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

malpractice

Harad Matthes, the boss of the anthroposophical Krankenhaus Havelhoehe and professor for Integrative and Anthroposophical Medicine at the Charite in Berlin, has featured on my blog before (see here and here). Now he is making headlines again.

Die Zeit‘ reported that Matthes went on German TV to claim that the rate of severe adverse effects of COVID-19 vaccinations is about 40 times higher than the official figures indicate. In the MDR broadcast ‘Umschau’ Matthes said that his unpublished data show a rate of 0,8% of severe adverse effects. In an interview, he later confirmed this notion. Yet, the official figures in Germany indicate that the rate is 0,02%.

How can this be?

Die ZEIT ONLINE did some research and found that Matthes’ data are based on extremely shoddy science and mistakes. The Carite also distanced themselves from Matthes’ evaluation: “The investigation is an open survey and not really a scientific study. The data are not suitable for drawing definitive conclusions regarding incidence figures in the population that can be generalized” The problems with Matthes’ ‘study’ seem to be sevenfold:

  1. The data are not published and can thus not be scrutinized.
  2. Matthes’ definition of a severe adverse effect is not in keeping with the generally accepted definition.
  3. Matthes did not verify the adverse effects but relied on the information volunteered by people over the Internet.
  4. Matthes’ survey is based on an online questionnaire accessible to anyone. Thus it is wide open to selection bias.
  5. The sample size of the survey is around 10 000 which is far too small for generalizable conclusions.
  6. There is no control group which makes it impossible to differentiate a meaningful signal from mere background noise.
  7. The data contradict those from numerous other studies that were considerably more rigorous.

Despite these obvious flaws Matthes insisted in a conversation with ZEIT ONLINE that the German official incidence figures are incorrect. As Germany already has its fair share of anti-vaxxers, Matthes’ unfounded and irresponsible claims contribute significantly to the public sentiments against COVID vaccinations. They thus endangering public health.

In my view, such behavior amounts to serious professional misconduct. I, therefore, feel that his professional body, the Aerztekammer, should look into it and prevent further harm.

Given the high prevalence of burdensome symptoms in palliative care (PC) and the increasing use of so-called alternative medicine (SCAM) therapies, research is needed to determine how often and what types of SCAM therapies providers recommend to manage symptoms in PC.

This survey documented recommendation rates of SCAM for target symptoms and assessed if, SCAM use varies by provider characteristics. The investigators conducted US nationwide surveys of MDs, DOs, physician assistants, and nurse practitioners working in PC.

Participants (N = 404) were mostly female (71.3%), MDs/DOs (74.9%), and cared for adults (90.4%). Providers recommended SCAM an average of 6.8 times per month (95% CI: 6.0-7.6) and used an average of 5.1 (95% CI: 4.9-5.3) out of 10 listed SCAM modalities. Respondents recommended mostly:

  • mind-body medicines (e.g., meditation, biofeedback),
  • massage,
  • acupuncture/acupressure.

The most targeted symptoms included:

  • pain,
  • anxiety,
  • mood disturbances,
  • distress.

Recommendation frequencies for specific modality-for-symptom combinations ranged from little use (e.g. aromatherapy for constipation) to occasional use (e.g. mind-body interventions for psychiatric symptoms). Finally, recommendation rates increased as a function of pediatric practice, noninpatient practice setting, provider age, and proportion of effort spent delivering palliative care.

The authors concluded that to the best of our knowledge, this is the first national survey to characterize PC providers’ SCAM recommendation behaviors and assess specific therapies and common target symptoms. Providers recommended a broad range of SCAM but do so less frequently than patients report using SCAM. These findings should be of interest to any provider caring for patients with serious illness.

Initially, one might feel encouraged by these data. Mind-body therapies are indeed supported by reasonably sound evidence for the symptoms listed. The evidence is, however, not convincing for many other forms of SCAM, in particular massage or acupuncture/acupressure. So encouragement is quickly followed by disappointment.

