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

alternative therapist

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

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

David Peters (osteopathy, homeopathy, UK)

Nicola Robinson (TCM, UK)

Peter Fisher (homeopathy, UK)

Simon Mills (herbal medicine, UK)

Gustav Dobos (various, Germany)

Claudia Witt (homeopathy, Germany and Switzerland)

George Lewith (acupuncture, UK)

John Licciardone (osteopathy, US)

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

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

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

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

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

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

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

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

Clinical Practice Guideline: Chiropractic Care for Low Back Pain.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hawk C, Kaeser MA, Beavers DV.

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

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

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

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

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

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

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

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

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

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

The role of chiropractic care in older adults.

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

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

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

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

Very well done indeed!

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

 

Britt Marie Hermes is a most remarkable woman. She is an ex-naturopath who has the courage to speak out against all that is wrong with naturopathy. On her website she writes:

I used to be a naturopathic doctor. For 3 years, I practiced naturopathic medicine, licensed in Washington and Arizona. I earned my degree at Bastyr University and then completed a one-year naturopathic residency in a private clinic. I stayed at this clinic until I moved to Tucson.

Naturopathic medicine is not what I was led to believe. I discovered that the profession functions as a system of indoctrination based on discredited ideas about health and medicine, full of anti-science rhetoric with many ineffective and dangerous practices.

I left the profession of naturopathic medicine to pursue an education in biomedical research. Since my departure, I have been working to understand my former biases within naturopathic medicine. I am now exploring the ethics and evidence, or lack thereof, of naturopathic education and practice. I hope I can convey the message that naturopathy must be highly scrutinized, as its proponents have a seemingly on-going history of deceit, exploitation, and medical fraud.

Her articles are a rich source of fascinating material about naturopathy, and I warmly recommend you read her criticisms; you will not find better-informed comments easily. Recently, she went one step further and started a petition against US naturopaths’ plight to call themselves ‘doctors’. It seems that this was one step too far for the mighty ‘BIG NATUROPATHY’.

Forbes Magazine reported that, on May 26th, 5 days after Hermes launched her petition, the AANP retaliated [the AANP is the leading naturopaths’ organization in the U.S., the American Association of Naturopathic Physicians]. The subject line of an email sent to all AANP membership:  “AANP Needs Your Help – Stop Britt’s Change.org Petition.”

“We need your help to stop this petition… This petition violates these [Change.org] policies:

  • Breaks the law – this is defamatory and libelous content
  • Impersonates others;  Britt Marie Hermes is not from the United States
  • Terms of service – does not abide by the law or respect the rights of others

Naturopaths found Britt Marie so threatening that they started a website entitled ‘BRITT MARIE HERMES FACT CHECK. Here they indulge in blatant character assassination:

Britt Marie Hermes Fact Check was established to provide an unbiased analysis of the claims that Britt Marie Hermes (Britt Marie Deegan) has made, and is making, about Naturopathic Medicine, its educational system, and its practitioners. For the past year she promoted herself as an expert on Naturopathic Medicine, having left the profession because of her unsuccessful time as a practitioner. It’s clear that she has an agenda against the profession while claiming to be an expert. She has consistently lied, and left out important facts when discussing aspects of the Naturopathic Medicine, its educational system and its practitioners. Accusations have been made that she is being paid by the pharmaceutical industry, although they haven’t been substantiated. What is clear, is that she was unsuccessful during her short time as a practitioner and now has an agenda against the profession.

This looks suspiciously like the dirt some alternative medicine fans have been throwing at me, I thought, and I asked Britt Marie (who I once had the pleasure of meeting in person) to comment – and she very kindly did:

I find it amusing to be accused of being an unsuccessful practitioner of naturopathic medicine. I graduated with high grades from Bastyr. I landed a highly competitive naturopathic residency. Had I remained in practice, I would currently be eligible to take the naturopathic pediatrics “board-certification” exam offered by the American Association of Naturopathic Pediatrics.

I was making decent money at my practices in Seattle and Tucson. By all accounts, I was a successful naturopathic doctor. My bosses at the Tucson clinic had even asked me if I were interested in becoming their business partner!

I walked away from my practice because my boss was committing a federal crime by importing and administering a non-FDA approved medication to his cancer patients. I decided to leave naturopathic medicine for good after a former president of the American Association of Naturopathic Physicians urged me not to report my boss’s criminal activity to the authorities.

These wounds still hurt. I lost dozens of friends. I lost eight years of my life. I lost my livelihood. The ND degree does not have any value in the academic community. It is a tarnish on my permanent record. It would have been in my financial interest to move to another practice and continue being a “successful” naturopath.

The problem with naturopaths is that they measure success by how much money one collects from patients, yet they fail to understand that naturopathic services are quackery. So by their logic, being a successful naturopath is dependent upon profiting by fooling patients and fooling oneself. If others want to describe me as an unsuccessful naturopath, then the term “success” has no useful meaning.

I am not employed to write about anything in particular about naturopathic medicine or with any particular tone. I am an independent blogger who wants to share my insights. I created my own opinions on naturopathic medicine by looking at the profession critically. This kind of task is fundamental to the scientific process that I only learned after leaving naturopathy and engaging with the academic community.

Naturopaths want to be recognized as primary care physicians in the U.S. and Canada. This is a big deal, and we all should be skeptical. This profession is claiming to have established a comprehensive medical education that trains competent medical practitioners, who somehow predominately rely upon unproven methods at best and debunked ones at worst.

Naturopaths essentially want to be allowed to take shortcuts in medical training. Instead of attending medical school, naturopaths attend naturopathic programs with low acceptance standards and faculty who are not qualified to teach medical topics. Instead of passing a standardized and peer-reviewed medical licensing exam, naturopaths have created their own secretive licensing exam that tests on homeopathy and other dubious treatments. What little real medical standards that seem to be tested on the exam have been botched, like the one question in which a child is gasping for air and the correct answer on how to treat is to give a homeopathic remedy.

Naturopaths have called me a liar, but have been unable to identify any specific fabrications. They say I am omitting facts and evidence, but they cannot show what information I allegedly missed. It seems that for naturopaths the only way to deal with legitimate criticism, is to undermine my integrity.

My blog harbors no hidden agenda. I write to prevent students from being duped into thinking they are being adequately trained as a primary care physicians in naturopathic programs. I write to protect patients from the poorly trained practitioners that these programs produce. I write because I have seen both worlds, and the naturopathic one is terrifying.

