EBM
The well-known Dr. Chris van Tulleken recently joined forces with Professor Michael Heinrich and Dr. Anthony Booker from the University College London School of Pharmacy to test a range of herbal products on sale in the UK. They bought over 70 herbal products from various high street stores and internet retailers. Some of the products were ‘THR’ (traditional herbal registration) herbal medicines, and some were marketed as food supplements. They then analyzed their chemistry to see whether each one really contained what the label says. The three popular herbal remedies we tested were:-
- Milk thistle (Silybum marianum),
- Ginkgo (Ginkgo biloba),
- Evening primrose (Oenothera).
The team at UCL used two different methods of analysis to verify the identity of these herbal products and extracts. High-performance thin-layer chromatography (HPTLC) is a sophisticated technique for the analysis of herbal products and is one of the most commonly used methods in the industry. HPTLC analysis creates a chemical fingerprint of the product which the researchers can then compare to an accepted reference standard for the herb. They look for a broad spectrum of ‘marker compounds’ these are the pharmacologically active and/or chemical constituents within a plant that can be used to verify its potency or identity. For complex samples or where additional confirmation is required, researchers often turn to ¹H nuclear magnetic resonance spectroscopy (¹H-NMR) which allows individual samples to be compared in detail against other samples or to the whole group.
In every THR product tested, the product contained what was claimed on the label. However, the food supplements showed a wide range of quality.
- Of the food supplement products labeled as Ginkgo, 8 out of 30 (27%) contained little or no ginkgo extract.
- 36% of the food supplement milk thistle products contained no detectable milk thistle. Although this is quite a small sample size it is still a startling result. Furthermore, in one case of milk thistle, unidentified adulterants suspected to be synthetic compounds were present in place of milk thistle.
- All of the evening primrose food products we tested did contain what the packet claimed.
The researchers concluded that their investigation shows that a regulatory system for herbal products, like the THR scheme, ensures that people have access to safe herbal medicine products. So, if you are considering buying herbal products then do look out for the THR mark– otherwise, you might not just be wasting your money, you might be consuming other, potentially dangerous, ingredients.
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This is an interesting investigation. The researchers should be commended for it! However, I disagree with some of their conclusions. Here is why:
- The investigation merely tested the quality of the products and NOT THEIR SAFETY! To claim that the THR ensures access to safe herbal medicines is incorrect. A product might be of adequate quality but can still be unsafe. The THR only implies safety because the herbal has been used for years without problems being noted. This is not the same as ensuring that it is safe. A direct test of safety is usually not available.
- The recommendation to buy a product with a THR mark is also somewhat misleading. It implies that these products are effective. I fail to see convincing evidence that either MILK THISTLE, GINKGO, or EVENING PRIMROSE are effective for any disease or condition. Thus the responsible recommendation should, in my view, be to NOT buy them regardless of whether they are of good quality or not.
A ‘manifesto’ is not something that I come across often in my area of research, i.e. so-called alternative medicine (SCAM). This one is in German, I, therefore, translated it for you:
Manifesto for healthy medicine
With the Manifesto for healthy medicine, we, the citizens and patients alliance weil’s hilft! (‘BECAUSE IT HELPS’) demand a fundamental change in our healthcare system, towards a diverse medicine that focuses on people and health. Be part of it! Sign the manifesto and become part of the movement.
It’s of paramount importance, the Manifesto for healthy medicine. About the way we live. It’s about our health. It’s about you and it’s about me.
We want our healthcare system to actually focus on health.
We want a medicine that doesn’t ask what’s missing, but what is possible.
We want a medicine that cares about people, that takes care, gets to the bottom of things, and uses innovative technologies to do so.
We want more bio, so that the chemistry is right, and we want naturopathic procedures and naturally effective medicines to be recognized, promoted, and researched further.
We want research that creates knowledge because, in addition to studies, it also takes into account the experience of physicians and the needs of patients.