Some people might say that in PC one must not insist on good evidence: if the patient wants it, why not? But the point is that there are several forms of SCAMs that are backed by good evidence for use in PC. So, why not follow the evidence and use those? It seems to me that it is not in the patients’ best interest to disregard the evidence in medicine – and this, of course, includes PC.

I just stumbled over a paper we published way back in 1997. It reports a questionnaire survey of all primary care physicians working in the health service in Devon and Cornwall. Here is an excerpt:

Replies were received from 461 GPs, a response rate of 47%. A total of 314 GPs (68%, range 32-85%) had been involved in complementary medicine in some way during the previous week. One or other form of complementary medicine was practised by 74 of the respondents (16%), the two most common being homoeopathy (5.9%) and acupuncture (4.3%). In addition, 115 of the respondents (25%) had referred at least one patient to a complementary therapist in the previous week, and 253 (55%) had endorsed or recommended treatment with complementary medicine. Chiropractic, acupuncture and osteopathy were rated as the three most effective therapies, and the majority of respondents believed that these three therapies should be funded by the health service. A total of 176 (38%) respondents reported adverse effects, most commonly after manipulation.

What I found particularly interesting (and had totally forgotten about) were the details of these adverse effects: Serious adverse effects of spinal manipulation included the following:

  • paraplegia,
  • spinal cord transection,
  • fractured vertebra,
  • unspecified bone fractures,
  • fractured neck of femur,
  • severe pain for years after manipulation.

Adverse effects not related to manipulation included:

  • death after a coffee enema,
  • liver toxicity,
  • anaphylaxis,
  • 17 cases of delay of adequate medical attention,
  • 11 cases of adverse psychological effects,
  • 14 cases of feeling to have wasted money.

If I remember correctly, none of the adverse effects had been reported anywhere which would make the incidence of underreporting 100% (exactly the same as in a survey we published in 2001 of adverse effects after spinal manipulations).

Today is WORLD ASTHMA DAY, a good opportunity perhaps to revisit a few of our own evaluations of so-called alternative medicine (SCAM) for asthma. Here are the abstracts of some of our systematic reviews on the subject:

YOGA

Objective: The objective of this systematic review was to assess the effectiveness of yoga as a treatment option for asthma.

Method: Seven databases were searched from their inception to October 2010. Randomized clinical trials (RCTs) and non-randomized clinical trials (NRCTs) were considered, if they investigated any type of yoga in patients with asthma. The selection of studies, data extraction, and validation were performed independently by two reviewers.

Results: Six RCTs and one NRCT met the inclusion criteria. Their methodological quality was mostly poor. Three RCTs and one NRCT suggested that yoga leads to a significantly greater reduction in spirometric measures, airway hyperresponsivity, dose of histamine needed to provoke a 20% reduction in forced expiratory volume in the first second, weekly number of asthma attacks, and need for drug treatment. Three RCTs showed no positive effects compared to various control interventions.

Conclusions: The belief that yoga alleviates asthma is not supported by sound evidence. Further, more rigorous trials are warranted.

SPINAL MANIPULATION

Some clinicians believe that spinal manipulation is an effective treatment for asthma. The aim of this systematic review was to critically evaluate the evidence for or against this claim. Four electronic databases were searched without language restrictions from their inceptions to September 2008. Bibliographies and departmental files were hand-searched. The methodological quality of all included studies was assessed with the Jadad score. Only randomised clinical trials of spinal manipulation as a treatment of asthma were included. Three studies met these criteria. All of them were of excellent methodological quality (Jadad score 5) and all used sham-manipulation as the control intervention. None of the studies showed that real manipulation was more effective than sham-manipulation in improving lung function or subjective symptoms. It is concluded that, according to the evidence of the most rigorous studies available to date, spinal manipulation is not an effective treatment for asthma.

