critical thinking
Today is WORLD ASTHMA DAY, a good opportunity perhaps to revisit a few of our own evaluations of so-called alternative medicine (SCAM) for asthma. Here are the abstracts of some of our systematic reviews on the subject:
Objective: The objective of this systematic review was to assess the effectiveness of yoga as a treatment option for asthma.
Method: Seven databases were searched from their inception to October 2010. Randomized clinical trials (RCTs) and non-randomized clinical trials (NRCTs) were considered, if they investigated any type of yoga in patients with asthma. The selection of studies, data extraction, and validation were performed independently by two reviewers.
Results: Six RCTs and one NRCT met the inclusion criteria. Their methodological quality was mostly poor. Three RCTs and one NRCT suggested that yoga leads to a significantly greater reduction in spirometric measures, airway hyperresponsivity, dose of histamine needed to provoke a 20% reduction in forced expiratory volume in the first second, weekly number of asthma attacks, and need for drug treatment. Three RCTs showed no positive effects compared to various control interventions.
Conclusions: The belief that yoga alleviates asthma is not supported by sound evidence. Further, more rigorous trials are warranted.
Some clinicians believe that spinal manipulation is an effective treatment for asthma. The aim of this systematic review was to critically evaluate the evidence for or against this claim. Four electronic databases were searched without language restrictions from their inceptions to September 2008. Bibliographies and departmental files were hand-searched. The methodological quality of all included studies was assessed with the Jadad score. Only randomised clinical trials of spinal manipulation as a treatment of asthma were included. Three studies met these criteria. All of them were of excellent methodological quality (Jadad score 5) and all used sham-manipulation as the control intervention. None of the studies showed that real manipulation was more effective than sham-manipulation in improving lung function or subjective symptoms. It is concluded that, according to the evidence of the most rigorous studies available to date, spinal manipulation is not an effective treatment for asthma.
Contradictory results from randomised controlled trials of acupuncture in asthma suggest both a beneficial and detrimental effect. The authors conducted a formal systematic review and meta-analysis of all randomised clinical trials in the published literature that have compared acupuncture at real and placebo points in asthma patients. The authors searched for trials published in the period 1970-2000. Trials had to measure at least one of the following objective outcomes: peak expiratory flow rate, forced expiratory volume in one second (FEV1) and forced vital capacity. Estimates of the standarised mean difference, between acupuncture and placebo were computed for each trial and combined to estimate the overall effect. Hetereogeneity was investigated in terms of the characteristics of the individual studies. Twelve trials met the inclusion criteria but data from one could not be obtained. Individual patient data were available in only three. Standardised differences between means ranging from 0.071 to 0.133, in favour of acupuncture, were obtained. The overall effect was not conventionally significant and it corresponds to an approximate difference in FEV1 means of 1.7. After exploring hetereogenenity, it was found that studies where bronchoconstriction was induced during the experiment showed a conventionally significant effect. This meta-analysis did not find evidence of an effect of acupuncture in reducing asthma. However, the meta-analysis was limited by shortcomings of the individual trials, in terms of sample size, missing information, adjustment of baseline characteristics and a possible bias against acupuncture introduced by the use of placebo points that may not be completely inactive. There was a suggestion of preferential publication of trials in favour of acupuncture. There is an obvious need to conduct a full-scale randomised clinical trial addressing these limitations and the prognostic value of the aetiology of the disease.
Background: Emotional stress can either precipitate or exacerbate both acute and chronic asthma. There is a large body of literature available on the use of relaxation techniques for the treatment of asthma symptoms. The aim of this systematic review was to determine if there is any evidence for or against the clinical efficacy of such interventions.
Methods: Four independent literature searches were performed on Medline, Cochrane Library, CISCOM, and Embase. Only randomised clinical trials (RCTs) were included. There were no restrictions on the language of publication. The data from trials that statistically compared the treatment group with that of the control were extracted in a standardised predefined manner and assessed critically by two independent reviewers.
Results: Fifteen trials were identified, of which nine compared the treatment group with the control group appropriately. Five RCTs tested progressive muscle relaxation or mental and muscular relaxation, two of which showed significant effects of therapy. One RCT investigating hypnotherapy, one of autogenic training, and two of biofeedback techniques revealed no therapeutic effects. Overall, the methodological quality of the studies was poor.
Conclusions: There is a lack of evidence for the efficacy of relaxation therapies in the management of asthma. This deficiency is due to the poor methodology of the studies as well as the inherent problems of conducting such trials. There is some evidence that muscular relaxation improves lung function of patients with asthma but no evidence for any other relaxation technique.
Background: Asthma is one of the most common chronic diseases in modern society and there is increasing evidence to suggest that its incidence and severity are increasing. There is a high prevalence of usage of complementary medicine for asthma. Herbal preparations have been cited as the third most popular complementary treatment modality by British asthma sufferers. This study was undertaken to determine if there is any evidence for the clinical efficacy of herbal preparations for the treatment of asthma symptoms.
Methods: Four independent literature searches were performed on Medline, Pubmed, Cochrane Library, and Embase. Only randomised clinical trials were included. There were no restrictions on the language of publication. The data were extracted in a standardised, predefined manner and assessed critically.
Results: Seventeen randomised clinical trials were found, six of which concerned the use of traditional Chinese herbal medicine and eight described traditional Indian medicine, of which five investigated Tylophora indica. Three other randomised trials tested a Japanese Kampo medicine, marihuana, and dried ivy leaf extract. Nine of the 17 trials reported a clinically relevant improvement in lung function and/or symptom scores.
Conclusions: No definitive evidence for any of the herbal preparations emerged. Considering the popularity of herbal medicine with asthma patients, there is urgent need for stringently designed clinically relevant randomised clinical trials for herbal preparations in the treatment of asthma.
Breathing techniques are used by a large proportion of asthma sufferers. This systematic review was aimed at determining whether or not these interventions are effective. Four independent literature searches identified six randomized controlled trials. The results of these studies are not uniform. Collectively the data imply that physiotherapeutic breathing techniques may have some potential in benefiting patients with asthma. The safety issue has so far not been addressed satisfactorily. It is concluded that too few studies have been carried out to warrant firm judgements. Further rigorous trials should be carried out in order to redress this situation.
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So, if you suffer from asthma, my advice is to stay away from SCAM. This might be easier said than done because SCAM practitioners are only too willing to lure asthma patients into their cult. In 2003, we have demonstrated this phenomenon by conducting a survey with chiropractors. Here is our short paper in full:
Classic chiropractic theory claims that vertebral subluxation blocks the flow of ‘‘innate intelligence’’ which, in turn, affects the health of asthma patients (1). Chiropractictors often use spinal manipulation (SM) to correct such malalignments and treat asthma (2). Several clinical trials of chiropractic SM exist, but the most rigorous ones are clearly negative (3,4). Chronic medication with corticosteroids can lead to osteoporosis, a condition, which is a contra-indication to chiropractic SM (5). Given this background, we aimed to determine whether chiropractors would advise an asthma patient on long-term corticosteroids (5 years) to try chiropractic as a treatment for this condition.
All 350 e-mail addresses listed at www.interadcom.com/chiro/html were randomised into two groups. A (deceptive) letter from a (fictitious) patient was sent to group A while group B was asked for advice on chiropractic treatment for asthma as part of a research project. Thus, groups A and B were asked the same question in di¡erent contexts: is chiropractic safe and e¡ective for an asthma patient on long-term steroids. After data collection, respondents from group A were informed that the e-mail had been part of a research project.