We want carers and doctors to be able to work in a way that is good for their patients and for themselves.
We want people from all healthcare professions to work together as equals.
We want a medicine that creates awareness for a good and healthy life because climate protection also begins in one’s own body.
We want an integrative medicine that puts people at the center and self-evidently combines conventional and natural healing methods.
And we want this medicine to be accessible and affordable for everyone.
We fight for a healthy medicine of the future.
Be part of it!
(sorry, if some of it might sound badly translated but the German original is in parts pure gibberish)
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Who writes such tosh composed of every thinkable platitude and then pompously calls it a MANIFESTO?
BECAUSE IT HELPS! (weil’s hilft!) is a citizens’ movement that demands a change in the health care system – towards the needs and preferences of patients, towards a holistic view of people, and a focus on health instead of disease. The sensible combination of natural medicine and conventional medicine, an integrative medicine, makes an indispensable contribution to this. This is because it relies fully on the patients and involves them as active partners in the treatment. Modern medicine of the future, therefore, needs the equal cooperation of natural medicine and conventional medicine – in the everyday life of physicians and patients, in the reimbursement by the health insurance companies as well as in research and teaching.
On the information platform www.weils-hilft.de weil’s hilft! informs about current developments in integrative medicine, provides background information, and publishes a podcast once a month. The movement is also active on social media at www.facebook.com/weilshilft and www.instagram.com/weilshilft.
weil’s hilft! is supported by the health and patient organizations GESUNDHEIT AKTIV, KNEIPP-BUND, and NATUR UND MEDIZIN. Together, the alliance represents the interests of more than 220,000 people.
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One could easily disclose the funny side of this, the utter stupidity of the arguments, the platitudes, fallacies, misunderstandings, ignorance, etc. Yes, that would hardly be difficult. But it would ignore how worrying this and similar movements are. They systematically misinform consumers with the sole aim of persuading them that the integration of unproven or disproven treatments into medical routine is in their interest. Yet, if we only scratch the surface of their arguments, we realize that it is exclusively in the interest of those who profit from this type of misinformation.
Exceptionally, this post is unrelated to so-called alternative medicine (SCAM). It addresses a new and worrisome development in UK healthcare. The UK has fewer doctors per population than most other developed countries. This shortage has now reached a level where it puts patients in danger. Recently, the government has unveiled a new NHS plan aimed to fix the problem.
The apprenticeship scheme could allow one in 10 doctors to start work without a traditional medical degree, straight after their A-levels. A third of nurses are also expected to be trained under the “radical new approach”. It is the centerpiece of a long-delayed NHS workforce strategy, following warnings that staff shortages in England could reach half a million without action to find new ways to train and recruit health workers. Amanda Pritchard, the head of NHS England, said: “This radical new approach could see tens of thousands of school-leavers becoming doctors and nurses or other key healthcare roles, after being trained on the job over the next 25 years.” She added that the plan offered a “once-in-a-generation opportunity to put the NHS on a sustainable footing”.
The “medical doctor degree apprenticeship” involves the same training and standards as traditional education routes, including a medical degree and all the requirements of the General Medical Council. Candidates will be expected to have similar A-levels as those for medical school, with qualifications in sciences, as well as options for graduates with non-medical degrees. The key difference behind such models is that apprentice medics would be available on the wards almost immediately, working under supervision, while being paid.
The medical degree apprenticeship is due to launch this autumn.
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I am impressed!
Sadly, not in a positive way.
In fact, I cannot remember having ever heard of a more stupid idea for dealing with doctor shortages.
As incompetent amateurs, do the Tories really think that a similar level of incompetence might work also in healthcare?
Such shortages have happened before.
They are regrettable and need swift and firm action.
The only countermeasure that works is to train more doctors.
REAL DOCTORS!
