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

EBM

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Individuals with large followings can influence public opinions and behaviors, especially during a pandemic. In the early days of the COVID pandemic, US president Donald J Trump endorsed the use of unproven therapies. Subsequently, a death attributed to the wrongful ingestion of a chloroquine-containing compound occurred.

This paper investigated Donald J Trump’s speeches and Twitter posts, as well as Google searches and Amazon purchases, and television airtime for mentions of hydroxychloroquine, chloroquine, azithromycin, and remdesivir. Twitter sourcing was catalogued with Factba.se, and analytics data, both past and present, were analyzed with Tweet Binder to assess average analytics data on key metrics. Donald J Trump’s time spent discussing unverified treatments on the United States’ 5 largest TV stations was catalogued with the Global Database of Events, Language, and Tone, and his speech transcripts were obtained from White House briefings. Google searches and shopping trends were analyzed with Google Trends. Amazon purchases were assessed using Helium 10 software.

From March 1 to April 30, 2020, Donald J Trump made 11 tweets about unproven therapies and mentioned these therapies 65 times in White House briefings, especially touting hydroxychloroquine and chloroquine. These tweets had an impression reach of 300% above Donald J Trump’s average. Following these tweets, at least 2% of airtime on conservative networks for treatment modalities like azithromycin and continuous mentions of such treatments were observed on stations like Fox News. Google searches and purchases increased following his first press conference on March 19, 2020, and increased again following his tweets on March 21, 2020. The same is true for medications on Amazon, with purchases for medicine substitutes, such as hydroxychloroquine, increasing by 200%.

The authors concluded that individuals in positions of power can sway public purchasing, resulting in undesired effects when the individuals’ claims are unverified. Public health officials must work to dissuade the use of unproven treatments for COVID-19.

Trump is by no means the only politician who misled the public in matters of healthcare through ignorance, or stupidity, or both. Other recent examples that we previously discussed include, for instance:

Yes, Trump is not the only, but he is the most influential and might well be the most ignorant one:

For this reason alone – and there are many more – I hope he will not soon become merely a dark and scary chapter in the history of the US.

The BBC has repeatedly misled the public on matters related to so-called alternative medicine (SCAM). Examples include:

Recently the BBC published an article about Ashwagandha. Here it is in its untouched beauty:

Ashwagandha is a herb (Withania somnifera) in the nightshade family, which also includes tomatoes and chilli peppers.  It has been used in traditional Indian medicine (Ayurveda) for thousands of years to make preparations for treating various ailments, from infectious diseases, like tuberculosis, to pain and inflammation, baldness and hiccups. In classic Ayurvedic texts, it’s also described as a ‘mental strength promoter’ (or ‘Balya’).

While lots of research has been done on ashwagandha, studies for specific conditions can be sparser. Perhaps the most recent assessment of its use for stress and anxiety comes from a 2022 review of studies by the Cochrane Collaboration, which is internationally recognised for its high-standard medical reviews. Although the Cochrane researchers were only able to find 12 studies on the subject, which together tested the herb on just 1,002 participants, their findings did suggest that ashwagandha can lower stress and anxiety. The researchers rated the ‘certainty’ of the evidence as ‘low’ and called for more detailed studies, though.

The benefits of ashwagandha are thought to be related to natural steroids called withanolides, but this group includes hundreds of compounds, with tens having been isolated from ashwagandha so far. As with any herbal remedy, the combination of compounds and the exact concoction you get depends on how and where the plant is grown, and how it’s prepared. This means that not all supplements based on the same plant are equal.

Remember, too, that herbal doesn’t mean risk-free. For some people, ashwagandha causes drowsiness and more serious side effects aren’t unknown. It’s best to treat it like a drug and not ‘just’ a herb.

