critical thinking
Trump says he never mocked a disabled journalist.
YET THE WHOLE WORLD SAW HIM DO IT!
UK Brexit politicians such as Boris Johnson claim they never promised £ 350 million per week of EU funds for the NHS.
BUT WE ALL SAW THE PICTURES OF THE CAMPAIGN BUS!
These are just two of the numerous, obvious and highly significant lies that we have been told in recent months. In fact, we have heard so many lies recently that some of us seem to be getting used to them. We even have a new term for the phenomenon: the ‘post-truth society’.
Personally I don’t like the word at all: it seems to reflect a tacit acceptance of lies and their legitimisation.
I find it dangerous to put up with falsehoods in that way. And I think the truth is far too valuable to abandon it without a fight. I will therefore continue to call a lie a lie!
And, by Jove, in alternative medicine, we have no shortage of them:
- Homeopaths claiming to be able to treat any condition with their ‘high potency remedies’.
- Chiropractors who claim that spinal manipulation improves health.
- Healers who state that their paranormal healing affects symptoms.
- Alternative practitioners who claim that they treat the root cause of diseases.
- Naturopaths who pretend they can treat childhood conditions.
- Acupuncturists who say that rebalancing yin and yang affects health.
- Alternative practitioners who insist they can detox our bodies.
- Politicians who claim that TCM save lives.
- Slapping therapists who say they can cure diabetes.
- Journalists who publish that Paleo-diet can cure inflammatory bowel diseases.
- Entrepreneurs who promote their unproven products as diabetes cures.
- Academics who teach homeopathy to medical students.
- Homeopaths who claim that their remedies are effective alternatives for vaccinations.
Do I need to go on?
These are not ‘post-truths’ – these are just lies, pure and simple.
We must not be lulled into complacency or false tolerance. Lies are lies, and they are wrong and unethical. In many instances they can even kill. To ignore or accept a steady stream of lies is not a solution; on the contrary, it can easily become part of the problem.
So, let’s continue to call them by their proper name – no matter whether they originate from the dizzy heights of world politics or the low lands of quackery.
At a recent conference in Montréal (October 2016), the WFC (World Federation of Chiropractic) and the ACC (Association of Chiropractic Colleges) reached a consensus on education. Consequently, recommendations were produced that offer 12 key ‘take away messages’. I take the liberty of reproducing these statements entitled ‘Training Tomorrow’s Spine Care Experts’ (the square brackets were inserted by me and refer to brief comments I made below).
START OF QUOTE
1. Chiropractic educational institutions have a responsibility to equip students with the skills and attributes necessary to become future spinal health care experts. This includes a commitment to astute diagnostic ability, a comprehensive knowledge of spine-related disorders [1], appreciation for the contributions of other health professionals and a commitment to collaborative, patient-centered and evidence-informed care [2].
2. Technological advances [3] provide an opportunity for the chiropractic profession to enhance, evolve and standardize core education and practice. This is relevant to the teaching of chiropractic skills, sharing of learning resources and assessment of performance. Emerging technologies that support the development of clinically-competent practitioners should be embedded within chiropractic programs.
3. The teaching and learning of specialized manual assessment and treatment skills should remain a key distinguishing element of chiropractic curricula.
4. Surveys of the public have a demonstrated a desire for consistency in the provision of chiropractic services. Such consistency need not compromise the identities of individual institutions but will cultivate public trust and cultural authority [4].
5. Globally consistent educational and practice standards will facilitate international portability [5] and promote greater health equity in the delivery of spine care.
6. Chiropractic programs should espouse innovation and leadership in the context of ethical [6], sustainable business [7] practices.
7. Chiropractic educational curricula should reflect current evidence [8] and high quality guidelines [9], and be subjected to regular review to ensure that students are prepared to work in collaborative health care environments.
8. The training of tomorrow’ s spine care experts should incorporate current best practices in education.
9. Interdisciplinary collaboration and strategic partnerships present opportunities to position chiropractors as leaders [10] and integral team players in global spine care.
10. Chiropractic educational institutions should champion the integration of evidence informed clinical practice [11], including clinical practice guidelines, in order to optimize patient outcomes. This will in turn foster principles of lifelong learning and willingness to adapt practice methods in the light of emerging evidence [12].
11. Students, faculty, staff and administrators must all contribute to a learning environment that fosters cultural diversity, critical thinking [13], academic responsibility and scholarly activity.
