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

education

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A pro-homeopathy site (to be taken with a pinch of salt) claims that today 300 homeopathic MDs belong to the “Unio Homoeopathica Belgica” and 4,000 MDs (about 10% of all doctors) are prescribing homeopathics at least occasionally.

See the source image

One-fourth of the Belgian population uses homeopathy. As of 1998, only MDs can legally practice homeopathy. But now it seems that the free ride for Belgian homeopathy is coming to an end. Belgium has joined the long list of countries (e.g. UK, US, Spain, France, Sweden, Russia) where the usefulness of homeopathy is being questioned.

‘Test Achats’ is a Belgian not-for-profit organization which promotes consumer protection. It was founded in 1957 and publishes research in a subscription magazine. It has been reported that this organiation has issued a crushing report on homoeopathy, describing it as “unacceptable” that homeopathic remedies are allowed to be described by practitioners as medication.

Il est inacceptable que des médicaments homéopathiques et des médicaments traditionnels à base de plantes puissent être vendus en tant que “médicament” en pharmacie sans que leur efficacité n’ait été démontrée. Il en va de même pour un certain nombre de médicaments classiques et de médicaments ordinaires à base de plantes, pour lesquels nous avons également de gros doutes quant à leur efficacité et/ou leur sécurité. Le statut de “médicament” leur confère une aura de crédibilité qu’ils ne méritent absolument pas. Notre banque de données de médicaments met un terme à cette tromperie et distingue les médicaments utiles de ceux qui ne le sont pas…

Pour les 55 médicaments homéopathiques avec indication, ces pourcentages sont … 84 % à “utilité contestable” et 16 % “à déconseiller”.

“The requirements of effectiveness, safety and quality to bring a product to market and be allowed to use the name of medication are sadly not the same for all products,” commented a spokesperson for Test-Achats. “Homeopathic products are required to be accompanied by a minimum of documentation, and the effectiveness of the product barely has to be proven.”

‘Test-Achats’ describes homoeopathy as “quack medicine,” and states that “there are conditions where the patient really has no time to lose on products whose effectiveness has not been demonstrated. People who are suffering from very real heart and vascular conditions should immediately seek treatment by a doctor, and with truly effective medication.”

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This is all very good news, I think.
It almost reads as though ‘Test Achat’ have discovered my blog.
Welcome!

One of the most difficult things in so-called alternative medicine (SCAM) can be having a productive discussion with patients about the subject, particularly if they are deeply pro-SCAM. The task can get more tricky, if a patient is suffering from a serious, potentially life-threatening condition. Arguably, the discussion would become even more difficult, if the SCAM in question is relatively harmless but supported only by scarce and flimsy evidence.

An example might be the case of a cancer patient who is fond of mindfulness cognitive therapy (MBCT), a class-based program designed to prevent relapse or recurrence of major depression. To contemplate such a situation, let’s consider the following hypothetical exchange between a patient (P) and her oncologist (O).

P: I often feel quite low, do you think I need some treatment for depression?

O: That depends on whether you are truly depressed or just a bit under the weather.

P: No, I am not clinically depressed; it’s just that I am worried and sometimes see everything in black.

O: I understand, that’s not an unusual thing in your situation.

P: Someone told me about MBCT, and I wonder what you think about it.

O: Yes, I happen to know about this approach, but I’m not sure it would help you.

P: Are you sure? A few years ago, I had some MBCT; it seemed to work and, at least, it cannot do any harm.

O: Yes, that’s true; MBCT is quite safe.

P: So, why are you against it?

O: I am not against it; I just doubt that it is the best treatment for you.

P: Why?

O: Because there is little evidence for it and even less for someone like you.

P: But I have seen some studies that seem to show it works.

O: I know, there have been trials but they are not very reliable.

P: But the therapy has not been shown to be ineffective, has it?

O: No, but the treatment is not really for your condition.

P: So, you admit that there is some positive evidence but you are still against it because of some technicalities with the science?

O: No, I am telling you that this treatment is not supported by good evidence.

P: And therefore you want me to continue to suffer from low mood? I don’t call that very compassionate!

O: I fully understand your situation, but we ought to find the best treatment for you, not just one that you happen to be fond of.

P: I don’t understand why you are against giving MBCT a try; it’s safe, as you say, and there is some evidence for it. And I have already had a good experience with it. Is that not enough?

O: My role as your doctor is to provide you with advice about which treatments are best in your particular situation. There are options that are much better than MBCT.

P: But if I want to try it?

O: If you want to try MBCT, I cannot prevent you from doing so. I am only trying to tell you about the evidence.

P: Fine, in this case, I will give it a go.

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Clearly this discussion did not go all that well. It was meant to highlight the tension between the aspirations of a patient and the hope of a responsible clinician to inform his patient about the best available evidence. Often the evidence is not in favour of SCAM. Thus there is a gap that can be difficult to breach. (Instead of using MBCT, I could, of course, have used dozens of other SCAMs like homeopathy, chiropractic, Reiki, etc.)

The pro-SCAM patient thinks that, as she previously has had a good experience with SCAM, it must be fine; at the very minimum, it should be tried again, and she wants her doctor to agree. The responsible clinician thinks that he ought to recommend a therapy that is evidence-based. The patient feels that scientific evidence tells her nothing about her experience. The clinician insists that evidence matters. The patient finds the clinician lacks compassion. The clinician feels that the most compassionate and ethical strategy is to recommend the most effective therapy.

As the discussion goes on, the gap is not closing but seems to be widening.

What can be done about it?

I wish I knew the answer!

Do you?

I have just given two lectures on so-called alternative medicine (SCAM) in France.