The review cited in the article is this one:

Clinical trial studies revealed conflicting results on the effect of Ashwagandha extract on anxiety and stress. Therefore, we aimed to evaluate the effect of Ashwagandha supplementation on anxiety as well as stress. A systematic search was performed in PubMed/Medline, Scopus, and Google Scholar from inception until December 2021. We included randomized clinical trials (RCTs) that investigate the effect of Ashwagandha extract on anxiety and stress. The overall effect size was pooled by random-effects model and the standardized mean difference (SMD) and 95% confidence interval (CIs) for outcomes were applied. Overall, 12 eligible papers with a total sample size of 1,002 participants and age range between 25 and 48 years were included in the current systematic review and meta-analysis. We found that Ashwagandha supplementation significantly reduced anxiety (SMD: −1.55, 95% CI: −2.37, −0.74; p = .005; I2 = 93.8%) and stress level (SMD: −1.75; 95% CI: −2.29, −1.22; p = .005; I2 = 83.1%) compared to the placebo. Additionally, the non-linear dose–response analysis indicated a favorable effect of Ashwagandha supplementation on anxiety until 12,000 mg/d and stress at dose of 300–600 mg/d. Finally, we identified that the certainty of the evidence was low for both outcomes. The current systematic review and dose–response meta-analysis of RCTs revealed a beneficial effect in both stress and anxiety following Ashwagandha supplementation. However, further high-quality studies are needed to firmly establish the clinical efficacy of the plant.

This review is NOT a Cochrane Review; what is more (and more important), it seem rather uncritical.

The BBC article seems to down-play the safety issue related to Ashwagandha. As we have discussed on this blog, Ashwagandha is far from harmless. In fact, Ashwagandha has been shown to be a herb with a high risk of hepatobiliary toxicity as well as heart problems.

So, why does the BBC misinform the public?

Search me.

Manfred Lucha has been Baden-Württemberg’s Minister for Social Affairs, Health and Integration since 12 May 2016. He also is a staunch defender of homeopathy.

Lucha has repeatedly spoken out in favour of maintaining the reimbursement of costs for homeopathy by health insurance companies. He described anthroposophy and homeopathy as the essence of the Green Party. In August 2022, Lucha positioned himself against the Baden-Württemberg Medical Association on the subject of homeopathy. The Association had announced that additional training for doctors in homeopathy would be removed from the medical training catalogue. Health Minister Lucha stated that he still believed in the effectiveness of homeopathy and announced a legal review of the decision, as the Ministry of Health has legal supervision over the Medical Association. Lucha also criticised the plan by Federal Health Minister Karl Lauterbach to no longer allow homeopathic treatments to be paid for by health insurance companies. Finally, it seems safe to assume that Lucha is not amused about the new development about which I reported yesterday.

With so much outspoken engagement in the medical field, one would expect that Lucha has a solid background in evidence-based medicine and science. Yet, one would be mistaken.

After an apprenticeship as a chemical worker, Lucha completed secondary school and trained as a nurse at the Weißenau Psychiatric State Hospital. He went on to gain his university entrance qualification and studied social work. In 2005, he also completed a Master’s degree in ‘Management in Social and Health Care’. He then became the technical director of a community psychiatric centre in Friedrichshafen. Lucha is spokesman for the Bodensee district community psychiatric association and deputy federal chairman of the Federal Working Group of Community Psychiatric Associations.

Any education in evidence-based medicine?

No!

So, why does he feel he knows better than the experts?

I am not sure.

 

PS

Mr. Lucha, if you read these lines, please tell us.

To show my appreciation, I would then send you a copy of the German translation of my book on homeopathy.

A new market report predicts that the worldwide market for so-called alternative medicine (SCAM) will grow from $100 billion in 2022 to $438 billion by 2032.

According to the report, the SCAM market is expected to see innovation and expansion through mergers, acquisitions, and partnerships among large companies. Companies that are capitalizing on these trends include health supplement companies, companies that specialize in Ayurvedic health, those that offer TCM solutions, and those that offer more general holistic solutions to health. Major supplement brands include Herb Pharm LLC, Gaia Herbs, NOW Foods, Life Extension, Pure Encapsulations, Douglas Laboratories, Nordic Naturals, Nordic Nutraceuticals, Quality of Life Labs, Nature’s Bounty Co., Valensa International, Herbo Nutra, and Emerson Ecologics.