12. Resources should be dedicated to embed and promote educational research activity in all chiropractic institutions.
END OF QUOTE
And here are my brief comments:
[1] Some chiropractors believe that all or most human conditions are ‘spine-related disorders’. We would need a clear statement here whether the WFC/ACC do support or reject this notion and what conditions we are actually talking about. [2] ‘Evidence-informed’??? I have come across this term before; it is used more and more by quacks of all types. It is clearly not synonymous with ‘evidence-based’, but aims at providing a veneer of respectability by creation an association with EBM. In concrete terms, asthma, for instance, might, in the eyes of some chiropractors, be an evidence-informed indication for chiropractic. In other words, ‘evidence-informed’ is merely a card blanch for promoting all sorts of nonsense. [3] It would be good to know which technical advances they are thinking of. [4] Public trust is best cultivated by demonstrating that chiropractic is doing more good than harm; by itself, this point sounds a bit like PR for maximising income. Sorry, I am not sure what they mean by ‘cultural authority’ – chiropractic as a cult? [5] ‘International portability’ – nice term, but what does it mean? [6] I get the impression that many chiropractors do not know what is meant by the term ‘ethics’. [7] But they certainly know much about business! [8] That is, I think, the most relevant statement in the entire text – see below. [9] Like those by NICE which no longer recommend chiropractic for back pain? No? They are not ‘high quality’? I see, only those that recommend chiropractic fulfil this criterion! [10] Chiropractors as leaders? Really? With their (largely ineffective) manipulations as the main contribution to the field? You have to be a chiropractor to find this realistic, I guess. [11] Again ‘evidence-informed’ instead of ‘evidence-based’ – who are they trying to kid? [12] The evidence that has been emerging since many years is that chiropractic manipulations fail to generate more good than harm. [13] In the past, I got the impression that critical thinking and chiropractic are a bit like fire and water.MY CONCLUSION FROM ALL THIS
What we have here is, in my view, little more than a mixture between politically correct drivel and wishful thinking. If chiropractors truly want chiropractic educational curricula to “reflect current evidence”, they need to teach the following main tenets:
- Chiropractic manipulations have not been shown to be effective for any of the conditions they are currently used for.
- Other forms of treatment are invariably preferable.
- Subluxation, as defined by chiropractors, is a myth.
- Spine-related disorders, as taught in many chiropractic colleges, are a myth.
- ‘Evidence-informed’ is a term that has no meaning; the proper word is ‘evidence-based’ – and evidence-based chiropractic is a contradiction in terms.
Finally, chiropractors need to be aware of the fact that any curriculum for future clinicians must include the core elements of critical assessment and medical ethics. The two combined would automatically discontinue the worst excesses of chiropractic abuse, such as the promotion of bogus claims or the financial exploitation of the public.
But, of course, none of this is ever going to happen! Why? Because it would mean teaching students that they need to find a different profession. And this is why I feel that statements like the above are politically correct drivel which can serve only one purpose: to distract everyone from the fundamental problems in that profession.
If you want to scientifically investigate this question, it might be a good idea NOT to start with the following sentence: “Auricular acupuncture (AA) is effective in the treatment of preoperative anxiety”. Yet, this is exactly what the authors did in their recent publication.
The aim of this new study was to investigate whether AA can reduce exam anxiety as compared to placebo and no intervention. Forty-four medical students were randomized to receive AA, placebo, or no intervention in a crossover manner. Subsequently they completed three comparable oral anatomy exams with an interval of one month between the exams/interventions.
A licensed acupuncturist with more than five years of experience with this technique applied AA at the acupuncture points MA-IC1 (Lung), MA-TF1 (ear Shenmen), MA-SC (Kidney), MA-AT1 (Subcortex) and MA-TG (Adrenal gland) bilaterally. Indwelling fixed ‘New Pyonex’ needles embedded in a skin-coloured adhesive tape were used for AA. The participants were instructed by the acupuncturist to stimulate the auricular needles for 3–5 minutes, if they felt anxious. For the placebo procedure, ‘New Pyonex’ placebo needles were attached to five sites on the helix of the auricle bilaterally. ‘New Pyonex’ placebo needles have the same appearance as AA needles but consist of self-adhesive tape only. In order to avoid potential physiologic effects of acupressure, the participants were not instructed to stimulate the attached ‘New Pyonex’ placebo needles. AA and placebo needles were left in situ until the next day and were removed out of sight of the participants after the exam by the investigator, who was not involved in acupuncture procedure
Levels of anxiety were measured using a visual analogue scale before and after each intervention as well as before each exam. Additional measures included the State-Trait-Anxiety Inventory, duration of sleep at night, blood pressure, heart rate and the extent of participant blinding.