To this, I have nothing to add – except a big THANK YOU to Britt Marie for her courage, honesty and tenacity.

The queue outside my ‘ALT MED HALL OF FAME’ was getting restless because I did not admit any new members for some time. So, I better get cracking!

You remember, of course, who has been honoured so far; the list of members (main research interest, country) is as follows:

Nicola Robinson (TCM, UK)

Peter Fisher (homeopathy, UK)

Simon Mills (herbal medicine, UK)

Gustav Dobos (various, Germany)

Claudia Witt (homeopathy, Germany and Switzerland)

George Lewith (acupuncture, UK)

John Licciardone (osteopathy, US)

Today, we are going to have a look at Prof David Peters. This is what our friends from the ‘COLLEGE OF MEDICINE’ say about him:

“David Peters MB, ChB, DRCOG, DMSMed MFHom FLCOM trained as a GP, a musculoskeletal physician and also as a homeopathic and osteopathic practitioner. For fifteen years he directed the complementary therapies development programme at Marylebone Health Centre. Professor Peters is one of the founding faculty of the University of Westminster’s School of Life Sciences, where he is Clinical Director. Professor Peters is a member of the Council and former chair of the British Holistic Medical Association and Editor of its Journal of Holistic Healthcare. He has co-authored or edited six books about integrated healthcare. His research interests include the role of non-pharmaceutical treatments in mainstream medicine, wellbeing in long-term conditions and the development of integrated practitioners.”

I did my usual Medline search but found only 16 Medline-listed articles authored by David Peters. This is amazing because he has been involved in UK alt med much longer than I have. Even more amazing is that none of these papers seem to refer to clinical trials. Perhaps he is not convinced of this type of research?

In order to evaluate his output, I took the sentence that came nearest to a conclusion from the most recent 10 articles. Below you find first the titles of each paper (with the link to it), second the list of its authors and third the sentence that formulated a conclusion (in bold).

Patient outcomes and experiences of an acupuncture and self-care service for persistent low back pain in the NHS: a mixed methods approach.

Cheshire A, Polley M, Peters D, Ridge D.

BMC Complement Altern Med. 2013 Nov 1;13:300. doi: 10.1186/1472-6882-13-300.

The BBPS provided a MSK pain management service that many patients found effective and valuable. Combining self-management with acupuncture was found to be particularly effective, although further consideration is required regarding how best to engage patients in self-management.

Is it feasible and effective to provide osteopathy and acupuncture for patients with musculoskeletal problems in a GP setting? A service evaluation.

Cheshire A, Polley M, Peters D, Ridge D.

BMC Fam Pract. 2011 Jun 13;12:49. doi: 10.1186/1471-2296-12-49.

Provision of acupuncture and osteopathy for MSK pain is achievable in General Practice. A GP surgery can quickly adapt to incorporate complementary therapy provided key principles are followed.

Gatekeepers and the Gateway–a mixed-methods inquiry into practitioners’ referral behaviour to the Gateway Clinic.

Unwin J, Peters D.

Acupunct Med. 2009 Mar;27(1):21-5. doi: 10.1136/aim.2008.000083.

The Gateway Clinic has become an increasingly popular referral resource. The influences that drive referral to the clinic are multiple and follow “tacit guidelines”. GPs select patients on the basis of their individual clinical experience, informed by positive patient feedback and often only after more conventional medical treatment options have been exhausted.

Complementary medicine: evidence base, competence to practice and regulation.

Lewith GT, Breen A, Filshie J, Fisher P, McIntyre M, Mathie RT, Peters D.

Clin Med (Lond). 2003 May-Jun;3(3):235-40. Review.

This paper describes the current status and evidence base for acupuncture, homeopathy, herbal and manipulative medicine, as well as the regulatory framework within which these therapies are provided. It also explores the present role of the Royal College of Physicians’ Subcommittee on Complementary and Alternative Medicine (CAM) in relation to these developments. A number of CAM professions have encouraged the Royal College of Physicians Subcommittee to act as a reference point for their discussions with the conventional medical profession and the subcomittee believes that they are able to fulfil this function.

Using a computer-based clinical management system to improve effectiveness of a homeopathic service in a fundholding general practice.

Peters D, Pinto GJ, Harris G.

Br Homeopath J. 2000 Jul;89 Suppl 1:S14-9

It is possible to introduce rigour and reflectiveness when providing a homeopathic service in general practice by assessing the needs of patient and practitioners, agreeing intake guidelines, developing referral processes, implementing audit cycles. Clear lines of communication can be established and a patient-centred outcome measure can be introduced into the treatment cycle.

I could not find any further articles that I could classify as providing data; so I stopped well short of the envisaged 10 papers. I have to admit, I was hesitant: does David deserve to be in the ALT MED HALL OF FAME? In the end, I gave him the benefit of the doubt. Why? Mainly because I am impressed with his scope of practice. Here is what he himself wrote about this aspect:

“I use a range of approaches: osteopathy and medical acupuncture, as well as nutrition and mind-body medicine – meditation, relaxation techniques, breath-work, self-hypnosis, biofeedback, and simple yoga-based exercises.  Sometimes herbal medicines, complex homeopathy, nutritional supplements, trigger-point or joint injections can be a valuable too. Somatic Experiencing is a gentle form of body-centred psychotherapy for problems that have come on after traumatic incidents. When I want to assess the impact of stress on the body I use a painless approach involving computer-based heart rate variability testing and breath analysis; sometimes salivary cortisol profiling too. Where required I can prescribe conventional medicine and  were they are needed I might suggest scans, X-rays or blood tests.”

Peter is perhaps not the most industrious researcher when it comes to publishing papers, but he fulfils the criterion of not ever publishing anything negative that might rock the boat or distract from the true value of alternative medicine.

LONG LIVE THE POSITIVE RESULT!

