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

Monthly Archives: January 2024

he German press reported yesterday that the country’s Health Minister Karl Lauterbach plans  to remove homeopathic treatments from the benefits catalog of statutory health insurance companies. “Services that have no medically verifiable benefit should not be financed from contribution funds,” states a recommendation paper by the minister. “For this reason, we will remove the option for health insurance companies to include homeopathic and anthroposophic services in their statutes, thereby avoiding unnecessary expenditure by health insurance companies.” However, private supplementary insurance should still be possible.

Lauterbach had already announced last year that he would review the funding of homeopathic treatments. “Although homeopathy is not significant in terms of expenditure, it has no place in a science-based healthcare policy,” the SPD politician told “Der Spiegel” last October. The measure would save merely a maximum of ten million Euros. This is because firstly not all health insurance companies offer the option to reimburse homeopathy, and secondly, because not that many Germans use homeopathy.

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Before I was joined about a decade ago by a group of excellent and effective skeptics, I seemed to be a lone, lost voice in Germany cautioning against the misunderstanding that homeopathy and anthroposophical medicine were backed by evidence. Thus, you probably think that I am rejoicing at this spectacular success. At first glance, it does indeed seem to be great news for those who support evidence-based medicine. But sadly, I also have second thoughts.

We should, I think, be concerned that Lauterbach intends to leave homeopathic and anthroposophical remedies reimbursible via private supplementary insurance. Most Germans have such insurance which means that, despite Lauterbach’s grand announcement, very little will probably change. Homeopathy and anthroposophic medicine, both pure placebo therapies, will still be able to pretend to be real medicine.

Moreover, we should be concerned about Lauterbach’s reasoning. It is, of course, laudable to point out that homeopathic and anthroposophic remedies are not demonstrably effective. But clearly, this is only half of the truth. The full truth is that they are based on totally ridiculous assumptions, that, in other words, they fly in the face of science. Only if we manage to get this message across, will we inform the public responsibly, in my view.

A total ban then? No, personally, I don’t want to ban homeopathic or anthroposophical remedies. If someone loves esoteric nonsense or placebos, he/she should, in my view, be able to buy them. But he/she should use their own money for the purchase. We should remember that wasting notoriously scarce public funds from either statutory or private health insurances is not just uneconomical but foremost unethical.

 

 

This systematic review aimed to investigate the effectiveness of cupping therapy on low back pain (LBP). Medline, Embase, Scopus and WANFANG databases were searched for relevant cupping RCTs on low back pain articles up to 2023. A complementary search was manually made on 27 September for update screening. Full-text English and Chinese articles on all ethnic adults with LBP of cupping management were included. Studies looking at acute low back pain only were excluded. Two independent reviewers screened and extracted data, with any disagreement resolved through consensus by a third reviewer. The methodological quality of the included studies was evaluated independently by two reviewers using an adapted tool. Change-from-baseline outcomes were treated as continuous variables and calculated according to the Cochrane Handbook. Data were extracted and pooled into the meta-analysis by Review Manager software (version 5.4, Nordic Cochrane Centre).

Eleven trials involving 921 participants were included. Five studies were assessed as being at low risk of bias, and six studies were of acceptable quality. The findings reveal:

  • High-quality evidence demonstrated cupping significantly improves pain at 2-8 weeks endpoint intervention (d=1.09, 95% CI: [0.35-1.83], p=0.004).
  • There was no continuous pain improvement observed at one month (d=0.11, 95% CI: [-1.02-1.23], p=0.85) and 3-6 months (d=0.39, 95% CI: [-0.09-0.87], p=0.11).
  • Dry cupping did not improve pain (d=1.06, 95% CI: [-0.34, 2.45], p=0.14) compared with wet cupping (d=1.5, 95% CI: [0.39-2.6], p=0.008) at the endpoint intervention.
  • There was no evidence indicating the association between pain reduction and different types of cupping (p=0.2).
  • Moderate- to low-quality evidence showed that cupping did not reduce chronic low back pain (d=0.74, 95% CI: [-0.67-2.15], p=0.30) and non-specific chronic low back pain (d=0.27, 95% CI: [-1.69-2.24], p=0.78) at the endpoint intervention.
  • Cupping on acupoints showed a significant improvement in pain (d=1.29, 95% CI: [0.63-1.94], p<0.01) compared with the lower back area (d=0.35, 95% CI: [-0.29-0.99], p=0.29).
  • A potential association between pain reduction and different cupping locations (p=0.05) was found.
  • Meta-analysis showed a significant effect on pain improvement compared to medication therapy (n=8; d=1.8 [95% CI: 1.22 – 2.39], p<0.001) and usual care (n=5; d=1.07 [95% CI: 0.21- 1.93], p=0.01).
  • Two studies demonstrated that cupping significantly mediated sensory and emotional pain immediately, after 24 hours, and 2 weeks post-intervention (d= 5.49, 95% CI [4.13-6.84], p<0.001).
  • Moderate evidence suggested that cupping improved disability at the 1-6 months follow-up (d=0.67, 95% CI: [0.06-1.28], p=0.03).
  • There was no immediate effect observed at the 2-8 weeks endpoint (d=0.40, 95% CI: [-0.51-1.30], p=0.39).
  • A high degree of heterogeneity was noted in the subgroup analysis (I2 >50%).

The authors concluded that high- to moderate-quality evidence indicates that cupping significantly improves pain and disability. The effectiveness of cupping for LBP varies based on treatment durations, cupping types, treatment locations, and LBP classifications. Cupping demonstrated a superior and sustained effect on pain reduction compared with medication and usual care. The notable heterogeneity among studies raises concerns about the certainty of these findings. Further research should be designed with a standardized cupping manipulation that specifies treatment sessions, frequency, cupping types, and treatment locations. The real therapeutic effects of cupping could be confirmed using a sham device or objective outcome measurements. Studies with at least six- to twelve-month follow-ups are needed to investigate the long-term efficacy of cupping in managing LBP.

Confused?

No need, it’s really quite simple: cupping can, according to this review, be shown to have some short-lasting effect, provided the study is flawed and does not control for placebo effects.

Surprised?

No need! There is hardly a form of so-called alternative medicine (SCAM) that does not have a similarly small effect of back pain, if tested in equally dodgy studies. This is particularly true for those treatments that can act as a theatrical placebo, e.g. acupuncture or chiropractic.

So, should a back pain sufferer try cupping?

If he/she insists, why not? But please don’t use wet cupping (which can do quite a bit of harm). Dry cupping (without injuring the skin) is arguably better (less risk, less expense, possibility of home treatment by your partner) than chiropractic, osteopathy, acupuncture, or many other SCAMs.

My conclusions – as mentioned many times previously – are as follows:

  1. Most SCAMs help a little with back pain (and similar conditions) because they can have a powerful placebo effect.
  2. Conventional medicine is also not convincingly effective for back pain.
  3. If you insist on SCAM, it is best to use one that is relatively harmless and inexpensive.

Diabetic peripheral neuropathy (DPN) is a common complication of diabetes mellitus and can lead to serious complications. Therapeutic strategies for pain control are available but there are few approaches that influence neurological deficits such as numbness.

This study investigated the effectiveness of acupuncture on improving neurological deficits in patients suffering from type 2 DPN.

The acupuncture in DPN (ACUDPN) study was a two-armed, randomized, controlled, parallel group, open, multicenter clinical trial. Patients were randomized in a 1:1 ratio into two groups: The acupuncture group received 12 acupuncture treatments over 8 wk, and the control group was on a waiting list during the first 16 wk, before it received the same treatment as the other group. Both groups received routine care.

Outcome parameters were evaluated after 8, 16 and 24 wk. They included:

  • neurological scores, such as an 11-point numeric rating scale (NRS) for hypesthesia,
  • neuropathic pain symptom inventory (NPSI),
  • neuropathy deficit score (NDS),
  • neuropathy symptom score (NSS);
  • nerve conduction studies (NCS) as assessed with a handheld point-of-care device.

