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

Monthly Archives: January 2019

The ‘Dunning Kruger Effect‘ (DuKE) has been discussed here before. The DuKE means that, the less you know, the less able you are to recognize how little you know, and the less likely you are to recognize your limitations. Consequently, your confidence in yourself is inflated and you believe you are more competent than your opponent. Expressed differently:

  • Incompetence prevents the recognition of incompetence.
  • Too stupid to doubt.

A recent paper brilliantly shows the DuKE in action; here is its abstract

There is widespread agreement among scientists that genetically modified foods are safe to consume and have the potential to provide substantial benefits to humankind. However, many people still harbour concerns about them or oppose their use. In a nationally representative sample of US adults, we find that as extremity of opposition to and concern about genetically modified foods increases, objective knowledge about science and genetics decreases, but perceived understanding of genetically modified foods increases. Extreme opponents know the least, but think they know the most. Moreover, the relationship between self-assessed and objective knowledge shifts from positive to negative at high levels of opposition. Similar results were obtained in a parallel study with representative samples from the United States, France and Germany, and in a study testing attitudes about a medical application of genetic engineering technology (gene therapy). This pattern did not emerge, however, for attitudes and beliefs about climate change.

As I have stated before, I suspect the DuKE can explain much of what is going on in the realm of SCAM (so-called alternative medicine). So much so that I am tempted to re-write part of the above abstract as follows:

As extremity of belief in SCAM increases, objective knowledge about science and medicine decreases. In parallel, perceived understanding of science and medicine increases. Extreme believers in SCAM know the least, but think they know the most. Moreover, the relationship between self-assessed and objective knowledge shifts from positive to negative at high levels of SCAM-belief.

Yes, yes, I know. You are absolutely correct: this is little more than speculation! And I also realise, of course, that not everyone can have a full understanding of SCAM, medicine and science; however, if someone has a strong interest in (plus a strong opinion of) these matters, it would be advisable to read up about at least the most basic facts.

In case you disapprove, please do have a look at some of the recent comments on this blog or assess what some of the most famous proponents of SCAM tell the public, and I am confident that you will begin to suspect that my speculation might be not that far off the mark.

Most chiropractors claim they can effectively treat a wide range of conditions. I have looked far and wide but I fail to see sound evidence to show that this assumption is true. On a good day, I might agree that chiropractic works for back pain (but this would need to be a very good day and I would need to close at least one eye) – and that’s basically it! Unsurprisingly, chiropractors vehemently disagree with me. Yet, they have an all too obvious conflict of interest in that question and, therefore, they are unlikely to be objective.

One regular commentator of this blog recently reminded me that the UK ‘ADVERTISING STANDARDS AUTHORITY’ (ASA) state on their website that based on all evidence submitted and reviewed to date, the ASA and CAP accept that chiropractors may claim to treat the following conditions:

  • Ankle sprain (short term management)
  • Cramp
  • Elbow pain and tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
  • Headache arising from the neck (cervicogenic
  • Joint pains
  • Joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
  • General, acute & chronic backache, back pain (not arising from injury or accident)
  • Generalised aches and pains
  • Lumbago
  • Mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)
  • Migraine prevention
  • Minor sports injuries
  • Muscle spasms
  • Plantar fasciitis (short term management)
  • Rotator cuff injuries, disease or disorders
  • Sciatica
  • Shoulder complaints (dysfunction, disorders and pain)
  • Soft tissue disorders of the shoulder
  • Tension and inability to relax

This is an impressive yet very odd list:

  • Why is ‘joint pain’ listed twice?
  • Can lateral epicondylitis arise from musculoskeletal conditions of the back and neck?
  • What exactly are ‘generalised aches and pains’?
  • Isn’t lumbago and backache the same?
  • Are ‘minor sports injuries’ (including a cut, bruise or haematoma?) a category that is well-defined?
  • What is a ‘soft tissue disorders of the shoulder’

But let’s not be pedantic. Let’s assume these are all defined conditions that need to be treated. The problem still remains that there is hardly any good evidence that they can be effectively treated by chiropractic spinal manipulation (in case you disagree, please post the evidence in the comments section).