 

I am editor in chief of a journal called FACT. It has a large editorial board, and I am always on the look-out for people who might be a good, productive and colourful addition to it. On 3 June, I sent an invitation to Mel Koppelman, who is by now well known to regular readers of this blog. Here is a copy:

Hi Mel,

can I ask you a question?

would you consider joining the ed-board of FACT [as you mentioned it in one of your comments, I assume you know this journal – but you are wrong in implying that it has anything to do with the pharmaceutical or any other industry]? if you agree, we would expect you to write 2-3 ‘summaries/commentaries’ per year. in return you get a free subscription and, of course, can submit other articles.

no, this is not a joke or a set-up. I like to have the full spectrum of opinion/expertise on my ed-board, and I do think you understand science quite well. our opinions differ but that’s what I think is good for the journal.

think about it – please.

cheers

edzard

On 6 June, she replied as follows:

Hi Edzard,

Great to hear from you, I hope you enjoyed your weekend.

Thank you very much for the kind offer, it’s something I would consider. I certainly have no problem with, and in fact embrace, people who have different opinions and views from my own, so long as I feel that they have integrity in their approach.

Just a few questions / comments:

1) Regarding FACT’s affiliations, what I said in my comment was that it was a publication of the Royal Pharmaceutical Society. According to Wiley’s website, Focus on Alternative and Complementary Medicine is copyright by Royal Pharmaceutical Society. It’s also listed on the Pharmaceutical Press website.

Are you telling me that’s incorrect? That I’m “wrong” in saying there’s a relationship? I obviously need to understand the nature of the publication whose editorial board I’m considering joining. Very confusing that you as editor say there’s no relationship to the RPS and yet they claim copyright over your publication. Incidentally, is FACT self-sufficient, earning all of its income from subscriptions? Or does any financial support come from the publishers?

2) As enticing as a free subscription to FACT is, I have access to more high quality peer-reviewed reading material than I could enjoy in many lifetimes. Because my skills seem to be in high demand and because I already spend 10-20 hours per week doing unpaid volunteer work, any additional projects that I take on at this time would need to be financially compensated. I understand that this may be a deal-breaker.   

3) While I have no issue with you having different views when it comes to medical research, in order to choose to work with your publication, it’s important to me that it’s run by people with a high level of academic integrity and put patient welfare at the forefront of it’s agenda.

In March, you came out in public support of the NICE draft guidelines. You were quoted in the Guardian as saying: “It is good to see that Nice have now caught up with the evidence. Neither spinal manipulation nor acupuncture are supported by good science when it comes to treating low back pain.”

Following this, it was brought to your attention that the recommendations were contrary to best evidence and that the conclusions were unsupportable. While you have the option of following this up to make sure that the record reflects best evidence, you have indicated that you have no interest in evaluating the situation and possibly admitting an error. This behaviour is concerning from the perspective of academic integrity, particularly when it directly leads to increased human suffering (policy in several countries has already been changed based on the draft), and I would be worried that by joining your board I could be associated with such unethical behaviour. 

Perhaps if I understood better your position, which seems to be to ignore the situation, not follow up on the concerns raised, and leave your comments uncorrected even though they may be inaccurate and backing guidelines that cause harm to patients, that might allay certain reservations.

Anyways, these are my initial thoughts. I hope you have an opportunity to enjoy the beautiful weather, and I look forward to hearing from you.

Best wishes,

Mel

At that stage, I began to fear that I had made a mistake. But, giving her the benefit of the doubt, I swallowed my pride and replied as politely as I could to her concerns which, in my view, were odd, to say the least. This is what I wrote on 7 June:

Hi Mel,

Thank you for your reply to my invitation. Let me address your points in turn:

  1. I said that FACT has nothing to do with the pharma industry which is true [when you state that “you as editor say there’s no relationship to the RPS” – it suggests to me that you did not read my email properly]. In their own words, the RPS is the professional membership body for pharmacists and pharmacy in Great Britain and an internationally renowned publisher of medicines information.” [http://www.rpharms.com/home/about-us.asp] They have a similar status as the Royal Colleges. In the 2 decades that I am running the journal, there has been not a single instance of interference of any kind. We use them simply as an excellent publishing house. And yes, FACT is to the best of my knowledge self-sufficient and survives without funds from 3rd parties.
  2. I am delighted to hear that your skills are in demand.
  3. I have stated my position regarding the draft NICE guideline ad nauseam: I prefer to wait until I see their next version of the draft before I make further comments on it. In my view, this is both reasonable and honourable. If you disagree, I can do little about it other than expressing my sincere regrets.

I hope these brief clarifications are helpful for you to arrive at a decision.

Regards

Edzard

On 8 June, I received Mel’s reply:

Hi Edzard,
 
Thanks for your reply.
 
After thinking about it, I’ve decided to pass on your offer for the time being. This is mainly because I’m moving house towards the end of the summer and I’m in the process of simplifying and reducing my responsibilities so I can focus on that and getting settled in. After the move, I plan to reassess what I’d like to be involved with and how I’d like to spend my time.
 
I’d be happy to write the odd article for FACT as and when, if something comes up that you think I can make a helpful contribution to. 
 
Thanks for thinking of me, I appreciate the opportunity.
 
Best wishes,
Mel
I have to admit, I was very relieved, mainly because meanwhile someone had alerted me to the fact that Mel had posted all the correspondence on facebook (I would otherwise not have re-published it here because I usually don’t consider this sort of thing to be very elegant) where her friends were making ample comments. Here are a few (I have omitted the most infantile ones):

How interesting! Is he trying to ‘keep his enemies closer’ or am I being too skeptical? He has recognised your talents and dedication and intellect so he is not altogether stupid after all! I eagerly await his response to your reply.

Those who have studied with Ernst say that he’s a genuine chap and misunderstood – which I know is almost unimaginable given his behaviour – but we always have to allow for the possibility that we have misjudged people however remote! Also, people can turn – especially when they get older and near retirement. Alternatively he may just fancy you!… 

I think it’s an impressive offer. If only we were so lucky to be asked!  
 
“…You understand science quite well”  What a backhanded compliment! Your response is so articulate and balanced. 
 
That’s a compliment. I quite like Edzard. If you go for it hope all goes well. It raises the voice of the profession just in a different way. Best wishes. 
 
“Keep your friends close and your enemies closer” – Michael Corleone.
 
Terrific response Mel!! We’re all proud of you!! 
 
This does bring a chortle. Well done Mel. He’ll be rolling over for you to tickle his tummy before you know it 
 
Wow, quite surprising! If you can, it might be a good idea? To see how the other half lives…? 
 
Wow, this guy is a piece of work!
 