All included participants finished the study. Anxiety levels were reduced after AA and placebo intervention compared to baseline and the no intervention condition (p < 0.003). Moreover, AA was also better at reducing anxiety than placebo in the evening before the exam (p = 0.018). Participants were able to distinguish between AA and placebo intervention.
The authors concluded that both auricular acupuncture and placebo procedure were shown to be effective in reducing levels of exam anxiety in medical students. The superiority of verum AA over placebo AA and no intervention is considered to be due to stimulation of cranial nerves, but may have been increased in effect by insufficient participant blinding.
Here are just three of the major concerns I have about this study:
- The trial design seems odd: a crossover study can only work well, if there is a stable baseline. This may not be the case with three consecutive exams; the anxiety experienced by students is bound to get less as time goes by. I think anyone who has passed a series of exams will confirm that there is a large degree of habituation.
- It seems inadequate to employ just one acupuncturist; it means that the trial might end up testing not acupuncture per se but the skills of the therapist.
- The placebo used for this study cannot possibly have fooled anyone into believing that it was real AA; volunteers were not even instructed to ‘stimulate’ the placebo devices. The difference to the ‘real thing’ must have been very clear to all involved. This means that the control for placebo-effects was woefully incomplete. In turn, this means that the observed outcomes are most likely due to residual bias.
In view of these concerns, allow me to re-phrase the authors’ conclusions:
THE RESULTS OF THIS POORLY-DESIGNED STUDY ARE DIFFICULT TO INTERPRET. MOST LIKELY THEY SHOW THAT ACUPUNCTURE IS NOT EFFECTIVE BUT MERELY WORKS THROUGH A PLACEBO-RESPONSE.
Can intercessory prayer improve the symptoms of sick people?
Why should it? It’s utterly implausible!
Because the clinical evidence says so?
No, the current Cochrane review concluded that [the] findings are equivocal and, although some of the results of individual studies suggest a positive effect of intercessory prayer, the majority do not and the evidence does not support a recommendation either in favour or against the use of intercessory prayer. We are not convinced that further trials of this intervention should be undertaken and would prefer to see any resources available for such a trial used to investigate other questions in health care.
Yet, not all seem to agree with this; and some even continue to investigate prayer as a medical therpy.
For this new study (published in EBCAM), the Iranian investigators randomly assigned 92 patients in 2 groups to receive either 40 mg of propranolol twice a day for 2 month (group “A”) or 40 mg of propranolol twice a day for 2 months with prayer (group “B”). At the beginning of study and 3 months after intervention, patients’ pain was measured using the visual analogue scale.
All patients who participate in present study were Muslim. At the beginning of study and before intervention, the mean score of pain in patients in groups A and B were 5.7 ± 1.6 and 6.5 ± 1.9, respectively. According to results of independent t test, mean score of pain intensity at the beginning of study were similar between patients in 2 groups (P > .05). Three month after intervention, mean score of pain intensity decreased in patients in both groups. At this time, the mean scores of pain intensity were 5.4 ± 1.1 and 4.2 ± 2.3 in patients in groups A and B, respectively. This difference between groups was statistically significant (P < .001).
The above figure shows the pain score in patients before and after the intervention.
The authors concluded that the present study revealed that prayer can be used as a nonpharmacologic pain coping strategy in addition to pharmacologic intervention for this group of patients.
Extraordinary claims require extraordinary proof. This study is, in fact, extraordinary – but only in the sense of being extraordinarily poor, or at least it is extraordinary in its quality of reporting. For instance, all we learn in the full text article about the two treatments applied to the patient groups is this: “The prayer group participated in an 8-week, weekly, intercessory prayer program with each session lasting 45 minutes. Pain reduction was measured at baseline and after 3 months, by registered nurses who were specialist in pain management and did not know which patients were in which groups (control or intervention), using a visual analogue scale.”
Intercessory prayer is the act of praying on behalf of others. This mans that the patients receiving prayer might have been unaware of being ‘treated’. In this case, the patients could have been adequately blinded. But this is not made clear in the article.