Why should that be anything to write home about?

Perhaps it isn’t; but during the last 25 years I have been lecturing all over the world and, even though I live partly in France and speak the language, I never attended a single SCAM-conference there. I have tried for a long time to establish contact with French SCAM-researchers, but somehow this never happened.

Eventually, I came to the conclusion that, although the practice of SCAM is hugely popular in this country, there was no or very little SCAM-research in France. This conclusion seems to be confirmed by simple Medline searches. For instance, Medline lists just 171 papers for ‘homeopathy/France’ (homeopathy is much-used in France), while the figures for Germany and the UK are 490 and 448.

These are, of course, only very rough indicators, and therefore I was delighted to be invited to participate for the first time in a French SCAM-conference. It was well-organised, and I am most grateful to the organisers to have me. Actually, the meeting was about non-pharmacological treatments but the focus was clearly on SCAM. Here are a few impressions purely on the SCAM-elements of this conference.

TERMINOLOGY

Already the title of the conference, ‘Non-pharmacological Interventions: Integrative, Preventive, Complementary and Personalised Medicines‘, contained a confusing shopping-list of terms. The actual lectures offered even more. Clear definitions of these terms were not forthcoming and are, as far as I can see, impossible. This meant that much of the discussion lacked focus. In both my presentations, I used the term ‘alternative medicine’ and stressed that all such umbrella terms are fairly useless. In my view, it is therefore best to name the precise modality (acupuncture, osteopathy, homeopathy etc.) one wants to discuss.

INTEGRATIVE MEDICINE

The term that seemed to dominate the conference was ‘INTEGRATIVE MEDICINE’ (IM). I got the impression that it was employed uncritically by some for bypassing the need for proper evaluation of any specific SCAM. The experts seemed to imply that, because IM is the politically and socially correct approach, there is no longer a need for asking whether the treatments to be integrated actually generate more good than harm. I got the impression that most of these researchers were confusing science with promotion.

RESEARCH METHODOLOGY

The discussions regularly touched upon research methodology – but they did little more than lightly touch it. People tended to lament that ‘conventional research methodology’ was inadequate for assessing SCAM, and that we therefore needed different methods and even paradigms. I did not hear any reasonable explanations in what respect the ‘conventional methodology’ might be insufficient, nor did I understand the concept of an alternative science or paradigm. My caution that double standards in medicine can only be detrimental, seemed to irritate and fell mostly on deaf ears.

RESEARCH QUESTIONS

My own research agenda has always been the efficacy and safety of SCAM; and I still have no doubt that these are the issues that need addressing more urgently than any others. My impression was that, during this conference, the researchers seemed to aim in entirely different directions. One speaker even explained that, if a homeopath is fully convinced of the assumptions of homeopathy, he is entirely within the ethical standards to treat his patients homeopathically, regardless of the fact that homeopathy is demonstrably wrong. Another speaker claimed that there is no doubt any longer about the efficacy of acupuncture; the research question therefore must be how to best implement it in routine healthcare. And yet another expert tried to explain TCM with quantum physics. I have, of course, heard similar nonsense before during such conferences, but rarely did it pass without objection or debate.

RESEARCH FUNDING

The lack of research funding was bemoaned repeatedly. Most researchers seemed to think that they needed dedicated funding streams for SCAM to take account of the need of softer methodologies and the unique nature of SCAM. The argument that there should be only one set of standards for spending scarce research funds – scientific rigor and relevance – was not one shared by the French SCAM enthusiasts. The US example was frequently cited as the one that we ought to follow. In my view, the US example foremost shows impressively that a ring-fenced funding stream for SCAM is a wasteful mistake.

THE COLLEGE

To my surprise I learnt during a conference presentation that there is such a thing as the ‘Collège Universitaire de Médecines Intégratives et Complémentaires‘ (How could I have been unaware of it all those years? Why did I never see any of their published work? Why did they never contact me and cooperate?). Its president is Prof Jacques Kopferschmitt from the University of Strasbourg, and many French Universities are members of this organisation. Here is the abstract of Kopferschmitt’s lecture on the topic of this College:

The multitude of complementary therapies or non-pharmacological interventions (NPIs) first requires pedagogical semantic harmonization to bring down the historical tensions that persist. If users often remain very or too seduced, it is not the same with health professionals! Behind the words, there are concepts that disturb because between efficiency and efficiency the nuances are subtle. However, nothing really stands in the way of modern western medicine, but there are really gaps that we could fill in the face of the growing scale of chronic diseases, the prerogative of the Western world. The need for a university investment in verification, validation and certification is essential in the face of the diversity of offers. The main beneficiaries are health professionals who need to invest in an integrative approach, particularly in France. The CUMIC promotes a different vision of efficiency and effectiveness with a broader vision of multidisciplinary evaluation, which we will discuss the main targets.

Kopferschmitt is Professor of Medical Therapy, which introduced him to a pluralism of approach to health concerns, including innovative by the introduction of the CT in the first and second cycle of medical studies. He is responsible for the teaching of Acupuncture, Auriculotherapy and hypnosis clinic. He is vice President of the Groupe d’Évaluation des Thérapies complémentaires Personnalisées (GETCOP). By founding the association of complementary Therapies at the University hospitals of Strasbourg he coordinates the introduction, teaching and research in both in Hospital and in University, who was organized many seminars on CT. He currently chairs the French University of Integrative and Complementary Medicine College (CUMIC).

This sounded odd to me; however, it got truly bizarre after I looked up what SCAM-research Kopferschmitt or any of the other officers of the College have published. I could not find a single SCAM-article authored by him/them.