ACUPUNCTURE

Contradictory results from randomised controlled trials of acupuncture in asthma suggest both a beneficial and detrimental effect. The authors conducted a formal systematic review and meta-analysis of all randomised clinical trials in the published literature that have compared acupuncture at real and placebo points in asthma patients. The authors searched for trials published in the period 1970-2000. Trials had to measure at least one of the following objective outcomes: peak expiratory flow rate, forced expiratory volume in one second (FEV1) and forced vital capacity. Estimates of the standarised mean difference, between acupuncture and placebo were computed for each trial and combined to estimate the overall effect. Hetereogeneity was investigated in terms of the characteristics of the individual studies. Twelve trials met the inclusion criteria but data from one could not be obtained. Individual patient data were available in only three. Standardised differences between means ranging from 0.071 to 0.133, in favour of acupuncture, were obtained. The overall effect was not conventionally significant and it corresponds to an approximate difference in FEV1 means of 1.7. After exploring hetereogenenity, it was found that studies where bronchoconstriction was induced during the experiment showed a conventionally significant effect. This meta-analysis did not find evidence of an effect of acupuncture in reducing asthma. However, the meta-analysis was limited by shortcomings of the individual trials, in terms of sample size, missing information, adjustment of baseline characteristics and a possible bias against acupuncture introduced by the use of placebo points that may not be completely inactive. There was a suggestion of preferential publication of trials in favour of acupuncture. There is an obvious need to conduct a full-scale randomised clinical trial addressing these limitations and the prognostic value of the aetiology of the disease.

RELAXATION THERAPIES

Background: Emotional stress can either precipitate or exacerbate both acute and chronic asthma. There is a large body of literature available on the use of relaxation techniques for the treatment of asthma symptoms. The aim of this systematic review was to determine if there is any evidence for or against the clinical efficacy of such interventions.

Methods: Four independent literature searches were performed on Medline, Cochrane Library, CISCOM, and Embase. Only randomised clinical trials (RCTs) were included. There were no restrictions on the language of publication. The data from trials that statistically compared the treatment group with that of the control were extracted in a standardised predefined manner and assessed critically by two independent reviewers.

Results: Fifteen trials were identified, of which nine compared the treatment group with the control group appropriately. Five RCTs tested progressive muscle relaxation or mental and muscular relaxation, two of which showed significant effects of therapy. One RCT investigating hypnotherapy, one of autogenic training, and two of biofeedback techniques revealed no therapeutic effects. Overall, the methodological quality of the studies was poor.

Conclusions: There is a lack of evidence for the efficacy of relaxation therapies in the management of asthma. This deficiency is due to the poor methodology of the studies as well as the inherent problems of conducting such trials. There is some evidence that muscular relaxation improves lung function of patients with asthma but no evidence for any other relaxation technique.

HERBAL MEDICINE

Background: Asthma is one of the most common chronic diseases in modern society and there is increasing evidence to suggest that its incidence and severity are increasing. There is a high prevalence of usage of complementary medicine for asthma. Herbal preparations have been cited as the third most popular complementary treatment modality by British asthma sufferers. This study was undertaken to determine if there is any evidence for the clinical efficacy of herbal preparations for the treatment of asthma symptoms.

Methods: Four independent literature searches were performed on Medline, Pubmed, Cochrane Library, and Embase. Only randomised clinical trials were included. There were no restrictions on the language of publication. The data were extracted in a standardised, predefined manner and assessed critically.

Results: Seventeen randomised clinical trials were found, six of which concerned the use of traditional Chinese herbal medicine and eight described traditional Indian medicine, of which five investigated Tylophora indica. Three other randomised trials tested a Japanese Kampo medicine, marihuana, and dried ivy leaf extract. Nine of the 17 trials reported a clinically relevant improvement in lung function and/or symptom scores.

Conclusions: No definitive evidence for any of the herbal preparations emerged. Considering the popularity of herbal medicine with asthma patients, there is urgent need for stringently designed clinically relevant randomised clinical trials for herbal preparations in the treatment of asthma.

BREATHING TECHNIQUES

Breathing techniques are used by a large proportion of asthma sufferers. This systematic review was aimed at determining whether or not these interventions are effective. Four independent literature searches identified six randomized controlled trials. The results of these studies are not uniform. Collectively the data imply that physiotherapeutic breathing techniques may have some potential in benefiting patients with asthma. The safety issue has so far not been addressed satisfactorily. It is concluded that too few studies have been carried out to warrant firm judgements. Further rigorous trials should be carried out in order to redress this situation.