Other major players mentioned in the report are:

  • AYUSH Ayurvedic Pte Ltd, Dabur India Ltd., Himalaya Global Holdings Ltd., Banyan Botanicals, and Arya Vaidya Pharmacy offer Ayurvedic health and wellness products while aiming to advance the science behind Ayurveda.
  • Sheng Chang Pharmaceutical Company produces traditional Chinese medicines and herbal products that is one of the largest TCM pharma companies.
  • All and One Medical provides healthcare solutions that combine conventional medicine with complementary and alternative therapies to promote overall wellness and preventive care.
  • The John Schumacher Unity Woods Yoga Center is another that focuses on enhancing physical and mental well-being through the practice of Iyengar Yoga and offers classes and workshops.
  • New Life Chiropractic aims to improve overall health and well-being by providing comprehensive chiropractic care that focuses on spinal health and preventive wellness.
  • The Chicago Body Works offers a range of therapies and treatments designed to enhance physical and mental well-being, including massage and bodywork services.
  • Weleda AG aims to connect people with nature by producing natural organic products that support health, beauty, and overall wellness while practicing sustainability and social responsibility.
  • Quantum-Touch Inc. teaches energy healing techniques that promote physical, emotional, and spiritual health.
  • Spectrum Chemical Manufacturing Corporation focuses on delivering high-quality chemicals and laboratory supplies to support scientific research and innovation across various industries, including health and wellness.

I must admit, I do like these market reports. They never fail to amuse me – for two main reasons:

  1. They are as reliable as reading tea leafs.
  2. The only reliable info they do provide is that the SCAM proponents’ often-voiced argument, “we are very different from BIG PHARMA” is pure nonsense.

Jay Kennedy is an experienced chiropractor of some standing.

In “2018, ‘The American Chiropractor’ wrote this about Jay Kennedy:

Jay Kennedy, DC, is a 1987 graduate of Palmer Chiropractic College and maintains afull time practice in western Pennsylvania. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy. Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges.

‘The Dynamic Chiropractor’ published plenty of articles authored by Jay Kennedy.

I am telling you this because Jay Kennedy recently posted a comment which is far too important to be burried in the many other comments on this blog. I think it deserves full recognition and loud applause. I have therefore decided to take the unusual step and re-post it here as an entirely seperate post.

Here we go:

I was a DC for 30+ years and a notable one for the last 20 years. I taught 200+ seminars, wrote innumerable articles and taught at many chiropractic colleges. I had (3) private practices and was a technique “guru”: “Kennedy decompression technique” or KDT. We “certified” nearly 5000 DCs to be “decompression experts”!

Kdt still sells farcical traction-tables I developed and designed (labeled as “decompression systems”) as well as useless lasers, ultrasonic vibrators and other scam modalities to confound the DCs and milk the public. (I have been out of it for several years now).

I am not proud of the fact I made a lot of money both in practice and as a lying cultist-entrepreneur.

I have read your blog for several years and many of your books, especially related to Chiropractic. You are not mistaken and I do NOT believe you are biased, the fact that you define the practice as SCAM and a cult is absolutely the case. As has been said before it is “the world’s largest non-scientific healthcare delivery system”. I was fortunate many years ago to meet Stuart McGill PhD. It changed my practice considerably. I opened a gym and focused dramatically on exercise. I also had other income steams from selling bullshit equipment. The regrettable feature is chiropractors sell “treatments”…. Some of which superficially alter pain signals temporarily like many OTHER less expensive and less mendacious things. This “traps” many patients into an erroneous paradigm….one a DC is ready, willing and able to exploit. “Chiropractic treatments” NEVER get to the root of a problem, alter any disease-process or substantially improve a patient. Regrettably selling exercise simply WILL NOT garner the income that selling (and coercing) subluxation-elimination treatments will (and virtually NO DC has the experience or expertise a PT PhD has in that arena).

Interestingly when you do seminars as a chiropractor, most states make you sign a waiver stating that you will not disparage Chiropractic or discuss information that minimize the value of Chiropractic. Can you imagine medical seminars or a scientific seminar having such a waiver? Chiropractic is and has always been a moneymaking scheme. That doesn’t exclude the fact there are many chiropractors who buy into it as a supreme truth….just like Muslims who murder with the thought of getting directly to Heaven to start porking some virgins.

I have discovered most DCs are on the low IQ scale, have poor critical thinking skills and rarely question their golden-goose (or perhaps more sympathetically; never venture outside the bounds of the profession and its rhetoric and hyperbole. They have been effectively able to compartmentalize Chiropractic from rightful and accurate criticism). Most of the successful ones are of course entrepreneurs with ravenous appetites for money, prestige and approval (and have little or no interest in the “truth”…..oops I described myself I guess).