And here we come to the crux of the matter, I think.

Chiropractors would say that they use so much more than spinal manipulations.

  • For a sport injury, they might apply an ice-pack.
  • For the inability to relax, they might give a massage.
  • For rotator cuff problems, they might administer exercises.
  • For tennis elbow, they might recommend immobilizing the joint.
  • Etc., etc.

But that’s not chiropractic!

Yes, it is what we do, insist the chiropractors.

I do not doubt it, but survey after survey shows that chiropractors treat almost all their patients with spinal manipulation. And the history of chiropractic is purely based on spinal manipulation. Yes, today they also use treatments borrowed from other disciplines, yet spinal manipulation is the treatment that defines them.

Let me try an example to make my point clear. Imagine a surgeon who specialises in an obsolete type of operation (e.g. ligation of the mammary artery as a treatment of coronary artery disease). Following the chiro-logic, he could claim that:

  • my approach is not ineffective because I do so much more than just operate,
  • I also prescribe medications,
  • I give dietary advice,
  • I give nutritional advice,
  • I recommend relaxation,
  • I suggest regular exercise.

And the results would, of course, show that many of his patients benefit from all this.

Does that mean our surgeon provides effective care for his patients?

Similarly, crystal healing could be seen as being effective, because some crystal healers tell their obese patients to eat less and exercise more?

So, the above-cited list of claims that the ASA now allows UK chiropractors to make is either way too long or much too short – in any case, it is nonsense. If we base it on the proven effectiveness of spinal manipulation, it must be very short indeed. If we base it on everything chiropractors might do in addition, it is far too short; in this case, it should include everything in the medical textbooks from AIDS to ZOSTER (I cannot imagine many conditions for which life-style advice, exercise or cryotherapy [for pain-control] etc. would not be helpful).

My conclusions from all this are as follows:

  • Chiropractors have tried to reinvent themselves by borrowing some treatments from other healthcare professions.
  • They have done this, I suspect, to avoid being judged by their largely ineffective hallmark intervention, spinal manipulation. The move may be commercially clever, but it is nevertheless transparently nonsensical and wholly unconvincing.
  • Chiropractors must be judged not by the treatments they borrowed and might use occasionally, but by the only therapy that is inherent to chiropractic: spinal manipulation.
  • And spinal manipulation is certainly not effective for a wide range of conditions.

Probiotics (live microorganisms for oral consumption) are undoubtedly popular, not least they are being cleverly promoted as a quasi panacea. But are they as safe as their manufacturers try to convince us? A synthesis and critical evaluation of the reports and series of cases on the infectious complications related to the ingestion of probiotics was aimed at finding out.

The authors extensive literature searches located 60 case reports and 7 case series including a total of 93 patients. Fungemia was the most common infectious complications with 35 (37.6%) cases. The genus Saccharomyces was the most frequent with 47 (50.6%) cases, followed by Lactobacillus, Bifidobacterium, Bacillus, Pedioccocus and Escherichia with 26 (27.9%), 12 (12.8%), 5 (5.4%), 2 (2.2%) and 1 (1.1%) case, respectively. Adults over 60 years of age, Clostridium difficile colitis, antibiotic use and Saccharomyces infections were associated with overall mortality. HIV infections, immunosuppressive drugs, solid organ transplantation, deep intravenous lines, enteral or parenteral nutrition were not associated with death.

The authors concluded that the use of probiotics cannot be considered risk-free and should be carefully evaluated for some patient groups.