__________________________________

So, if you suffer from asthma, my advice is to stay away from SCAM. This might be easier said than done because SCAM practitioners are only too willing to lure asthma patients into their cult. In 2003, we have demonstrated this phenomenon by conducting a survey with chiropractors. Here is our short paper in full:

Classic chiropractic theory claims that vertebral subluxation blocks the flow of ‘‘innate intelligence’’ which, in turn, affects the health of asthma patients (1). Chiropractictors often use spinal manipulation (SM) to correct such malalignments and treat asthma (2). Several clinical trials of chiropractic SM exist, but the most rigorous ones are clearly negative (3,4). Chronic medication with corticosteroids can lead to osteoporosis, a condition, which is a contra-indication to chiropractic SM (5). Given this background, we aimed to determine whether chiropractors would advise an asthma patient on long-term corticosteroids (5 years) to try chiropractic as a treatment for this condition.

All 350 e-mail addresses listed at www.interadcom.com/chiro/html were randomised into two groups. A (deceptive) letter from a (fictitious) patient was sent to group A while group B was asked for advice on chiropractic treatment for asthma as part of a research project. Thus, groups A and B were asked the same question in di¡erent contexts: is chiropractic safe and e¡ective for an asthma patient on long-term steroids. After data collection, respondents from group A were informed that the e-mail had been part of a research project.

Of 97 e-mails in group A, we received 31 responses (response rate = 32% (95% CI, 0.23^ 0.41)). Seventy-four per cent (23 respondents) recommended visiting a chiropractor (95% CI, 0.59^ 0.89). Thirty-five per cent (11 respondents) mentioned minimal or no adverse effects of SM (95% CI, 0.18 ^ 0.52). Three chiropractors responded that some adverse e¡ects exist, e.g. risk of bone fracture, or stroke. Two respondents noted that other investigations (X-rays, spinal and neurological examination) were required before chiropractic treatment. Three respondents suggested additional treatments and one warned about a possible connection between asthma and the measles vaccine. Of 77 e-mails sent to group B, we received 16 responses (response rate = 21% (95% CI, 0.17^ 0.25)). Eleven respondents (69%) recommended visiting a chiropractor (95% CI, 0.46 ^ 0.91). Ten respondents mentioned minimal or no adverse effects of SM (95% CI, 0.39^ 0.87). Five chiropractors responded that adverse effects of SM exist (e.g. bone fracture). Five respondents suggested pre-testing the patient to check bone density, allergy, diet, exercise level, hydration and blood. Additional treatments were recommended by three respondents. The pooled results of groups A and B suggested that the majority of chiropractors recommend chiropractic treatment for asthma and the minority mention any adverse effects.

Our results demonstrate that chiropractic advice on asthma therapy is as readily available over the Internet as it is likely to be misleading. The majority of respondents from both groups (72%) recommended chiropractic treatment. This usually entails SM, a treatment modality which has been demonstrated to be ineffective in rigorous clinical trials (3,4,6). The advice may also be dangerous: the minority of the respondents of both groups (17%) caution of the risk of bone fracture. Our findings also suggest that, for the research question asked, a degree of deception is necessary. The response rate in group B was 12% lower than that of group A, and the answers received differed considerably between groups. In group A, 10% acknowledged the possibility of adverse e¡ects, this figure was 33% in group B. In conclusion, chiropractors readily provide advice regarding asthma treatment, which is often not evidence-based and has the potential to put patients at risk.

__________________________

As I stated above: if you suffer from asthma, my advice is to

stay away from SCAM.