Of 97 e-mails in group A, we received 31 responses (response rate = 32% (95% CI, 0.23^ 0.41)). Seventy-four per cent (23 respondents) recommended visiting a chiropractor (95% CI, 0.59^ 0.89). Thirty-five per cent (11 respondents) mentioned minimal or no adverse effects of SM (95% CI, 0.18 ^ 0.52). Three chiropractors responded that some adverse e¡ects exist, e.g. risk of bone fracture, or stroke. Two respondents noted that other investigations (X-rays, spinal and neurological examination) were required before chiropractic treatment. Three respondents suggested additional treatments and one warned about a possible connection between asthma and the measles vaccine. Of 77 e-mails sent to group B, we received 16 responses (response rate = 21% (95% CI, 0.17^ 0.25)). Eleven respondents (69%) recommended visiting a chiropractor (95% CI, 0.46 ^ 0.91). Ten respondents mentioned minimal or no adverse effects of SM (95% CI, 0.39^ 0.87). Five chiropractors responded that adverse effects of SM exist (e.g. bone fracture). Five respondents suggested pre-testing the patient to check bone density, allergy, diet, exercise level, hydration and blood. Additional treatments were recommended by three respondents. The pooled results of groups A and B suggested that the majority of chiropractors recommend chiropractic treatment for asthma and the minority mention any adverse effects.
Our results demonstrate that chiropractic advice on asthma therapy is as readily available over the Internet as it is likely to be misleading. The majority of respondents from both groups (72%) recommended chiropractic treatment. This usually entails SM, a treatment modality which has been demonstrated to be ineffective in rigorous clinical trials (3,4,6). The advice may also be dangerous: the minority of the respondents of both groups (17%) caution of the risk of bone fracture. Our findings also suggest that, for the research question asked, a degree of deception is necessary. The response rate in group B was 12% lower than that of group A, and the answers received differed considerably between groups. In group A, 10% acknowledged the possibility of adverse e¡ects, this figure was 33% in group B. In conclusion, chiropractors readily provide advice regarding asthma treatment, which is often not evidence-based and has the potential to put patients at risk.
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As I stated above: if you suffer from asthma, my advice is to
stay away from SCAM.
The DAILY EXPRESS (DE) is not my favorite newspaper – perhaps even the opposite. During the last years, I have often been questioned by journalists on matters relating to so-called alternative medicine (SCAM). I do not recall, however, being interviewed by the DE (I might have forgotten, of course, but it certainly did not happen very often). I was therefore surprised to find that, in the last 13 years (this is as far back as I was able to search), the DE quoted me 22 times. Therefore, I decided to do a quick analysis of these 22 articles rating them (generously) for accuracy on a scale of 0 (totally inaccurate) to 10 (totally accurate).
1. Title (date of publication): Tracking down the safe alternatives (25 March 2008)
Subject: a new regulatory body (the Complementary and Natural Healthcare Council (CNHC)) might help separate the cranks from the credible.
Quote: The CNHC has been described as complementary medicine’s equivalent of the General Medical Council – the body which sets standards for GPs. It will investigate complaints and therapists who fall below expected standards could be struck off. The new organisation has been set up by Prince Charles’s Foundation for Integrated Health and receives part funding from the NHS. The Prince, who is a fan of homeopathy, believes that complementary therapies should have a greater role within the NHS…
Edzard Ernst, the UK’s first professor of complementary medicine, is scathing, describing the £2million cost of founding the CNHC as a waste of money. He says the new body does not challenge the safety or effectiveness of the therapies. “This organisation could give the public false confidence. Some of these therapies can do more harm than good. It will give them a status they don’t deserve.”
My comment (score): The subject matter was relevant. The article seems correct and my comment is true; the CNHC did, in fact, turn out to be a waste of space. (10)
2. Title (date of publication): Chinese Medicine: A risky remedy? (19 May 2008)
Subject: How much do we really know about how they work and could they actually be harmful to our health?
Quote: Traditional Chinese Medicine (TCM) is enjoying a boom with hundreds of shops appearing on high streets. The herbal medicine industry, which includes Chinese medicines, is worth an estimated £200million in the UK as thousands place their faith in ancient remedies for everything from acne to infertility…
Edzard Ernst, professor of complementary medicine at the University of Exeter and co-author of the book Trick Or Treatment: Alternative Medicine On Trial, says: “People think that because something is ancient or natural it must be good. That’s simply not true. Plenty of these medicines have side effects and can be dangerous. “TCMs are grossly under-researched in the UK. China’s research is hard to access and hard to understand. TCMs are frequently contaminated with toxic heavy metals. “This is because of poor quality, because soil is contaminated and supplying procedures are unregulated. The most worrying thing about TCMs is that they are regularly found to contain synthetic prescription drugs, which in extreme cases, taken wrongly, can kill.”
My comment (score): The subject matter was relevant. The article seems correct and my comment is true. (10)
3. Title (date of publication): Alternative treatments face calls for regulation (17 June 2008)
Subject: Alternative medicines must be regulated to protect patients from harm, according to an influential group of experts.
Quote: A government-appointed steering group said it was ridiculous that eight years after regulation was first called for, nothing had been done. And in a report to UK ministers, who have reserved powers on regulating health professionals, they warned it must be introduced “without delay”…
Prof Edzard Ernst, professor of complementary medicine at the University of Exeter, said there was no scientific evidence that homoeopathy works. Homoeopathy is the treatment of disease using minute doses of drugs diluted in water. Prof Ernst and author Simon Singh have pledged to give £10,000 to anyone who could prove, in a scientific way, that these treatments work as well as conventional medicines.
My comment (score): The subject matter was relevant. The article seems a bit confused. My comment seems to be from elsewhere and is out of context. (5)
4. Title (date of publication): Thank you for the music (28 June 2008)
Subject: Nerve disorder fibromyalgia left musician Emily Maguire housebound and in constant pain. As she prepares to play the Glastonbury festival she tells ABIGAIL JACKSON how her love of music pulled her through…
Quote: Dr Peter Fisher from the Royal London Homeopathic Hospital … has claimed to have success in treating fibromyalgia patients with homeopathic remedies. He prescribed ignacia, used as a remedy for numerous complaints from depression and sleeplessness to backache. A month later, Emily says the pain was gone. “I couldn’t believe it,” she says. “I feel so blessed.”
Although Emily is confident that taking ignacia (as well as maintaining a healthy lifestyle) did the trick, there are growing concerns over whether homeopathic remedies have any effect. Last week Edzard Ernst, the UK’s only professor of complementary medicine, offered £10,000 for any proof of a successful homeopathic treatment.
My comment (score): The subject matter is basically a case report which is not very relevant. The article seems confused and goes from the positive effects of music to homeopathy. What the article reports about our £10, 000 challenge is not relevant. (3)
5. Title (date of publication): Charles hit by ‘dodgy’ detox quackery row (11 March 2009)
Subject: Prince Charles was accused yesterday of using “quackery” to exploit gullible people after his Duchy Originals label launched a controversial detox tincture.
Quote: Andrew Baker, chief executive of Duchy Originals… said: “Duchy Herbals Detox Tincture is traded as a food supplement and in accordance with all of the relevant sections of both UK and European food laws. It is a natural aid to digestion and supports the body’s natural elimination processes. It is not – and has never been described as – a medicine, remedy or cure for any disease.”