The German Heilpraktiker (HP), a non-medically trained practitioner of so-called alternative medicine (SCAM), has repeatedly been the subject of my posts. In a nutshell: the profession was created by the Nazis and was originally destined to disappear within one generation. But this did not happen, and today there are ~100 000 HPs who are allowed to treat almost any condition without mandatory training or experience. Many HP schools exist but you can also become an HP without formal training.
Now a report has been published by undercover journalists investigating these HP schools in Germany. Here I have summarized a few crucial passages for you (if you read German, I strongly recommend reading the original article):
There are more than 150 HP schools in Germany. On average, training costs several thousand euros. There is no uniform and state regulation for the training. The curricula are mostly created by the schools themselves.
In addition to medical and psychological content, the schools often offer seminars that are not based on scientific knowledge. The curricula sometimes include courses such as astrology, homeopathy, or so-called quantum healing. HP organizations give indeed training guidelines. However, these are not met by about 83% of the schools.
The students were isolated at the HP school from their environment and urged to break off contact with their families. “Without us you are nothing. That came so often and I then, unfortunately, believed in it, because I was alone. If I had had no one else from school, then I would really have been completely alone,” explains a former student in an interview. “During that time, I also thought for the first time: Are we in some kind of cult here?
The school’s principal rejects the cult accusation: “We have been confronted with the allegation that we are a cult for some time and have always dealt with it very openly because we are not a cult. The principal also denies other accusations made by former students, saying that the allegations of suggestion, coercion, compulsion, or sweeping statements are simply false. He said he would be happy to face them “in a personal conversation outside the public eye to answer their questions.”
In order to get to the bottom of the treatment methods, the reporter also had herself treated by the principal of the school in an undercover self-experiment. In the first session, she determined that the reporter’s sciatica had been passed on to her by her mother, which is why she should sever her ties with her. In the second session, she recommended that she no longer visit her cancer-stricken grandfather. When the principal learned that the ill grandpa was of the zodiac sign Cancer, she concluded, “Cancer gets cancer.” The cancer, she said, was due to the fact that he had done nothing for his soul. And further, the patient runs the risk of adopting the grandfather’s cancer symptoms when she visits him.
The Hamburg health authority, which is listed as a “supervisory authority” on the school’s homepage, explains in response to an inquiry that no official supervision exists for HP schools. To obtain permission for opening a school, no training is necessary. Neither possible training courses nor institutions offering such training courses are regulated by the state.
The journalist also asked the Federal Health Ministry whether it sees the need for action and legal control. The Ministry’s response was evasive: “If necessary,” the HP law should be reformed in the future.
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This is shocking news for many Germans who believe that HPs are well-trained healthcare professionals. However, those who have read my recently published book cannot be surprised. Poor training is only one of a myriad of deficits of HPs. It is time that the government realizes that the current is unacceptable and endangers public health. It is time, in other words, that the government does something about the HP profession.
According to a German court ruling, the homeopathic remedy Meditonsin for colds may no longer be advertised with certain statements. The Higher Regional Court in Hamm, Germany made it clear that it shares the opinion of the Regional Court in Dortmund, which had sentenced the marketing company to desist from making statements such as “rapid and reliable reduction of the intensity of the typical cold symptoms”. Such statements falsely generate the impression that therapeutic success can be expected with certainty. The court made it clear that the company’s appeal against the previous ruling was unlikely to be successful. The company subsequently withdrew its appeal today – and the judgment is now legally binding.
The lawsuit filed by a consumer organization was thus successful. It had criticized several statements as unfair and inadmissible advertising. The Dortmund court shared this view in September 2022 – and according to the spokesman, the Higher Regional Court in Hamm now followed the argumentation of the lower court.
The statements that
- “good efficacy and tolerability were once again impressively confirmed by a pharmacy-based observational study”,
- and “all cold complaints showed a clear improvement in the course of the disease”,
were deemed to be misleading advertising. They must therefore be omitted, the ruling stated.