The majority however struggle to get by and are constantly seeking SOMETHING that might actually work. Thus 70%+ use and advertise “decompression”, Activators (and other ridiculous “adjusting guns”), drop-tables, energy-techniques, orthotics and whatever other nonsense some company advertises in Chiropractic Economics with a testimonial of how much money can be made. It always fascinated me that if “subluxation-reduction or elimination” was the solution for disease and pain WHY did the profession embrace all of these other nonsensical modalities? If your guess is: “chiropractic doesn’t really work”…give yourself a beer.

When you graduate as a DC you CAN ONLY be in private SCAM practice….no other opportunities exist. Is it really any wonder that lying is the only avenue available to support a practice and an income stream? Nope.

______________________

I wish to express my thanks to Jay for his courage and honesty in writing these lines.

People living with HIV (PLWH) are common users of so-called alternative medicine (SCAM). The main objective of this study was to study the frequency and patterns of SCAM natural products use in a large cohort of PLWH and to identify potential drug–drug interactions (DDIs) and the impact on their antiretroviral treatment (ART) adherence and efficacy.

This was a cross-sectional multicenter survey including 420 PLWH from different Spanish hospitals. Participants completed a face-to-face questionnaire on SCAM consumption and different sociodemographic and clinical data were collected. DDIs between SCAM and ART were identified and classified according to the Liverpool University Database and patient factors related to SCAM consumption were assessed.

In total, 420 participants were included (82.6% male, mean age 47 years); 209 patients (49.8%) were taking at least one SCAM. The most consumed SCAM were:

  • green, black and red tea (n=146, 25.4%),
  • ginger (n=26, 4.5%),
  • fish oil (n=25, 4.4%),
  • cannabis (n=24, 4.2%).

An ART based on integrase inhibitors was the only factor independently associated with SCAM consumption (OR 1.54, 95% CI 1.04 to 2.26). 50 potential SCAM–ART interactions in 43 (20.6%) patients taking SCAM were identified, being clinically significant in 80% of the cases. SCAM products most frequently involved with a potential significant DDI were supplements containing divalent cations (n=11) and garlic (n=7). No differences in ART efficacy and adherence were observed between patients with and without SCAM consumption.

The authors concluded that almost 50% of patients were taking at least one SCAM product and its use was associated with an integrase inhibitor based ART. One out of every six patients was at risk of presenting with an interaction between a SCAM and their ART, confirming the need to review continuously the use of SCAM as part of the medication review process.

So, the authors found that half of all PLWHs use some form of SCAM (whether I would classify tea as a SCAM is a different question). They also point out that this might put many PLWHs at risk. What I don’t understand is why they do not take the next logical step and ask what the benefits of the SCAMs for PLWHs are.

Allow me to answer this question: they are zero or very close to zero!

And this means that SCAMs generate a risk for PLWHs without creating any meaningful benefit. In other words the risk-benefit balance fails to be positive.

I think that this is an important point which needs to be stressed clearly in the conclusions. Therefore, I suggest to re-formulate them as follows:

Almost 50% of patients were taking at least one SCAM product. One out of every six patients was at risk of presenting with an interaction between a SCAM and their ART. The SCAMs used convey no appreciatable benefit. Therefore, SCAM use fails to generate more good than harm. It follows that responsible healthcare professionals should discurage SCAM use.

This study aimed to investigate the clinical effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention to prevent the recurrence of low back pain.

WalkBack was a two-armed, randomised clinical trial, which recruited adults (aged 18 years or older) from across Australia who had recently recovered from an episode of non-specific low back pain that was not attributed to a specific diagnosis, and which lasted for at least 24 h. Participants were randomly assigned to an individualised, progressive walking and education intervention facilitated by six sessions with a physiotherapist across 6 months or to a no treatment control group (1:1). The randomisation schedule comprised randomly permuted blocks of 4, 6, and 8 and was stratified by history of more than two previous episodes of low back pain and referral method. Physiotherapists and participants were not masked to allocation. Participants were followed for a minimum of 12 months and a maximum of 36 months, depending on the date of enrolment. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected in the intention-to-treat population via monthly self-report. Cost-effectiveness was evaluated from the societal perspective and expressed as incremental cost per quality-adjusted life-year (QALY) gained. The trial was prospectively registered (ACTRN12619001134112)