Other authors have previously warned that individuals under neonatal stages and/or those with some clinical conditions including malignancies, leaky gut, diabetes mellitus, and post-organ transplant convalescence likely fail to reap the benefits of probiotics. Further exacerbating the conditions, some probiotic strains might take advantage of the weak immunity in these vulnerable groups and turn into opportunistic pathogens engendering life-threatening pneumonia, endocarditis, and sepsis. Moreover, the unregulated and rampant use of probiotics potentially carry the risk of plasmid-mediated antibiotic resistance transfer to the gut infectious pathogens. 

And yet another review had concluded that the adverse effects of probiotics were sepsis, fungemia and GI ischemia. Generally, critically ill patients in intensive care units, critically sick infants, postoperative and hospitalized patients and patients with immune-compromised complexity were the most at-risk populations. While the overwhelming existing evidence suggests that probiotics are safe, complete consideration of risk-benefit ratio before prescribing is recommended.

Proponents of probiotics will say that these risks are rare and confined to small groups of particularly vulnerable patients. This may well be so, but in view of the often uncertain benefits of probiotics, the incessant hype and aggressive marketing, I find it nevertheless important to keep these risks in mind.

As with any therapy, the question must be, does this treatment really generate more good than harm?

I would warn every parent who thinks that taking their child to a chiropractor is a good idea. For this, I have three main reasons:

  1. Chiropractic has not been shown to be effective for any paediatric condition.
  2. Chiropractors often advise parents against vaccinating their children.
  3. Chiropractic spinal manipulations can cause harm to kids.

The latter point seems to be confirmed by a recent PhD thesis of which so far only one short report is available. Here are the relevant bits of information from it:

Katie Pohlman has successfully defended her PhD thesis, which focused on the assessment of safety in pediatric manual therapy. As a clinical research scientist at Parker University, Dallas, Texas, she identified a lack of prospective patient safety research within the chiropractic population in general and investigated this deficit in the paediatric population in particular.

Pohlman used a cross-sectional survey to assess the barriers and facilitators for participation in a patient safety reporting system. At the same time, she also conducted a randomized controlled trial comparing the quantity and quality of adverse event reports in children under 14 years receiving chiropractic care.

The RCT recruited 69 chiropractors and found adverse events reported in 8.8% and 0.1% of active and passive surveillance groups respectively. Of the adverse events reported, 56% were considered mild, 26% were moderate and 18% were severe. The frequency of adverse events was more common than previously thought.

This last sentence from the report is somewhat puzzling. Our systematic review of the risks of spinal manipulation showed that data from prospective studies suggest that minor, transient adverse events occur in approximately half of all patients receiving spinal manipulation. The most common serious adverse events are vertebrobasilar accidents, disk herniation, and cauda equina syndrome. Estimates of the incidence of serious complications range from 1 per 2 million manipulations to 1 per 400,000. Given the popularity of spinal manipulation, its safety requires rigorous investigation.

The 8.8% reported by Pohlman are therefore not even one fifth of the average incidence figure reported previously in all age groups.

What could be the explanation for this discrepancy?

There are, of course, several possibilities, including the fact that infants cannot tell the clinician when their pain has increased. However, the most likely one, in my view, lies in the fact that RCTs are wholly inadequate for investigating risks because they typically include far too few patients to generate reliable incidence figures about adverse events. More importantly, clinicians included in such studies are self-selected (and thus particularly responsible/cautious) and are bound to behave most carefully while being part of a clinical trial. Therefore it seems possible – I would speculate even likely – that the 8.8% reported by Pohlman is unrealistically low.

Having said that, I do feel that the research by Kathie Pohlman is a step in the right direction and I do applaud her initiative.