Acupuncture for animals has a long history in China. In the West, it was introduced in the 1970s when acupuncture became popular for humans. A recent article sums up our current knowledge on the subject. Here is an excerpt:

Acupuncture is used mainly for functional problems such as those involving noninfectious inflammation, paralysis, or pain. For small animals, acupuncture has been used for treating arthritis, hip dysplasia, lick granuloma, feline asthma, diarrhea, and certain reproductive problems. For larger animals, acupuncture has been used for treating downer cow syndrome, facial nerve paralysis, allergic dermatitis, respiratory problems, nonsurgical colic, and certain reproductive disorders.Acupuncture has also been used on competitive animals. There are veterinarians who use acupuncture along with herbs to treat muscle injuries in dogs and cats. Veterinarians charge around $85 for each acupuncture session.[8]Veterinary acupuncture has also recently been used on more exotic animals, such as chimpanzees (Pan troglodytes)[9] and an alligator with scoliosis,[10] though this is still quite rare.

In 2001, a review found insufficient evidence to support equine acupuncture. The review found uniformly negative results in the highest quality studies.[11] In 2006, a systematic review of veterinary acupuncture found “no compelling evidence to recommend or reject acupuncture for any condition in domestic animals”, citing trials with, on average, low methodological quality or trials that are in need of independent replication.[1] In 2009, a review on canine arthritis found “weak or no evidence in support of” various treatments, including acupuncture.[12]

To put it in a nutshell: acupuncture for animals is not evidence-based.

How can I be so sure?

Because ref 1 in the text above refers to our paper. Here is its abstract:

Acupuncture is a popular complementary treatment option in human medicine. Increasingly, owners also seek acupuncture for their animals. The aim of the systematic review reported here was to summarize and assess the clinical evidence for or against the effectiveness of acupuncture in veterinary medicine. Systematic searches were conducted on Medline, Embase, Amed, Cinahl, Japana Centra Revuo Medicina and Chikusan Bunken Kensaku. Hand-searches included conference proceedings, bibliographies, and contact with experts and veterinary acupuncture associations. There were no restrictions regarding the language of publication. All controlled clinical trials testing acupuncture in any condition of domestic animals were included. Studies using laboratory animals were excluded. Titles and abstracts of identified articles were read, and hard copies were obtained. Inclusion and exclusion of studies, data extraction, and validation were performed independently by two reviewers. Methodologic quality was evaluated by means of the Jadad score. Fourteen randomized controlled trials and 17 nonrandomized controlled trials met our criteria and were, therefore, included. The methodologic quality of these trials was variable but, on average, was low. For cutaneous pain and diarrhea, encouraging evidence exists that warrants further investigation in rigorous trials. Single studies reported some positive intergroup differences for spinal cord injury, Cushing’s syndrome, lung function, hepatitis, and rumen acidosis. These trials require independent replication. On the basis of the findings of this systematic review, there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals. Some encouraging data do exist that warrant further investigation in independent rigorous trials.

This evidence is in sharp contrast to the misinformation published by the ‘IVAS’ (International Veterinary Acupuncture Society). Under the heading “For Which Conditions is Acupuncture Indicated?“, they propagate the following myth:

Acupuncture is indicated for functional problems such as those that involve paralysis, noninfectious inflammation (such as allergies), and pain. For small animals, the following are some of the general conditions which may be treated with acupuncture:

  • Musculoskeletal problems, such as arthritis, intervertebral disk disease, or traumatic nerve injury
  • Respiratory problems, such as feline asthma
  • Skin problems such as lick granulomas and allergic dermatitis
  • Gastrointestinal problems such as diarrhea
  • Selected reproductive problems

For large animals, acupuncture is again commonly used for functional problems. Some of the general conditions where it might be applied are the following:

  • Musculoskeletal problems such as sore backs or downer cow syndrome
  • Neurological problems such as facial paralysis
  • Skin problems such as allergic dermatitis
  • Respiratory problems such as heaves and “bleeders”
  • Gastrointestinal problems such as nonsurgical colic
  • Selected reproductive problems

In addition, regular acupuncture treatment can treat minor sports injuries as they occur and help to keep muscles and tendons resistant to injury. World-class professional and amateur athletes often use acupuncture as a routine part of their training. If your animals are involved in any athletic endeavor, such as racing, jumping, or showing, acupuncture can help them keep in top physical condition.

And what is the conclusion?

Perhaps this?