Sixty-two participants were included. The NRS for numbness showed a difference of 2.3 (P < 0.001) in favor of the acupuncture group, the effect persisted until week 16 with a difference of 2.2 (P < 0.001) between groups and 1.8 points at week 24 compared to baseline. The NPSI was improved in the acupuncture group by 12.6 points (P < 0.001) at week 8, the NSS score at week 8 with a difference of 1.3 (P < 0.001); the NDS and the TNSc score improved for the acupuncture group in week 8, with a difference of 2.0 points (P < 0.001) compared to the control group. Effects were persistent in week 16 with a difference of 1.8 points (P < 0.05). The NCS showed no meaningful changes. In both groups only minor side effects were reported.

The authors concluded that acupuncture may be beneficial in type 2 diabetic DPN and seems to lead to a reduction in neurological deficits. No serious adverse events were recorded and the adherence to treatment was high. Confirmatory randomized sham-controlled clinical studies with adequate patient numbers are needed to confirm the results.

That “acupuncture may be beneficial” has been known before and presumably was the starting point of the present study. So, why conduct an open, under-powered trial with non-blind assessors and without defining a primary outcome measure?

Could the motivation be to add yet another false-positive study to the literature of acupuncture?

False-positive, you ask?

Yes, let me explain by having a look at the outcome measures:

  • NRS = a subjective endpoint.
  • NPSI = a subjective endpoint.
  • NDS = a subjective endpoint.
  • NSS = a subjective endpoint.
  • NCS = the only objective endpoint.

And what is remarkable about that?

  • Subjective endpoints are likely to respond to placebo effects.
  • Objective endpoints are not likely to respond to placebo effects.

In other words, what the authors of this study have, in fact, confirmed with their study is this:

acupuncture is a theatrical placebo!

Representatives of six Australian professional organizations of so-called alternative medicine (SCAM) developed a survey for e-mail distribution to members. The anonymous online Qualtrics survey was based on previous surveys to identify workforce trends over time. Survey data were analyzed descriptively using Qualtrics and STATA statistical software.

Responses were recorded from 1921 participants. Respondents were predominantly female (79.7%); 71.8% were aged over 45 years. Remedial massage therapists represented 32.1% and naturopaths represented 23.7% of respondents. Highest qualifications were diplomas (37.7%), bachelor’s degrees (28.9%), and advanced diplomas (21.8%). Metropolitan locations accounted for 68.1% of practices. Solo private practice was the main practice setting (59.8%); 13.8% practiced in group private practice with SCAM practitioners; and 10.6% practiced with allied health practitioners. Approximately three quarters of respondents (73.9%) saw 0–5 new clients per week; 42.2% had 0–5 follow-up consultations per week. Collaboration rates with SCAM practitioners, other non-SCAM practitioners, and general medical practitioners (GPs) were 68.7%, 24.4%, and 9.2%, respectively. A total of 93% did not suspect an adverse event from their treatment in the past year. Businesses of 75.9% of respondents were reportedly affected by the pandemic.

The authors concluded that comparisons with previous surveys show ongoing predominance of female practitioners, an aging workforce, a high proportion of remedial massage and naturopathy practitioners, and an increasingly qualified SCAM workforce. There was little change in the very low number of adverse events suspected by practitioners, number of consultations per week, and low levels of income of most SCAM practitioners compared with the average income in Australia. Respondents collaborated at similar rates as in the past; however, more with SCAM practitioners than with GPs.

Yet another fairly useless SCAM survey to add to the endless list of similarly wasteful investigations!