The German Association of Medical Homeopaths (Deutscher Zentralverein homöopathischer Ärzte (DZVhÄ)) have recently published an article where, amongst other things, they lecture us about evidence-based medicine (EBM). If you feel that this might be a bit like an elephant teaching Fred Astaire how to step-dance, you could have a point. Here is their relevant paragraph:

… das Konzept der modernen Evidenzbasierte Medizin nach Sackett [stützt sich] auf drei Säulen: auf die klinischen Erfahrung der Ärzte, auf die Werte und Wünsche des Patienten und auf den aktuellen Stand der klinischen Forschung. Homöopathische Ärzte wehren sich gegen einen verengten Evidenzbegriff der Kritiker, der Evidenz allein auf die Säule der klinischen Forschung bzw. ausschließlich auf RCT verengen möchte und die anderen beiden Säulen ausblendet. Experten schätzen, dass bei einer solchen Auffassung von EbM rund 70 Prozent aller Leistungen der GKV nicht evidenzbasiert sei. Nötiger als eine Homöopathie-Debatte hat die deutsche Ärzteschaft aus unserer Sicht eine klare Verständigung darüber, welcher Evidenzbegriff nun gilt.

For those who cannot understand the full splendour of their argument because of the language problem, I translate as literally as I can:

… the concept of the modern EBM according to Sackett is based on three pillars: on the clinical experience of the doctors, on the values and wishes of the patient and on the current state of the clinical research. Homeopaths defend themselves against the narrowed understanding of ‘evidence’ of the critics which aims at narrowing evidence solely to the pillar of the clinical research or exclusively to RCT, while eliminating the other two pillars. Experts estimate that, with such an view of EBM, about 70% of all treatments reimbursed by our health insurances would not be evidence-based. We feel that we more urgently need a clear understanding which evidence definition applies than a debate about homeopathy.

END OF MY TRANSLATION

So, where is the hilarity in this?

I don’t know about you, but I find the following things worth a giggle:

  1. ‘narrowed understanding of evidence’ – this is a classical strawman; non-homeopaths tend to apply Sackett’s definition which states that ‘evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical experience with the best available external clinical evidence from systematic research‘;
  2. as we see, Sackett’s definition is quite different from the one cited by the homeopaths;
  3. the three pillars cited by the homeopaths are those subsequently developed for Evidence Based Practice (EBP) and include: A) patient values, B) clinical expertise and C) external best evidence;
  4. as we see, these three pillars are also not quite the same as those suggested by the homeopaths;
  5. non-homeopaths do certainly not aim at eliminating the ‘other two pillars’;
  6. current best evidence clearly includes much more than just RCTs – to mention RCTs in this context therefore suggests that the ones guilty of narrowing anything might, in fact, be the homeopaths;
  7. even if it were true that 70% of reimbursable treatments are not evidence-based, this would hardly be a good reason to employ homeopathic remedies of which 100% are not even remotely evidence-based;
  8. unbeknown to the German homeopaths, the discussion about a valid definition of EBM has been intense, is as old as EBM itself, and would by now probably fill a mid-size library;
  9. this discussion does, however, in no way abolish the need to bring the debate about homeopathy to the only evidence-based conclusion possible, namely the discontinuation of reimbursement of this and all other bogus therapies.

In conclusion, I do thank the German homeopaths for being such regular contributors to fun and hilarity. I shall miss them, once they have fully understood EBM and are thus compelled to stop prescribing placebos.

Having been frantically searching for a decent quality study reporting a positive result, I am delighted to announce that I might have had some luck.

This study examined the effects of whole-body massage on knee osteoarthritis, compared to active control (light-touch) and usual care. Assessments were done at baseline and weeks 8, 16, 24, 36, and 52. Subjects in massage or light-touch groups received eight weekly treatments each lasting one hour, then were randomized to biweekly intervention or usual care to week 52. The original usual care group continued to week 24. Analysis was performed on an intention-to-treat basis. Five hundred fifty-one screened for eligibility, 222 adults with knee osteoarthritis enrolled, 200 completed 8-week assessments, and 175 completed 52-week assessments.

The primary endpoint was the ‘Western Ontario and McMaster Universities Arthritis Index’. Visual analog pain scale, PROMIS Pain Interference, knee range of motion, and timed 50-ft walk were secondary outcome measures.