Meditonsin is currently being advertised as follows:
For support of the immune system at the first signs of a cold to help the body build up the defense against pathogens effectively.
In addition, conditions are made more difficult for the intruders – through an effective medicine: the well-known Meditonsin® supports your defenses and naturally fights the onset of inflammation of the ears, nose and throat with pure homeopathic ingredients.
If applied early and correctly, Meditonsin® helps to ensure that the typical unpleasant symptoms have no chance to develop. Because Meditonsin® is particularly well tolerated and protects the organism, it is for both adults and children alike – a family medicine in the best sense.
Meditonsin contains two homeopathic ingredients in the D5 and one in the D8 dilution. To the best of my knowledge, there is no sound evidence that the remedy is effective for anything.
Imagine you have caught a cold. You think it is not necessary to see a doctor, but you want to take something that helps your body to get better. What is your choice of remedy? There are many options provided by conventional medicine as well as by so-called alternative medicine (SCAM).
Many people opt for SCAM to address health issues or prevent diseases. Yet, the evidence for SCAMs is either lacking or controversial due to methodological weaknesses. Thus, practitioners and patients primarily rely on subjective references rather than credible evidence from systematic research.
This study investigated whether cognitive and personality factors explain the differences in belief in SCAM and homeopathy. The researchers investigated the robustness of 21 predictors when examined together to obtain insights into some key determinants of such beliefs in a sample of 599 participants (60% female, 18-81 years). A combination of predictors explained 20% of the variance in SCAM belief. These predictors were:
- ontological confusions,
- spiritual epistemology,
- agreeableness,
- death anxiety,
- gender.
Approximately 21% of the variance in belief in homeopathy was explained by the following predictors:
- ontological confusions,
- illusory pattern perception,
- need for cognitive closure,
- need for cognition,
- honesty-humility,
- death anxiety,
- gender,
- age.
The authors concluded that some of the predictors from previous research replicated whereas others did not. Demographics and certain cognitive variables seem to be key determinants associated with beliefs in SCAM and homeopathy. Those individual differences and cognitive biases might result in a different perception of the world. However, variables related to abilities did not predict the beliefs. Thus, they might not be a result of inability but rather of ignorance.
Previous studies have shown that SCAM believers tend to believe in paranormal phenomena and conspiracies. I think that, in the discussion sections of this blog, we have ample evidence for this to be true. Paranormal beliefs are usually built on a magical worldview without reasoned review, which is shared by SCAM proponents. Such beliefs advocate emotional criteria for truth instead of data and logical considerations. Another belief, namely spirituality, is closely related to paranormal beliefs and religiosity and also associated with being a SCAM user. Lindeman found that SCAM belief could be best explained by intuitive reasoning, paranormal beliefs, and ontological confusions, defined as category mistakes in which properties of living and lifeless entities are mixed.
The authors point out that their results do not replicate previous findings that showed predictive value of certain cognitive variables such as cognitive style. An explanation could be that rather inattention to accuracy than the inability to consider empirical evidence fosters the beliefs. People might simply not be aware of the absence of evidence. Another possibility is that people are aware of the absence of evidence but are reluctant to engage with it. Practitioners and patients often claim “whatever works is good” or “the main thing is that it works”. Thus, it is ignorance rather than a lack of capacity to appropriately process the evidence.
The authors of this study are well aware of the limitations of their research:
“As with most cross-sectional studies using questionnaires, our results are based on self-reports. Additionally, single items were used for measuring belief strength. Even if multi-item measures often have advantages, single items can be advantageous in terms of practical benefits, e.g., adapting to subjects’ limited attention and time resources. There are several single item measures successfully used to measure diverse concepts including attitudes. Also, the variance on those items in our sample shows that participants were able to reflect their beliefs and rank them on the scale provided. Another limitation is that the findings are based on regression analyses, which do not provide insight into causality. Thus, the relationship remains correlational. Even if our sample was broader than in many other psychological studies—it was slightly unbalanced, especially in comparison to the German population. It over-represented educated individuals which may lead to an inadequate variation of the cognitive variables if we consider the relationship between cognition and education. However, education and the cognitive variables are only weakly correlated. Thus, it can be assumed that the unbalanced sample did not affect the distribution of cognitive variables to a great extent.”