DIFFERENT PLANET

Altogether I found the conference enjoyable and was pleased to meet many interesting and very kind people. But I often felt like having arrived on a different planet. Many of the discussions, lectures, ideas, comments, etc. reminded me of 1993, the year I had arrived in the UK to start our research in SCAM. What is more, I fear that French experts involved in real science might feel the same about those colleagues who seem to engage themselves in SCAM research with more enthusiasm than expertise, scientific rigour or track record. The planet I had landed on was one where critical thinking was yet to be discovered, I felt.

ADVICE

Who am I to teach others what to do?

Yes, I do hesitate to give advice – but, after all, I have researched SCAM for 25 years and published more on the subject that any researcher on the planet; and I too was once more of a SCAM-enthusiast as is apparent today. So, for what it’s worth, here is some hopefully constructive advice that crossed my mind while driving home through the beautiful French landscape:

  • Sort out the confusion in terminology and define your terms as accurately as you can.
  • Try to focus on the research questions that are justifiably the most important ones for improving healthcare.
  • Do not attempt to re-invent the wheel.
  • Once you have identified a truly relevant research question, read up what has already been published on it.
  • While doing this, differentiate between rigorous research and fluff that does not meet this criterion.
  • Remember to abandon your own prejudices; research is about finding the truth and not about confirming your beliefs.
  • Avoid double standards like the pest.
  • Publish your research in top journals and avoid SCAM-journals that nobody outside SCAM takes seriously.
  • If you do not have a track record of publishing articles in top journals, please do not pretend to be an expert.
  • Involve sceptics in discussions and projects.
  • Remember that criticism is a precondition of progress.

I sincerely hope that this advice is not taken the wrong way. I certainly do not mean to hurt anyone’s feelings. What I do want is foremost that my French colleagues don’t have to repeat all the mistakes we did in the UK and that they are able to make swift progress.

I am being told to educate myself and rethink the subject of NAPRAPATHY by the US naprapath Dr Charles Greer. Even though he is not very polite, he just might have a point:

Edzard, enough foolish so-called scientific, educated assesments from a trained Allopathic Physician. When asked, everything that involves Alternative Medicine in your eyesight is quackery. Fortunately, every Medically trained Allopathic Physician does not have your points of view. I have partnered with Orthopaedic Surgeons, Medical Pain Specialists, General practitioners, Thoracic Surgeons, Forensic Pathologists and Others during the course, whom appreciate the Services that Naprapaths provide. Many of my current patients are Medical Physicians. Educate yourself. Visit a Naprapath to learn first hand. I expect your outlook will certainly change.

I have to say, I am not normally bowled over by anyone who calls me an ‘allopath’ (does Greer not know that Hahnemann coined this term to denigrate his opponents? Is he perhaps also in favour of homeopathy?). But, never mind, perhaps I was indeed too harsh on naprapathy in my previous post on this subject.

So, let’s try again.

Just to remind you, naprapathy was developed by the chiropractor Oakley Smith who had graduated under D D Palmer in 1899. Smith was a former Iowa medical student who also had investigated Andrew Still’s osteopathy in Kirksville, before going to Palmer in Davenport. Eventually, Smith came to reject Palmer’s concept of vertebral subluxation and developed his own concept of “the connective tissue doctrine” or naprapathy.

Dr Geer published a short article explaining the nature of naprapathy:

Naprapathy- A scientific, Evidence based, integrative, Alternative form of Pain management and nutritional assessment that involves evaluation and treatment of Connective tissue abnormalities manifested in the entire human structure. This form of Therapeutic Regimen is unique specifically to the Naprapathic Profession. Doctors of Naprapathy, pronounced ( nuh-prop-a-thee) also referred to as Naprapaths or Neuromyologists, focus on the study of connective tissue and the negative factors affecting normal tissue. These factors may begin from external sources and latently produce cellular changes that in turn manifest themselves into structural impairments, such as irregular nerve function and muscular contractures, pulling its’ bony attachments out of proper alignment producing nerve irritability and impaired lymphatic drainage. These abnormalities will certainly produce a pain response as well as swelling and tissue congestion. Naprapaths, using their hands, are trained to evaluate tissue tension findings and formulate a very specific treatment regimen which produces positive results as may be evidenced in the patients we serve. Naprapaths also rely on information obtained from observation, hands on physical examination, soft tissue Palpatory assessment, orthopedic evaluation, neurological assessment linked with specific bony directional findings, blood and urinalysis laboratory findings, diet/ Nutritional assessment, Radiology test findings, and other pertinent clinical data whose information is scrutinized and developed into a individualized and specific treatment plan. The diagnostic findings and results produced reveal consistent facts and are totally irrefutable. The deductions that formulated these concepts of theory of Naprapathic Medicine are rationally believable, and have never suffered scientific contradiction. Discover Naprapathic Medicine, it works.

What interests me most here is that naprapathy is evidence-based. Did I perhaps miss something? As I cannot totally exclude this possibility, I did another Medline search. I found several trials:

1st study (2007)

Four hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks, recruited at 2 large public companies in Sweden in 2005, were included in this randomized controlled trial. The 2 interventions were naprapathy, including spinal manipulation/mobilization, massage, and stretching (Index Group) and support and advice to stay active and how to cope with pain, according to the best scientific evidence available, provided by a physician (Control Group). Pain, disability, and perceived recovery were measured by questionnaires at baseline and after 3, 7, and 12 weeks.