More importantly perhaps, the authors fail to provide any numeric results. All that we are given is the above figure. It is not possible therefore to run any type of check on the data. We are simply asked to believe what the authors have written. I for one have great difficulties in doing so. All I do believe in relation to this article is that
- the journal EBCAM is utter trash,
- constantly publishing rubbish is unethical and a disservice to everyone,
- prayer does not need further research of this nature,
- and poor studies often generate false-positive findings.
Is acupuncture a pseudoscience? An interesting question! It was used as the title of a recent article. Knowing who authored it, the question unfortunately promised to be rhetorical. Dr Mike Cummings is (or was?) the ‘Medical Director at British Medical Acupuncture Society’ – hardly a source of critical or sceptical thinking about acupuncture, I’d say. The vast majority of his recent publications are in ‘ACUPUNCTURE IN MEDICINE’ and his blog post too is for that journal. Nevertheless, his thoughts might be worth considering, and therefore I present the essence of his post below [the footnotes refer to my comments following Cummings’ article]:
…Wikipedia has branded acupuncture as pseudoscience and its benefits as placebo [1]. ‘Acupuncture’ is clearly is not pseudoscience; however, the way in which it is used or portrayed by some may on occasion meet that definition. Acupuncture is a technique that predates the development of the scientific method [2] … so it is hardly fair to classify this ancient medical technique within that framework [3]. It would be better to use a less pejorative classification within the bracket of history when referring to acupuncture and other ancient East Asian medical techniques [4]. The contemporary use of acupuncture within modern healthcare is another matter entirely, and the fact that it can be associated with pre-scientific medicine does not make it a pseudoscience.
The Wikipedia acupuncture page is extensive and currently runs to 302 references. But how do we judge the quality or reliability of a text or its references? … I would generally look down on blogs, such as this, because they lack … hurdles prior to publication [5]. Open peer review was introduced relatively recently associated with immediate publication. But all this involves researchers and senior academics publishing and reviewing within their own fields of expertise. Wikipedia has a slightly different model built on five pillars. The second of those pillars reads:
Wikipedia is written from a neutral point of view: We strive for articles that document and explain major points of view, giving due weight with respect to their prominence in an impartial tone. We avoid advocacy and we characterize information and issues rather than debate them. In some areas there may be just one well-recognized point of view; in others, we describe multiple points of view, presenting each accurately and in context rather than as “the truth” or “the best view”. All articles must strive for verifiable accuracy, citing reliable, authoritative sources, especially when the topic is controversial or is on living persons. Editors’ personal experiences, interpretations, or opinions do not belong.
Experts within a field may be seen to have a certain POV (point of view), and are discouraged from editing pages directly because they cannot have the desired NPOV (neutral POV). This is a rather unique publication model in my experience, although the editing and comments are all visible and traceable, so there is no hiding… apart from the fact that editors are allowed to be entirely anonymous. Have a look at the talk page behind the main acupuncture page on Wikipedia. You may be shocked by the tone of much of the commentary. It certainly does not seem to comply with the fourth of the five pillars, which urges respect and civility, and in my opinion results primarily from the security of anonymity. I object to the latter, but there is always a balance to be found between freedom of expression (enhanced for some by the safety of anonymity) and cyber bullying (almost certainly fuelled in part by anonymity). That balance requires good moderation, and whilst there was some evidence of moderation on the talk page, it was inadequate to my mind… I might move to drop anonymity from Wikipedia if moderation is wanting.
Anyway my impression, for what it’s worth, is that the acupuncture page on Wikipedia is not written from an NPOV, but rather it appears to be controlled by semi professional anti-CAM pseudosceptics [6]. I have come across these characters [6] regularly since I was introduced to the value of needling in military general practice. I have a stereotypical mental image: plain or scary looking bespectacled geeks and science nuts [6], the worst are often particle physicists … Interacting with them is at first intense, but rapidly becomes tedious as they know little of the subject detail [6], fall back on the same rather simplistic arguments [6] and ultimately appear to be motivated by eristic discourse rather than the truth [6].
I am not surprised that they prefer to close the comments, because I imagine that some people might object rather strongly to many of the statements made in this text.