Between Sept 23, 2019, and June 10, 2022, 3206 potential participants were screened for eligibility, 2505 (78%) were excluded, and 701 were randomly assigned (351 to the intervention group and 350 to the no treatment control group). Most participants were female (565 [81%] of 701) and the mean age of participants was 54 years (SD 12). The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio 0·72 [95% CI 0·60–0·85], p=0·0002). The median days to a recurrence was 208 days (95% CI 149–295) in the intervention group and 112 days (89–140) in the control group. The incremental cost per QALY gained was AU$7802, giving a 94% probability that the intervention was cost-effective at a willingness-to-pay threshold of $28 000. Although the total number of participants experiencing at least one adverse event over 12 months was similar between the intervention and control groups (183 [52%] of 351 and 190 [54%] of 350, respectively, p=0·60), there was a greater number of adverse events related to the lower extremities in the intervention group than in the control group (100 in the intervention group and 54 in the control group).

The authors concluded that an individualised, progressive walking and education intervention significantly reduced low back pain recurrence. This accessible, scalable, and safe intervention could affect how low back pain is managed.

Rigorous clinical trials of excercise therapy are difficult to conceive and conduct because of a range of methodological issues. For instance, there is no obvious placebo and thus it is hardly possible to control for placebo effects. Nonetheless, the benefits of exercise therapy for back pain is undoubted. As previously discussed on this blog, a recent systematic review concluded that “the relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance.”

I have always been convinced of the health benefits of excercise. In fact, 40 years ago, when I did my inaugural lecture at the University of Munich (LMU), excercise was its topic and I concluded that, if exercise were a pharmaceutical product, it would out-sell any drug. The new study only confirms my view. It adds to our knowledge by suggesting that exercise also reduces the risk of recurrences.

Forget about spinal manipulation, acupuncture, etc., despite the undeniable weaknesses in the evidence, exercise is by far the most promissing treatment for back pain

An article in ‘METRO’  caught my eye – not least because it quotes me. Here are a few edited excerpts:

Peter Stott lost his first wife to cancer in 1998. Her death, he believes, was due to geopathic stress (GS) – harmful energies that originate from the Earth. ‘I found out that the house where we had lived had a serious GS problem,’ he says. The discovery prompted him to become a professional ‘dowser’, devoting his life to finding and managing geopathic stress.

But what exactly is this mysterious force erupting from the surface of the Earth – and can it really harm people?Geopathic stress is said to cause discomfort and health issues for certain individuals. These energies, also called ‘harmful Earth rays’ by believers, can be detrimental, beneficial or neutral according to those who think they are ‘in the know’.

Peter Stott
Peter Stott is a professional dowser

The word ‘geopathic’ is derived from the Greek words ‘Geo’ meaning the Earth and ‘pathos’, meaning disease or suffering – hence the term pathogens, the medical terms for bugs that make us ill.

Dowsing, practitioners say, is a method used to detect the presence of various subtle Earth energies and assess their nature and quality. They argue that some of these energies can be linked to geomagnetic anomalies caused by flowing underground water, dry faults and fissures, subterranean cavities, or mineral and crystal deposits.

Dowsing is carried out by a dowser, practitioners who try to find the source of these energies using special tools, such as pendulums, rods, and bobbers – essentially sexed-up tree branches. The person holds the tool, waiting for it to move or react, which they take as a sign that they’ve found what they’re looking for. The odd practice can allegedly also be used to identify leaks, stress fractures, environmental pollutants, electromagnetic fields, nutritional deficiencies, black spots, and, rather oddly, sexing pigeons.

Peter claims that a skilled dowser effectively advises on the optimal placement of buildings and structures to mitigate the impact of geopathic stress, and often possesses the ability to reduce or eliminate it through the use of various methods. He emphasises the fact that GS ‘does not affect everybody in the same way. Cancer has been described as “a disease of location”,’ he says. ‘And if there is a family history of cancer – as there was in my late wife’s case – a person can be more susceptible to GS being a contributing factor in succumbing to the disease.’ Peter believes that GS impacts our immune system, depleting its resources and hindering its ability to function optimally. By eliminating GS from our surroundings, we allow our immune system to operate more efficiently, he contends. Our susceptibility to GS varies, he says, with some experiencing mild symptoms like sleep disturbances and fatigue, while others may face more severe health issues such as arthritis, multiple sclerosis and cancer.