At 8 weeks, massage significantly improved WOMAC Global scores compared to light-touch and usual care. Massage also improved pain, stiffness, and physical function WOMAC subscale scores compared to light-touch and usual care. At 52 weeks, the omnibus test of any group difference in the change in WOMAC Global from baseline to 52 weeks was not significant, indicating no significant difference in change across groups. Adverse events were minimal.

The authors concluded that the efficacy of symptom relief and safety of weekly massage make it an attractive short-term treatment option for knee osteoarthritis. Longer-term biweekly dose maintained improvement, but did not provide additional benefit beyond usual care post 8-week treatment.

Massage therapy is supported by encouraging evidence from several systematic reviews, for instance:

  • One overview identified 31 systematic reviews of massage for pain control, of which 21 were considered high-quality. The most common type of pain included in systematic reviews was neck pain (n=6). Findings from high-quality systematic reviews describe potential benefits of massage for pain indications including labour, shoulder, neck, back, cancer, fibromyalgia, and temporomandibular disorder. However, no findings were rated as moderate- or high-strength.
  • A systematic review showed that massage therapy has promise for caner palliation: massage can alleviate a wide range of symptoms: pain, nausea, anxiety, depression, anger, stress and fatigue. However, the methodological quality of the included studies was poor, a fact that prevents definitive conclusions. The evidence is, therefore, encouraging but not compelling. The subject seems to warrant further investigations which avoid the limitations of previous studies.

So, should massage be recommended for knee osteoarthritis?

Yes and NO.

Yes, because it does seem to alleviate pain with only few adverse effects.

No, because it is merely symptomatic and does not cure the problem. Patients who want to treat the ‘root cause’ of knee osteoarthritis (which is often possible) ought to see an orthopaedic surgeon.

Come to think of it, this is almost a general rule: Patients who want to treat the ‘root cause‘ of any disease (which is often possible) ought to see a real doctor and not an alternative practitioner.

The 2018 World Federation of Chiropractic ACC Education Conference was held on 24-27 October in London. It resulted in several consensus statements developed by the attendees. I happen to know this from a short report that has just been published; it can be found here.

Of the 10 points made in this consensus, I find only the following noteworthy:

“Chiropractic education programs have an ethical obligation to support an evidence-based teaching and learning environment.”

Perhaps it is me – English is not my first language – but I find the phraseology used in this sentence strangely complicated and confusing. I have been a teacher of medical students for most of my life, but I am not sure what an ‘evidence-based teaching and learning environment’ is. I know what ‘evidence-based’ means, of course. However, what exactly is:

  • a teaching environment?
  • a learning environment?
  • and how does ‘evidence-based’ apply to either of the two?

Is there evidence that some environments are better suited than others for teaching?

Is there evidence that some environments are better suited than others for learning?

I suppose the answer must be YES!

The environment, i. e. the space and conditions in which teaching and learning happen should, for instance, be/include:

  • quiet,
  • not cramped,
  • not too cold,
  • not too hot,
  • equipped with ergometric chairs and desks,
  • well-lit,
  • there should be visual aids,
  • access to computers,
  • a library,
  • good mentoring and support,
  • etc.

So, the consensus of the education conference wanted to optimise the environmental conditions of teaching and learning for chiropractic lecturers and students? Most laudable, I must say!

But still, it seems like a missed opportunity for an ‘Education Conference’ not to have stated something about the content of teaching and learning. Personally, I find it a pity that they did not state: Chiropractic education programs have an ethical obligation to be evidence-based.

Or is that what they really wanted to say?

Naaahh … come to think of it … they cannot possibly make such a demand.

Why?

Because, in this case, they would have to teach students not to become chiropractors.