If I had to extract anything potentially relevant from it, it would be just three points:

  • The authors speak of an ‘increasingly qualified workforce’. The basis for this claim is that the highest qualifications were diplomas (37.7%), bachelor’s degrees (28.9%), and advanced diplomas (21.8%). Oh dear, oh dear! Anyone can issue ‘diplomas’ which are not recognised qualifications. In other words, the SCAM workforce is woefully underqualified to take charge of patients.
  • Only 9% of SCAM practitioners ‘collaborated’ with GPs. By collaboration, the authors mean the very minimum of informing the GPs what type of SCAM they might be getting. Such information can be essential for avoiding harm (e.g. interactions with prescribed drugs). In other words, even the minimum of ethical and safe practice is not met in 91% of the cases.
  • The fact that a total of 93% SCAM practitioners did not suspect a single adverse event from their treatment in the past year is extraordinary. It does, I fear, not demonstrate thaat SCAM id safe but that SCAM practitioners are totally oblivious to the possibility of adverse effects. In other words, they don’t inquire about adverse effects and thus don’t notice any.

Yes, these are data from Australia, and one could argue that elsewhere the situation is different. But different does not necessarily mean better. Until I see convincing evidence, I am not optimistic about the clinical practice of SCAM. Altogether, these findings do not convince me that SCAM practitioners should be let anywhere near a person who needs medical attention.

Many years ago, when I was first invited to give a talk to a gathering of skeptics, I started my lecture by stating: “I am very sceptical – so much so that I am even sceptical about the skeptics.” Now it seems that my words are about to acquire a new meaning.

Since several years, I am a member of the scientific committee of the German sceptic organisation GWUP and I have observed with increasing bewilderment what is happenting to this formerly solid organization.

For me, scepticism is based on at least three elements:

  • free thought,
  • open discourse,
  • pursuit of the truth through criticical assessment.

The leadership of the GWUP, recent developments seem to suggest, have lost sight of these elements. It occurred after the election of the new board of the GWUP in May 2023 (https://skepticalinquirer.org/2023/10/shakeup-among-german-skeptics). Subsequently, the open exchange of ideas made way to an atmosphere where dissent is discouraged or stifled. Examples of this phenomenon, particularly by Hümmler the newly elected chair, are becoming increasingly evident.

The incident involving the German philosopher Andreas Edmüller might serve as an example. His presentation for a GWUP regional group on ‘The WOKE Phenomenon – A frontal assault on the values of the enlightenment?’ (https://www.youtube.com/watch?v=ljm0iqqFoqk) was met with vitriol before he even spoke. One individual even called Edmüller an “asshole” (‘Arschloch’ https://twitter.com/Diaphanoskopie/status/1715441184431067512). Hümmler, rather than apologising to Edmüller for the undue abuse, chose to lecture him on politically correct language and accuse him of spreading ‘alt-right’ talking points (https://twitter.com/hummler/status/1719114920250265733).

Another example is the case of Stefan Kirsch, a long-standing member of GWUP. “He has been dismissed by Hümmler from his role as ‘communication manager’. Why? Because, would you believe it, he shared Edmüller’s presentation on X (formerly Twitter) (https://twitter.com/gwup/status/1715284877375942964).

To make matters worse, Hümmler is also said to have interfered with the organizing committee’s decisions for the upcoming Skepkon conference in May 2024. He apparently insisted on removing presentations from some GWUP members who had been critical of his leadership. In addition, Hümmler repeatedly denied the GWUP’s scientific committtee to share material with the GWUP’s members.

Up to now, I have watched this embarrassing spectacle from the sidelines and deliberately stayed out of any disputes. But I do feel strongly that skeptics, of all people, must not endanger our good causes by behaving like children on an ego-trip. We are in danger of becoming the laughing stock of our opponents!

I for one have grown increasingly sceptical about the GWUP and its future – so much so that I am now seriously considering my association with this organisation. If this embarrassingly counter-productive behavior does not demonstrably change after the annual convention in May this year, I (and probably many other German skeptics) will simply depart from the ruins of this organization.

PS

(added 8/1/2024)

I have been asked to be as transparent as possible and provide evidence for the statements I made above. Let me try:

 

  1. How do I know that Hümmler has interfered with the selection of the conference organising committee? Sorry, but I have been given this information in confidence; that is, I promised to not disclose the source. I tried my best to express this situation by wording my text accordingly: “Hümmler is also said to have interfered with the organizing committee’s decisions for the upcoming Skepkon conference in May 2024. He apparently insisted on removing presentations from some GWUP members who had been critical of his leadership.” Because of the interest in this matter, have now asked some people who may know about this to come forward to confirm my statement (e.g. on social media).

