual frequency more than no intervention (0.37, 95% CI 0.21 to 0.53, 31 women). There was no evidence of a difference between the groups in adverse events. Evidence was very low quality with very wide CIs and very low event rates. Overall evidence was low or very low quality. The main limitations were failure to report important clinical outcomes and very serious imprecision.

The authors concluded that, thus far, only a limited number of RCTs have been reported. At present, there is insufficient evidence to support the use of acupuncture for treatment of ovulation disorders in women with PCOS.

This is, in my view, a rigorous assessment of the evidence leading to a clear conclusion. Foremost, I applaud the authors from the Faculty of Science, University of Technology Sydney for using such clear language. Such clarity seems to be getting a rare event in reviews of alternative medicine. To demonstrated this point, here are the most recent 5 systematic reviews which came up on my screen when I searched today Medline for ‘complementary alternative medicine, systematic review’.

The combination of TGP and LEF in treatment of RA presented the characteristics of notably decreasing the levels of laboratory indexes and higher safety in terms of liver function. However, this conclusion should be further investigated based on a larger sample size.

Compared to control groups, both MA and EA were more effective in improving AHI and mean SaO2. In addition, MA could further improve apnea index and hypopnea index compared to control.

CHM as an adjunctive therapy is associated with a decreased risk of in-hospital mortality compared with WT in patients with AKI. Further studies with high quality and large sample size are needed to verify our conclusions.

clinicians may consider Tai Chi as a viable complementary and alternative medicine for chronic pain conditions.

As an important supplementary treatment, TCM may provide benefits in repair of injured spinal cord. With a general consensus that future clinical approaches will be diversified and a combination of multiple strategies, TCM is likely to attract greater attention in SCI treatment.

I think the phenomenon is fairly obvious: authors of such papers are far too often not able or willing to express the bottom line of their work openly. As systematic reviews are supposed to be the ultimate type of evidence, this trend is very worrying, I think. In my view, such conclusions merely display the bias of the authors. If the evidence is not convincingly positive (which it very rarely is), authors have an ethical obligation to clearly say so.

If they don’t do it, journal editors have the duty to correct the error. If neither of these actions happen, funding agencies should make sure that such teams get no further research money until they can demonstrate that they have learnt the lesson.

This may sound a bit drastic but I think such steps would be both necessary and urgent. The problem is now extremely common, and if we do not quickly implement some effective preventative measures, our scientific literature will become contaminated to the point of becoming useless. This surely would be a disaster that affects us all.

There can, of course, be several reasons for the evidence being not positive:

  • there can be a paucity of data
  • the results might be contradictory
  • the trials might be open to bias
  • some of the primary data might look suspicious

In all of these cases, the evidence would be not convincingly positive, and it would be wrong and unhelpful not to be frank about it. Beating about the bush, like so many authors nowadays do, is misleading, unhelpful, unethical and borderline fraudulent. Therefore it constitutes a disservice to everyone concerned.

Edzard Ernst – why he changed his mind! This is the title of a blog which I just found. It is such fun to read that I must show it to you in full [I added a few numbered footnotes in square brackets]:

BBC Radio 4 gave Professor Edzard Ernst a 15 minute slot to explain “Why I Changed My Mind’ on Wednesday 4th May 2016. It was repeated on 12th May 2016. He was interviewed by Dominic Lawson [1]. The programme demonstrates the lengths to which the BBC is prepared to go in order under undermine Alternative Medicine, and Homeopathy, in particular [2].

Lawson set the tone. Ernst, he stated, is hated by alternative health practitioners, the Prince of Wales tried to get him sacked, and he eventually lost his academic post because of the criticism he attracted for his work. Ernst was left to agree with this dreadfully unfair and unreasonable treatment [3]. So Ernst was then led to explain his ‘change of mind’ about homeopathy. As a friend and colleague of mine said,

“Ernst (says) that as a German, he was raised on Homeopathy, and later treated his patients with homeopathy. And it worked! But when he approached it ‘scientifically’, he concluded that it’s merely placebo.”