I found this acupuncture study from the Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome, Rome, Italy. As this seems to be a respectable institution, I had a look. What I found was remarkable! Let me show you the abstract in its full beauty:
Background: Pain related to Temporomandibular Disorders (TMD) is severe, negatively affecting patients’ quality of life, and often resistant to conventional treatments. Abdominal Acupuncture (AA) is known to be particularly effective for pain, especially chronic and musculoskeletal pain, but it is still poorly studied and never investigated in TMD patients. Objectives: To analyze the efficacy of AA for the treatment of patients with subacute and chronic pain related to TMD and non-responding to previous conventional therapies (occlusal splint, medications, physical therapy).
Methods: Twenty-eight patients, 24 F and four M (mean age 49.36 years), were recruited from January 2019-February 2021. All patients underwent AA treatment: two sessions per week for four weeks, for a total of eight sessions. At the beginning of therapy (T0) and at the end of the cycle (T1) the following data were evaluated: maximum mouth opening (MMO); cranio-facial pain related to TMD (verbal numeric scale, VNS); pain interference with normal activities and quality of life of patients (Brief Pain Inventory, BPI); oral functioning (Oral Behavior Checklist, OBC); impression of treatment effectiveness (Patients’ Global Impression of Improvement, PGI-I Scale). Statistical comparison of data before and after the AA treatment was performed by Wilcoxon’s signed-rank test (significance level p < 0.05).
Results: The MMO values were significantly improved after one cycle of AA (p = 0.0002). In addition, TMD-related pain had a statistically significant decline following AA treatment (all p < 0.001). Patients’ general activity and quality of life (BPI) were described as improved following a course of AA, with statistically significant values for all aspects considered (all p < 0.05).
Conclusion: Abdominal acupuncture resulted in effective treatment of subacute/chronic resistant pain related to TMD, capable of improving mandibular function and facial pain, and reduced the interference of pain affecting patients’ quality of life.
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Shocked?
Me too!
This study did not include a control group. Such uncontrolled studies are not necessarily useless. In areas where there is no prior evidence, they can be a reasonable starting point for further research. In the case of TMD/acupuncture, however, this does not imply. Here we already have about a dozen controlled trials. This means an uncontrolled study cannot possibly contribute to our knowledge. This means that the present study is useless. And that, in turn, means it is unethical.
But even if we ignore all this, the study is very misleading. It concludes that acupuncture improved TMD. This, however, can be doubted!
- What about placebo?
- What about regression toward the mean?
- What about the natural history of the condition?
Bad science is regrettable and dangerous, as it
- wastes resources,
- misleads vulnerable patients,
- violates ethics,
- and undermines trust in science.
I fear that the Italian group has just provided us with a prime example of these points.
Social media platforms are frequently used by the general public to access health information, including information relating to complementary and alternative medicine (CAM). The aim of this study was to measure how often naturopathic influencers make evidence-informed recommendations on Instagram, and to examine associations between the level of evidence available or presented, and user engagement.
A retrospective observational study using quantitative content analysis on health-related claims made by naturopathic influencers with 30 000 or more followers on Instagram was conducted. Linear regression was used to measure the association between health-related posts and the number of Likes, and Comments.
A total of 494 health claims were extracted from eight Instagram accounts, of which 242 (49.0%) were supported by evidence and 34 (6.9%) included a link to evidence supporting the claim. Three naturopathic influencers did not provide any evidence to support the health claims they made on Instagram. Posts with links to evidence had fewer Likes (B=-1343.9, 95% CI=-2424.4 to -263.4, X=-0.1, P=0.02) and fewer Comments (B=-82.0, 95% CI=-145.9 to -18.2, X=-0.2, P=0.01), compared to posts without links to evidence. The most common areas of health were claims relating to ‘women’s health’ (n=94; 19.0%), and ‘hair, nail, and skin’ (n=74; 15.0%).