Slowly, I seem to be turning into a masochist! Yes, I sometimes read publications like ‘HOMEOPATHY 360’. It carries articles that are enragingly ill-informed. But in my defence, I might say that some are truly funny. Here is the abstract of one that I found outstanding in that category:

The article explains about Gangrene and its associated amputations which is a clinically challenging condition, but Homeopathy offers therapy options. The case presented herein, details about how the Homeopathic treatment helped in the prevention of amputation of a body part. Homeopathy stimulates the body’s ability to heal through its immune mechanisms; consequently, it achieves wound healing and establishes circulation to the gangrenous part. Instead of focusing on the local phenomena of gangrene pathology, treatment focuses on the general indications of the immune system, stressing the important role of the immune system as a whole. The aim was to show, through case reports, that Homeopathic therapy can treat gangrene thus preventing amputation of the gangrenous part, and hence has a strong substitution for consideration in treating gangrene.

The paper itself offers no less than 13 different homeopathic treatments for gangrene:

  1. Arsenicum album– Medicine for senile gangrene;gangrene accompanied by foetid diarrhoea; ulcers extremely painful with elevated edges, better by warmth and aggravation from cold; great weakness and emaciation.
  2. Bromium – Hospital gangrene; cancerous ulcers on face; stony hard swelling of glands of lower jaw and throat.
  3. Carbo vegetabilis – Senile and humid gangrene in the persons who are cachectic in appearance; great exhaustion of vital powers; marked prostration; foul smell of secretions; indolent ulcers, burning pain; tendency to gangrene of the margins; varicose ulcers.
  4. Bothrops– Gangrene; swollen, livid, cold with hemorrhagic infiltration; malignant erysipelas.
  5. Echinacea– Enlarged lymphatics; old tibial ulcers; gangrene; recurrent boils; carbuncles.
  6. Lachesis– Gangrenous ulcers; gangrene after injury; bluish or black looking blisters; vesicles appearing here and there, violent itching and burning; swelling and inflammation of the parts; itching pain and painful spots appearing after rubbing.
  7. Crotalus Horridus– Gangrene, skin separated from muscles by a foetid fluid; traumatic gangrene; old scars open again.
  8. Secale cornatum– Pustules on the arms and legs, with tendency to gangrene; in cachectic, scrawny females with rough skin; skin shriveled, numb; mottled dusky-blue tinge; blue color of skin; dry gangrene, developing slowly; varicose ulcers; boils, small, painful with green contents; skin feels too cold to touch yet covering is not tolerated. Great aversion to heat;formication under skin.
  9. Anthracinum– Gangrene; cellular tissues swollen and oedematous; gangrenous parotitis; septicemia; ulceration, and sloughing and intolerable burning.
  10. Cantharis – Tendency to gangrene; vesicular eruptions; burns, scalds, with burning and itching; erysipelas, vesicular type, with marked restlessness.
  11. Mercurius– Gangrene of the lips, cheeks and gums; inflammation and swelling of the glands of neck; pains aggravated by hot or cold applications.
  12. Sulphuric acid– Traumatic gangrene; haemorrhages from wounds; dark pustules; blue spots like suggillations; bedsores.
  13. Phosphoric acid– Medicine for senile gangrene. Gunpowder, calendula are also best medicines.

But the best of all must be the article’s conclusion: “Homeopathy is the best medicine for gangrene.

I know, there are many people who will not be able to find this funny, particularly patients who suffer from gangrene and are offered homeopathy as a cure. This could easily kill the person – not just kill, but kill very painfully. Gangrene is the death of tissue in part of the body, says the naïve little caption. What it does not say is that it is in all likelihood also the death of the patient who is treated purely with homeopathy.

And what about the notion that homeopathy stimulates the body’s ability to heal through its immune mechanisms?

Or the assumption that it might establish circulation to the gangrenous part?

Or the claim that through case reports one can show the effectiveness of an intervention?

Or the notion that any of the 13 homeopathic remedies have a place in the treatment of gangrene?

ALL OF THIS IS TOTALLY BONKERS!

Not only that, it is highly dangerous!

Since many years, I am trying my best to warn people of charlatans who promise bogus cures. Sadly it does not seem to stop the charlatans. This makes me feel rather helpless at times. And it is in those moments that I decide to look at from a different angle. That’s when I try to see the funny side of quacks who defy everything we know about healthcare and just keep on lying to themselves and their victims.