RESULTS:

At 7-week and 12-week follow-ups, statistically significant differences between the groups were found in all outcomes favoring the Index Group. At 12-week follow-up, a higher proportion in the naprapathy group had improved regarding pain [risk difference (RD)=27%, 95% confidence interval (CI): 17-37], disability (RD=18%, 95% CI: 7-28), and perceived recovery (RD=44%, 95% CI: 35-53). Separate analysis of neck pain and back pain patients showed similar results.

DISCUSSION:

This trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.

2nd study (2010)

Subjects with non-specific pain/disability in the back and/or neck lasting for at least two weeks (n = 409), recruited at public companies in Sweden, were included in this pragmatic randomized controlled trial. The two interventions compared were naprapathic manual therapy such as spinal manipulation/mobilization, massage and stretching, (Index Group), and advice to stay active and on how to cope with pain, provided by a physician (Control Group). Pain intensity, disability and health status were measured by questionnaires.

RESULTS:

89% completed the 26-week follow-up and 85% the 52-week follow-up. A higher proportion in the Index Group had a clinically important decrease in pain (risk difference (RD) = 21%, 95% CI: 10-30) and disability (RD = 11%, 95% CI: 4-22) at 26-week, as well as at 52-week follow-ups (pain: RD = 17%, 95% CI: 7-27 and disability: RD = 17%, 95% CI: 5-28). The differences between the groups in pain and disability considered over one year were statistically significant favoring naprapathy (p < or = 0.005). There were also significant differences in improvement in bodily pain and social function (subscales of SF-36 health status) favoring the Index Group.

CONCLUSIONS:

Combined manual therapy, like naprapathy, is effective in the short and in the long term, and might be considered for patients with non-specific back and/or neck pain.

3rd study (2016)

Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of Naprapathögskolan – the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 1057) were randomized to one of three treatment arms a) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage), b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes.

RESULTS:

At 12 weeks follow-up, 64% had a minimal clinically important improvement in pain intensity and 42% in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58% and 40% respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately.

CONCLUSION:

The effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option.

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I don’t know about you, but I don’t call this ‘evidence-based’ – especially as all the three trials come from the same research group (no, not Greer; he seems to have not published at all on naprapathy). Dr Greer does clearly not agree with my assessment; on his website, he advertises treating the following conditions:

Anxiety
Back Disorders
Back Pain
Cervical Radiculopathy
Cervical Spondylolisthesis
Cervical Sprain
Cervicogenic Headache
Chronic Headache
Chronic Neck Pain
Cluster Headache
Cough Headache
Depressive Disorders
Fibromyalgia
Headache
Hip Arthritis
Hip Injury
Hip Muscle Strain
Hip Pain
Hip Sprain
Joint Clicking
Joint Pain
Joint Stiffness
Joint Swelling
Knee Injuries
Knee Ligament Injuries
Knee Sprain
Knee Tendinitis
Lower Back Injuries
Lumbar Herniated Disc
Lumbar Radiculopathy
Lumbar Spinal Stenosis
Lumbar Sprain
Muscle Diseases
Musculoskeletal Pain
Neck Pain
Sciatica (Not Due to Disc Displacement)
Sciatica (Not Due to Disc Displacement)
Shoulder Disorders
Shoulder Injuries
Shoulder Pain
Sports Injuries
Sports Injuries of the Knee
Stress
Tendonitis
Tennis Elbow (Lateral Epicondylitis)
Thoracic Disc Disorders
Thoracic Outlet Syndrome
Toe Injuries

Odd, I’d say! Did all this change my mind about naprapathy? Not really.

But nobody – except perhaps Dr Greer – can say I did not try.

And what light does this throw on Dr Greer and his professionalism? Since he seems to be already quite mad at me, I better let you answer this question.

So-called alternative medicine (SCAM) for animals is popular. A recent survey suggested that 76% of US dog and cat owners use some form of SCAM. Another survey showed that about one quarter of all US veterinary medical schools run educational programs in SCAM. Amazon currently offers more that 4000 books on the subject.

The range of SCAMs advocated for use in animals is huge and similar to that promoted for use in humans; the most commonly employed practices seem to include acupuncture, chiropractic, energy healing, homeopathy (as discussed in the previous post) and dietary supplements. In this article, I will briefly discuss the remaining 4 categories.

ACUPUNCTURE

Acupuncture is the insertion of needles at acupuncture points on the skin for therapeutic purposes. Many acupuncturists claim that, because it is over 2 000 years old, acupuncture has ‘stood the test of time’ and its long history proves acupuncture’s efficacy and safety. However, a long history of usage proves very little and might even just demonstrate that acupuncture is based on the pre-scientific myths that dominated our ancient past.

There are many different forms of acupuncture. Acupuncture points can allegedly be stimulated not just by inserting needles (the most common way) but also with heat, electrical currents, ultrasound, pressure, bee-stings, injections, light, colour, etc. Then there is body acupuncture, ear acupuncture and even tongue acupuncture. Traditional Chinese acupuncture is based on the Taoist philosophy of the balance between two life-forces, ‘yin and yang’. In contrast, medical acupuncturists tend to cite neurophysiological theories as to how acupuncture might work; even though some of these may appear plausible, they nevertheless are mere theories and constitute no proof for acupuncture’s validity.

The therapeutic claims made for acupuncture are legion. According to the traditional view, acupuncture is useful for virtually every condition. According to ‘Western’ acupuncturists, acupuncture is effective mostly for chronic pain. Acupuncture has, for instance, been used to improve mobility in dogs with musculoskeletal pain, to relieve pain associated with cervical neurological disease in dogs, for respiratory resuscitation of new-born kittens, and for treatment of certain immune-mediated disorders in small animals.