 

  1. As to my assertion that Hümmler “repeatedly denied the GWUP’s scientific committee to share material with the GWUP’s members”, I have first and knowledge of the situation. As a member of the committee, I was copied in to all the relevant exchanges. Moreover, his refusal is also documented in the minutes of the committee.

I hope this addresses the concerns that some readers have voiced.

Since the introduction of their new Education Standards in March 2023, the General Chiropractic Council (GCC) has been working with chiropractic education providers to support them in implementing the changes to their curricula. Recently, the GCC have stated this:

We expect students to be taught evidence-based practice: integrating individual clinical expertise, the best available evidence from current and credible clinical research, and the values and preferences of patients. Chiropractors are important members of a patient’s healthcare team, and interprofessional approaches enable the best outcomes. Programmes that meet these Standards will teach ethical, professional care and produce competent healthcare professionals who can serve the needs of patients.

These are indeed most encouraging words!

Basically, they are saying that chiropractic education will now have to be solidly based on the principles of evidence-based medicine (EBM) as well as sound medical ethics. Let me spell out what this really means. Chiropractic courses must teach that:

  • The current and credible clinical evidence suggesting that spinal manipulations, the hallmark intervention of chiropractors, are effective is weak for back pain and negative or absent for all other conditions.
  • The current and credible clinical evidence suggests that spinal manipulations, the hallmark intervention of chiropractors, can cause harm which in many instances is serious.
  • The current and credible clinical evidence thus suggests that the risk/benefit balance for spinal manipulations, the hallmark intervention of chiropractors, is not positive.
  • Medical ethics require that competent healthcare professionals inform their patients that spinal manipulations, the hallmark intervention of chiropractors, may not generate more good than harm which is the reason why they cannot employ these therapies.

So, the end of chiropractic in the UK is looming!

Unless, of course, the GCC’s words are not really meant to be translated into action. They could be just window dressing and politically correct bullshit. But that’ s really far too far fetched – after all they come from the GENERAL CHIROPRACTIC COUNCIL, known for its excellent track record, e.g.:

On this blog, I have often been highly critical of integrative (or integrated) medicine (IM) – see, for instance:

Recently, I began to realize that my previously critical stance has been largely due to the fact that 1) a plethora of definitions of IM exist causing endless confusion, 2) most, if not all, of the definitions of IM are vague and insufficient. At the same time, IM is making more and more inroads which makes it imprudent to ignore it.

I therefore decided it is time to change my view on IM and think more constructively. The first step on this new journey is to define IM in such a way that all interested parties can come on board. So, please allow me to present to you a definition of IM that is constructive and in the interest of progress:

IM is defined as the form of healthcare that employs the best available research to clinical care integrating evidence on all types of interventions with clinical expertise and patient values. By best available research, I mean clinically relevant (i.e., patient oriented) research that:

  • establishes the efficacy and safety of all types of therapeutic, rehabilitative, or preventive healthcare strategies and
  • seeks to understand the patient experience.

Healthcare practitioners who are dedicated to IM use their clinical skills and prior experience to identify each patient’s unique clinical situation, applying the evidence tailored to the individual’s risks versus benefits of potential interventions. Ultimately, the goal of IM is to support the patient by contextualising the evidence with their preferences, concerns, and expectations. This results in a process of shared decision making, in which the patient’s values, circumstances, and setting dictate the best care.

If applied appropriately, IM has the potential to be a great equaliser – striving for equitable care for patients in disparate parts of the world. Furthermore, IM can play a role in policy making; politicians are increasingly speaking to their use of research evidence to inform their decision making as a declaration of legitimacy. IM reflects the work of countless people who have improved the process of generating clinical evidence over several decades, and that it continues to evolve.

Developing the skills to practise IM requires access to evidence, opportunities to practise, and time. IM proponents strive to find novel ways to integrate evidence into personal holistic health in the best interest of our patients.