The authors concluded that this study is one of the first to look at the evidence available to support health-related claims by naturopathic influencers on Instagram. Our findings indicate that around half of Instagram posts from popular naturopathic influencers with health claims are supported by high-quality evidence.
At first sight, these findings amazed me; I would have thought that the percentage of supported claims was lower. As it turned out, I was not far off: in the paper, the authors differentiate the results into more categories and state that ” of those with evidence clearly available, approximately 10% of health claims were underpinned by high-quality evidence such as systematic reviews of randomised controlled trials.”
Even though interesting, the study has significant limitations. The authors are well aware of them and explain:
A key limitation was relying on the 10 most relevant retrieved articles in PubMed, rather than conducting an extensive search for evidence, when not provided alongside the claim. It is possible we did not identify existing evidence to support some of the claims; however, it would not have been feasible to construct a comprehensive search strategy and screen articles for every health claim made. Our search strategy served as a proxy measure for the evidence to support the claim and it is unlikely that the 10 most relevant articles on PubMed would systematically fail to identify existing supporting evidence.
The risk of subjectivity in the extraction of interventional health claims from Instagram posts and conversion into a PICO is another limitation. The subjectivity of data extraction was minimised using standards which included extracting specific terms used by the naturopathic influencer to perform database searches on PubMed. If not explicitly stated, the intended target audience of the health claims were made using educated guesses based on the intervention and outcome promoted in the claim. For the claim to be considered supported by evidence, study participants must match the intended audience of the health claim on Instagram(e.g., postmenopausal women, athletes). When the study with the highest level of evidence were inconclusive due to reasons such as inadequate cohort size, conflicting results for different cohort (e.g., male vs. females), heterogeneity between studies and poor quality of studies, it was concluded that the evidence did not support the health claim. When there was considerable uncertainty related to the health intervention or outcome, it was excluded from the study.
So, in the end, I guess, it boils down to whether you are an optimist or a pessimist:
About half of the claims made by prominent naturopaths are supported by at least a bit of evidence.
About half of the claims made by prominent naturopaths are not supported by evidence.
I came across an article entitled “Consent for Paediatric Chiropractic Treatment (Ages 0-16)“. Naturally, it interested me. Here is the full paper; I have only inserted a few numbers in square brackets which refer to my comments below:
By law, all Chiropractors are required to inform you of the risks and benefits of chiropractic spinal manipulation and the other types of care we provide. Chiropractors use manual therapy alongside taking a thorough history, and doing a neurological, orthopaedic and chiropractic examination to both diagnose and to treat spinal, cranial and extremity dysfunction. This may include taking joints to the end range of function, palpating soft tissues (including inside the mouth and the abdomen), mobilisation, soft tissue therapy and very gentle manipulation [1]. Our Chiropractors have been educated to perform highly specific types of bony or soft tissue manipulation and we strive to follow a system of evidence-based care [2]. At the core of our belief system is “Do No Harm”. We recognise that infants and children are not tiny adults. The force of an adjustment used in a child is at least less than half of what we might use with a fully grown adult. Studies by Hawk et al (2016) and Marchand (2013) agreed that Chiropractors use 15 – 35 x less force in the under 3-month age group when compared to medical practitioners doing manipulation (Koch, 2002) [3]. We also use less force in all other paediatrics groups, especially when compared to adults (Marchand, 2013). In addition to using lower force, depth, amplitude and speed in our chiropractic adjustments [4], we utilise different techniques. We expect all children under the age of 16 years to be accompanied by a responsible adult during appointments unless prior permission to treat without a consenting adult e.g., over the age of 14 has been discussed with the treating chiropractor.