While the use of acupuncture seems to gain popularity, the evidence fails to support this. Our systematic review of acupuncture (to the best of my knowledge the only one on the subject) in animals included 14 randomized controlled trials and 17 non-randomized controlled studies. The methodologic quality of these trials was variable but, on average, it was low. For cutaneous pain and diarrhoea, encouraging evidence emerged that might warrant further investigation. Single studies reported some positive inter-group differences for spinal cord injury, Cushing’s syndrome, lung function, hepatitis, and rumen acidosis. However, these trials require independent replication. We concluded that, overall, 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.

Serious complications of acupuncture are on record and have repeatedly been discussed on this blog: acupuncture needles can, for instance, injure vital organs like the lungs or the heart, and they can introduce infections into the body, e. g. hepatitis. About 100 human fatalities after acupuncture have been reported in the medical literature – a figure which, due to lack of a monitoring system, may disclose just the tip of an iceberg. Information on adverse effects of acupuncture in animals is currently not available.

Given that there is no good evidence that acupuncture works in animals, the risk/benefit balance of acupuncture cannot be positive.

CHIROPRACTIC

Chiropractic was created by D D Palmer (1845-1913), an American magnetic healer who, in 1895, manipulated the neck of a deaf janitor, allegedly curing his deafness. Chiropractic was initially promoted as a cure-all by Palmer who claimed that 95% of diseases were due to subluxations of spinal joints. Subluxations became the cornerstone of chiropractic ‘philosophy’, and chiropractors who adhere to Palmer’s gospel diagnose subluxation in nearly 100% of the population – even in individuals who are completely disease and symptom-free. Yet subluxations, as understood by chiropractors, do not exist.

There is no good evidence that chiropractic spinal manipulation might be effective for animals. A review of the evidence for different forms of manual therapies for managing acute or chronic pain syndromes in horses concluded that further research is needed to assess the efficacy of specific manual therapy techniques and their contribution to multimodal protocols for managing specific somatic pain conditions in horses. For other animal species or other health conditions, the evidence is even less convincing.

In humans, spinal manipulation is associated with serious complications (regularly discussed in previous posts), usually caused by neck manipulation damaging the vertebral artery resulting in a stroke and even death. Several hundred such cases have been documented in the medical literature – but, as there is no system in place to monitor such events, the true figure is almost certainly much larger. To the best of my knowledge, similar events have not been reported in animals.

Since there is no good evidence that chiropractic spinal manipulations work in animals, the risk/benefit balance of chiropractic fails to be positive.

ENERGY HEALING

Energy healing is an umbrella term for a range of paranormal healing practices, e. g. Reiki, Therapeutic Touch, Johrei healing, faith healing. Their common denominator is the belief in an ‘energy’ that can be used for therapeutic purposes. Forms of energy healing have existed in many ancient cultures. The ‘New Age’ movement has brought about a revival of these ideas, and today ‘energy’ healing systems are amongst the most popular alternative therapies in many countries.

Energy healing relies on the esoteric belief in some form of ‘energy’ which refers to some life force such as chi in Traditional Chinese Medicine, or prana in Ayurvedic medicine. Some proponents employ terminology from quantum physics and other ‘cutting-edge’ science to give their treatments a scientific flair which, upon closer scrutiny, turns out to be little more than a veneer of pseudo-science.

Considering its implausibility, energy healing has attracted a surprisingly high level of research activity in the form of clinical trials on human patients. Generally speaking, the methodologically best trials of energy healing fail to demonstrate that it generates effects beyond placebo. There are few studies of energy healing in animals, and those that are available are frequently less than rigorous (see for instance here and here). Overall, there is no good evidence to suggest that ‘energy’ healing is effective in animals.

Even though energy healing is per se harmless, it can do untold damage, not least because it can lead to neglect of effective treatments and it undermines rationality in our societies. Its risk/benefit balance therefore fails to be positive.

DIETARY SUPPLEMENTS

Dietary supplements for veterinary use form a category of remedies that, in most countries, is a regulatory grey area. Supplements can contain all sorts of ingredients, from minerals and vitamins to plants and synthetic substances. Therefore, generalisations across all types of supplements are impossible. The therapeutic claims that are being made for supplements are numerous and often unsubstantiated. Although they are usually promoted as natural and safe, dietary supplements do not have necessarily either of these qualities. For example, in the following situations, supplements can be harmful:

  1. Combining one supplement with another supplement or with prescribed medicines
  2. Substituting supplements for prescription medicines
  3. Overdosing some supplements, such as vitamin A, vitamin D, or iron

Examples of currently most popular supplements for use in animals include chondroitin, glucosamine, probiotics, vitamins, minerals, lutein, L-carnitine, taurine, amino acids, enzymes, St John’s wort, evening primrose oil, garlic and many other herbal remedies. For many supplements taken orally, the bioavailability might be low. There is a paucity of studies testing the efficacy of dietary supplements in animals. Three recent exceptions (all of which require independent replication) are:

Dietary supplements are promoted as being free of direct risks. On closer inspection, this notion turns out to be little more than an advertising slogan. As discussed repeatedly on this blog, some supplements contain toxic materials, contaminants or adulterants and thus have the potential to do harm. A report rightly concluded that many challenges stand in the way of determining whether or not animal dietary supplements are safe and at what dosage.  Supplements considered safe in humans and other cross-species are not always safe in horses, dogs, and cats.  An adverse event reporting system is badly needed.  And finally, regulations dealing with animal dietary supplements are in disarray.  Clear and precise regulations are needed to allow only safe dietary supplements on the market.

It is impossible to generalise about the risk/benefit balance of dietary supplements; however, caution is advisable.

