fraud
Systematic reviews are widely considered to be the most reliable type of evidence for judging the effectiveness of therapeutic interventions. Such reviews should be focused on a well-defined research question and identify, critically appraise and synthesize the totality of the high quality research evidence relevant to that question. Often it is possible to pool the data from individual studies and thus create a new numerical result of the existing evidence; in this case, we speak of a meta-analysis, a sub-category of systematic reviews.
One strength of systematic review is that they minimise selection and random biases by considering at the totality of the evidence of a pre-defined nature and quality. A crucial precondition, however, is that the quality of the primary studies is critically assessed. If this is done well, the researchers will usually be able to determine how robust any given result is, and whether high quality trials generate similar findings as those of lower quality. If there is a discrepancy between findings from rigorous and flimsy studies, it is obviously advisable to trust the former and discard the latter.
And this is where systematic reviews of alternative treatments can run into difficulties. For any given research question in this area we usually have a paucity of primary studies. Equally important is the fact that many of the available trials tend to be of low quality. Consequently, there often is a lack of high quality studies, and this makes it all the more important to include a robust critical evaluation of the primary data. Not doing so would render the overall result of the review less than reliable – in fact, such a paper would not qualify as a systematic review at all; it would be a pseudo-systematic review, i.e. a review which pretends to be systematic but, in fact, is not. Such papers are a menace in that they can seriously mislead us, particularly if we are not familiar with the essential requirements for a reliable review.
This is precisely where some promoters of bogus treatments seem to see their opportunity of making their unproven therapy look as though it was evidence-based. Pseudo-systematic reviews can be manipulated to yield a desired outcome. In my last post, I have shown that this can be done by including treatments which are effective so that an ineffective therapy appears effective (“chiropractic is so much more than just spinal manipulation”). An even simpler method is to exclude some of the studies that contradict one’s belief from the review. Obviously, the review would then not comprise the totality of the available evidence. But, unless the reader bothers to do a considerable amount of research, he/she would be highly unlikely to notice. All one needs to do is to smuggle the paper past the peer-review process – hardly a difficult task, given the plethora of alternative medicine journals that bend over backwards to publish any rubbish as long as it promotes alternative medicine.
Alternatively (or in addition) one can save oneself a lot of work and omit the process of critically evaluating the primary studies. This method is increasingly popular in alternative medicine. It is a fool-proof method of generating a false-positive overall result. As poor quality trials have a tendency to deliver false-positive results, it is obvious that a predominance of flimsy studies must create a false-positive result.
A particularly notorious example of a pseudo-systematic review that used this as well as most of the other tricks for misleading the reader is the famous ‘systematic’ review by Bronfort et al. It was commissioned by the UK GENERAL CHIROPRACTIC COUNCIL after the chiropractic profession got into trouble and was keen to defend those bogus treatments disclosed by Simon Singh. Bronfort and his colleagues thus swiftly published (of course, in a chiro-journal) an all-encompassing review attempting to show that, at least for some conditions, chiropractic was effective. Its lengthy conclusions seemed encouraging: Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation. Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.
Chiropractors across the world cite this paper as evidence that chiropractic has at least some evidence base. What they omit to tell us (perhaps because they do not appreciate it themselves) is the fact that Bronfort et al
- failed to formulate a focussed research question,
- invented his own categories of inconclusive findings,
- included all sorts of studies which had nothing to do with chiropractic,
- and did not to make an assessment of the quality of the included primary studies they included in their review.
If, for a certain condition, three trials were included, for instance, two of which were positive but of poor quality and one was negative but of good quality, the authors would conclude that, overall, there is sound evidence.
Bronfort himself is, of course, more than likely to know all that (he has learnt his trade with an excellent Dutch research team and published several high quality reviews) – but his readers mostly don’t. And for chiropractors, this ‘systematic’ review is now considered to be the most reliable evidence in their field.
Whenever a new trial of an alternative intervention emerges which fails to confirm the wishful thinking of the proponents of that therapy, the world of alternative medicine is in turmoil. What can be done about yet another piece of unfavourable evidence? The easiest solution would be to ignore it, of course – and this is precisely what is often tried. But this tactic usually proves to be unsatisfactory; it does not neutralise the new evidence, and each time someone brings it up, one has to stick one’s head back into the sand. Rather than denying its existence, it would be preferable to have a tool which invalidates the study in question once and for all.
The ‘fatal flaw’ solution is simpler than anticipated! Alternative treatments are ‘very special’, and this notion must be emphasised, blown up beyond all proportions and used cleverly to discredit studies with unfavourable outcomes: the trick is simply to claim that studies with unfavourable results have a ‘fatal flaw’ in the way the alternative treatment was applied. As only the experts in the ‘very special’ treatment in question are able to judge the adequacy of their therapy, nobody is allowed to doubt their verdict.