So let’s be clear. Ernst’s experience of homeopathy has  been that it does work [4], but that the science he has looked at does not demonstrate that it works. (Even this is wrong [5], but leave that for now!) So people do get better as the result of homeopathic treatment, but ‘science’, or at least Ernst’s science [6], does not understand why it should [7]. Ernst also said that he was convinced, at the time, that he was ‘helping patients’.

Lawson then asked his most difficult question (sic). If he knew that homeopathy worked, why did it work? Ernst’s response was that it was charlatanism and quackery, and was “quite puzzling’ really [8]. So as homeopathy worked, but science said it should not work [8], he went on to study this in his post at Exeter University.

Lawson, in the great tradition of BBC impartiality [2], (sic), continued to lead him on. “When did you decide that homeopathy was useless, delusional?”

Ernst said that when he ‘did the science’ it became clear that homeopathy is placebo.

Now, lets look at this word, placebo. The Oxford English Dictionary defines ‘the placebo effects’ as”

“A beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient’s belief in that treatment”

So by using the term ‘placebo’ Ernst is once again saying the homeopathy has a ‘beneficial effect’ on patients who are ill [9]. Lawson did ask Ernst whether there was anything wrong using placebo if this brought positive benefits to patients. Ernst said that people got better anyway! (Is it really is a simple as this?) [7]

Lawson, now thoroughly convinced of Ernst’s arguments, asked his whether he thought homeopaths were lying. With some apparent grace, Ernst said that lying was a strong term, by the were ‘deluded’, and ‘treated homeopathy as a religion’.

Lawson came back, asking why there were lots of qualified doctors who believe in homeopathy, and whether they should they be struck off, or stopped from practising? No, said Ernst, they were just not thinking critically, and needed to be educated out of their delusions.

Presumably, for both Lawson and Ernst, using a medical therapy that worked and brought benefit to patients [7], but which science could not explain, should be restricted, if not banned altogether.

Lawson’s final question clearly demonstrated his impartiality. “Can we justify homeopathy, or any other kind of quackery? (My emphasis). “No”, said Ernst, predictably!

The BBC regularly broadcasts these kind of anti-homeopathy, anti-alternative-medicine programmes, with never an attempt to redress the balance [2]. They will never broadcast a programme that provides an alternative medical view. The BBC appears to be firmly in the camp of the conventional medical establishment [2], and committed to providing time to anti-homeopaths without any ‘right of reply’.

Why, for example, was there no question about the quality of the ‘science’ Ernst is associated with?  Certainly, his science has come under serious scrutiny. For instance, I blogged about “The contribution of Professor Edzard Ernst to disinformation about Homeopathy” in September 1915 [!!!]. This followed an assessment made by Professor Robert Kahn about the quality of Ernst’s science. This was his conclusion [10].

“I have never seen a science writer so blatantly biased as Edzard Ernst: his work should not be considered of any worth at all, and discarded.”

Kahn’s paper shows, in his view, how ‘science’ has been taken over by ideology, (or as I suggested the financial interests of Big Corporations like Big Pharma). He revealed that in order to demonstrate homeopathy is ineffective over 95% of scientific research into homeopathy has to be discarded or removed! [10]

There was, of course, no mention of this in the BBC programme! [11]

So if Ernst’s change of mind was ‘scientific’, it was based on bad science [12], the kind of science much discussed in this blog, bought science, cheque book science, the kind of science based on university faculties funded by the pharmaceutical industry [13]. Ernst’s funding dried up when his academic position had become untenable [14], and he lost the support of his financial backers [15]. As my friends and colleague said, in response to the programme:

“Ernst’s religion is Science, not the well being of the patients. I wonder how many listeners will
be influenced by him as he does come across as an experienced and rational man?” 