CONCLUSION

SCAM for animals is an important subject, not least because of the current popularity of many treatments that fall under this umbrella. For most therapies, the evidence is woefully incomplete. This means that most SCAMs are unproven. Arguably, it is unethical to use unproven medicines in routine veterinary care.

 

 

 

PS

I was invited several months ago to write this article for VETERINARY RECORD. It was submitted to peer review and subsequently I withdrew my submission. The above post is a slightly revised version of the original (in which I used the term ‘alternative medicine’ rather than ‘SCAM’) which also included a section on homeopathy (see my previous post). The reason for the decision to withdraw this article was the following comment by the managing editor of VETERINARY RECORD:  A good number of vets use these therapies and a more balanced view that still sets out their efficacy (or otherwise) would be more useful for the readership.

Today is WORLD CANCER DAY. A good reason, I feel, to remind everyone of the existence of CAM-CANCER, an initiative that I have been involved with from its start (in fact, I was one of its initiators). Essentially, we – that is an international team of CAM-experts – conduct systematic reviews of CAMs often advertised for cancer. We then offer them as a free web resource providing the public with evidence-based information about all sorts of CAMs for cancer.

CAM-Cancer follows a strict methodology to produce CAM-summaries of high quality. Writing, review and editorial processes all follow pre-defined methods and the CAM-Cancer editorial team and Executive Committee ensure that CAM-summaries comply with the guidelines and templates. We are independent from commercial funders and strive to be as objective as possible. Most of the experts are more enthusiastic about the value of CAM than I am, but we do our very best to avoid letting sentiments get in the way of rigorous scientific assessments.

So far, we have managed to publish a respectably large and diverse array of summaries. Here is the full list:

A

B

C

D

E

F

G

H

I

L

M

N

O

P

Q

R

S

T

U

V

Y

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Let me pick out just one of the summaries, Gerson therapy. This topic has led to fierce debates on my blog. The ‘key points’ of the CAM-CANCER summary are as follows:

  • Gerson therapy uses a special diet, supplements and coffee enemas with the aim of detoxifying and stimulating the body’s metabolism.
  • No substantial evidence exists in the scientific literature to support the claims that the Gerson therapy is an effective alternative therapy for cancer.
  • Some evidence exists to suggest that elements of the therapy (coffee enemas in particular) are potentially dangerous if used excessively.
  • The specific safety problems, advice to stop conventional cancer therapies and the lack of substantial evidence for efficacy outweigh any benefits associated with the Gerson therapy.

I think this is clear enough and it certainly corresponds well with what I previously wrote about Gerson on this blog. The style of presentation might be different, but the information and conclusions are almost identical.

Altogether, our CAM-CANCER summaries are well-informed, concise, and strictly evidence-based. On this WORLD CANCER DAY, I therefore warmly recommend them to everyone and sincerely hope you make good use of them, for instance, by telling other interested parties about this little-known but precious resource.

The 2018 World Federation of Chiropractic ACC Education Conference was held on 24-27 October in London. It resulted in several consensus statements developed by the attendees. I happen to know this from a short report that has just been published; it can be found here.

Of the 10 points made in this consensus, I find only the following noteworthy:

“Chiropractic education programs have an ethical obligation to support an evidence-based teaching and learning environment.”

Perhaps it is me – English is not my first language – but I find the phraseology used in this sentence strangely complicated and confusing. I have been a teacher of medical students for most of my life, but I am not sure what an ‘evidence-based teaching and learning environment’ is. I know what ‘evidence-based’ means, of course. However, what exactly is:

  • a teaching environment?
  • a learning environment?
  • and how does ‘evidence-based’ apply to either of the two?

Is there evidence that some environments are better suited than others for teaching?

Is there evidence that some environments are better suited than others for learning?

I suppose the answer must be YES!

The environment, i. e. the space and conditions in which teaching and learning happen should, for instance, be/include:

  • quiet,
  • not cramped,
  • not too cold,
  • not too hot,
  • equipped with ergometric chairs and desks,
  • well-lit,
  • there should be visual aids,
  • access to computers,
  • a library,
  • good mentoring and support,
  • etc.

So, the consensus of the education conference wanted to optimise the environmental conditions of teaching and learning for chiropractic lecturers and students? Most laudable, I must say!

But still, it seems like a missed opportunity for an ‘Education Conference’ not to have stated something about the content of teaching and learning. Personally, I find it a pity that they did not state: Chiropractic education programs have an ethical obligation to be evidence-based.

Or is that what they really wanted to say?

Naaahh … come to think of it … they cannot possibly make such a demand.

Why?

Because, in this case, they would have to teach students not to become chiropractors.

My last post was rather depressive, and I certainly do not want my readers to be under the weather when they go into 2019. For this last post of 2018, I have therefore selected 20 events which gave me hope that perhaps we – those who prefer rationality to nonsense – are making progress.