Prof Ernst said: …“Products like this are a dangerous waste of money. Charles is exploiting gullible people during hard times. It’s outright quackery.” The academic, who has been a professor at Exeter for 15 years, labelled the Prince’s firm “Dodgy Originals”.
My comment (score): The subject matter was relevant, in my view. The article and my comments are both correct. (10)
6. Title (date of publication): Homeopathy: A ‘cure’ that is all in the mind? (11 February 2010)
Subject: Imagine if an electronics store publicly admitted that an entire range of the products it sold didn’t work. It wasn’t that the DVD players were not very good quality, it simply didn’t have any evidence that they played DVDs at all.
Quote: A report published yesterday by the House of Commons Science and Technology Committee said the products were no more effective than a dummy pill and recommended the NHS stop funding them. Back in October last year Paul Bennett, the professional standards director of Boots, appeared in front of the Committee’s inquiry into alternative medicine. When asked if he believed that homeopathic products worked he said: “There is certainly a consumer demand for these products. I have no evidence to suggest they are efficacious.”
Scientists say there is no evidence water has such a memory or that homeopathy works at all beyond a basic placebo effect. “The principles are simply implausible,” says Professor Edzard Ernst, Professor of Complementary Medicine at the Peninsular Medical School in Exeter. “It might be OK that the principle is implausible if the method still worked but rigorous clinical trials have demonstrated that the method doesn’t work. On both levels the result is negative.”
My comment (score): The subject matter was relevant. The article seems correct but my comment seems a bit confusing. (8)
7. Title (date of publication): Acupuncture ‘a waste of time’ for couples trying for a baby (10 March 2010)
Subject: Couples who have acupuncture to boost their chances of becoming parents are wasting their time and money, experts said yesterday.
Quote: New guidelines from the British Fertility Society, which represents fertility clinics, said there was “no evidence” that either acupuncture or traditional Chinese herbal remedies could improve the success rate of In-Vitro Fertilisation.
Edzard Ernst, professor of complementary medicine at the Peninsula Medical School, based at the universities of Exeter and Plymouth, said: “This is a long-overdue clarification. Infertile women have been misled for some time now to think that traditional Chinese medicine can help them getting pregnant. This analysis shows two things very clearly: The totality of the acupuncture trials does not support this notion, and for Chinese herbs, we have no evidence at all. This will help infertile women not to waste their money.”
My comment (score): The subject matter was relevant. The article seems correct and my comment is true. (10)
8. Title (date of publication): Prince Charles’s charity in £150 000 fraud quiz (4 April 2010)
Subject: One of Prince Charles’s charities is being investigated by police amid allegations of a £150,000 fraud.
Quote: The Prince’s Foundation for Integrated Health … which campaigns for the wider use of complementary therapies, has failed to file its annual return. According to the Charity Commission website it is 154 days overdue. A spokesman for the foundation said: “Due to staff and structural changes, there was a delay in preparing the 2008 accounts. While getting these accounts ready for filing, our auditors Kingston Smith questioned some of the transactions. A t their recommendation a complaint has been made to the police. ” … Dr Michael Dixon, medical director for the foundation, said: “We should not abandon patients we cannot help with conventional scientific medicine. If homeopathy is getting results for those patients then of course we should continue to use it.”
The complaint also claimed the foundation’s trustees allowed staff to pursue a “vendetta” against a prominent critic , Edzard Ernst, professor of complementary medicine at Exeter University. Republic accused the foundation of being partly responsible for the imminent closure of Professor Ernst’s department after he publicly attacked its draft guide to complementary medicines as “outrageous and deeply flawed”.
My comment (score): The subject matter was relevant. The article seems correct albeit slightly confusing (the ‘vendetta’ is not really relevant here) the quotes are somewhat beside the point; mine seems copied from elsewhere. (7)
9. Title (date of publication): Prince Charles’s charity amid £300k fraud inquiry (30 April 2010)
Subject: PRINCE Charles’s homeopathy charity has been shut down amid a Scotland Yard investigation into a £300,000 fraud.
Quote: The 49-year-old man was arrested on Monday with a 54-year-old woman, both on suspicion of the same offences, after an investigation into £300,000 of unaccounted funds in the charity’s books.
… while the foundation has enjoyed successes, sometimes working with the Prince’s Duchy Originals company to produce alternative health care products, it has also become embroiled in a series of controversies. Critics have accused it of promoting “unscientific” approaches to health care. In February, MPs on the Commons Science and Technology Committee called for an end to homeopathy treatment on the NHS, arguing there was no evidence to support its effectiveness. Edzard Ernst, professor of complementary medicine at Exeter University, last year described a detox tincture made by Duchy Originals as “outright quackery” and regulators ordered the firm to withdraw misleading advertising claims about the effectiveness of two natural remedies.
My comment (score): The subject matter was relevant. The article seems correct and my comment seems copied from elsewhere and is beside the point. (8)
10. Title (date of publication): ‘Snake oil seller’ Prince Charles cost me my job, claims professor (26 July 2011)
Subject: A university professor, who labelled Prince Charles and other supporters of complementary medicine as “snake-oil salesmen”, last night accused the heir to the throne of costing him his job.
Quote: Edzard Ernst, a consistent critic of Prince Charles and his Duchy Originals food company, is stepping down from his post at Exeter University as Britain’s only professor of complementary medicine after a long-running dispute with the Prince about the merits of alternative therapies. He said: “Almost directly, Prince Charles has managed to interfere in my professional life and almost managed to close my unit.” He blamed Charles, a prominent advocate of alternative therapies such as acupuncture, herbal remedies and homeopathy, for undermining him and leading his bosses to lose faith in him.
A spokeswoman for Charles claimed last night that the Prince was unaware that his private secretary had complained about the professor. She declined to respond to the description of her boss as a “snake-oil salesman”.
My comment (score): The subject matter was relevant. The article seems correct and my comment is true. (10)
11. Title (date of publication): Do detox diets work? (10 January 2012)
Subject: Most of us overdo it during the festive season. No wonder January is the most popular month for detox diets which typically involve drinking pints of water each day, eating a very restricted diet and taking particular supplements.
Quote: The theory is toxins from unhealthy types of food and drink build up in the body and can lead to health problems. Purging these toxins is meant to leave you feeling full of energy and thinner.
The principle of detox goes back to medieval times but it is anti-science, agrees Professor Edzard Ernst, Britain’s first professor of complementary medicine, who works at Peninsula College of Medicine & Dentistry in Exeter. “You can’t overindulge on food and drink, then wave some magic wand,” he says. “The only thing that detox removes is money from your wallet.”
My comment (score): The subject matter was relevant. The article seems correct and my comment is true. (10)
12. Title (date of publication): Kevin Sorbo: Three strokes left me fighting for my life (28 February 2012)
Subject: Becoming a key speaker at a medical conference may seem an unlikely part for a Hollywood tough guy. Nevertheless that’s the role Hercules star Kevin Sorbo took after breaking his silence over three life-threatening strokes.
Quote: He made an appointment with his chiropractor. “I had been seeing this guy for eight years and he never cracked my neck,” recalls Kevin. “He knew I didn’t like it.” So he was surprised when the therapist did crack his neck. When he asked him why, the chiropractor responded by saying “I felt you needed it”. Irritated, the star paid his bill and started driving back to the home of his girlfriend, now wife, Sam. “I heard two very loud pops in the back of my head and my vision went crazy. I felt like I was falling backwards and I couldn’t stop. It was like that feeling you get when you stand up too quickly and get dizzy but multiplied by 10,” he says. Kevin managed to drive to Sam’s apartment and despite hearing two more “pops” went on to appear on a TV chat show after his agent insisted he could not pull out at the last minute. “I don’t remember what we discussed. I was on auto-pilot. The entire world was spinning, my head was throbbing. It was the best acting of my life, acting as though I was healthy.”