17th Century dowsing illustration
Dowsing has been around for millennia (Picture: Getty)

In 2017, rather incredibly, a report revealed that 10 out of 12 water companies in the UK were employing the practice of water dowsing to identify and locate leaks. Even more incredibly, last year, it emerged that Thames Water and Severn Trent Water were still using this form of ‘witchcraft’ for leak detection, despite scientific research indicating its lack of efficacy.

But water companies aren’t the only ones turning to dowsers for help. Peter believes that ‘it is also possible to carry a token or amulet on your person that has been imbued with the powers of protection by someone who is proficient in [dowsing]’. ‘This can protect you from GS and other detrimental energies wherever you go anywhere throughout the world,’ he claims. ‘Other protection techniques can also offer a degree of protection.’

However, Dr Edzard Ernst, a man who has dedicated years of his life to examining questionable, science-based claims, won’t be enlisting the services of a GS specialist or house healer anytime soon. ‘Geopathic stress cannot cause health problems for the simple reason that it does not exist,’ says the retired physician. ‘It is a sly invention of quacks who exploit gullible consumers. The methods to diagnose GS are as bogus as the ones that allegedly treat it. But the quacks don’t mind – as long as the consumer pays.’

Peter fully acknowledges ‘that dowsing and this work in general is not a catch-all solution for every ailment or every person’s situation’. ‘However, often we are approached by people who are “at the end of their tether” due to their exasperation of experiencing events or circumstances in their lives that are not well catered for in the mainstream wellbeing sector,’ he says. ‘I can only speak personally, I cannot speak for the possibly tens of thousands of dowsers around the world. If our work can help ease a person’s experience of life then that is a good enough reason to continue to help where I can’. He adds that ‘we are never going to change the minds of people like Dr Edzard Ernst’, someone ‘who seems to focus exclusively on debunking anything for which there is not a scientific explanation’. Moreover, science, he notes, ‘is moving on with research done into quantum physics and the theory that everything in the universe is connected and is also accessible to everyone’.

_________________________

Oh, dear Peter!

Perhaps you should learn the difference between critical evaluation and debunking (this ‘debunker’ has shown more forms of so-called alternative medicine (SCAM) to be worthy of integrating into the NHS than anyone else).

Perhaps you should read up about the difference between evidence and belief?

And perhaps the chapter on dowsing in my book could help you in this endeavour:

Dowsing is a common but unproven method for divining water and other materials. In alternative medicine, it is sometimes used as a technique for diagnosing diseases or the causes of health problems.

      1. Dowsers employ a motor automatism, amplified through a pendulum, divining rod or similar device. The effect is that the device seemingly provides an independent, visible reaction, while the dowser is, in fact, its true cause.
      2. Dowsing is used by some homeopaths as an aid to prescribe the optimal remedy and as a tool for identify a miasm or toxin load.
      3. The assumptions upon which dowsing is based lack plausibility.
      4. Dowsing has not often been submitted to clinical trials.
      5. All rigorous attempts to test water dowsing have failed, and it is no longer considered a viable method for this purpose.
      6. The only randomized double-blind trial that has tested whether homeopaths are able to distinguish between a homeopathic remedy and placebo by dowsing failed to show that it is a valid method. Its authors (well-known homeopaths) drew the following conclusion: “These results, wholly negative, add to doubts whether dowsing in this context can yield objective information.”[1]
      7. If dowsing is employed for differentiating between truly effective treatments (rather than homeopathic remedies), the risk of false choices would be intolerably high, and serious harm would inevitably be the result.

[1] McCarney et al. (2002).

 

We have recently heard much about spinal manipulations for kids. It might therefore be relevant to learn about an international taskforce of clinician-scientists formed by specialty groups of World Physiotherapy – International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) & International Organisation of Physiotherapists in Paediatrics (IOPTP) – to develop evidence-based practice position statements directing physiotherapists clinical reasoning for the safe and effective use of spinal manipulation and mobilisation for paediatric populations (<18 years) with varied musculoskeletal or non-musculoskeletal conditions.

A three-stage guideline process using validated methodology was completed: 1. Literature review stage (one scoping review, two reviews exploring psychometric properties); 2. Delphi stage (one 3-Round expert Delphi survey); and 3. Refinement stage (evidence-to-decision summative analysis, position statement development, evidence gap map analyses, and multilayer review processes).