Excellent response Mel.
 
wow the white flag. Maybe thats his way of trying to save face
 
Excellent reply Mel .. indeed a perfect reply. I’m glad to hear that Charlie things Ernst is a genuine guy but having read his blogs and communicated with him quite a bit I would say he’s on the margins of some kind of personality disorder. I would be very cautious of getting into bed with him (as it were)
 
Go For It. A chance to debate is a chance to influence. If you have this opportunity to engage in an INVITED platform this is goldust. 
 
You very much understand science and of course more than ‘quite well’! I would imagine it is a difficult decision to make: both Peter Jonathan and Jani White have made good comments and as long as you are allowed to maintain your integrity within the position (and you can also get out if you want to), it might be a great opportunity to make real changes from within and open up all sorts of possibilitie and closed minds.
 
Well done. Your mind is as sharp as a needle can be.
 
I’ve come to this saga quite late yet regardless of my lack of knowledge..I LOVE paragraph 2…the first sentence especially. Freakin’ brilliant and hilarious!!! 
 
If you can’t beat them, join them. And then beat them! 
 
Curiouser and curiouser and I’m with Sandro but on the other hand I think you can beat them. 

Mel Koppelman Really enjoying hearing y’all’s thoughts on this. I just want to say that If I had thought that the chances of me being able to create positive change by joining FACT were high, I would have tempered the tone of my reply. But the simple fact that EE can’t even be factual or forthright about whose journal it is suggests an irreparable break with reality. And surely there’s an issue (academic? ethical? legal?) with recruiting someone to your board and denying an industry tie when there is one? Not to mention that if the RSP does fund his journal, he’s been lying about his conflicts of interest. Is that someone I want to spend time adding value to that could be spent with family, patients, time in nature or really making positive change by supporting the ANF? I’ll be interested to read his reply if there is one and especially how he responds regarding the relationship between FACT and RSP. Will keep y’all posted. 

Mel, you are amazing! Can’t wait to read how this plays out. Understand your concerns and think the way you have dealt with him is very professional. Go Mel!!
 
Great reply Mel. I would very much share your concerns about getting into bed with EE, so to speak (sorry for that image!). One day Hollywood will make a movie about this…
END OF FIRST SET OF COMMENTS; THE FOLLOWING COMMENTS WERE POSTED AFTER MEL PUBLISHED MY REPLY

Max Forrester keep your friends close; keep your enemies closer…

Ooh. ..he’s not a happy bunny
Such a soap opera…
 
I’m loving all these updates, who needs a telly lol. Jokes aside, thank you Mel for fighting our battles so eloquently. I would definitely buy the book if you decided to write one
 
OK this is interesting. The two American editors of FACT are William M. London who “currently writes and teaches about scientifically implausible and fraudulent health care practices”, and Stephen Barrett of Quackwatch (see a devastating critique of him here: http://www.quackpotwatch.org/quackpots/quackpots/barrett.htm). 
 
De-licensed MD Stephen Barrett. What kind of man would drop out of the medical profession and dedicate his life to STOPPING advancement in the health sciences?> <title>De</title> <base target=
quackpotwatch.org

John McDonald Healthy skepticism! Healthy journal! And it’s 99% fact-free! 

I think your talents are better used elsewhere than being co-opted to the Ernst prejudice-engine, Mel!
END OF COMMENTS

I hope that you find these exchanges as amusing as I did – but are they important? Perhaps not exactly, but revealing certainly. They shed some light on the mind-set of acupuncturists and perhaps other alternative practitioners as well. Let me try to explain.

What struck me first was the degree of suspicion, even outright hostility from the acupuncturists. I had made it quite clear that I was asking Mel to join my Editorial-Board because of her views which vastly differ from mine. In science, differences of opinions and backgrounds can be stimulating and often generate progress. That is not something that seems to be wanted by alternative practitioners; they do not seem to tolerate criticism, different perspectives or views. One cannot help asking to what degree this attitude is immature or even dogmatic.

The next thing that baffled me was the speed with which conclusions are jumped upon. Everyone seemed to be instantly convinced that I was via my journal FACT in the pocket of the pharmaceutical industry. Nobody even bothered to look up what the Royal Pharmaceutical Society truly stand for and to verify that they do NOT represent ‘BIG PHARMA’. This blindness to the possibility of being wrong confirms my fear that alternative therapists are guided by strong beliefs which must not be questioned and are hard to influence, even with facts that take less than a minute to research.

And then there are, of course, the personal attacks which came quick, thick and fast. Its authors might think that such attacks get under my skin. If so, they are mistaken: if anything, they amuse me! I have long been of the opinion that they are important victories of reason. When an acupuncturist went as far as diagnosing me as being borderline psychopathic, I almost fell off my chair laughing! To me, this remark (which has emerged several times before) is emblematic, as it suggests several things at once:

  • The author is obviously rude
  • He/she is incompetent, even stupid
  • He/she lacks empathy – after all, one would expect from a healthcare professional to show some understanding, if I were truly ill! And if not, one would expect more respect towards mentally ill patients.
  • But, of course, he/she did not mean it like that; he/she merely meant to insult me. And employing mental health issues for this purpose shows a remarkable lack of professionalism, in my view.
[Whenever I or someone in a similar position point out such things, the ‘other side’ starts shouting “AD HOMINEM!” Do they not see that my analysis of their attempted insult is merely a reaction to their ad hominem?]

Am I making too much of all this? Perhaps – sorry, I am almost done.

But first I need to briefly address Mel’s doubts about my integrity. She can, of course, question what she likes as often as she wants. My point is that repeating nonsensical arguments ad nauseam does not render then sensical.

Finally, there is Mel’s public claim that I have been lying about my conflict of interests. To me, it suggests a degree of desperation, perhaps even fanaticism, that is only surpassed by her inability to apologize after the truth had become undeniable even to her.

I know that there are some people who would have sued for libel.

Not I!

For that I find all this far too hilarious.

The subject of placebo is a complex but fascinating one, particularly for those interested in alternative medicine. Most sceptics believe that alternative therapies rely heavily, if not entirely, on the placebo effect. Some alternative practitioners, when unable to produce convincing evidence that their treatment is effective, seem to have now settled to admitting that their therapy works (mostly or entirely) via a placebo effect. They the hasten to add that this is perfectly fine, because it is just an explanation as to how it works – a mechanism of action, in other words. Causing benefit via a placebo effect still means, they insist, that their therapy is effective.