Whether or not the cracking technique is dangerous is a controversial issue. A study by Professor Edzard Ernst, director of complementary medicine at the UK’s Peninsula Medical School says: “Numerous deaths have occurred after chiropractic manipulations.” He thinks the risks of this treatment by far outweigh its benefit and adds: “In my view a chiropractor should not go near the neck.”
However Haymo Thiel, vice-principal of the Anglo-European College of Chiropractic, says: “There is risk in anything. It would be foolish to say not. But there is a difference between coincidence of timing and causation.”
My comment (score): Even though this is merely a case report, the subject matter seems relevant. The article seems correct and my comments are true. The Thiel comment at the end might serve as a nice example of false balance. (8)
13. Title (date of publication): Menopause: Natural remedies vs HRT (29 January 2013)
Subject: Are natural remedies best for the menopause, or is HRT still the strongest defence against its many unpleasant symptoms?
Quote: Since two major studies called hormone replacement therapy into question a decade ago – raising fears of breast cancer, stroke and heart disease – women confronting the menopause have faced a confusing choice.
“Few of the herbal remedies have been properly studied,” says Edzard Ernst, professor of complementary medicine at the university of Exeter. “Some promising evidence has emerged for black cohosh and red clover, but even these are not as strongly beneficial as HRT.”
My comment (score): The subject matter was relevant. The article seems correct and my comment is true. (10)
14. Title (date of publication): How safe is our herbal medicine? (19 March 2013)
Subject: For many of us hoping to take care of our aches and pains, boost our immune system or improve our mood, herbal remedies are often the first resort. Seen as a healthier and more natural option than conventional medication few of us stop to ask how safe these supplements actually are.
Quote: High street health chain Holland & Barrett is the most recent to fall foul of these rules. In January it was ordered to recall a blend of black cohosh and agnus castus called Flash Fighters which it was selling as a food supplement. A spokesman for the chain confirmed: “The MHRA stated the product’s name implied it could be used to treat ‘hot flushes’.” He added that the store is undergoing the process of having Flash Fighters reclassified under the Traditional Herbal Medicine Registration Scheme (THR).
Professor Edzard Ernst, world’s first professor of complementary medicine, warns: “The notion that natural equals safe can be dangerously misleading.”
My comment (score): The subject matter was relevant. The article seems correct and my comment is true. (10)
15. Title (date of publication): Prince Charles SLAMMED as ‘immoral’ for peddling ‘rubbish’ alternative medicines (18 January 2018)
Subject: Charles is under fire from a renowned scientist who accuses him of being an “immoral snake oil salesman” for promoting alternative medicines in a shocking new book that lambasts the future monarch.
Quote: Professor Edzard Ernst, who previously accused Charles of “selling snake oil”, has now hit out with a new book called “More Harm than Good?” He scalds Charles for being a vocal supporter of homeopathy, lobbying health ministers to set up a register of holistic practitioners and making impassioned speeches at the World Health Assembly and British Medical Association. The authors of the book, Professor Ernst and Dr Kevin Smith, of Abertay University in Dundee, said alternative medicines are “immoral”. Professor Ernst said: “You can’t have alternative medicine just because Prince Charles likes it, because that is not in the best interest of the patients.
My comment (score): The basis for the article was a presentation of a new book at the ‘Science Media Centre’. The book merely mentioned Charles merely in passing. The article and our comments seem correct, however, they were not to focus of our presentation. (7)
16. Title (date of publication): Weight loss pills: Are they actually effective in helping you lose weight? (10 September 2018)
Subject: Weight loss pills claiming to help you lose weight, are widely advertised. But do they actually live up to their claims; are they effective in helping you to lose weight or are they simply a con?
Quote: More than one-third of adults are overweight in England alone, with nearly one-quarter obese, and growing numbers of people are turning to weight loss pills and products as a means to shed excess weight. Many weight loss pills claim to contain herbs or natural substances that speed up metabolism or make you feel full up to discourage you from eating. But according to the NHS, there is little evidence that some products sold by reputable retailers and over the internet actually work, and could even be packed with harmful substances. Even products marketed as ‘guaranteed, clinically-proven and 100 per cent natural’ come with no guarantees, the NHS warned.
Some manufacturers of weight loss products also only focus on positive trials, failing to mention the negative or failed trials. “Manufacturers cherry-pick and only ever mention the positive trials,” said academic physician and researcher Edzard Ernst. “They then also fail to mention the mostly poor quality of their studies. Desperate people are being misled to buy unproven treatments at considerable expense.”
My comment (score): The subject matter was relevant. The article seems correct and my comment is true. (10)
17. Title (date of publication): Prince Charles under fire for becoming patron of 175-year-old homeopathy group (26 June 2019)
Subject: The Prince of Wales has been criticised after being made a patron of a 175-year-old homeopathy group, which supports medical professionals with alternative treatments.
Quote: Charles has long advocated homeopathic medicine, which is seen as an alternative to regular chemical-based treatments. Homeopathy attempts to treat some conditions, including headaches and colds, so the body will get better by itself. But after Charles was accused of being an “immoral snake oil salesman” by a medical professor in 2017, it seems more are lining up to take aim at the future monarch for further endorsement of alternative medicine.
Professor Edzard Ernst, who made the initial criticisms of Charles last year, told the Guardian: “In view of Charles’s long love affair with homeopathy, this news is unsurprising. The question is whether this will change anything about the sharp decline homeopathy has taken in this and several other countries, and whether it will alter the verdicts of dozens of independent organisations which recently have certified it to be a pure placebo therapy.”
My comment (score): The subject matter was relevant. The article seems correct my quotes are borrowed from elsewhere. (7)
18. Title (date of publication): China sparks fresh coronavirus fears by turning to traditional medicine to fight virus (29 June 2020)
Subject: Chinese government papers have revealed that a shocking majority of the country’s cases have been treated with traditional medicine.
Quote: Coronavirus currently has very little universally approved and clinically proven treatments, but scientists have made some discoveries into potentially effective drugs.
Edzard Ernst, a retired UK-based researcher of complementary medicines, said that there is no science behind the recommendation to support it’s usage. He said to Nature: “For TCM there is no good evidence and therefore its use is not just unjustified, but dangerous.”
My comment (score): The subject matter was relevant. The article seems correct my quotes are borrowed from elsewhere. (7)
19. Title (date of publication): Prince Charles fury: Scientist’s shock claim royal ‘treated him like dirt’ exposed (1 July 2020)
Subject: Prince Charles is known to be enthusiastic about alternative medicines and therapies. Yet, Professor Edzard Ernst, who has several times criticised the royal for his influence in the world of pseudo-medicine, once claimed that the prince “silenced” and treated him “like dirt”, a shocking unearthed report revealed.
Quote:
Prince Charles for decades has welcomed alternative medicines and therapies to apparently “cure” his ailments. One of the pseudo-sciences most popular with the prince appears to be homeopathy. Homeopathy is the largely discredited practice of treating illness with diluted substances to trigger the body’s own healing mechanisms.