Here are my short comments:
[1] I should perhaps stress that I am not the author of nor a contributor to this Wiki (or any other) page. [2] Is this an attempt to employ the ‘appeal to tradition’ fallacy? [3] The Wiki page does by no means classify the ancient history of acupuncture as pseudoscience. [4] I have always felt that classification of science or medicine according to geography is nonsensical; they should not be classified as Western or Asian but as sound or not, effective or not, etc. [5] As we have often seen on this blog, the ‘hurdles’ (peer-review) are often laughable, particularly in the realm of alternative medicine. [6] This article is essentially trying to show that the Wiki page is biased. Yet it ends with a bonanza of insults which essentially reveal the profound bias of the author.IS ACUPUNCTURE PSEUDOSCIENCE? Cummings’ article promised to address this question. Sadly it did nothing of the sort. It turned out to be an incompetent rant about a Wiki page. If anything, Cummings contributed to the neutral reader of his text getting convinced that, indeed, acupuncture IS a pseudoscience! At least Wiki used facts, arguments, evidence etc. and it went a lot further in finding a rational answer to this intriguing question.
With well over 800 articles, this blog has become somewhat of a reference library for subjects related to alternative medicine (I know that some journalists already employ it in this way [if you want to use it in this way, try the search box on the right top of the page]). To review the year 2016 in alternative medicine, I will now use it for exactly this purpose. In other words, I will highlight those posts from 2016 which, in my view, have taught us something potentially valuable or are otherwise remarkable.
Here we go!
19 January 2016: What are the competencies of a paediatric chiropractor? Chiropractors disagree, of course, but I think they should be foremost to realise that chiropractors must not treat children.
21 January 2016: Are naturopaths dangerous? The short answer is, yes, many are!
29 January 2016: Is the Internet a good source of information for cancer patients? No, in the realm of alternative medicine, the Internet can be very dangerous indeed.
15 February 2016: Alternative practitioners employ a multitude of diagnostic techniques. These methods are not validated and run an unacceptably high risk of false-positive or false-negative results.
22 March 2016: The career-path to becoming a convinced homeopath … may be less far puzzling than you think.
24 March 2016: Even the most respected medical journals are now beginning to publish very weak, borderline fraudulent studies of alternative medicine.
26 March 2016: Alternative practitioners seem to never protest even against the most outrageous quackery within their ranks.
28 March 2016: NICE might finally start being a little more critical about the value of alternative therapies.
02 April 2016: The ability to think critically seems extremely rare amongst alternative practitioners.
13 April 2016: Many, if not most, of the ‘research’ papers published in alternative medicine seem to have little to do with science but turn out to be exercises in promotion.
16 April 2016: There is no epidemic that does not bring some dangerously delusional homeopaths to the fore.
29 April 2016: Most alternative practitioners have little idea about medical ethics (see also here).
01 May 2016: Some, one could even say most CAM journals are not worth the paper they are printed on (see also here).
23 May 2016: Integrative medicine is one of the most colossal deceptions in healthcare today.
24 May 2016: Some CAM researcher are too good to be true.
10 June 2016: Pharmacists who sell quackery are probably quacks.
22 July 2016: Far too many TCM products are of lamentably poor quality.
19 August 2016: The German ‘HEILPRAKTIKER’ is a relic from the Nazis that continues to endanger public health.
03 September 2016: Homeoprophylaxis is a criminally bad idea; it has the potential to endanger public health.
04 September 2016: Quackery can kill people – and sadly, it does so with depressing regularity.
06 September 2016: Research into alternative medicine is scarce and usually of deplorably poor quality.
26 September 2016: Holistic dentistry is a con – just like holistic medicine; the term ‘holistic’ has degenerated into an advertising gimmick.
04 October 2016: Data fabrication in China is rife and further undermines the trustworthiness of TCM studies.
21 October 2016: Most (if not all) of the money spent on chiropractic is wasted.
10 December 2016: When sceptics criticise homeopathy, they are often wrong.
19 December 2016: Charlatans‘ income crucially relies on advertising lies.
22 December 2016: Homeopathy is not just useless for humans, it also does not work in animals.
HAPPY NEW YEAR EVERYONE!
Yesterday I received an electronic Christmas card from two homeopathic institutions called ‘Homeopathic Associates and The Homeopathic College’. It read: WISHING YOU THE BEST OF HEALTH AND HAPPINESS FOR THE NEW YEAR!
Naturally I was puzzled, particularly since I had no recollection of ever having been in contact with them. The card was signed by Manfred Mueller, MA, DHM, RSHom(NA), CCH, and I decided to find out more about this man. It turns out that Manfred Mueller developed The Mueller Method or “Extra-Strength Homeopathy” to meet today’s complex chronic conditions, drug induced disorders, vaccine injuries, toxic overload, radiation-induced health problems, cancers, etc.