_________________________

I feel confident that this could create a basis for a fresh start in the dabate about the merits of IM. I for one am all for it!

In case some of my readers thought that the wording of my definition sounded somewhat familiar, I should perhaps tell you that it is my adaptation of the definition of evidence-based medicine (EBM) as published in ‘BMJ Best Practice‘.

What does that mean?

The points I am trying to make are the ones that I have tried to get across many times before:

  1. IM is a flawed, unethical, superflous and counter-productive concept.
  2. It is flawed because it is aimed at smuggling unproven or disproven treatments into routine care which can only render healthcare less safe and less effective.
  3. It is unethical because it cannot provide the best possible healthcare and thus is not in the best interest of patients.
  4. It is superflous because the aspects of IM that might seem valuable to proponents of so-called alternative medicine (SCAM) are already part of EBM.
  5. It is counter-productive because it distracts from the laudable efforts of EBM.

 

Following on from my recent post about chiropractic denial, I feel like elaborating a little on an argument that is regularly used by those who try to defend the indefensible:

YOU ARE NOT COMPETENT TO CRITICIZE!

The notion is extremely popular not just with chiropractors but with virtually all practitioners of so-called alternative medicine (SCAM).

  • Discuss with a chiropractor the merits of chiropractic, and she will soon ask you for your qualifications in the subject. If you are not a qualified chiropractor, she will say something like: sorry, but you are not qualified to discuss this because chiropractic is a complex subject that requires a lot of study to fully understand.
  • Discuss with a homeopath the merits of homeopathy, and she will soon ask you for your qualifications in the subject. If you are not a qualified homeopath, she will say something like: sorry, but you are not qualified to discuss this because homeopathy is a complex subject that requires a lot of study to fully understand.
  • Discuss with a energy healer the merits of energy healing, and she will soon ask you for your qualifications in the subject. If you are not a qualified energy healer, she will say something like: sorry, but you are not qualified to discuss this because energy healing is a complex subject that requires a lot of study to fully understand.
  • Discuss with a osteopath the merits of osteopathy, and she will soon ask you for your qualifications in the subject. If you are not a qualified osteopath, she will say something like: sorry, but you are not qualified to discuss this because osteopathy is a complex subject that requires a lot of study to fully understand.
  • Discuss with a acupuncturist the merits of acupuncture, and she will soon ask you for your qualifications in the subject. If you are not a qualified acupuncturist, she will say something like: sorry, but you are not qualified to discuss this because acupuncture is a complex subject that requires a lot of study to fully understand.
  • etc. I’m sure you get the drift.

The first question to ask oneself here is this: what are these SCAM qualifications? Once you look into it, you might find – depending on national differences – that they consist of a series of courses that are more akin to brain-washing than to proper study. In other words, the arrogant pretence of SCAM practitioners to have more knowledge than the opponent is nil and void. What they do have is mostly pseudo-knowledge aquired during the brain-wash they assumed to be study.

But this is not what I wanted to explore today. I am more interested in another aspect of the ‘YOU ARE NOT COMPETENT TO CRITICIZE’ argument.

It has the effect that, from the persective of the SCAM practitioner, criticism voiced by people who are not experts in the SCAM in question can be dismissed. These people are simply not competent to criticize!

Consequently, criticism can only be considered, if it originates from someone who is an accepted expert in the SCAM. This means that:

  • Only a well-versed chiropractor can legitimately criticize chiropractic.
  • Only a well-versed homeopath can legitimately criticize homeopathy.
  • Only a well-versed energy healer can legitimately criticize energy healing.
  • Only a well-versed osteopath can legitimately criticize osteopathy.
  • Only a well-versed acupuncturist can legitimately criticize acupuncture.
  • etc. I’m sure you get the drift.

To perfect this culture of avoiding criticism, a final step is essential: a definition of what constitutes a ‘well-versed’ practitioner. A ‘well-versed’ SCAM practitioner is someone who is fully trained and understands and subscribes to the assumptions on which the SCAM in question is based. ‘Fully trained’ means, of course, that he/she went through the process of brain washing where the dogmas of the SCAM in question are internalized.