In 2015, Professor Edzard Ernst, claimed he had been “treated like dirt” as a result of Charles trying to “silence” him. Prof Ernst is a staunch critic of using alternative medicines such as homeopathy as a direct means of treatment. He instead champions complementary medicine – the process of using alternative medicines to help alleviate the negative aspects of standard medicines – having held the first complementary medicine post in the world at the University of Exeter. His unscrupulous and rigorous application of evidence-based science and outspoken views found him at loggerheads with Charles.
My comment (score): The subject matter was only marginally relevant. I am pretty sure that I never said Charles treated me like dirt. I did say, however, that my university did treat me like dirt when dealing with the complaint from Charles’s first private secretary, Sir Michael Peat. My comments are borrowed from elsewhere. (4)
20. Title (date of publication): Prince Charles’ ‘plot’ with Andy Burnham for UK healthcare unveiled: ‘He was open to it’ (23 October 2020)
Subject: Prince Charles was once in agreement with Andy Burnham on the future direction of the UK’s healthcare, letters have revealed.
Quote: …this is not the first time Mr Burnham has been caught up in a divisive matter over healthcare. In 2009, the Greater Manchester Mayor was the Health Secretary under then Prime Minister Gordon Brown and was found to be corresponding with the Prince of Wales about the UK healthcare system. Charles has a reputation for being a “meddling” royal, particularly after his so-called ‘black spider memos’ to Government ministers were published in 2015.
Professor of complementary medicine Edzard Ernst told The Guardian in 2015: “The letters demonstrate yet again that Prince Charles relentlessly meddles in UK health politics and thus disrespects his constitutional role. “His arguments in favour of CAM [complementary and alternative medicine] and in particular homeopathy, show a devastating lack of knowledge and understanding; they are ill-informed, invalid and embarrassingly naive – but at the same time they are remarkably persistent.”
My comment (score): The subject matter was relevant. The article seems confusing my quotes are borrowed from elsewhere. (7)
21. Title (date of publication): Meghan Markle warning: Charles’ business blunder exposed amid new career move (17 December 2020)
Subject: Meghan Marle has just moved into the business sector after investing in a start-up – but she should be careful to avoid Prince Charles’ previous industry error which triggered a public outcry.
Quote: The Duchess of Sussex has ventured into the investment sector this week. It was announced that she has invested in Clevr Blends, a California-based sustainable start-up which sells four flavours of instant oat milk lattes. The company says its produce is sustainable, ethically sourced and healthy with organic ingredients, while its shipping materials are 100 percent recyclable.
However, Meghan’s father-in-law was accused of exploiting the public when Britain was still recovering from the recession with his Duchy Originals line. The UK’s first professor of complementary medicine, Edzard Ernst, dubbed the Duchy Originals detox tincture — which was being sold on the market at the time — “outright quackery”. The product, called Duchy Herbals’ Detox Tincture, was advertised as a “natural aid to digestion and supports the body’s elimination processes” and a “food supplement to help eliminate toxins and aid digestion”. The artichoke and dandelion mix cost £10 for a 50ml bottle.
My comment (score): The subject matter seems fairly irrelevant and far-fetched. My quotes belong to a different story. (2)
22. Title (date of publication): Prince Charles rejected by experts before Gwyneth Paltrow’s long Covid row: ‘Witchcraft’ (25 February 2021)
Subject: Prince Charles was rejected by scientists for his views on “witchcraft” alternative medicine well before Gwyneth Paltrow became embroiled in a row over her unapproved treatments for long Covid.
Quote: Gwyneth Paltrow has been urged to stop spreading misinformation by the medical director of NHS England after she suggested on her blog Goop that long Covid could be treated with various alternative medicines. The Hollywood star described how she herself had caught coronavirus and had since suffered with “long-tail fatigue and brain fog”. However, she claimed to have successfully treated it with “intuitive fasting”, herbal cocktails and regular visits to an “infrared sauna”.
The Prince of Wales has been specifically called out for advocating the controversial treatments, too. He was branded an “immoral snake oil salesman” by renowned scientist Professor Edzard Ernst in his book ‘More Harm Than Good?’ Prof Ernst founded the department of Complementary Medicine at the University of Exeter, became the world’s first academic on the subject and has founded two medical journals. Over the years, he has published a lot of critical research exposing methods that lack documentation of efficacy. The expert lambasted Charles for lobbying health ministers to set up a register of holistic practitioners and making impassioned speeches at the World Health Assembly and British Medical Association. He said: “You can’t have alternative medicine just because Prince Charles likes it, because that is not in the best interest of the patients. “The quality of the research is not just bad, but dismal. It ignores harms. There is a whole shelf of rubbish being sold and that is simply unethical.” His co-author, Dr Kevin Smith ‒ a senior lecturer at Abertay University specialising in Complementary and Alternative Medicine and genetics ‒ agreed that these alternative medicines are “immoral”. He added: “We certainly are very worried about the future King being a proponent.
My comment (score): The subject matter seems fairly irrelevant and far-fetched. My quotes belong to a different story. (2)
________________________________________
When I set out doing this analysis, I expected to find rather poor reporting by the DE. Yet, I was pleasantly surprised. Quite a lot of it is good. A few things did nevertheless occur to me:
- I find it remarkable how often Prince Charles is the focus of these stories. Occasionally, my various disputes with Charles were ‘pulled in’ even though they do not really fit into the context of the article.
- It is noticeable, I think, that the quality of the reporting deteriorated quite dramatically over time.
- The DE repeatedly borrows quotes from other publications and even from different stories altogether. This seems to me to be lazy and rather poor journalism.
My point is that there is really no need for lazy or poor journalism on SCAM. Journalists should do their work properly; they can always reach me via the contact option of this blog (I invariably reply swiftly). I feel they owe it to their readers to do at least this minimal and quick amount of effort.
Acupuncture for animals has a long history in China. In the West, it was introduced in the 1970s when acupuncture became popular for humans. A recent article sums up our current knowledge on the subject. Here is an excerpt:
Acupuncture is used mainly for functional problems such as those involving noninfectious inflammation, paralysis, or pain. For small animals, acupuncture has been used for treating arthritis, hip dysplasia, lick granuloma, feline asthma, diarrhea, and certain reproductive problems. For larger animals, acupuncture has been used for treating downer cow syndrome, facial nerve paralysis, allergic dermatitis, respiratory problems, nonsurgical colic, and certain reproductive disorders.Acupuncture has also been used on competitive animals. There are veterinarians who use acupuncture along with herbs to treat muscle injuries in dogs and cats. Veterinarians charge around $85 for each acupuncture session.[8]Veterinary acupuncture has also recently been used on more exotic animals, such as chimpanzees (Pan troglodytes)[9] and an alligator with scoliosis,[10] though this is still quite rare.
To put it in a nutshell: acupuncture for animals is not evidence-based.
How can I be so sure?
Because ref 1 in the text above refers to our paper. Here is its abstract:
Acupuncture is a popular complementary treatment option in human medicine. Increasingly, owners also seek acupuncture for their animals. The aim of the systematic review reported here was to summarize and assess the clinical evidence for or against the effectiveness of acupuncture in veterinary medicine. Systematic searches were conducted on Medline, Embase, Amed, Cinahl, Japana Centra Revuo Medicina and Chikusan Bunken Kensaku. Hand-searches included conference proceedings, bibliographies, and contact with experts and veterinary acupuncture associations. There were no restrictions regarding the language of publication. All controlled clinical trials testing acupuncture in any condition of domestic animals were included. Studies using laboratory animals were excluded. Titles and abstracts of identified articles were read, and hard copies were obtained. Inclusion and exclusion of studies, data extraction, and validation were performed independently by two reviewers. Methodologic quality was evaluated by means of the Jadad score. Fourteen randomized controlled trials and 17 nonrandomized controlled trials met our criteria and were, therefore, included. The methodologic quality of these trials was variable but, on average, was low. For cutaneous pain and diarrhea, encouraging evidence exists that warrants further investigation in rigorous trials. Single studies reported some positive intergroup differences for spinal cord injury, Cushing’s syndrome, lung function, hepatitis, and rumen acidosis. These trials require independent replication. On the basis of the findings of this systematic review, there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals. Some encouraging data do exist that warrant further investigation in independent rigorous trials.