Now, this sounds interesting, I thought, and read on. Just a few clicks further, Mueller offers his wisdom on homeopathic cancer treatments in a lengthy article entitled ‘Is Homeopathy an Effective Cancer Treatment?‘
According to Mueller, the answer to his question is a clear yes. I will spare you the torture of reading the entire paper (if you have masochistic tendencies, you can read it via the link I provided above); instead, I will just copy Mueller’s conclusion:
START OF QUAOTE
Laboratory studies in vitro and in vivo show that homeopathic drugs, in addition to having the capacity to reduce the size of tumors and to induce apoptosis, can induce protective and restorative effects. Additionally homeopathic treatment has shown effects when used as a complementary therapy for the effects of conventional cancer treatment. This confirms observations from our own clinical experience as well as that of others that when suitable remedies are selected according to individual indications as well as according to pathology and to cell-line indications and administered in the appropriate doses according to the standard principles of homeopathic posology, homeopathic treatment of cancer can be a highly effective therapy for all kinds of cancers and leukemia as well as for the harmful side effects of conventional treatment. More research is needed to corroborate these clinical observations.
Homeopathy over almost two decades of its existence has developed more than four hundred remedies for cancer treatment. Only a small fraction have been subjected to scientific study so far. More homeopathic remedies need to be studied to establish if they have any significant action in cancer. Undoubtedly the next big step in homeopathic cancer research must be multiple comprehensive double-blinded, placebo-controlled, randomized clinical trials. To assess the effect of homeopathic treatment in clinical settings, volunteer adult patients who prefer to try homeopathic treatment instead of conventional therapy could be recruited, especially in cases for which no conventional therapy has been shown to be effective.
Many of the researchers conducting studies — cited here but not discussed — on the growing interest in homeopathic cancer treatment have observed that patients are driving the demand for access to homeopathic and other alternative modes of cancer treatment. So long as existing cancer treatment is fraught with danger and low efficacy, it is urgent that the research on and the provision of quality homeopathic cancer treatment be made available for those who wish to try it.
END OF QUOTE
Amazing! What could be more wrong than this?
But it’s the season of joy and love; so, let’s not go into the embarrassing details of this article. Instead, I feel like returning the curtesy of Mr Mueller’s Christmas card. Therefore, I have decided to post this open ‘Christmas card’ to him:
Dear Mr Mueller,
thank you for your card, the good wishes, and the links you provided to your websites, articles, etc. I only read the one on cancer but was impressed. It is remarkably misguided, unethical and dangerous. Crucially, it has the potential to shorten the lives of many desperate patients. I therefore urge you to desist making your opinions public or from applying them in your clinical practice. I say this not merely because I am concerned about the patients that have the misfortune to fall into your hands, but also to prevent you from getting into trouble for immoral, unethical or unlawful behaviour.
In this spirit, I wish you happiness for the New Year.
Edzard Ernst
The fact that much of chiropractic might be bogus has frequently been discussed on this blog. A recent press-release provided me with more evidence for this notion. It proudly announced a new book entitled “Beyond the Back: The Chiropractic Alternative For Conditions Beyond Back Pain”
The text claimed that shortly after the launch, the book hit #1 on the Amazon.com best seller list out of all Chiropractor books and also reached #1 for the category of Holistic Medicine.
When I checked (22/12/2016), I was not able to confirm this statement: #47 in Kindle Store > Kindle eBooks > Medical eBooks > Alternative & Holistic > Holistic Medicine, #58 in Books > Medical Books > Allied Health Professions > Chiropractic. But let’s not be petty; let’s rather see what the book has to offer.
‘Beyond the Back’ focuses on how Chiropractic care can do so much more than just alleviate back pain, the press-release says. From avoiding knee surgery to resolving athletic injuries, chiropractic care allegedly is a 100% natural health solution for a wide variety of conditions… In fact, in some cases, chiropractors can help their patients get off medications entirely and even avoid surgery, the press-release continues.
In the book itself, the authors claim that chiropractic is effective for a multitude of conditions, including asthma and colic (in fact, the authors try to give the impression that chiropractic is a veritable panacea), and that there is sound evidence for all these indications from hundreds, if not thousands of studies. The authors make it very clear – even on the book cover – that chiropractic is not an adjunct to conventional healthcare but an alternative to it; an idea, of course, that goes back to the founding fathers of chiropractic. As if this were not enough, the book also promotes diagnostic techniques such as applied kinesiology.