I agree with her assessment. Anyone can come over as an ‘experience and rational man’ when given an uncritical platform, such as this BBC programme proved to be. Certainly, Peter Fisher, the Queen’s homeopath, was one of his main critics. Why, Lawson asked Ernst, did homeopathy have ‘such a grip’ on the Royal Family? Ernst did not know, but he did know that “when they get really ill they do not go to a homeopathy, otherwise they would not get so old!”

At this point I began to wonder on what knowledge Ernst used to know how the Royal Family were being treated, and scientific basis his belief that their longevity was nothing to do with homeopathy? The question was never asked, so we will, I fear, never know! [16] [1] you can listen to the programme here

[2] a serious allegation for which no evidence is provided, and I suppose none exists

[3] this is the truth

[4] not true, my experience was that patients got better for which there are good, scientifically sound explanations that do not involve homeopathy

[5] no, it’s not

[6] the best available evidence today which has little to do with ‘my’ science; might this be a little attempt at an ad hominem?

[7] no, science does understand the phenomena involved well: placebo, regression towards the mean, natural history of the disease etc.

[8] a wilful misinterpretation of my words

[9] no, this is not what I said, homeopathic remedies are ineffective and the observed effects are due to other phenomena

[10] not Kahn but Hahn; and his criticism is laughable, see here

[11] the programme is a series of interviews with people who have changed their mind on an important subject; such questions do not belong there

[12] any proof for that other than Hahn?

[13] false and libellous allegation

[14] no, when HRH had filed his complaint; this is all described in detail in my memoir

[15] poor logic: if I had been funded by the ‘enemies of homeopathy’, my funding should have increased

[16] anyone who follows the news bulletins about the Royals will know where they go when seriously ill.

It has been reported in most newspapers that Prince Charles has proposed a solution to the problem of antibiotic over-use in animals and humans. He told an international gathering of scientists and government officials in London that he treats his own cows and sheep with homeopathy. Many people reacted with dismay. I, however, plead for more understanding of this thoroughly good-willed man.

In fact, I intend to go one step further.

We have often heard that he is a considerate and caring man. We ought to give him the benefit of the doubt. I have tried therefore to empathise with his situation, put myself into his shoes and repeat the considerations that made him say what he said. My empathy went so far that I tried to re-live and formulate his thoughts in the first person singular (or should I have used the ‘Royal We’?). The result is the following little monologue where I categorised the considerations under 7 headings.

THE OCCASION

I wonder why they invited me to give a speech. True, I am a farmer at heart and I know all about husbandry, but I have no real expertise in the field of antibiotics.

Perhaps it is an occasion to tell them a bit about homeopathy. Yes, that subject would surely fascinate the audience!

THE INTELLECTUAL ENVIRONMENT

They tell me that the conference will be packed with very bright people. That sort of thing always makes me a bit self-conscious. Perhaps I should decline the invitation after all? Sometimes, I have the impression that people make fun at me.

No, I must not think like that – after all, I have had a very expensive education too, and I know my stuff.

THE ISSUE

Homeopathy is such a wonderful subject. I must try to win them over and make them appreciate its beauty. These experts should realize that homeopathy is the future.

I have heard rumours that some blinkered scientists doubt that homeopathy works. But my advisors tell me that it is best to ignore this sort of thing. And my advisors know their stuff even better than I.

POTENTIAL IMPACT

This conference is going to have a very high impact. The press will be there. It will be reported across the world. And government’s chief medical officer, Dame Sally Davies (why can we not have more holistic doctors in position like these; I must remember to discuss this with Michael Dixon asap); she once called homeopathy ‘rubbish’ – enough to throw her in the Tower!

Mustn’t think like that! On the contrary, I will make sure they all get the message. I will bowl them over! The press will surely be on my side. This will be a victory for homeopathy.

THE RISKS

Mother might be upset; she does not like me to stick my neck out like that…goes on about constitutional role and such trivia…she thinks we should not put our nose into things that are none of our business. And the Royal PR team will not like it either. They do what they can to distract from the image of ‘THE MEDDLING PRINCE’ might think that my speech is a hindrance to their efforts. I better don’t tell anyone in advance about this, they might try to stop me.