Should someone disagree with them (i.e. begin to criticize the SCAM) he/she is thus easily identified as being a heritic who is insufficiently ‘well-versed’ and incompetent to criticize. Consequently his/her criticism can be declared as invalid and can be ignored: a heritic would, of course, disagree – what else do you expect? – but that has no relevance because the maveric does not understand the subtleties of the SCAM and is quite simply incompetent.

Bob’s your uncle!

Criticism has been successfully averted.

No legitimate criticism of SCAM has ever been formulated.

SCAM practitioners are thus on the right track and should carry on as always.

 

 

PS

In order to make a clear point, I occasionally exaggerate – but only slightly.

 

As regulars on this blog know, I am very sceptical about the plethora of nonsensical surveys published in the realm of so-called alternative medicine (SCAM) and thus rarely refer to them here. Today, however, I will make an exception. This international online-survey assessed the demographical data, clinical practice, and sources of information used by SCAM practitioners in Austria, Germany, United States of America, Australia, and New Zealand.

In total, 404 respondents completed the survey, of which 254 (62.9%) treated cancer patients. Most practitioners were acupuncturists and herbalists (57.1%), had (16.8 ± 9.9) years of clinical experience and see a median of 2 (1, 4) cancer patients per week. Breast cancer (61.8%) is the most common cancer type seen in SCAM clinics. Adjunctive SCAM treatments are frequently concurrent with the patient’s cancer specific treatment (39.9%), which is also reflected by the main goal of a SCAM treatment to alleviate side effects (52.4%). However, only 28.0% of the respondents are in contact with the treating oncologist. According to the respondents, pain is most effectively treated using acupuncture, while herbal medicine is best for cancer-related fatigue. SCAM practitioners mostly use certified courses (33.1%) or online databases (28.3%) but often believe that experts are more reliable to inform their practice (37.0%) than research publications (32.7%).

The authors concluded that acupuncturists and herbalists commonly treat cancer patients. Most practitioners use SCAM as an adjunct to biomedicine as supportive care and use it largely in accordance with current oncological guidelines.

You would think that the combined expertise of these institutions are capable of producing a decent survey:

  • Palliative Care Unit, Division of Oncology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
  • Northern College of Acupuncture, York YO1 6LJ, United Kingdom
  • School of Health and Society, Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton WV1 1LY, United Kingdom
  • National Institute of Complementary Medicine Health Research Institute, Western Sydney University, Penrith NSW 2751, Australia
  • Translational Health Research Institute, Western Sydney University, Penrith NSW 2751, Australia
  • Medical Research Institute of New Zealand, Wellington 6021, New Zealand
  • Translational Oncology, University Hospital of Augsburg, 86156 Augsburg, Germany

Well, you would have been mistaken! This surely is one of the worst investigations I have seen for a while. Here are just three reasons why:

  • The researchers designed an anonymous self-completion questionnaire collecting data about the participating practitioners’ demographics and clinical practice of integrative oncology. Someone should tell them that one ought to validate questionnairs before using them and that validated questionnairs exist. Unvalidated questionnairs cannot tell us much of value.
  • The researchers  invited SCAM practitioners in Austria, Germany, USA, Australia, and New Zealand to participate in this study. Invitations were distributed through social media and emails between October 2022 and December 2022 by professional organizations. Someone should tell them that research needs to be reproducible and surveys need to cover a representative population – both criteria that are not met here.
  • The survey participants had to hold a valid license to perform acupuncture, herbal medicine, or both. That excludes all other SCAM practitioners.

Despite these serious flaws, the survey shows two findings that might be worth mentioning:

  • only 28.0% of the SCAM practitioners were in contact with the treating oncologist;
  • SCAM practitioners believe that “experts” are more reliable to inform their practice than research publications.

For me, these two points alone would be sufficient reason to run a mile!