Risks
- Research into chiropractic care for children in the past 70 years has shown it to have a low risk of adverse effects (Miller, 2019) [5]. These effects tend to be mild and of short duration e.g., muscular or ligament irritation. Vorhra et al (2007) found the risk of severe of adverse effects (e.g. fracture, quadriplegia, paraplegia, and death) is very, very rare and was more likely to occur in individuals where there is already serious underlying pathology and missed diagnosis by other medical profession [6]. These particular cases occurred more than 25 years ago and is practically unheard of now since research and evidence-based care has become the norm [7].
- The most common side effect in infants following chiropractic treatment includes fussiness or irritability for the first 24 hours, and sleeping longer than usual or more soundly. (Miller and Benfield, 2008) [8]
- In older children, especially if presenting with pain e.g., in the neck or lower back, the greatest risk is that this pain may increase during examination due to increasing the length of involved muscles or ligaments [9]. Similarly, the child may also experience pain, stiffness or irritability after treatment (Miller & Benfield, 2008) [10]. Occasionally children may experience a headache.[11] We find that children experience side effects much less often than adults.[12]
Benefits
- Your child might get better with chiropractic care. [13] If they don’t, we will refer you on [14].
- Low risk of side effects and very rare risk of serious adverse effects [15].
- Drug-free health care. We are not against medication, but we do not prescribe [16].
- Compared with a medical practitioner, manual therapy carried out by a chiropractor is 20 x less likely to result in injury (Koch et al 2002, Miller 2009).[17]
- Children do not often require long courses of treatment (>3 weeks) unless complicating factors are present.[18]
- Studies have shown that parents have a high satisfaction rate with Chiropractic care [19].
- Physical therapies are much less likely to interfere with biomedical treatments. (McCann & Newell 2006) [20]
- You will have a better understanding of diagnosis of any complain and we will let you know what you can do to help.[21]
We invite you to have open discussions and communication with your treating chiropractor at all times. Should you need any further clarification please just ask.
References
- Hawk, C. Shneider, M.J., Vallone, S and Hewitt, E.G. (2016) – Best practises recommendations for chiropractic care of children: A consensus update. JMPT, 39 (3), 158-168.
- Marchand, A. (2013) – A Proposed model with possible implications for safety and technique adaptations for chiropractic spinal manipulative therapy for infants and children. JMPT, 5, 1-14
- Koch L. E., Koch, H, Graumann-Brunnt, S. Stolle, D. Ramirez, J.M., & Saternus, K.S. (2002) – Heart rate changes in response to mild mechanical irritation of the high cervical cord region in infants. Forensic Science International, 128, 168-176
- Miller J (2019) – Evidence-Based Chiropractic Care for Infants: Rational, Therapies and Outcomes. Chapter 11: Safety of Chiropractic care for Infants p111. Praeclarus Press
- Vohra, S. Johnston, B.C. Cramer, K, Humphreys, K. (2007) – Adverse events associated with paediatric spinal manipulation: A Systematic Review. Pediatrics, 119 (1) e275-283
- Miller, J and Benfield (2008) – Adverse effects of spinal manipulative therapy in children younger than 3 years: a retrospective study in a chiropractic teaching clinic. JMPT Jul-Aug;31(6):419-23.