But now I feel quite unstoppable.

THE SPEECH

This is what I will tell them about homeopathy: “It was one of the reasons I converted my farming operation to an organic – or agro-ecological – system over 30 years ago and why we have been successfully using homeopathic – yes, homeopathic – treatments for my cattle and sheep as part of a programme to reduce the use of antibiotics.” I think this will convince everyone. Who needs science when there is powerful rhetoric like this?

LAST DOUBTS

What if it does not go well? They will not dare to contradict me, I am the future King, for heaven’s sake! Even if they disagree, they will not show it. They just don’t have the guts. And anyway, I will not take questions, I never do enter into any debate on homeopathy. It is simply too tedious to argue with people who do not understand the issues involved.

It is decided – I’ll do it. I’ll do it for homeopathy and for the good of mankind. If they then chose to misunderstand me, that’s their problem, and my people will issue a statement for the press saying “Homeopathy is used on a case-by-case basis at Home Farm, in combination with more conventional medicine, to minimise dependence on antibiotics.”

 

*In case you are a lawyer hired by HRH to check out this post: it is pure satire through and through, there is not a factual sentence here; if you want to sue me, please find another reason.

In a previous post, I asked this important question: how can research into alternative medicine ever save a single life?

The answer I suggested was as follows:

Since about 20 years, I am regularly pointing out that the most important research questions in my field relate to the risks of alternative medicine. I have continually published articles about these issues in the medical literature and, more recently, I have also made a conscious effort to step out of the ivory towers of academia and started writing for a much wider lay-audience (hence also this blog). Important landmarks on this journey include:

– pointing out that some forms of alternative medicine can cause serious complications, including deaths,

– disclosing that alternative diagnostic methods are unreliable and can cause serious problems,

– demonstrating that much of the advice given by alternative practitioners can cause serious harm to the patients who follow it,

– that the advice provided in books or on the Internet can be equally dangerous,

– and that even the most innocent yet ineffective therapy becomes life-threatening, once it is used to replace effective treatments for serious conditions.

Alternative medicine is cleverly, heavily and incessantly promoted as being natural and hence harmless. Several of my previous posts and the ensuing discussions on this blog strongly suggest that some chiropractors deny that their neck manipulations can cause a stroke. Similarly, some homeopaths are convinced that they can do no harm; some acupuncturists insist that their needles are entirely safe; some herbalists think that their medicines are risk-free, etc. All of them tend to agree that the risks are non-existent or so small that they are dwarfed by those of conventional medicine, thus ignoring that the potential risks of any treatment must be seen in relation to their proven benefit.

For 20 years, I have tried my best to dispel these dangerous myths and fallacies. In doing so, I had to fight many tough battles  (sometimes even with the people who should have protected me, e.g. my peers at Exeter university), and I have the scars to prove it. If, however, I did save just one life by conducting my research into the risks of alternative medicine and by writing about it, the effort was well worth it.

END OF QUOTE FROM MY PREVIOUS POST

Just now, I received an email from someone who clearly and vehemently disagrees with any of the above. As this blog is a forum where all sorts of opinions can and should be voiced, I thought I share this communication with you. Here it is:

Having been out of chiropractic practice for a while, I was thrilled to hear that you have been forced into early retirement on today’s Radio 4 programme. You have caused so many good people anguish and pain and your tunnel-visioned arrogance is staggering and detrimental to humanity. You REALLY think modern science has all the answers? Wow.

The question I ask myself is who is correct, the (ex-)chiropractor or I?

Specifically:

  1. Have I caused anguish and pain to many?
  2. Do I suffer from tunnel-vision?
  3. Am I arrogant?
  4. Is my work detrimental to humanity?
  5. Do I believe that modern science has all the answers?

Here is what I think about these specific questions:

  1. I have probably caused anguish (but no pain, as far as I am aware). This sadly is unavoidable if one seeks the truth in an area as alternative medicine.
  2. I am not the best person to judge this.
  3. Possibly; again I cannot judge.
  4. I truly don’t see this at all.
  5. No, not for one second.