  1. It has been reported that New Brunswick judge ruled this week that Canadian naturopaths — pseudoscience purveyors who promote a variety of “alternative medicines” like homeopathy, herbs, detoxes, and acupuncture — cannot legally call themselves “medically trained.”
  2. The Spanish Ministries of Health and Sciences announced their ‘Health Protection Plan against Pseudotherapies’.
  3. The medical school of Vienna axed their courses in homeopathy.
  4. A most comprehensive review of homeopathy concluded that the effects of homeopathy do not differ from those of placebo.
  5. The UK Pharmaceutical Society has stated that it does not endorse homeopathy and that pharmacists must advise patients considering a homeopathic product about their lack of efficacy beyond that of a placebo.
  6. A top medical journal has retracted a dodgy meta-analysis of acupuncture.
  7. A prominent BMJ columnist wrote : Many people seek to make money from those who don’t understand science. Doctors should call out bollocksology when they see it.
  8. Pharmacare and Bioglan received a ‘Stonky’ for its over-the-counter Melatonin Homeopathic Sleep Formula.
  9. The Governing Body of Bristol, North Somerset and South Gloucestershire (BNSSG) Clinical Commissioning Group (CCG) approved changes that mean NHS funded homeopathy will only be available in exceptional circumstances in the area.
  10. Health ministers of all German counties have decided that they will start reforming the profession of the Heilpraktiker, the German non-medically trained alternative practitioners.
  11. The NHS chief, Simon Stevens was quoted saying: There is no robust evidence to support homeopathy which is at best a placebo and a misuse of scarce NHS funds.
  12. A systematic review concluded that there is no evidence in the literature of an effect of chiropractic treatment in the scope of primary prevention or early secondary prevention for disease in general. Chiropractors have to assume their role as evidence-based clinicians and the leaders of the profession must accept that it is harmful to the profession to imply a public health importance in relation to the prevention of such diseases through manipulative therapy/chiropractic treatment.
  13. A Cochrane review did not show any benefit of homeopathic medicinal products compared to placebo on recurrence of acute respiratory tract infections or cure rates in children. 
  14. The French minister of health stated that ‘the French are very attached [to homeopathy]; it’s probably a placebo effect. If it can prevent the use of toxic medicine, I think that we all win. I does not hurt.
  15. The Australian Acupuncture and Chinese Medicine Association retracted false accusation against me about their assumption that I had undeclared conflicts of interest.
  16. The ‘Daily Telegraph‘ published the following statement after misquoting me: Emeritus Professor Edzard Ernst, Britain’s first professor of complementary medicine at Exeter University said that doctors should make it clear to patients that they could not be taking herbal remedies alongside drugs. Prof Ernst said there was no good evidence that they work and that doctors were ‘contributing to disinformation’ by turning a blind eye to the practice.
  17. A comprehensive overview of the therapeutic options for chronic low back pain showed that chiropractic is not any better than over-the-counter painkillers or exercise, and that patients need to take precautions when seeking out a chiropractor.

Hold on, you promised 20, but these are just 17!!!, I hear my attentive readers mutter.

Correct! I tried to find 20 to match my last post; and I only found 17. This might be a reflection that, in the realm of SCAM, the bad still outweighs the good news (by much more that 20:17, I fear).

Yet, this should not depress us. On the contrary, let’s see it as a challenge to get on with out work of fighting for good evidence, ethical standards, rationality and critical thinking.In this spirit, I wish you all a very good, healthy and productive year 2019.

Need a last minute X-mas present?

I might have just the right thing for you: Healing Courses Online.

They are run by true professionals who clearly know what they are doing: The founders of The Online Bio Energy Healing Training Course are John Donohoe and Patricia Hesnan, both of whom have been working in the alternative complementary healing area for over 25 years. Our healing centre clinic has been involved in teaching, development and trainings since it was first established in 1990, and we continue to promote and hold our regular live training courses.

Healing Courses Online is registered with the CMA (Complementary Medical Association), which is internationally recognized as the leading organization in professional, ethical complementary medicine by professional practitioners, therapists, and the public in general. Having completed this course, you can apply for membership of the CMA which offers a number of benefits including supplying professional accreditation. The CAM industry does not have a single regulatory body at present. With this in mind here at Oisin Centre Limited and Healing Courses Online we provide certification and training of the highest standards and expect our students to adhere to all statutory regulations, standards and codes of ethics regarding professional practice as therapists. You can feel safe in the knowledge that we are an experienced and trusted provider of Energy Healing training courses.

 

AND HERE ARE THE DETAILS AND PRICE-TAGS OF 4 COURSES:

 

A diploma course in energy healing. It includes 58 professional video lessons, 8 PDF lectures in a carefully constructed A, B, C, step-by-step format, allowing you to learn each technique and each application in easy stages. When you have completed the course you receive a Certified Diploma in Energy Healing. Once you have the knowledge and understand how to apply this energy healing therapy you can help yourself and others to activate the body’s own natural process of self-healing.

€97.00 – Was €375.00

A diploma course in sound healing. It includes 37 professional video lessons, 18 PDF lectures in a carefully constructed A, B, C, step-by-step format, allowing you to learn each technique and each application in easy stages. When you have completed the course, you receive a Certified Diploma in Sound Healing. Learn the secrets to sound healing with Tibetan singing bowls, Chinese gong, Tuning forks, the Human Voice, plus energy healing clearing for chakras plus much more.

€69.00 – Was €275.00

A diploma course in animal energy healing. It includes 30 practical video lessons and 5 PDF lectures in a carefully constructed A, B, C, step-by-step format, allowing you to learn each technique and each application in easy stages. When you have completed the course, you receive a Certified Diploma in Animal Healing. This is an ideal course to learn how you can help your pet or any animal so they may be healthy, happy and content.

€59.00 – Was €225.00

SELF HEALING / SELF HELP ONLINE COURSE includes 24 professional video lessons, plus 20 PDF lectures in a carefully constructed A, B, C, step-by-step format, allowing you to learn each technique and each application in easy stages and certification of completion. You can view a video with simple Qi-Gong exercises filmed at picturesque Galway Bay in Ireland. The aim of using singing bowls, crystal bowls, tuning forks, healing music, or the human voice as a self healing modality is to help restore the body to its normal.