In a previous post, I have tried to demonstrate that this belief is erroneous and where the notion comes from. It originates, I believe, from a mistaken definition of ‘effectiveness’: for many alternative practitioners ‘effectiveness’ encompasses the specific plus the non-specific (e. g. placebo) effects of their therapy. In real medicine, ‘effectiveness’ is the degree to which a treatment works under real life conditions.

The ‘alternative’ definition is, of course, incorrect but alternative practitioners stubbornly refuse to acknowledge this fact. Here are just two reasons why it cannot be right:

  • If it were correct, it would be hardly conceivable to think of a treatment that is NOT effective. Applied with empathy and compassion, virtually all treatments – however devoid of specific effects – will produce a placebo effect. Thus they will all be effective, and the term would be superfluous because ‘treatment’ would automatically mean ‘effective’. An ineffective treatment would, in other words, be a contradiction in terms.
  • If it were correct, any pharmaceutical or devices company could legally market ineffective drugs or gadgets and rightly claim (or even prove) that they are effective. Any such therapy could very easily be shown to generate a placebo-effect under the right circumstances; and as long as this is the case, it would be certifiably effective.

I do sympathise with alt med enthusiasts who find this hard or even impossible to accept. They see almost every day how their placebo-therapy benefits their patients. (It seems worth remembering that not just the placebo phenomenon but several other factors are involved in such outcomes – take, for instance, the natural history of the disease and the regression towards the mean.) And they might think that my arguments are nothing but a devious attempt do away with the beneficial power of the placebo.

The truth, however, is that nobody wants to do anything of the sort; we all want to help patients as much as possible, and that does, of course, include the use of the placebo effect. In clinical practice, we usually want to maximise the placebo effect where possible. But for this goal, we do not require placebo therapies. If we administer a specifically effective therapy with compassion, we undoubtedly also generate a placebo response. In addition, our patients would benefit from the specific effects of the prescribed therapy. Both elements are essential for an optimal therapeutic response, and I don’t know any conventional healthcare professionals who do not aim at this optimal outcome.

Giving just placebos will not normally generate an optimal outcome, and therefore it cannot truly be in the interest of the patient. It is also ethically problematic because it usually entails a degree of deception of the patient. Moreover, placebo effects are unreliable and usually of short duration. Foremost, they do not normally cure a disease; they may alleviate symptoms but they almost never tackle their causes. These characteristics hardly make placebos an acceptable choice for routine clinical practice.

The bottom line is clear and simple: a drug that is not better than placebo can only be classified as being ineffective. The same applies to all non-drug therapies. Double standards are not acceptable in healthcare. And the demonstration of a placebo effect does not turn an ineffective therapy into an effective one.

I know that many alternative practitioners do not agree with this line of thought – so, let’s hear their counter-arguments.

This post is dedicated to Mel Koppelman.

Those who followed the recent discussions about acupuncture on this blog will probably know her; she is an acupuncturist who (thinks she) knows a lot about research because she has several higher qualifications (but was unable to show us any research published by herself). Mel seems very quick in lecturing others about research methodology. Yesterday, she posted this comment in relation to my previous post on a study of aromatherapy and reflexology:

Professor Ernst, This post affirms yet again a rather poor understanding of clinical trial methodology. A pragmatic trial such as this one with a wait-list control makes no attempt to look for specific effects. You say “it is quite simply wrong to assume that this outcome is specifically related to the two treatments.” Where have specific effects been tested or assumed in this study? Your statement in no way, shape or form negates the author’s conclusions that “aromatherapy massage and reflexology are simple and effective non-pharmacologic nursing interventions.” Effectiveness is not a measure of specific effects.

I am most grateful for this comment because it highlights an issue that I had wanted to address for some time: The meanings of the two terms ‘efficacy and effectiveness’ and their differences as seen by scientists and by alternative practitioners/researchers.

Let’s start with the definitions.

I often use the excellent book of Alan Earl-Slater entitled THE HANDBOOK OF CLINICAL TRIALS AND OTHER RESEARCH. In it, EFFICACY is defined as ‘the degree to which an intervention does what it is intended to do under ideal conditions. EFFECTIVENESS is the degree to which a treatment works under real life conditions. An EFFECTIVENESS TRIAL is a trial that ‘is said to approximate reality (i. e. clinical practice). It is sometimes called a pragmatic trial’. An EFFICACY TRIAL ‘is a clinical trial that is said to take place under ideal conditions.’

In other words, an efficacy trial investigates the question, ‘can the therapy work?’, and an effectiveness trial asks, ‘does this therapy work?’ In both cases, the question relate to the therapy per se and not to the plethora of phenomena which are not directly related to it. It seems logical that, where possible, the first question would need to be addressed before the second – it does make little sense to test for effectiveness, if efficacy has not been ascertained, and effectiveness without efficacy does not seem to be possible.

In my 2007 book entitled UNDERSTANDING RESEARCH IN COMPLEMENTARY AND ALTERNATIVE MEDICINE (written especially for alternative therapists like Mel), I adopted these definitions and added: “It is conceivable that a given therapy works only under optimal conditions but not in everyday practice. For instance, in clinical practice patients may not comply with a therapy because it causes adverse effects.” I should have added perhaps that adverse effects are by no means the only reason for non-compliance, and that non-compliance is not the only reason why an efficacious treatment might not be effective.

Most scientists would agree with the above definitions. In fact, I am not aware of a debate about them in scientific circles. But they are not something alternative practitioners tend to like. Why? Because, using these strict definitions, many alternative therapies are neither of proven efficacy nor effectiveness.

What can be done about this unfortunate situation?

Simple! Let’s re-formulate the definitions of efficacy and effectiveness!

Efficacy, according to some alternative medicine proponents, refers to the therapeutic effects of the therapy per se, in other words, its specific effects. (That coincides almost with the scientific definition of this term – except, of course, it fails to tell us anything about the boundary conditions [optimal or real-life conditions].)

Effectiveness, according to the advocates of alternative therapies, refers to its specific effects plus its non-specific effects. Some researchers have even introduced the term ‘real-life effectiveness’ for this.