Take acupuncture, for instance; it is an ancient ‘art’ which only the very best will ever master – at least that is what we are being told. So, all the proponents need to do in order to invalidate a trial, is read the methods section of the paper in full detail and state ‘ex cathedra’ that the way acupuncture was done in this particular study is completely ridiculous. The wrong points were stimulated, or the right points were stimulated but not long enough [or too long], or the needling was too deep [or too shallow], or the type of stimulus employed was not as recommended by TCM experts, or the contra-indications were not observed etc. etc.
As nobody can tell a correct acupuncture from an incorrect one, this ‘fatal flaw’ method is fairly fool-proof. It is also ever so simple: acupuncture-fans do not necessarily study hard to find the ‘fatal flaw’, they only have to look at the result of a study – if it was favourable, the treatment was obviously done perfectly by highly experienced experts; if it was unfavourable, the therapists clearly must have been morons who picked up their acupuncture skills in a single weekend course. The reasons for this judgement can always be found or, if all else fails, invented.
And the end-result of the ‘fatal flaw’ method is most satisfactory; what is more, it can be applied to all alternative therapies – homeopathy, herbal medicine, reflexology, Reiki healing, colonic irrigation…the method works for all of them! What is even more, the ‘fatal flaw’ method is adaptable to other aspects of scientific investigations such that it fits every conceivable circumstance.
An article documenting the ‘fatal flaw’ has to be published, of course – but this is no problem! There are dozens of dodgy alternative medicine journals which are only too keen to print even the most far-fetched nonsense as long as it promotes alternative medicine in some way. Once this paper is published, the proponents of the therapy in question have a comfortable default position to rely on each time someone cites the unfavourable study: “WHAT NOT THAT STUDY AGAIN! THE TREATMENT HAS BEEN SHOWN TO BE ALL WRONG. NOBODY CAN EXPECT GOOD RESULTS FROM A THERAPY THAT WAS NOT CORRECTLY ADMINISTERED. IF YOU DON’T HAVE BETTER STUDIES TO SUPPORT YOUR ARGUMENTS, YOU BETTER SHUT UP.”
There might, in fact, be better studies – but chances are that the ‘other side’ has already documented a ‘fatal flaw’ in them too.
It is usually BIG PHARMA who stands accused of being less than honest with the evidence, particularly when it runs against commercial interests; and the allegations prove to be correct with depressing regularity. In alternative medicine, commercial interests exist too, but there is usually much less money at stake. So, a common assumption is that conflicts of interest are less relevant in alternative medicine. Like so many assumptions in this area, this notion is clearly and demonstrably erroneous.
The sums of money are definitely smaller, but non-commercial conflicts of interest are potentially more important than the commercial ones. I am thinking of the quasi-religious beliefs that are so very prevalent in alternative medicine. Belief can move mountains, they say – it can surely delude people and make them do the most extraordinary things. Belief can transform advocates of alternative medicine into ‘ALCHEMISTS OF ALTERNATIVE EVIDENCE’ who turn negative/unfavourable into positive/favourable evidence.
The alchemists’ ‘tricks of the trade’ are often the same as used by BIG PHARMA; they include:
- drawing conclusions which are not supported by the data
- designing studies such that they will inevitably generate a favourable result
- cherry-picking the evidence
- hiding unfavourable findings
- publishing favourable results multiple times
- submitting data-sets to multiple statistical tests until a positive result emerges
- defaming scientists who publish unfavourable findings
- bribing experts
- prettify data
- falsifying data
As I said, these methods, albeit despicable, are well-known to pseudoscientists in all fields of inquiry. To assume that they are unknown in alternative medicine is naïve and unrealistic, as many of my previous posts confirm.
In addition to these ubiquitous ‘standard’ methods of scientific misconduct and fraud, there are a few techniques which are more or less unique to and typical for the alchemists of alternative medicine. In the following parts of this series of articles, I will try to explain these methods in more detail.
One of the perks of researching alternative medicine and writing a blog about it is that one rarely runs out of good laughs. In perfect accordance with ERNST’S LAW, I have recently been entertained, amused, even thrilled by a flurry of ad hominem attacks most of which are true knee-slappers. I would like to take this occasion to thank my assailants for their fantasy and tenacity. Most days, these ad hominem attacks really do make my day.
I can only hope they will continue to make my days a little more joyous. My fear, however, is that they might, one day, run out of material. Even today, their claims are somewhat repetitive:
- I am not qualified
- I only speak tosh
- I do not understand science
- I never did any ‘real’ research
- Exeter Uni fired me
- I have been caught red-handed (not quite sure at what)
- I am on BIG PHARMA’s payroll
- I faked my research papers
Come on, you feeble-minded fantasists must be able to do better! Isn’t it time to bring something new?