This evidence is in sharp contrast to the misinformation published by the ‘IVAS’ (International Veterinary Acupuncture Society). Under the heading “For Which Conditions is Acupuncture Indicated?“, they propagate the following myth:
Acupuncture is indicated for functional problems such as those that involve paralysis, noninfectious inflammation (such as allergies), and pain. For small animals, the following are some of the general conditions which may be treated with acupuncture:
- Musculoskeletal problems, such as arthritis, intervertebral disk disease, or traumatic nerve injury
- Respiratory problems, such as feline asthma
- Skin problems such as lick granulomas and allergic dermatitis
- Gastrointestinal problems such as diarrhea
- Selected reproductive problems
For large animals, acupuncture is again commonly used for functional problems. Some of the general conditions where it might be applied are the following:
- Musculoskeletal problems such as sore backs or downer cow syndrome
- Neurological problems such as facial paralysis
- Skin problems such as allergic dermatitis
- Respiratory problems such as heaves and “bleeders”
- Gastrointestinal problems such as nonsurgical colic
- Selected reproductive problems
In addition, regular acupuncture treatment can treat minor sports injuries as they occur and help to keep muscles and tendons resistant to injury. World-class professional and amateur athletes often use acupuncture as a routine part of their training. If your animals are involved in any athletic endeavor, such as racing, jumping, or showing, acupuncture can help them keep in top physical condition.
And what is the conclusion?
Perhaps this?
Never trust the promotional rubbish produced by SCAM organizations.
This story made the social media recently:
Yes, I can well believe that many chiros are daft enough to interpret the incident in this way. Yet I think it’s a lovely story, not least because it reminds me of one of my own experiences:
I was on a plane to Toronto and had fallen asleep after a good meal and a few glasses of wine when a stewardess woke me saying: “We think you are a doctor!?”
“That’s right, I am a professor of alternative medicine”, I said trying to wake up.
“We have someone on board who seems to be dying. Would you come and have a look? We moved him into 1st class.”
Arrived in 1st class, she showed me the patient and a stethoscope. The patient was unconscious and slightly blue in the face. I opened his shirt and used the stethoscope only to find that this device is utterly useless on a plane; the sound of the engine by far overwhelms anything else. With my free hand, I tried to find a pulse – without success! Meanwhile, I had seen a fresh scar on the patient’s chest with something round implanted underneath. I concluded that the patient had recently had a pacemaker implant. Evidently, the electronic device had malfunctioned.
At this stage, two stewardesses were pressing me: “The captain needs to know now whether to prepare for an emergency stop in Newfoundland or to fly on. It is your decision.”
I had problems thinking clearly. What was best? The patient was clearly dying and there was nothing I could do about it. I replied by asking them to give me 5 minutes while I tried my best. But what could I do? I decided that I could do nothing but hold the patient’s hand and let him die in peace.
The Stewardesses watched me doing this and must have thought that I was trying some sort of energy healing, perhaps Reiki. This awkward situation continued for several minutes until – out of the blue – I felt a regular, strong pulse. Evidently, the pacemaker had started functioning again. It did not last long until the patient’s color turned pink and he began to talk. I instructed the pilot to continue our path to Toronto.
After I had remained with the patient for another 10 minutes or so, the Stewardesses came and announced: “We have moved your things into 1st class; like this, you can keep an eye on him.” The rest of the journey was uneventful – except the Stewardesses came repeatedly giving me bottles of champagne and fine wine to take with me into Toronto. And each time they politely asked whether my healing method would not also work for the various ailments they happened to suffer from – varicose veins, headache, PMS, fatigue …
So, here is my message to all the fellow energy healers out there:
We honor the creator’s design.
We know of the potential of the body is limitless.
Remember, you did not choose energy healing.
Energy healing chose you.
You were called for a time like this.
In case you are beginning to wonder whether I have gone round the bend, the answer is NO! I am not an energy healer. In fact, I am as much NOT an energy healer, as the chiropractor in the above story has NOT saved the life of his patient. Chiropractors and stewardesses, it seems to me, have one thing in common: they do not understand much about medicine.
PS
On arrival in Toronto, the patient was met by a team of fully equipped medics. I explained what had happened and they took him off to the hospital. As far as I know, he made a full recovery after the faulty pacemaker had been replaced. After my return to the UK, British Airways sent me a huge hamper to thank me.
This systematic review and meta-analysis of clinical trials were performed to summarize the evidence of the effects of Urtica dioica (UD) consumption on metabolic profiles in patients with type 2 diabetes mellitus (T2DM).
Eligible studies were retrieved from searches of PubMed, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar databases until December 2019. Cochran (Q) and I-square statistics were used to examine heterogeneity across included clinical trials. Data were pooled using a fixed-effect or random-effects model and expressed as weighted mean difference (WMD) and 95% confidence interval (CI).
Among 1485 citations, thirteen clinical trials were found to be eligible for the current metaanalysis. UD consumption significantly decreased levels of fasting blood glucose (FBG) (WMD = – 17.17 mg/dl, 95% CI: -26.60, -7.73, I2 = 93.2%), hemoglobin A1c (HbA1c) (WMD = -0.93, 95% CI: – 1.66, -0.17, I2 = 75.0%), C-reactive protein (CRP) (WMD = -1.09 mg/dl, 95% CI: -1.64, -0.53, I2 = 0.0%), triglycerides (WMD = -26.94 mg/dl, 95 % CI = [-52.07, -1.82], P = 0.03, I2 = 90.0%), systolic blood pressure (SBP) (WMD = -5.03 mmHg, 95% CI = -8.15, -1.91, I2 = 0.0%) in comparison to the control groups. UD consumption did not significantly change serum levels of insulin (WMD = 1.07 μU/ml, 95% CI: -1.59, 3.73, I2 = 63.5%), total-cholesterol (WMD = -6.39 mg/dl, 95% CI: -13.84, 1.05, I2 = 0.0%), LDL-cholesterol (LDL-C) (WMD = -1.30 mg/dl, 95% CI: -9.95, 7.35, I2 = 66.1%), HDL-cholesterol (HDL-C) (WMD = 6.95 mg/dl, 95% CI: -0.14, 14.03, I2 = 95.4%), body max index (BMI) (WMD = -0.16 kg/m2, 95% CI: -1.77, 1.44, I2 = 0.0%), and diastolic blood pressure (DBP) (WMD = -1.35 mmHg, 95% CI: -2.86, 0.17, I2= 0.0%) among patients with T2DM.
The authors concluded that UD consumption may result in an improvement in levels of FBS, HbA1c, CRP, triglycerides, and SBP, but did not affect levels of insulin, total-, LDL-, and HDL-cholesterol, BMI, and DBP in patients with T2DM.