By guest blogger Dr Richard Rawlins (Orthopaedic and trauma surgeon and author of Real Secrets of Alternative Medicine)

The National Center for Complementary and Alternative Medicine (NCCAM) was the US Federal Government’s lead agency, under the auspices of the US National Institutes of Health (NIH), for scientific research on complementary and alternative medicine (CAM). Originally set up in 1991 as the Office for Alternative Medicine (OAM), its first Director, Dr Joseph J. Jacobs had impeccable scientific credentials and intentions but resigned two years later, telling Science he “blasted politicians – especially Senator Tom Harkin…for pressuring his office, promoting certain therapies and attempting an end run around objective science”, and expressing his concern he was expected to “dance to the tune of the alternative medicine lobby.” OAM changed its name to NNCAM in 1998 continuing with a remit “To answer important scientific questions about natural products, mind and body practices and pain management.” It has failed. It has become directed by those who have no intention of enquiring into any scientifically derived evidence as to whether CAMs have a beneficial effect on any specific condition, and is now directed by doctors who believe that they do, and who want to have CAM (SCAM/camistry – by whatever name known), integrated with regular orthodox progressive medical practice. Apparently still dancing to lobbyists’ tunes.

NCCAM even rebranded itself a couple of years ago, dropping any suggestion it might critically consider ‘alternative’ medical approaches such as chiropractic, osteopathy, acupuncture or homeopathy (all of whose founders or original proponents stated that their modalities were ‘alternative’ to the regular medicine of their day) – and is now styled as the ‘National Center for Complementary and Integrated Health’ (NCCIH).

Ad hominem commentary is normally best avoided, but when the NCCIH’s current Director speaks, we should take note. The 2019 New Year’s Message from Dr Helene Langevin M.D. allows us critical insight into her state of mind, her facility with logical fallacies, and her lack of critical thinking. All of which is important considering that the Center has spent $2.5B over the past ten years on research, and found no benefit from the modalities studied beyond the placebo. The Center’s current budget is $142M p.a.

Here follows Dr Langevin’s ‘2019 New Year message’, and a slightly more critical review (in italics) than her own insights and editing offered:

”It has been my longstanding conviction that integrative health care is more than just the sum of conventional and complementary health approaches. When combined, these approaches provide a frontier of new insights into the physiology of health and the pathophysiology underlying diseases and disorders. Dr. Straus, Dr. Briggs, and Dr. Shurtleff have built a strong foundation for NCCIH’s strategic priorities and partnerships.”

Dr Langevin fails to mention her predecessor Dr Josephine Brigg’s opinion when, as Director of the US National Center for Complementary and Alternative Medicine she said: “Integrative medicine represents an invasive rebranding of modern equivalents of ‘snake oil’ by practitioners who raise unrealistic hopes and promote approaches that are not sensible, supported by evidence or proven safe.”

“I plan to help the Center continue to reach beyond its walls and across NIH, encouraging an emphasis on health promotion, whole person care, and nonpharmacologic treatments, especially for pain management.”

What she plans is the integration of implausible pseudo-scientific modalities with regular medical practices. She ignores the wise words of Dr Mark Crislip: “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.”

“Our current approach to patient care, in general, is fundamentally limited. It often emphasizes the treatment of disease alone, while it many times neglects the promotion, support, and restoration of health.”

That may be a valid critique of ‘our current approach’, but that need not be the case. Orthodox treatment can adopt the other dimensions Dr Langevin identifies without having to ‘integrate’ with CAM modalities.

“Integrative health care can help correct this limitation by giving more consideration to the patient’s long-term recovery and overall health when treating an acute illness or injury.”

But can only do so within a framework of implausible pseudo-science.

“Another limitation of the conventional medical approach is its specialization, based on the basic organization of the body into physiological systems, which can lead not only to fragmented health care, but also fragmented research.”