This is why, the authors of the study discussed in my previous post, could conclude that “aromatherapy massage and reflexology are simple… effective… interventions… to help manage pain and fatigue in patients with rheumatoid arthritis.” Based on their data, neither aromatherapy nor reflexology has been shown to be effective. They might appear to be effective because patients expected to get better, or patients in the no-treatment control group felt worse for not getting the extra care. Based on studies of this nature, giving patients £10 or a box of chocolate might also turn out to be “simple… effective… interventions… to help manage pain and fatigue in patients with rheumatoid arthritis.” Based on these definitions of efficacy and effectiveness, there are hardly any limits to bogus claims for any old quackery.

Such obfuscation suits proponents of alternative therapies fine because, using such definitions, virtually every treatment anyone might ever think of can be shown to be effective! Wishful thinking, it seems, can fulfil almost any dream, it can even turn the truth upside down.

Or can anyone name an alternative treatment that cannot even generate a placebo response when administered with empathy, sympathy and care? Compared to doing nothing, virtually every ineffective therapy might generate outcomes that make the treatment look effective. Even the anticipation of an effect alone might do the trick. How often have you had a tooth-ache, went to the dentist, and discovered sitting in the waiting room that the pain had gone? Does that mean that sitting in a waiting room is an effective treatment for dental pain?

In fact, some enthusiasts of alternative medicine could soon begin to argue that, with their new definition of ‘effectiveness’, we no longer need controlled clinical trials at all, if we want to demonstrate how effective alternative therapies truly are. We can just do observational studies without a control group, note that lots of patients get better, and ‘Bob is your uncle’!!! This is much faster, saves money, time and effort, and has the undeniable advantage of never generating a negative result.

To most outsiders, all this might seem a bit like splitting hair. However, I fear that it is far from that. In fact, it turns out to be a fairly fundamental issue in almost any discussion about the value or otherwise of alternative medicine. And, I think, it is also a matter of principle that reaches far beyond alternative medicine: if we allow various interest groups, lobbyists, sects, cults etc. to use their own definitions of fundamentally important terms, any dialogue, understanding or progress becomes almost impossible.

WHAT IS THE WORST THAT COULD HAPPEN TO HOMEOPATHS?

This might seem like a strange question, but I think it is quite interesting… bear with me.

The worse, you might think, is that the we all agree that highly diluted homeopathic remedies are pure placebos. Apart from the fact that this already is a broad consensus shared by virtually everyone in healthcare (except the homeopaths, of course), I think this is not the worst that could happen to homeopaths. They simply ignore the consensus, continue much as before and carry on earning a living by fooling the public (and often themselves as well).

No, the worse is the opposite of the above. The worse is that we all accept the homeopaths’ view. The worse is to say: Very well, we agree for the moment that your remedies are highly effective. And therefore we need to regulate them just as any other medicine.

In our yesterday’s response to the German homeopaths’ statement affirming the effectiveness of homeopathy, we tried to express exactly that. Here is the passage I am referring to:

Wenn dies für Homöopathen also so eindeutig ist, dann können die zuständigen Institutionen in den Arzneimittel-Gesellschaften (BfArM, AMG) Homöopathika genau so bewerten wie normale Medikamente…  die Politik sollte die Homöopathen bei ihrem eigenen Wort nehmen und sie denselben Prüfverfahren unterwerfen wie alle anderen Behandlungsverfahren auch.

And this is my (somewhat liberal) translation:

If homeopathy’s effectiveness is so crystal clear, the regulators should assess homeopathic remedies just like normal drugs…  politicians and regulators should take homeopaths by their own word and should apply the same standards as for all other medicines.

In the past, homeopaths have always wanted the cake and eat it; they pleaded that their remedies are so special and therefore they need special regulations and extra considerations. Because of these, they were sheltered and escaped any legal or ethical obligations to demonstrate effectiveness. This introduced an unjustified and regressive double standard with was detrimental to good healthcare, medical ethics and scientific progress.

Now that homeopaths (the Germans are merely an example, other countries’ homeopaths are much the same) have agreed on what they think is solid scientific proof, it is right and necessary to remove the special protection which homeopathy used to enjoy. Let’s for the moment accept the homeopaths’ argument (‘homeopathy is effective just like other medicines) and then force them to deliver the proof of their opinion according to the standards all medicines must be judged by!

That would surely be the end of all this nonsense, and homeopaths would find themselves hoisted by their own petard.

Yesterday, I wrote about a new acupuncture trial. Amongst other things, I wanted to find out whether the author who had previously insisted I answer his questions about my view on the new NICE guideline would himself answer a few questions when asked politely. To remind you, this is what I wrote:

This new study was designed as a randomized, sham-controlled trial of acupuncture for persistent allergic rhinitis in adults investigated possible modulation of mucosal immune responses. A total of 151 individuals were randomized into real and sham acupuncture groups (who received twice-weekly treatments for 8 weeks) and a no acupuncture group. Various cytokines, neurotrophins, proinflammatory neuropeptides, and immunoglobulins were measured in saliva or plasma from baseline to 4-week follow-up.

Statistically significant reduction in allergen specific IgE for house dust mite was seen only in the real acupuncture group. A mean (SE) statistically significant down-regulation was also seen in pro-inflammatory neuropeptide substance P (SP) 18 to 24 hours after the first treatment. No significant changes were seen in the other neuropeptides, neurotrophins, or cytokines tested. Nasal obstruction, nasal itch, sneezing, runny nose, eye itch, and unrefreshed sleep improved significantly in the real acupuncture group (post-nasal drip and sinus pain did not) and continued to improve up to 4-week follow-up.

The authors concluded that acupuncture modulated mucosal immune response in the upper airway in adults with persistent allergic rhinitis. This modulation appears to be associated with down-regulation of allergen specific IgE for house dust mite, which this study is the first to report. Improvements in nasal itch, eye itch, and sneezing after acupuncture are suggestive of down-regulation of transient receptor potential vanilloid 1.

…Anyway, the trial itself raises a number of questions – unfortunately I have no access to the full paper – which I will post here in the hope that my acupuncture friend, who are clearly impressed by this paper, might provide the answers in the comments section below:

  1. Which was the primary outcome measure of this trial?
  2. What was the power of the study, and how was it calculated?
  3. For which outcome measures was the power calculated?
  4. How were the subjective endpoints quantified?
  5. Were validated instruments used for the subjective endpoints?
  6. What type of sham was used?
  7. Are the reported results the findings of comparisons between verum and sham, or verum and no acupuncture, or intra-group changes in the verum group?
  8. What other treatments did each group of patients receive?
  9. Does anyone really think that this trial shows that “acupuncture is a safe, effective and cost-effective treatment for allergic rhinitis”?