In case you wonder what programme the author of the above email had been listening to, you can find it here.

Is there a bottom line? I am not sure. Perhaps this: whenever strong believes clash with scientific facts, some people are going to be unhappy. If we want to make progress, this seems to be almost unavoidable; all we can try to do is to minimize the anguish by being humble and by showing human decency.

I am pleased to report that my ‘ALTERNATIVE MEDICINE HALL OF FAME’ is growing steadily. So far, this elite club includes:

Gustav Dobos

Claudia Witt

George Lewith

John Licciardone

Time, I think, to elect another member. I was fascinated to read what the COLLEGE OF MEDICINE (I have published about this organisation before, for instance, here) writes about a former co-worker of mine, Simon Mills (those who have read my memoir will know more about him and about my struggle to disassociate me and my work from him and his activities):

Simon Mills is a member of the College of Medicine Council. He is a Cambridge graduate in medical sciences who has since 1977 been a herbal practitioner and natural therapist in Exeter. In that time he has led the main organizations for herbal medicine in the UK (the British Herbal Medicine Association, the College of Practitioners of Phytotherapy, and National Institute of Medical Herbalists) and served on Government and House of Lords committees. Since 1997 he has been Secretary of ESCOP, the lead herbal scientific network in Europe, that produces defining monographs on herbal medicines for the European Medicines Agency. He has also written award-winning seminal herbal medicine textbooks, notably with Kerry Bone the two editions of Principles and Practice of Phytotherapy and the Essential Book of Herbal Safety. He has long been involved in academic work having co-founded the world’s first University centre for complementary health in Exeter (1987), the first integrated health course at a UK medical school at the Peninsula Medical School in Exeter (2000) and the first masters degree programme in herbal medicine in the USA (2001). He has published in many peer-reviewed scientific journals including full clinical trials with herbal medicines, and has supervised 10 successful doctorate theses. Simon is currently building a new role for healthcare practitioners as ‘health guides. With health workbooks, training programmes, community projects and websites.

It was new to me that he has ‘published in many peer-reviewed scientific journals’, so I did a Medline search and found a total of 14 articles. Most of these were comments, letters etc. I decided to identify the first 10 papers that drew some sort of conclusions about the value of alternative therapies. This is what I found (as usual, I have copied the conclusions in bold):

Short-term study on the effects of rosemary on cognitive function in an elderly population.

Pengelly A, Snow J, Mills SY, Scholey A, Wesnes K, Butler LR.

J Med Food. 2012 Jan;15(1):10-7. doi: 10.1089/jmf.2011.0005. Epub 2011 Aug 30.

The positive effect of the dose nearest normal culinary consumption points to the value of further work on effects of low doses over the longer term.

Continuous PC6 wristband acupressure for relief of nausea and vomiting associated with acute myocardial infarction: a partially randomised, placebo-controlled trial.

Dent HE, Dewhurst NG, Mills SY, Willoughby M.

Complement Ther Med. 2003 Jun;11(2):72-7.

Continuous 24-h PC6 acupressure therapy as an adjunct to standard antiemetic medication for post-MI nausea and vomiting is feasible and is well accepted and tolerated by patients. In view of its benefits, further studies are worthwhile using earlier onset of treatment.

Effect of a proprietary herbal medicine on the relief of chronic arthritic pain: a double-blind study.

Mills SY, Jacoby RK, Chacksfield M, Willoughby M.

Br J Rheumatol. 1996 Sep;35(9):874-8.

It is concluded that Reumalex has a mild analgesic effect in chronic arthritis at a level appropriate to self-medication.

Yes, there were just three such papers; perhaps the College of Medicine’s description is just a trifle misleading? As all of these arrived at positive conclusions, I think Mr Mills nevertheless deserves a place in my ALTERNATIVE MEDICINE’S HALL OF FAME.

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