- McCann, L.J. & Newell, S.J. (2006). Survey of paediatric complementary and alternative medicine in health and chronic disease. Archives of Diseases of Childhood, 91, 173-174
- Corso, M., Cancelliere, C. , Mior., Taylor-Vaise, A. Côté, P. (2020) – The safety of spinal manipulative therapy in children under 10 years: a rapid review. Chiropractic Manual therapy 25: 12
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- “taking joints to the end range of function” (range of motion, more likely) is arguably not “very gently”;
- “we strive to follow a system of evidence-based care”; I do not think that this is possible because pediatric chiropractic care is hardy evidence-based;
- as a generalizable statement, this seems to be not true;
- ” lower force, depth, amplitude and speed”; I am not sure that there is good evidence for that;
- research has foremost shown that there might be significant under-reporting;
- to blame the medical profession for diagnoses missed by chiropractors seems odd;
- possibly because of under-reporting;
- possibly because of under-reporting;
- possibly because of under-reporting;
- possibly because of under-reporting;
- possibly because of under-reporting;
- your impressions are not evidence;
- your child might get even better without chiropractic care;
- referral rates of chiropractors tend to be low;
- possibly because of under-reporting;
- chiropractors have no prescription rights but some lobby hard for it;
- irrelevant if we consider the intervention useless and thus obsolete;
- any evidence for this statement?;
- satisfaction rates are no substitute for real evidence;
- that does not mean they are effective, safe, or value for money;
- this is perhaps the strangest statement of them all – do chiropractors think they are the optimal diagnosticians for all complaints?
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According to its title, the paper was supposed to deal with consent for chiropractic pediatric care. It almost totally avoided the subject and certainly did not list the information chiropractors must give to parents before commencing treatment.
Considering the arguments that the article did provide has brought me to the conclusion that chiropractors who treat children are out of touch with reality and seem in danger of committing child abuse.
Social prescribing (SP) has been mentioned here several times before. It seems important to so-called alternative medicine (SCAM), as some enthusiasts – not least King Charles – are trying to use it as a means to smuggle nonsensical treatments into routine healthcare.
SP is supposed to enable healthcare professionals to link patients with non-medical interventions available in the community to address underlying socioeconomic and behavioural determinants. The question, of course, is whether it has any relevant benefits.
This systematic review included all randomised controlled trials of SP among community-dwelling adults recruited from primary care or community setting, investigating any chronic disease risk factors defined by the WHO (behavioural factors: smoking, physical inactivity, unhealthy diet and excessive alcohol consumption; metabolic factors: raised blood pressure, overweight/obesity, hyperlipidaemia and hyperglycaemia). Random effect meta-analyses were performed at two time points: completion of intervention and follow-up after trial.
The researchers identified 9 reports from 8 trials totalling 4621 participants. All studies evaluated SP exercise interventions which were highly heterogeneous regarding the content, duration, frequency and length of follow-up. The majority of studies had some concerns about the risk of bias. A meta-analysis revealed that SP likely increased physical activity (completion: mean difference (MD) 21 min/week, 95% CI 3 to 39, I2=0%; follow-up ≤12 months: MD 19 min/week, 95% CI 8 to 29, I2=0%). However, SP may not improve markers of adiposity, blood pressure, glucose and serum lipid. There were no eligible studies that primarily target unhealthy diet, smoking or excessive alcohol-drinking behaviours.
The authors concluded that SP exercise interventions probably increased physical activity slightly; however, no benefits were observed for metabolic factors. Determining whether SP is effective in modifying the determinants of chronic diseases and promotes sustainable healthy behaviours is limited by the current evidence of quantification and uncertainty, warranting further rigorous studies.
Great! Regular exercise improves physical fitness.
But do we need SP for this?
Don’t get me wrong, I have nothing against connecting patients with social networks to improve their health and quality of life. I do, however, object if SP is used to smuggle unproven or disproven SCAMs into EBM. In addition, I ask myself whether we really need the new profession of a ‘link worker’ to facilitate SP. I remember being taught that a good doctor should look after his/her patients holistically, and surely that includes mentioning and facilitating social networks for those who need them.
I, therefore, fear that SP is taking something valuable out of the hands of doctors. And the irony is that SP is favoured by those who are all too quick to turn around and say: LOOK AT HOW FRIGHTFULLY REDUCTIONIST AND HEARTLESS DOCTORS HAVE BECOME. WE NEED MORE HOLISM IN MEDICINE AND THAT CAN ONLY BE PROVIDED BY SCAM PRACTITIONERS!