Some commentators on this blog have argued that the chiropractic profession is in the midst of giving up much of the nonsense upon it was originally based and to which it has clung on for more than hundred years. This book, written by 9 US authors of the new generation of chiropractors, seems to demonstrate the opposite.
On Amazon, the book currently has one single customer review: Value information and an easy read! I am a strong believer of chiropractic and this makes it easy for me to share this info with my friends !
This comment is apt because it makes clear that chiropractic is a belief system. We must not expect rational thoughts or facts from what, in effect, is a religion for many. I can understand this in a way: belief can be a cosy shelter from the truth; it does not require much thinking; it hardly needs any learning, no changing of minds, etc. However, belief can never be a basis for good healthcare. In my view, ‘Beyond The Back’ provides a perfect example of that.
This meta-analysis was performed “to ascertain the effectiveness of oral aloe vera consumption on the reduction of fasting blood glucose (FBG) and hemoglobin A1c (HbA1c).”
PubMed, CINAHL, Natural Medicines Comprehensive Database, and Natural Standard databases were searched. The searches were limited to clinical trials or observational studies conducted in humans and published in English. Studies of aloe vera’s effect on FBG, HbA1c, homeostasis model assessment-estimated insulin resistance (HOMA-IR), fasting serum insulin, fructosamine, and oral glucose tolerance test (OGTT) in prediabetic and diabetic populations were examined.
Nine studies were included in the FBG parameter (n = 283); 5 of these studies included HbA1c data (n = 89). Aloe vera decreased FBG by 46.6 mg/dL (p < 0.0001) and HbA1c by 1.05% (p = 0.004). Significant reductions of both endpoints were maintained in all subgroup analyses. Additionally, the data suggested that patients with an FBG ≥200 mg/dL may see a greater benefit. A mean FBG reduction of 109.9 mg/dL was observed in this population (p ≤ 0.0001). There was evidence of publication bias with FBG but not with HbA1c.
The authors concluded that the results of this meta-analysis support the use of oral aloe vera for significantly reducing both FBG (46.6 mg/dL) and HbA1c (1.05%) in prediabetic and diabetic patients. However, given the current overall quality and relative scarcity of data, further clinical studies that are more robust and better controlled are warranted to confirm and further explore these findings.
Oh no, the results do not support the use of aloe vera at all!!
Why?
Because this ‘meta-analysis’ is of unacceptably poor quality. Here are just some of the flaws that render it totally useless, particularly for issuing advice such as above:
- The authors included uncontrolled observational studies which make no attempt to control for non-specific effects.
- In several studies, the use of concomitant anti-diabetic medications was allowed; therefore it is not possible to establish cause and effect by aloe vera.
- The search strategy was woefully inadequate; for instance non-English publications were not considered.
- There was no assessment of the scientific rigor of the included studies; this totally invalidates the reliably of the conclusions.
- The included studies used preparations of widely different aloe vera preparations, and there is no way of knowing the does of the active ingredients.
Diabetes is a serious condition that affects millions worldwide. If some of these patients are sufficiently gullible to follow the conclusions of this paper, they might be dead within a matter of days. This makes this article one of the most dangerous papers that I have seen in the ‘peer-reviewed’ literature of alternative medicine.
Who publishes such utter and irresponsible rubbish?
You may well ask.
The journal has been discussed on this blog before for the junk that regularly appears in its pages, and so has its editor in chief. The authors (and the reviewers) are not known to me, but one thing is for sure: they don’t know the first thing about conducting a decent systematic review/meta-analysis.
The boom of alternative medicine in the US – and consequently in the rest of the developed world – is intimately connected with a NHI centre now called NCCIH (National Center for Complementary and Integrative Health). It was founded in the early 1990s because some politicians were bent on promoting quackery. Initially the institution had modest funding but, after more political interference, it had ample cash to pursue all sorts of activities, including sponsoring research into alternative therapies at US universities. A most interesting video summarising the history of the NCCIH can be seen here.
No other institution in the world had more funds for research into alternative medicine than the NCCIH, and it soon became the envy of alt med researchers globally. I have been invited by the NCCHI on several occasions and invariably was impressed by their apparent affluence. While we Europeans usually had to do our research on a shoe-string, our American colleagues seemed to be ‘rolling in it’.
I was often far less impressed with the research they sponsored. Not only it was invariably eye-wateringly expensive, but also its quality seemed often dismal. Sometimes, I even got the impression that research was used as a means of mainstreaming quackery for the unsuspecting American – and consequently world-wide – public.