In the comments section, the author wrote: “after you have read the full text and answered most of your questions for yourself, it might then be a more appropriate time to engage in any meaningful discussion, if that is in fact your intent”, and I asked him to send me his paper. As he does not seem to have the intention to do so, I will answer the questions myself and encourage everyone to have a close look at the full paper [which I can supply on request].

  1. The myriad of lab tests were defined as primary outcome measures.
  2. Two sentences are offered, but they do not allow me to reconstruct how this was done.
  3. No details are provided.
  4. Most were quantified with a 3 point scale.
  5. Mostly not.
  6. Needle insertion at non-acupoints.
  7. The results are a mixture of inter- and intra-group differences.
  8. Patients were allowed to use conventional treatments and the frequency of this use was reported in patient diaries.
  9. I don’t think so.

So, here is my interpretation of this study:

  • It lacked power for many outcome measures, certainly the clinical ones.
  • There were hardly any differences between the real and the sham acupuncture group.
  • Most of the relevant results were based on intra-group changes, rather than comparing sham with real acupuncture, a fact, which is obfuscated in the abstract.
  • In a controlled trial fluctuations within one group must never be interpreted as caused by the treatment.
  • There were dozens of tests for statistical significance, and there seems to be no correction for multiple testing.
  • Thus the few significant results that emerged when comparing sham with real acupuncture might easily be false positives.
  • Patient-blinding seems questionable.
  • McDonald as the only therapist of the study might be suspected to have influenced his patients through verbal and non-verbal communications.

I am sure there are many more flaws, particularly in the stats, and I leave it to others to identify them. The ones I found are, however, already serious enough, in my view, to call for a withdrawal of this paper. Essentially, the authors seem to have presented a study with largely negative findings as a trial with positive results showing that acupuncture is an effective therapy for allergic rhinitis. Subsequently, McDonald went on social media to inflate his findings even more. One might easily ask: is this scientific misconduct or just poor science?

I would be most interested to hear what you think about it [if you want to see the full article, please send me an email].

“Conflicts of interest should always be disclosed.”

This is what I wrote in the ‘RULES’ of this blog when I first started it almost 4 years ago. Sadly, very few people writing comments observe this rule. Perhaps, I just thought, I did not observe it either? So, here are my conflicts of interest: none.

Not true!!! I hear some people say. But it is!

I have no financial interest in any ‘Big Pharma’ or  ‘TINY CAM’, and I get not a penny for writing this blog.

How do I pay for my living? Mind your own business… well, on second thought, even that must not be a secret: I get a small pension and have some savings.

Still not convinced?

Perhaps it’s time to define what ‘conflicts of interests’ are. According to Wikipedia, they can be defined as  situations in which a person or organization is involved in multiple interests, financial interest, or otherwise, one of which could possibly corrupt the motivation of the individual or organization.

So, not having financial benefits from my current work does not necessarily mean that I have no conflicts of interest. The above definitions vaguely mentions ‘or otherwise’ – and that could be important. What could this mean in the context of this blog?

Well, I might have very strong beliefs, for instance (for instance, very strong beliefs that acupuncture is by definition nonsense [see below]). We all know that strong beliefs can corrupt motivation (and a lot more). And if I ask myself, do you have strong beliefs?, I have to say: Yes, absolutely!

I believe that:

  • good evidence is a prerequisite for progress in healthcare,
  • good evidence must be established by rigorous research,
  • we should not tolerate double standards in healthcare,
  • patients deserve to be treated with the best available treatments,
  • making therapeutic claims that are not supported by sound evidence is wrong.

These strong beliefs might make me biased in the eyes of many who comment on this blog. In Particular, we recently had a bunch of acupuncturists who went on the rampage attacking me personally the best they could. However, a rational analysis of my beliefs can hardly produce evidence for bias against anything other than the promotion of unproven therapies to the unsuspecting public.

The above mentioned acupuncturists seem to think that I have always been against acupuncture for the sake of being against acupuncture. However, this is not true. The proof for this statement is very simple: I have published quite a bit of articles that concluded positively – even (WOULD YOU BELIEVE IT?) about acupuncture for back pain! A prominently published meta-analysis of 2005 (with me as senior author) concluded:  “Acupuncture effectively relieves chronic low back pain.” (This of course was 11 years ago when the evidence was, in fact, positive; today, this seems to have changed – just like the NICE guidelines [probably not a coincidence!])

Conflicts of interest? No, not on my side, I think.

But what about the ‘other side’?

The unruly horde of acupuncturists (no, this is not an ad hominem attack, it’s a fact) who recently made dozens of ad hominem attacks against me, what about them?

  • They earn their money with acupuncture.
  • They have invested in acupuncture training often for long periods of time.
  • They have invested in practice equipment etc.
  • Some of them sell books on acupuncture.
  • Others run courses.
  • And all of them very clearly and demonstrably  have strong beliefs about acupuncture.

I think the latter point constitutes by far the most important conflict of interest in this context.

And this is where the somewhat trivial story has an unexpected twist and gets truly bizarre:

I have just leant that the same group of conflicted acupuncturists are now planning to publicly attack the panel of experts responsible for drafting the NICE guidelines. The reason? They feel that this panel had significant conflicts of interest that led them to come out against acupuncture.

Perhaps I should mention that I was not a member of this group, but I suspect that some of its members might have links to the pharmaceutical industry. It is almost impossible to find top experts in any area of medicine who do not have such links. You either gather experts with potential conflicts of interest, or you get non-experts without them. Would that bias them against acupuncture or any other alternative therapy? I very much doubt it.

What I do not doubt for a minute is that conflicts of interest are of major importance in these discussions. And by that I mean the more than obvious (but nevertheless undeclared) conflicts of interest of the acupuncturists. It seems that those with the strongest conflicts of interest shout the loudest about the non-existent or irrelevant conflict of interest of those who do not happen to share their quasi-religious belief in acupuncture.

In 2008, I published a paper entitled ‘CHIROPRACTIC, A CRITICAL EVALUATION’ where I reviewed most aspects of this subject, including the historical context. Here is the passage about the history of chiropractic. I believe it is relevant to much of the current discussions about the value or otherwise of chiropractic.