Several plants have been reported to affect the parameters of diabetes. Whenever I read such results, I cannot stop wondering whether this is a good or a bad thing. It seems to be positive at first glance, yet I can imagine at least two scenarios where such effects might be detrimental:
- A patient reads about the antidiabetic effects and decides to swap his medication for the herbal remedy which is far less effective. Consequently, the patient’s metabolic control is insufficient.
- A patient adds the herbal remedy to his therapy. Consequently, his blood sugar drops too far and he suffers a hypoglycemic episode.
My advice to diabetics is therefore this: if you want to try herbal antidiabetic treatments, please think twice. And if you persist, do it only under the close supervision of your doctor.
There is a lack of data describing the state of naturopathic or complementary veterinary medicine in Germany. This survey maps the currently used treatment modalities, indications, existing qualifications, and information pathways. It records the advantages and disadvantages of these medicines as experienced by veterinarians. Demographic influences are investigated to describe the distributional impacts of using veterinary naturopathy and complementary medicine.
A standardized questionnaire was used for the cross-sectional survey. It was distributed throughout Germany in a written and digital format from September 2016 to January 2018. Because of the open nature of data collection, the return rate of questionnaires could not be calculated. To establish a feasible timeframe, active data collection stopped when the previously calculated limit of 1061 questionnaires was reached.
With the included incoming questionnaires of that day, a total of 1087 questionnaires were collected. Completely blank questionnaires and those where participants did not meet the inclusion criteria were not included, leaving 870 out of 1087 questionnaires to be evaluated. A literature review and the first test run of the questionnaire identified the following treatment modalities:
- homeopathy,
- phytotherapy,
- traditional Chinese medicine (TCM),
- biophysical treatments,
- manual treatments,
- Bach Flower Remedies,
- neural therapy,
- homotoxicology,
- organotherapy,
- hirudotherapy.
These were included in the questionnaire. Categorical items were processed using descriptive statistics in absolute and relative numbers based on the population of completed answers provided for each item. Multiple choices were possible.
Overall 85.4% of all the questionnaire participants used naturopathy and complementary medicine. The treatments most commonly used were:
- complex homoeopathy (70.4%, n = 478),
- phytotherapy (60.2%, n = 409),
- classic homoeopathy (44.3%, n = 301),
- biophysical treatments (40.1%, n = 272).
The most common indications were:
- orthopedic (n = 1798),
- geriatric (n = 1428),
- metabolic diseases (n = 1124).
Over the last five years, owner demand for naturopathy and complementary treatments was rated as growing by 57.9% of respondents (n = 457 of total 789). Veterinarians most commonly used scientific journals and publications as sources for information about naturopathic and complementary contents (60.8%, n = 479 of total 788). These were followed by advanced training acknowledged by the ATF (Academy for Veterinary Continuing Education, an organisation that certifies independent veterinary continuing education in Germany) (48.6%, n = 383). The current information about naturopathy and complementary medicine was rated as adequate or nearly adequate by many (39.5%, n = 308) of the respondents.
The most commonly named advantages in using veterinary naturopathy and complementary medicine were:
- expansion of treatment modalities (73.5%, n = 566 of total 770),
- customer satisfaction (70.8%, n = 545),
- lower side effects (63.2%, n = 487).
The ambiguity and unclear evidence of the mode of action and effectiveness (62.1%, n = 483) and high expectations of owners (50.5%, n = 393) were the disadvantages mentioned most frequently. Classic homoeopathy, in particular, has been named in this context (78.4%, n = 333 of total 425). Age, gender, and type of employment showed a statistically significant impact on the use of naturopathy and complementary medicine by veterinarians (p < 0.001). The university of final graduation showed a weaker but still statistically significant impact (p = 0.027). Users of veterinary naturopathy and complementary medicine tended to be older, female, self-employed and a higher percentage of them completed their studies at the University of Berlin. The working environment (rural or urban space) showed no statistical impact on the veterinary naturopathy or complementary medicine profession.
The authors concluded that this is the first study to provide German data on the actual use of naturopathy and complementary medicine in small animal science. Despite a potential bias due to voluntary participation, it shows a large number of applications for various indications. Homoeopathy was mentioned most frequently as the treatment option with the most potential disadvantages. However, it is also the most frequently used treatment option in this study. The presented study, despite its restrictions, supports the need for a discussion about evidence, official regulations, and the need for acknowledged qualifications because of the widespread application of veterinary naturopathy and complementary medicine. More data regarding the effectiveness and the mode of action is needed to enable veterinarians to provide evidence-based advice to pet owners.
I can only hope that the findings are seriously biased and not a true reflection of the real situation. The methodology used for recruiting participants (it is fair to assume that those vets who had no interest in SCAM did not bother to respond) strongly indicates that this might be the case. If, however, the findings were true, one would have to conclude that, for German vets, evidence-based healthcare is still an alien concept. The evidence that the preferred SCAMs are effective for the listed conditions is very weak or even negative. If the findings were true, one would need to wonder how much of veterinary SCAM use amounts to animal abuse.
The objective of this study was to compare chronic low back pain patients’ perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment.
Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data:
- The SMT group began long-term management with SMT but no prescribed drugs.
- The PDT group began long-term management with prescription drug therapy but no spinal manipulation.
- This group employed SMT for chronic back pain, followed by initiation of long-term management with PDT in the same year.
- This group used PDT for chronic back pain followed by initiation of long-term management with SMT in the same year.
A total of 1986 surveys were sent out and 195 participants completed the survey. The respondents were predominantly female and white, with a mean age of approx. 77-78 years. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short-Form Health Survey to measure HRQoL.
Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort’s reported concern about PDT (P = .03).
The authors concluded that among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.
The main issue here is that the ‘study’ was a mere survey which by definition cannot establish cause and effect. The groups were different in many respects which rendered them not comparable. For instance, participants who received SMT had higher self-reported physical and mental health on average than those who received PDT. Differences also existed between the SMT and the PDT groups for agreement with the notion that “spinal manipulation for LBP makes a lot of sense”; 96% of the SMT group and 35% of the PDT group agreed with it. Compare this with another statement, “taking /having prescription drug therapy for LBP makes a lot of sense” and we find that only 13% of the SMT cohort agreed with, 95% of the PDT cohort agreed. Thus, a powerful bias exists toward the type of therapy that each person had chosen. Another determinant of the outcome is the fact that SMT means hands-on treatments with time, compassion, and empathy given to the patient, whereas PDT does not necessarily include such features. Add to these limitations the dismal response rate, recall bias, and numerous potential confounders and you have a survey that is hardly worth the paper it is printed on. In fact, it is little more than a marketing exercise for chiropractic.
In summary, the findings of this survey are influenced by a whole range of known and unknown factors other than the SMT. The authors are clever to avoid causal inferences in their conclusions. I doubt, however, that many chiropractors reading the paper think critically enough to do the same.
This study describes the use of so-called alternative medicine (SCAM) among older adults who report being hampered in daily activities due to musculoskeletal pain. The characteristics of older adults with debilitating musculoskeletal pain who report SCAM use is also examined. For this purpose, the cross-sectional European Social Survey Round 7 from 21 countries was employed. It examined participants aged 55 years and older, who reported musculoskeletal pain that hampered daily activities in the past 12 months.
Of the 4950 older adult participants, the majority (63.5%) were from the West of Europe, reported secondary education or less (78.2%), and reported at least one other health-related problem (74.6%). In total, 1657 (33.5%) reported using at least one SCAM treatment in the previous year.