An example of this mainstreaming is an article in JAMA published yesterday. Here is a short but telling excerpt:
Researchers led by Richard L. Nahin, PhD, MPH, lead epidemiologist at the NIH’s National Center for Complementary and Integrative Health (NCCIH), examined efficacy and safety evidence in 105 randomized controlled trials (RCTs) conducted between January 1966 and March 2016. The review—geared toward primary care physicians as part of the journal’s Symposium on Pain Medicine—focused on popular complementary approaches to common pain conditions.
Unlike a typical systematic review that assigns quality values to the studies, the investigators conducted a narrative review, in which they simply looked at the number of positive and negative trials. “If there were more positives than negatives then we generally felt the approach had some value,” Nahin explained. “If there were more negatives, we generally felt the approach had less value.” Trials that were conducted outside of the United States were excluded from the review.
Based on a “preponderance” of positive vs negative trials, complementary approaches that may offer pain relief include acupuncture and yoga for back pain; acupuncture and tai chi for osteoarthritis of the knee; massage therapy for neck pain; and relaxation techniques for severe headaches and migraine. Several other techniques had weaker evidence, according to the qualitative assessments, for specific pain conditions (see “Selected Complementary Health Approaches for Pain”). The treatments were generally safe, with no serious adverse events reported.
To me, this looks that NCCIH has now managed to persuade even the editors of JAMA to white-wash their dodgy science. The review referred to here is a paper we discussed some time ago on this blog. I then stated about it the following:
Reading the article carefully, it is impossible not to get troubled. Here are a few points that concern me most:
- the safety of a therapy cannot be evaluated on the basis of data from RCTs (particularly as it has been shown repeatedly that trials of alternative therapies often fail to report adverse effects); much larger samples are needed for that; any statements about safety in the aims of the paper are therefore misplaced;
- the authors talk about efficacy but seem to mean effectiveness;
- the authors only included RCTs from the US which must result in a skewed and incomplete picture;
- the article is from the National Center for Complementary and Integrative Health which is part of the NIH but which has been criticised repeatedly for being biased in favour of alternative medicine;
- not all of the authors seem to be NIH staff, and I cannot find a declaration of conflicts of interest;
- the discussion of the paper totally lacks any critical thinking;
- there is no assessment of the quality of the trials included in this review.
My last point is by far the most important. A summary of this nature that fails to take into account the numerous limitations of the primary data is, I think, as good as worthless. As I know most of the RCTs included in the analyses, I predict that the overall picture generated by this review would have changed substantially, if the risks of bias in the primary studies had been accounted for.
I find it puzzling that the ‘lead epidemiologist at the NIH’s National Center for Complementary and Integrative Health’ would publish such dubious research. Why does he do it? If you have watched the video mentioned above, you are inclined to think that it might be because of political interference.
However, I suggest another, in a way much more damming reason or contributing factor: the NCCIH has so long indulged in such poor science that even its top people have forgotten what good science looks like. I know this is a bold hypothesis; so, let me try to support it with some data.
Several years ago, my team together with several other researches have looked at the NCCIH-sponsored research systematically according to 4 different subject areas. Here are the conclusions of our articles reporting the findings:
ACUPUNCTURE
Seven RCTs had a low risk of bias. Numerous methodological shortcomings were identified. Many NCCAM-funded RCTs of acupuncture have important limitations. These findings might improve future studies of acupuncture and could be considered in the ongoing debate regarding NCCAM-funding. [Focus on Alternative and Complementary Therapies Volume 17(1) March 2012 15–21]
HERBAL MEDICINE
This independent assessment revealed a plethora of serious concerns related to NCCAM studies of herbal medicine. [Perfusion 2011; 24: 89-102]
ENERGY MEDICINE
In conclusion, the NCCAM-funded RCTs of energy medicine are prime examples of misguided investments into research. In our opinion, NCCAM should not be funding poor-quality studies of implausible practices. The impact of any future studies of energy medicine would be negligible or even detrimental. [Focus on Alternative and Complementary Therapies Volume 16(2) June 2011 106–109 ]
CHIROPRACTIC
In conclusion, our review demonstrates that several RCTs of chiropractic have been funded by the NCCAM. It raises numerous concerns in relation to these studies; in particular, it suggests that many of these studies are seriously flawed. [https://www.ncbi.nlm.nih.gov/pubmed/21207089]
I think I can rest my case and urge you to watch the video mentioned above.