The history of chiropractic is “rooted in quasi-mystical concepts.”  Bone-setters of various types are part of the folk medicine of most cultures, and bone-setting also formed the basis on which chiropractic developed.

The birthday of chiropractic is said to be September 18, 1895. On this day, D.D. Palmer manipulated the spine of a deaf janitor by the name of Harvey Lillard, allegedly curing him of his deafness. Palmer’s second patient, a man suffering from heart disease, was also cured. About one year later, Palmer opened the first school of chiropractic. There is evidence to suggest that D.D. Palmer had learned manipulative techniques from Andrew Taylor Still, the founder of osteopathy. He combined the skills of a bone-setter with the background of a magnetic healer and claimed that “chiropractic was not evolved from medicine or any other method, except that of magnetic.” He coined the term “innate intelligence” (or “innate”) for the assumed “energy” or “vital force,” which, according to the magnetic healers of that time, enables the body to heal itself. The “innate” defies quantification. “Chiropractic is based on a metaphysical epistemology that is not amenable to positivist research or experiment.”

The “innate” is said to regulate all body functions but, in the presence of “vertebral subluxation,” it cannot function adequately. Chiropractors therefore developed spinal manipulations to correct such subluxations,  which, in their view, block the flow of the “innate.” Chiropractic is “a system of healing based on the premise that the body requires unobstructed flow through the nervous system of innate intelligence.” Anyone who did not believe in the “innate” or in “subluxations” was said to have no legitimate role in chiropractic.

“Innate intelligence” evolved as a theological concept, the representative of Universal Intelligence ( = God) within each person. D.D. Palmer was convinced he had discovered a natural law that pertained to human health in the most general terms. Originally, manipulation was not a technique for treating spinal or musculoskeletal problems, it was a cure for all human illness: “95% of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints.” Early chiropractic pamphlets hardly mention back pain or neck pain, but assert that, “chiropractic could address ailments such as insanity, sexual dysfunction, measles and influenza.” D.D. Palmer was convinced that he had “created a science of principles that has existed as long as the vertebra.” Chiropractors envision man as a microcosm of the universe where “innate intelligence” determines human health as much as “universal intelligence” governs the cosmos; the discovery of the “innate intelligence” represents a discovery of the first order, “a reflection of a critical law that God used to govern natural phenomena.”

Early chiropractic displayed many characteristics of a religion. Both D.D. Palmer and his son, B.J. Palmer, seriously considered establishing  chiropractic as a religion. Chiropractic “incorporated vitalistic concepts of an innate intelligence with religious concepts of universal intelligence,” which substituted for science. D.D. Palmer declared that he had discovered the answer to the timeworn question, “What is life?” and added that chiropractic made “this stage of existence much more efficient in its preparation for the next step – the life beyond.”

Most early and many of today’s chiropractors agree: “Men do not cure. It is that inherent power (derived from the creator) that causes wounds to heal, or a part to be repaired. The Creator…uses the chiropractor as a tool…chiropractic philosophy is truly the missing link between Religion or Power of the various religions.” Today, some chiropractors continue to relate the “innate” to God. Others, however, warn not to “dwindle or dwarf chiropractic by making a religion out of a technique.”

Initially, the success of chiropractic was considerable. By 1925, more than 80 chiropractic schools had been established in the United States. Most were “diploma mills” offering an “easy way to make money,” and many “were at one another’s throats.” Chiropractors believed they had established their own form of science, which emphasized observation rather than experimentation, a vitalistic rather than mechanistic philosophy, and a mutually supportive rather than antagonist relationship between science and religion. The gap between conventional medicine and chiropractic thus widened “from a fissure into a canyon.” The rivalry was not confined to conventional  medicine; “many osteopaths asserted that chiropractic was a bastardized version of osteopathy.”

Rather than arguing over issues such as efficacy, education, or professional authority, the American Medical Association insisted that all competent health care providers must have adequate knowledge of the essential subjects such as anatomy, physiology, pathology, chemistry, and bacteriology. By that token, the American Medical Association claimed, chiropractors were not fit for practice. Some “martyrs,” including D.D. Palmer himself, went to jail for practicing medicine without a licence.

Chiropractors countered that doctors were merely defending their patch for obvious financial reasons (ironically, chiropractors today often earn more than conventional doctors), that orthodox science was morally corrupt and lacked open-mindedness. They attacked the “germo-anti-toxins-vaxiradi-electro-microbioslush death producers” and promised a medicine “destined to the grandest and greatest of this or any age.”

Eventually, the escalating battle against the medical establishment was won in “the trial of the century.” In 1987, sections of the U.S. medical establishment were found “guilty of conspiracy against chiropractors,” a decision which was upheld by the U.S. Supreme Court in 1990. In other countries, similar legal battles were fought, usually with similar outcomes. Only rarely did they not result in the defeat of the “establishment:” In 1990, a Japanese Ministry of Health report found that chiropractic is “not based on the knowledge of human anatomy but subjective and unscientific.”

These victories came at the price of “taming” and “medicalizing” chiropractic. In turn, this formed the basis of a conflict within the chiropractic profession – the dispute between “mixers” and “straights” – a conflict which continues to the present day.

The “straights” religiously adhere to D.D. Palmer’s notions of the “innate intelligence” and view subluxation as the sole cause and manipulation as the sole cure of all human disease. They do not mix any non-chiropractic techniques into their therapeutic repertoire, dismiss physical examination (beyond searching for subluxations) and think medical diagnosis is irrelevant for chiropractic. The “mixers” are somewhat more open to science and conventional medicine, use treatments other than spinal manipulation, and tend to see chiropractors as back pain specialists. Father and son Palmer warned that the “mixers” were “polluting and diluting the sacred teachings” of chiropractic. Many chiropractors agreed that the mixers were “bringing discredit to the chiropractic.”

The “straights” are now in the minority but nevertheless exert an important influence. They have, for instance, recently achieved election victories within the British General Chiropractic Council. Today, two different chiropractic professions exist side by sided “one that wishes to preserve the non-empirical, non-positivist, vitalist foundations (the straights) and the other that wishes to be reckoned as medical physicians and wishes to utilize the techniques and mechanistic viewpoint of orthodox medicine (the mixers).” The International Chiropractic Association represents the “straights” and the American Chiropractic Association the “mixers.”

(for references, see the original article)

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