That is because as ‘medicine’ has advanced since the 16th century Enlightenment, and specialisation has allowed the more focussed scientific consideration and attention to detail that is necessary to advance understanding. The CAM modalities have failed to ‘move on’ and are anachronistic. Any perceived fault of ‘the conventional medical approach’ leading to ‘fragmented health care’ can be remedied by greater co-operation and collaboration amongst conventional doctors. ‘Integration’ with camists (who practice CAMs) is simply not necessary, and proves a distraction.

“In contrast, many traditional healing systems, especially those based on Eastern philosophies, emphasize an understanding of the person as a whole.”

That may be their emphasis – given the lack of scientific endeavour in ‘traditional’ systems, they can hardly do otherwise – they have little else to offer. But conventional medicine is doing all it can to ‘understand the person as a whole’, without the encumbrance of outmoded approaches.

“Further, the widespread role of pharmaceuticals as the default means of medical treatment is an important issue, and nowhere is this more urgent than for pain management.”

So, don’t use them! Conventional medicine can change its ‘default mode’, and does so in the face of scientific evidence.

“NCCIH is playing an increasing role in finding solutions to the current opioid crisis with research on non-drug approaches for pain.”

We must all look forward to published evidence of the benefit arising from NCCIH’s approach to pain management.

Happy New Year, and may the Wu be with you all. (Wu: Chinese, nothingness – wherein CAM resides.)

Lumbar spinal stenosis (LSS) is a common reason for spine surgery. Several non-surgical LSS treatment options are also available, but their effectiveness remains unproven. The objective of this study was to explore the comparative clinical effectiveness of three non-surgical interventions for patients with LSS:

  • medical care,
  • group exercise,
  • individualised exercise plus manual therapy.

All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat.

Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists. The primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes).

A total of 259 participants were allocated to medical care (n = 88), group exercise (n = 84), or manual therapy/individualized exercise (n = 87). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care or group exercise. Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates.

The authors concluded that a combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity.

In many ways, this is a fairly rigorous study; in one important way, however, it is odd. One can easily see why one group received the usual standard care (except perhaps for the fact that standard medical care should also include exercise). I also understand why one group attended group exercise. Yet, I fail to see the logic in the third intervention, individualised exercise plus manual therapy.

Individualised exercise is likely to be superior to group exercise. If the researchers wanted to test this hypothesis, they should not have added the manual therapy. If they wanted to find out whether manual therapy is better that the other two treatments, they should not have added individualised exercise. As it stands, they cannot claim that either manual therapy or individualised exercise are effective (yet, I am sure that the chiropractic fraternity will claim that this study shows their treatment to be indicated for LSS [three of the authors are chiropractors and the 1st author seems to have a commercial interest in the matter!]).

Manual therapy procedures used in this trial included:

  • lumbar distraction mobilization,
  • hip joint mobilization,
  • side posture lumbar/sacroiliac joint mobilization,
  • and neural mobilization.

Is there any good reason to assume that these interventions work for LSS? I doubt it!

And this is what makes the new study odd, in my view. Assuming I am correct in speculating that individualised exercise is better than group exercise, the trial would have yielded a similarly positive result, if the researchers had offered, instead of the manual therapy, a packet of cigarettes, a cup of tea, a chocolate bar, or swinging a dead cat. In other words, if someone had wanted to make a useless therapy appear to be effective, they could not have chosen a better trial design.

And why do I find such studies objectionable?

Mainly because they deliberately mislead many of us. In the present case, many non-critical observers might conclude that manual therapy is effective for LSS. Yet, the truth could well be that it is useless or even harmful (assuming that the effect size of individualised exercise is large, adding a harmful therapy would still render the combination effective). To put it bluntly, such trials

  • could harm patients,
  • might waste money,
  • and hinder progress.

 

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted but you must tick the box: “Save my name, email, and website in this browser for the next time I comment.”

The most recent comments from all posts can be seen here.

Categories