Yes, I know, innovation is not an easy task. The best ad hominem attacks are, of course, always based on a kernel of truth. In that respect, the ones that have been repeated ad nauseam are sadly wanting. Therefore I have decided to provide all would-be attackers with some true and relevant facts from my life. These should enable them to invent further myths and use them as ammunition against me.
Sounds like fun? Here we go:
Both my grandfather and my father were both doctors
This part of my family history could be spun in all sorts of intriguing ways. For instance, one could make up a nice story about how I, even as a child, was brain-washed to defend the medical profession at all cost from the onslaught of non-medical healers.
Our family physician was a prominent homeopath
Ahhhh, did he perhaps mistreat me and start me off on my crusade against homeopathy? Surely, there must be a nice ad hominem attack in here!
I studied psychology at Munich but did not finish it
Did I give up psychology because I discovered a manic obsession or other character flaw deeply hidden in my soul?
I then studied medicine (also in Munich) and made a MD thesis in the area of blood clotting
No doubt this is pure invention. Where are the proofs of my qualifications? Are the data in my thesis real or invented?
My 1st job as a junior doctor was in a homeopathic hospital in Munich
Yes, but why did I leave? Surely they found out about me and fired me.
I had hands on training in several forms of alternative medicine, including homeopathy
Easy to say, but where are the proofs?
I moved to London where I worked in St George’s Hospital conducting research in blood rheology
Another invention? Where are the published papers to document this?
I went back to Munich university where I continued this line of research and was awarded a PhD
Another thesis? Again with dodgy data? Where can one see this document?
I became Professor Rehabilitation Medicine first at Hannover Medical School and later in Vienna
How did that happen? Did I perhaps bribe the appointment panels?
In 1993, I was appointed to the Chair in Complementary Medicine at Exeter university
Yes, we all know that; but why did I not direct my efforts towards promoting alternative medicine?
In Exeter, together with a team of ~20 colleagues, we published > 1000 papers on alternative medicine, more than anyone else in that field
Impossible! This number clearly shows that many of these articles are fakes or plagiaries.
My H-Index is currently >80
Same as above.
In 2012, I became Emeritus Professor of the University of Exeter
Isn’t ’emeritus’ the Latin word for ‘dishonourable discharge’?
I HOPE I CAN RELY ON ALL OF MY AD HOMINEM ATTACKERS TO USE THIS INFORMATION AND RENDER THE ASSAULTS MORE DIVERSE, REAL AND INTERESTING.
What is ear acupressure?
Proponents claim that ear-acupressure is commonly used by Chinese medicine practitioners… It is like acupuncture but does not use needles. Instead, small round pellets are taped to points on one ear. Ear-acupressure is a non-invasive, painless, low cost therapy and no significant side effects have been reported.
Ok, but does it work?
There is a lot of money being made with the claim that ear acupressure (EAP) is effective, especially for smoking cessation; entrepreneurs sell gadgets for applying the pressure on the ear, and practitioners earn their living through telling their patients that this therapy is helpful. There are hundreds of websites with claims like this one: Auricular therapy (Acupressure therapy of the ear region) has been used successfully for Smoking cessation. Auriculotherapy is thought to be 7 times more powerful than other methods used for smoking cessation; a single auriculotherapy treatment has been shown to reduce smoking from 20 or more cigarettes a day down to 3 to 5 a day.
But what does the evidence show?
This new study investigated the efficacy of EAP as a stand-alone intervention for smoking cessation. Adult smokers were randomised to receive EAP specific for smoking cessation (SSEAP) or a non-specific EAP (NSEAP) intervention, EAP at points not typically used for smoking cessation. Participants received 8 weekly treatments and were requested to press the five pellets taped to one ear at least three times per day. Participants were followed up for three months. The primary outcome measures were a 7-day point-prevalence cessation rate confirmed by exhaled carbon monoxide and relief of nicotine withdrawal symptoms (NWS).
Forty-three adult smokers were randomly assigned to SSEAP (n = 20) or NSEAP (n = 23) groups. The dropout rate was high with 19 participants completing the treatments and 12 remaining at followup. One participant from the SSEAP group had confirmed cessation at week 8 and end of followup (5%), but there was no difference between groups for confirmed cessation or NWS. Adverse events were few and minor.
And is there a systematic review of the totality of the evidence?
Sure, the current Cochrane review arrives at the following conclusion: There is no consistent, bias-free evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation…
So?