Evidence-based practice position statements were developed to guide the appropriate use of spinal manipulation and mobilisation for paediatric populations. All were predicated on clinicians using biopsychosocial clinical reasoning to determine when the intervention is appropriate.

1. It is not recommended to perform:

• Spinal manipulation and mobilisation on infants.

• Cervical and lumbar spine manipulation on children.

•Spinal manipulation and mobilisation on infants, children, and adolescents for non-musculoskeletal paediatric conditions including asthma, attention deficit hyperactivity disorder, autism spectrum disorder, breastfeeding difficulties, cerebral palsy, infantile colic, nocturnal enuresis, and otitis media.

2. It may be appropriate to treat musculoskeletal conditions including spinal mobility impairments associated with neck-back pain and neck pain with headache utilising:

• Spinal mobilisation and manipulation on adolescents;

• Spinal mobilisation on children; or

• Thoracic manipulation on children for neck-back pain only.

3. No high certainty evidence to recommend these interventions was available.

Reports of mild to severe harms exist; however, risk rates could not be determined.

It was concluded that specific directives to guide physiotherapists’ clinical reasoning on the appropriate use of spinal manipulation or mobilisation were identified. Future research should focus on trials for priority conditions (neck-back pain) in children and adolescents, psychometric properties of key outcome measures, knowledge translation, and harms.

Whether one agrees with these directions or not (and I am not sure I fully do), I have always thought that people who, despite the largely lacking or flimsy evidence for spinal manipulations, insist on having manual therapy should consult a physiotherapist, rather than a chiropractor or osteopath.

Why?

Because, in my experience, physiotherapist:

  • display less cult-dependent behaviours,
  • do not follow the gospel of charlatans, like Palmer and Still,
  • do not believe in the fiction of subluxation,
  • are not so money-minded,
  • less prone to use un- or disproven methods, like applied kinesiology, homeopathy, cranial osteopathy, etc.,
  • unlikely to try to sell you useless dietary supplements,
  • tend to judge better their limits of professional competence,
  • are far less likely to try to persuade you of BS related to anti-vax, anti-drug, anti-science, anti-EBM, etc.

In response to criticism voiced against Australian chiropractors’ decision to re-commence manipulating children, the Australian Chiropractors Association (ACA) president, David Cahill, welcomed the updated statement on paediatric care by the Chiropractic Board of Australia. “The statement serves to reinforce the confidence the Australian public has in chiropractic care provided by registered ACA member chiropractors,” said Cahill.

The Safer Care Victoria Review has shown chiropractic care for children to be extremely safe. Of the 29,599 online submissions received from across Australia (the largest survey of its kind), there were no reports of harm to a child receiving chiropractic healthcare. Of those submissions, 21,824 responses were from parents who had accessed chiropractic healthcare for their children, and there was not a single report of significant harm in these submissions. “In a particularly strong endorsement, 99.6% of those parental submissions affirmed that chiropractic healthcare benefitted their child highlighting the exemplary safety record of chiropractic healthcare,” Cahill said.

ACA member chiropractors are healthcare professionals who effectively treat a wide range of musculoskeletal disorders. Chiropractors are 5-year university degree educated healthcare professionals, equipped with expertise enabling them to tailor the appropriate care for people of all ages including children. Established in 1938, the Australian Chiropractors Association (ACA) is the peak body representing chiropractors. The ACA promotes the importance of maintaining spinal health to improve musculoskeletal health through non-invasive, drug-free spinal health and lifestyle advice to help Australians of all ages lead and maintain healthy lives.

_________________________

Mr Cahill and the Australian Chiropractors Association have thus demonstrated that they fail to understand how one needs to establish the benefits and harms of a therapy. That chiropractic spinal manipulations are “extremely safe” cannot be established by an online survey which might or might not have been manipulated by the chiropractors who have an interest in not loosing the lucrative option of treating children. It cannot even establish “the confidence the Australian public has in chiropractic care”.

Mr Cahill and the Australian Chiropractors Association should know that chiropractic spinal manipulation – just like any other intervention – must be evaluated according to accepted principles of risk-benefit analyses. No proven benefit and a possibility of harm mean that the risk-benefit balance fails to be positive. And this means that it is irresponsible to use chiropractic spinal manipulations.

Mr Cahill and the Australian Chiropractors Association, however, seem to not know even the essentials of ethical healthcare. The obvious conclusion, therefore, is to send the lot of them back to school.

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