The most commonly used SCAMs were:
- manual body-based therapies (MBBTs) including massage therapy (17.9%),
- osteopathy (7.0%),
- homeopathy (6.5%)
- herbal treatments (5.3%).
SCAM use was positively associated with:
- younger age,
- physiotherapy use,
- female gender,
- higher levels of education,
- being in employment,
- living in West Europe,
- multiple health problems.
(Many years ago, I have summarized the most consistent determinants of SCAM use with the acronym ‘FAME‘ [female, affluent, middle-aged, educated])
The authors concluded that a third of older Europeans with musculoskeletal pain report SCAM use in the previous 12 months. Certain subgroups with higher rates of SCAM use could be identified. Clinicians should comprehensively and routinely assess SCAM use among older adults with musculoskeletal pain.
I often mutter about the plethora of SCAM surveys that report nothing meaningful. This one is better than most. Yet, much of what it shows has been demonstrated before.
I think what this survey confirms foremost is the fact that the popularity of a particular SCAM and the evidence that it is effective are two factors that are largely unrelated. In my view, this means that more, much more, needs to be done to inform the public responsibly. This would entail making it much clearer:
- which forms of SCAM are effective for which condition or symptom,
- which are not effective,
- which are dangerous,
- and which treatment (SCAM or conventional) has the best risk/benefit balance.
Such information could help prevent unnecessary suffering (the use of ineffective SCAMs must inevitably lead to fewer symptoms being optimally treated) as well as reduce the evidently huge waste of money spent on useless SCAMs.
There is hardly a form of therapy under the SCAM umbrella that is not promoted for back pain. None of them is backed by convincing evidence. This might be because back problems are mostly viewed in SCAM as mechanical by nature, and psychological elements are thus often neglected.
This systematic review with network meta-analysis determined the comparative effectiveness and safety of psychological interventions for chronic low back pain. Randomised controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain were included.
A total of 97 randomised controlled trials involving 13 136 participants and 17 treatment nodes were included. Inconsistency was detected at short term and mid-term follow-up for physical function, and short term follow-up for pain intensity, and were resolved through sensitivity analyses. For physical function, cognitive behavioural therapy (standardised mean difference 1.01, 95% confidence interval 0.58 to 1.44), and pain education (0.62, 0.08 to 1.17), delivered with physiotherapy care, resulted in clinically important improvements at post-intervention (moderate-quality evidence). The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physiotherapy care, at least until mid-term follow-up (0.63, 0.25 to 1.00; low-quality evidence). No studies investigated the long term effectiveness of pain education delivered with physiotherapy care. For pain intensity, behavioural therapy (1.08, 0.22 to 1.94), cognitive behavioural therapy (0.92, 0.43 to 1.42), and pain education (0.91, 0.37 to 1.45), delivered with physiotherapy care, resulted in clinically important effects at post-intervention (low to moderate-quality evidence). Only behavioural therapy delivered with physiotherapy care maintained clinically important effects on reducing pain intensity until mid-term follow-up (1.01, 0.41 to 1.60; high-quality evidence).
Forest plot of network meta-analysis results for physical function at post-intervention. *Denotes significance at p<0.05. BT=behavioural therapy; CBT=cognitive behavioural therapy; Comb psych=combined psychological approaches; Csl=counselling; GP care=general practitioner care; PE=pain education; SMD=standardised mean difference. Physiotherapy care was the reference comparison group
The authors concluded that for people with chronic, non-specific low back pain, psychological interventions are most effective when delivered in conjunction with physiotherapy care (mainly structured exercise). Pain education programmes (low to moderate-quality evidence) and behavioural therapy (low to high-quality evidence) result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness. Although inconsistency was detected, potential sources were identified and resolved.
The authors’ further comment that their review has identified that pain education, behavioural therapy, and cognitive behavioural therapy are the most effective psychological interventions for people with chronic, non-specific LBP post-intervention when delivered with physiotherapy care. The most sustainable effects of treatment for physical function and fear avoidance are achieved with pain education programmes, and for pain intensity, they are achieved with behavioural therapy. Although their clinical effectiveness diminishes over time, particularly in the long term (≥12 months post-intervention), evidence supports the clinical benefits of combining physiotherapy care with these specific types of psychological interventions at the onset of treatment. The small total sample size at long term follow-up (eg, for physical function, n=6986 at post-intervention v n=2469 for long term follow-up; for pain intensity, n=6963 v n=2272) has resulted in wide confidence intervals at this time point; however, the magnitude and direction of the pooled effects seemed to consistently favour the psychological interventions delivered with physiotherapy care, compared with physiotherapy care alone.
Commenting on their paper, two of the authors, Ferriera and Ho, said they would like to see the guidelines on LBP therapy updated to provide more specific recommendations, the “whole idea” is to inform patients, so they can have conversations with their GP or physiotherapist. Patients should not come to consultations with a passive attitude of just receiving whatever people tell them because unfortunately people still receive the wrong care for chronic back pain,” Ferreira says. “Clinicians prescribe anti-inflammatories or paracetamol. We need to educate patients and clinicians about options and more effective ways of managing pain.”
Is there a lesson here for patients consulting SCAM practitioners for their back pain? Perhaps it is this: it is wise to choose the therapy that has been demonstrated to be effective while having the least potential for harm! And this is not chiropractic or any other form of SCAM. It could, however, well be a combination of physiotherapeutic exercise and psychological therapy.
S-adenosyl methionine – SAMe for short – is a popular dietary supplement available freely via the Internet. It is a naturally occurring methyl radical donor involved in enzymatic transmethylation reactions in humans and animals. It has been used for treating postpartum depression, cholestatic jaundice, osteoarthritis, and numerous other conditions. SAM-e has poor oral bioavailability. SAM-e has so far been thought of as safe. The most frequent adverse effects reported were gastrointestinal, such as nausea, and skin rashes.
I have been involved in two systematic reviews that produced positive evidence for the effectiveness of SAMe:
- One review found “consistent evidence that … S-adenosyl methionine was effective in the management of osteoarthritis.”
- Another review showed that for fibromyalgia “the effects of … S-adenosylmethionine … showed at least one statistically significant improved outcome compared with placebo.”
Now the safety of SAMe has been questioned by new research. A team from Manchester and Kyoto universities reported that the supplement can break down inside the body into substances that cause a wide range of medical problems, including kidney and liver damage. Their study showed that “excess S-adenosylmethionine disrupts rhythms and, rather than promoting methylation, is catabolized to adenine and methylthioadenosine, toxic methylation inhibitors.”
Jean-Michel Fustin, of Manchester University, said experiments that he and his collaborators had carried out had revealed that SAMe breaks down into adenine and methylthioadenosine in the body. These substances are known to be toxic, he added. “This discovery came out of the blue,” Fustin said last week. “When we gave the supplement to mice we expected they would become healthier. But instead we found the opposite. We found that when SAMe breaks down in the body, it produces very toxic molecules, including adenine which causes gout, kidney disease and liver disease.” Fustin added that, although their study was carried out on mice, their results were relevant for humans. “We have not yet tested the supplement on men and women but we have added it to human cells in laboratory cultures and have found it had the same effect as it had on mice.”
Their study, which was funded by the Medical Research Council and the Japanese Society for the Promotion of Science, makes it clear that the health benefits of SAMe are questionable, to say the very least, Fustin added. “It is unclear what dose of it might be safe, so there is a good chance that a safe dose will be exceeded if someone takes this supplement – if a safe dose exists at all.”