Yes, we may well ask! If most TCM practitioners use EAP or acupuncture for smoking cessation telling their customers that it works (and earning good money when doing so), while the evidence fails to show that this is true, what should we say about such behaviour? I don’t know about you, but I find it thoroughly dishonest.
Preston Long’s book has featured on this blog before. It is truly an important contribution to the literature on chiropractic, and I recommend that anyone with an interest in the subject should read it. Harriet Hall wrote about it even if you think you’ve heard it all before, there are revelations here that will be new to you, that will elicit surprise, indignation, and laughter.
In a way, an even better ‘recommendation’ comes from someone who previously made numerous vile comments on my blog, Eugen Roth: In my opinion the close relationship that the author has with both Stephen Barrett and Prof Edzard Ernst makes this book just another part of the witch hunt against chiropractic which was initiated more than 50 years ago… In my opinion Prof Ernst and Dr Barrett have continued this witch hunt over many years and have now teamed up with the author to try and give credence to their misguided message. I have no ‘close relationship’ with Long, and his book is not a witch hunt; it is a factual and fascinating of chiropractic abuse, fraud and make-belief.
Chiropractors are in many ways not that different from other health care professionals. Most of them, like Preston Long, go into their profession with all the very best intentions; they study hard what is being taught at Chiropractic College; they pass their exams and set up a practice to earn a decent living. During their career, they subsequently treat thousands of patients, and many of them perceive some benefit. Those who don’t fail to return and are quickly forgotten. Over the years, chiropractors thus become convinced that their interventions are effective.
In several other ways, however, chiropractors differ from conventional health care professionals. The most fundamental differences, I think, relate to the facts that chiropractic is based on the erroneous dogma of its founding fathers, and that chiropractors fail to abide by the rules of evidence-based medicine and practice. Preston Long writes eloquently about many other rules which some chiropractors fail to abide to in addition.
D.D. Palmer, the ‘inventor’ of chiropractic, believed that all human illness was the result of ‘subluxations’ of the spine which impeded the flow of the ‘Innate’ and required correction through spinal adjustments. To his followers, this new approach to healing was the only correct one – one that could cure all health problems. When these assumptions were first formulated, more than a century ago, they might not even have appeared entirely ridiculous; today, in the face of an immense amount of new knowledge, they can easily be disclosed as pure fantasy and chiropractors who believe in Palmer’s gospel have become the laughing stock of all health care professionals.
Some chiropractors are therefore struggling to free themselves from the burden of Palmer’s nonsensical notions. But this struggle rarely is entirely successful. After all, chiropractors have been to Chiropractic College where they memorised so many falsehoods, were kept from numerous important truths, and failed to acquire the essential skills of being (self-) critical. As a result, most find it virtually impossible to completely recover from the ‘brain-wash’ they were submitted to at the beginning of their career. And even if some courageous innovators, one day, managed to expunge all the falsehoods, myths and bogus claims from their profession, the obvious question would still be, how would such a ‘chiropractic minus woo’ differ from physiotherapy?
Most chiropractors have very little inkling what evidence-based practice amounts to; the good intentions that once motivated them have long given way to the need to make money. They are unable to critically assess their own activities, and all the bogus claims they have been exposed to are thus endlessly and profitably perpetuated. The principles of medical ethics have remained alien to most of them. In fact, ‘evidence-based chiropractic’ is an oxymoron: either you abide by evidence – in which case you cannot possibly conceive the idea of adjusting spinal ‘subluxations’ – or you believe in the myth of ‘subluxations’ in which case your practice is not evidence-based. Long is right, I think, when he states: the most efficient way to protect against chiropractic mistreatment is to avoid chiropractors altogether.
Whenever someone dares to criticise their bizarre interventions, chiropractors react with anger, personal attacks, defamation or even libel suits. One argument that is voiced with unfailing regularity in such a context is the claim that the critic lacks the knowledge, insight and experience to be credible. External criticism is thus usually completely ignored.
Preston Long has been a chiropractor himself, and therefore his authority, inside knowledge and expertise cannot be undermined in this fashion. He knows what he is writing about and has been an eye-witness to most of the abuses he reports in his book. His comments are not criticism from the outside; they are thoughtful insights, hand-on experiences and first-hand accounts of fraud and abuse which originate from the very heart of chiropractic. It is this fact that makes this book unique.
Preston Long’s book provides a most valuable perspective on the education, training, thinking, misunderstandings, wrong-doings and unethical behaviours of chiropractors. He also gives valuable instructions on how we can protect ourselves against chiropractic abuse. It would be nice to think that Long’s outstanding and in many ways constructive criticism might contribute to a much-needed and long over-due reformation of chiropractic; but I would not hold my breath.