The risks of chiropractic spinal manipulations (CSMs) feature regularly on my blog, not least because most chiropractors are in denial of this important issue and insist that chiropractic spinal manipulations are safe!!!. I therefore thought it might be a good idea to try and summarize the arguments they often put forward in promoting their dangerously fallacious and quasi-religious belief that CSMs are safe:

  1. There is not evidence to suggest that CSMs do harm. Such a statement is based on wishful thinking and ignorance motivated by the need of making a living. The evidence shows a different picture.
  2. There are hundreds of clinical trials that demonstrate the safety of CSMs. This argument is utterly unconvincing for at least two reasons: firstly clinical trials are far too small for identifying rare (but serious) complications; secondly, we know that clinical trials of CSM very often fail to report adverse events.
  3. Case reports of adverse effects are mere anecdotes and thus not reliable evidence. As there is no post-marketing surveillance system of adverse events after CSMs, case reports are, in fact, the most important and informative source of information we currently have on this subject.
  4. Case reports of harm by CSMs are invariably incomplete and of poor quality. Case reports are usually published by doctors who often have to rely on incomplete information. It would be up to chiropractors to publish case reports with the full details; yet chiropractors hardly ever do this.
  5. Case reports cannot establish cause and effect. True, but they do provide important signals which then should be investigated further. It would be up to chiropractors to do this; sadly, this is not what is happening.
  6. Adverse effects such as arterial dissections or strokes occur spontaneaously. True, but many have an identifiable cause, and it is our duty to find it.
  7. The forces applied during CSM are small and cannot cause an injury. This might be true under ideal conditions, but in clinical practice the conditions are often not ideal.
  8. If an arterial dissection occurs nevertheless, it is because there was a pre-existing injury. This argument is largely based on wishful thinking. Even if it were true, it would be foolish to aggravate a pre-existing injury by CSMs.
  9. Injuries happen only if the contra-indications of CSMs are ignored. This obviously begs the question: what are the contra-indications and how well established are they? The answer is that they are largely based on guess-work and not on systematic research. Thus chiropractors are able to claim that, once an adverse effects has occurred, the incident was due to a disregard of contra-indication and not due to the inherent risks of CSM.
  10. Only poorly trained chiropractors cause harm. This is evidently untrue, yet the argument provides yet another welcome escape route for those defending CSMs: if something went wrong, it must have been due to the practitioner and not the intervention!
  11. Chiropractors are an easy target. In my fairly extensive experience in this field, the opposite is true. Chiropractors tend to have multiple excuses and escape routes. As a consequence, they are difficult to pin down.
  12. Other causes, e.g. car accidents, are much more common causes of vascular injuries. Even if this were true, it does certainly not mean that CSM can be ruled out as the cause of serious harm.
  13. Patients who experience harm had pre-existing issues. Again, this notion is mostly based on wishful thinking and not based on sound evidence. Yet, it clearly is another popular escape route for chiropractors. And again, it is irresponsible to administer CSM if there is the possibility that pre-existing issues are present.
  14. The alleged harms of CSMs are merely an obsession for people who don’t really understand chiropractic. That is an old trick of someone trying to defend the indefensible. Chiropractors like to pompously claim that opponents are ignorant and only chiropractors understand the subject area. They use arrogance in an attempt to intimidate or scilence experts who disagree with them.
  15. Chiropractors do so much more than just CSN. True. They have ‘borrowed’ many modalities from physiotherapy and, by pointing that out, they aim at distracting from the dangers of CSMs. Yet, it is also true that practically every patient who consults a chiropractor will receive a CSM.
  16. Doctors are just jealous of the success of chiropractors. This fallacy is used when chiropractors run out of proper arguments. Rather than addressing the problem, they try to distract from it by claiming the opponent has ulterior motives.
  17. Medical treatments cause much more harm than CSM. Chiropractors are keen to mislead us into believing that NSAIDs, for instance, are much more dangerous than CSMs. The notion is largely based on one lousy article and thus not convincing. Even if it were true, it would obviously be no reason to ignore the risks of CSNs.

I am sure my list is far from complete. If you can think of further (pseudo-) arguments, please use the comments section below to let us know.

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