€19.99 – Was €199.00

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IN CASE YOU WONDER WHAT YOU CAN DO ONCE YOU HAVE PASSED ONE OF THOSE COURSES, THE COURSE DIRECTORS GIVE IT TO YOU STRAIGHT:

Energy healing can be used as a standalone therapy or in conjunction with many other modalities including counselling, psychotherapy, hypnosis, acupuncture, massage, reflexology, and many more.

As soon as you have completed the course plus a short 10 question test, you will be granted your diploma, which you can download and print. (Your diploma is also automatically sent to your email account.)

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On this blog and elsewhere, my critics regularly complain that I do not have any qualifications in alternative medicine. Therefore, I am tempted to enrol (as a generous and high-value X-mas present to myself) – even though I am still uncertain which of the 4 courses might be best for me (and, of course, I cannot be sure to pass the ’10 question test’!).

How about you?

Will you join me?

A few weeks ago, I was interviewed by a journalist who wanted to publish the result in a magazine. He now informed me that his editor decided against it, and the interview thus remained unpublished. I have the journalist’s permission to publish it here. The journalist who, in my view, was well-prepared (much better than most), prefers to remain unnamed.

Q: How would you describe yourself?

A: I am a researcher of alternative medicine.

Q: Not a critic of alternative medicine?

A: Primarily, I am a researcher; after all, I have published more Medline-listed research papers on the subject than anyone else on the planet.

Q: You are retired since a few years; why do you carry on working?

A: Mainly because I see a need for a critical voice amongst all the false and often dangerous claims made by proponents of alternative medicine. But also because I enjoy what I am doing. Since I retired, I can focus on the activities I like. There is nobody to tell me what to do and what not to do; the latter happened far too often when I was still head of my research unit.

Q: Fine, but I still do not quite understand what drives you. Who is motivating you to criticise alternative medicine?

A: Nobody. Some people claim I am paid for my current activities. This is not true. My blog actually costs me money. My books never return enough royalties to break even, considering the time they take to write. And for most of my lectures I don’t charge a penny.

Q: There are people who find this hard to believe.

A: I know. This just shows how money-orientated they are. Do they want me to publish my tax returns?

Q: Sorry, but I still don’t understand your motivation.

A: I guess what motivates me is a sense of responsibility, a somewhat naïve determination to do something good as a physician. I am one of the only – perhaps even THE only – scientist who has researched alternative medicine extensively and who is not a promoter of bogus therapies but voices criticism about them. There are several other prominent and excellent critics of alternative medicine, of course, but they all come ‘from the outside’. I come from the inside of the alternative medicine business. This probably gives me a special understanding of this field. In any case, I feel the responsibility to counter-balance all the nonsense that is being published on a daily basis.

Q: What’s your ultimate aim?

A: I want to create progress through educating people to think more critically.

Q: Which alternative medicine do you hate most?

A: I do not hate any of them. In fact, I still have more sympathy for them than might be apparent. For my blog, for instance, I constantly search for new research papers that are rigorous and show a positive result. The trouble is, there are so very few of those articles. But when I find one, I am delighted to report about it. No, I do not hate or despise any alternative medicine; I am in favour of good science, and I get irritated by poor research. And yes, I do dislike false claims that potentially harm consumers. And yes, I do dislike it when chiropractors or other charlatans defraud consumers by taking their money for endless series of useless interventions.

Q: I noticed you go on about the risks of alternative medicine. But surely, they are small compared to the risks of conventional healthcare, aren’t they?

A: That’s a big topic. To make it simple: alternative medicine is usually portrayed as risk-free. The truth, however, is that there are numerous risks of direct and indirect harm; the latter is usually much more important than the former. Crucially, the risk-free image is incongruent with reality. I want to redress this incongruence. And as to conventional medicine: sure, it can be much more harmful. But one always has to see this in relation to the proven benefit. Chemotherapy, for instance, can kill a cancer patient, but more likely it saves her life. Homeopathic remedies cannot kill you, but employed as an alternative to an effective cancer treatment, homeopathy will certainly kill you.

Q: Homeopathy seems to be your particular hobby horse.

A: Perhaps. This is because it exemplifies alternative medicine in several ways, and because I started my alternative ‘career’ in a homeopathic hospital, all those years ago.

Q: In what way is homeopathy exemplary?

A: Its axioms are implausible, like those of many other alternative modalities. The clinical evidence fails to support the claims, like with so many alternative therapies. And it is seemingly safe, yet can do a lot of harm, like so many other treatments.

Q: You have no qualification in homeopathy, is that right?

A: No, I have no such qualifications. And I never said so. When I want to tease homeopaths a little, I state that I am a trained homeopath; and that is entirely correct.

Q: In several countries, homeopathy has taken spectacular hits recently. Is that your doing?

A: No, I don’t think so. But I do hope that my work has inspired the many dedicated activists who are currently protesting against the reimbursement of homeopathy by the public purse in the UK, Germany, France, Spain, etc.

Q: You often refer to medical ethics; why is that?

A: Because, in the final analysis, many of the questions we already discussed are really ethical issues. And in alternative medicine, few people have so far given the ethical dimensions any consideration. I think ethics are central to alternative medicine, so much so that I co-authored an entire book on this topic this year.

Q: Any plans for the future?

A: Plenty.

Q: Can you tell me more?

A: I will publish another book in 2019 with Springer. It will be a critical evaluation of precisely 150 different alternative modalities. I am thinking of writing yet another book, but have not yet found a literary agent who wants to take me on. I have been offered a new professorship at a private University in Vienna, and am hesitant whether to accept or not. I have been invited to give a few lectures in 2019 and hope to receive more invitations. Last not least, I work almost every day on my blog.

Q: More than enough for a retiree, it seems. Thank you for your time.

A: My pleasure.

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