Never trust the promotional rubbish produced by SCAM organizations.

On this blog, I have almost exclusively written about so-called alternative medicine (SCAM), and I intend to continue along these lines. But today, I have to make an exception. The reason is the UK government’s ‘Rwanda Project’. I heard about it this morning while listening to the BBC, and I am too shocked to not write about it.

Already in 2020, it had been reported that the UK home secretary, Priti Patel, had asked officials to look into the possibility of sending all asylum seekers to Ascension, an isolated volcanic British island south of the Equator in the Atlantic Ocean.[1] At the time, the idea was met with much criticism and opposition. Today she is about to announce that a modification of her plan will, in fact, be implemented; our government is about to unveil plans to send ‘illegal migrants’ who reach Britain to Rwanda:

Flying asylum seekers to Rwanda to be processed is “despicable” and “evil”, critics have said as they hit out at government plans expected to be announced on Monday. ITV News has seen a government document that raises issues over the legality of such a policy, as ministers attempt to tackle small boat crossings of the Channel. The government document says the policy would carry the risk of legal challenges but is possible under current legislation should the government wish to push ahead. Boris Johnson is set to argue on Thursday that action is needed to combat the “vile people smugglers” turning the ocean into a “watery graveyard”. Many details of the expected announcement, such as whether it would apply just to those who arrived by what the government calls illegal means, remain unclear. The document seen by ITV News also states that any agreement of this nature would require the government to financially incentivise whichever country it reaches a deal with. Initial estimates had the policy costing in the tens of millions of pounds, but the document says this has been revised to the hundreds of millions of pounds.

The plan sounds utterly cynical, irrational, illegal, and expensive; and again there is an outrage; QC tweeted, for instance, this: “And if an asylum applicant who’s been dumped in Rwanda is then refused, what happens then? The whole thing is the stuff of nightmares. It feels like things are becoming increasingly dystopian as the days pass. Why oh why can’t we have some creative and humane people in charge.”

One might well ask, where does such an inhumane concept come from?

It turns out that it resembles an idea of the Third Reich that was equally baffling and similarly cruel.

Anticipating the German invasion of France in 1940, the German diplomat, Franz Rademacher, developed his Madagascar project, a bizarre plan to rid Europe of all Jews. It envisaged that:

  • once defeated, France would agree to make Madagascar available,
  • American Jewry would be blackmailed into funding the operation,
  • France would be forced to find an alternate home for the 25,000 French inhabitants of Madagascar.

The plan may now sound ridiculous but, in 1940, it was seriously considered by the Nazi leadership. In June of that year, Rademacher, who then was the head of the German Foreign Ministry’s Jewish Department, presented the idea to his boss, Joachim von Ribbentrop, who then explained it to Hitler. Hitler was sufficiently impressed to discuss it with Mussolini. Rademacher wrote that “The approaching victory gives Germany the possibility, and in my view also the duty, of solving the Jewish question in Europe. The desirable solution is: All Jews out of Europe.” [2] 

When Reinhard Heydrich, chief of the Reich Main Security Office, learned about the “Madagascar Project”, he highjacked it and swiftly put Adolf Eichmann in charge of it. On August 15, 1940, Eichmann published a pamphlet on the “Madagascar Project.” It envisaged that the deportation of the Jews would be carried out by the British merchant marine, after the anticipated invasion and defeat of the United Kingdom. Two ships per day would then leave Europe for Madagascar, each one carrying 1,500 Jews. In just a few years, Europe would thus become ‘Juden-frei’, free of Jews.

The Madagascar plan envisaged turning Madagascar into a monumental concentration camp under German control. The island is merely 228,900 square miles in size and would not have provided sufficient room for millions. It was therefore understood that many of the prisoners would perish, not least because of the lack of food, housing and healthcare as well as the difficult climate. 

Eventually, the Madagascar plan had to be abandoned. What was decided subsequently with Rademacher’s cooperation about the fate of the Jews, the ‘final solution’, was even more unspeakably outrageously abhorrent.

The main players involved in the Madagascar project did all perish:

  • Ribbentrop was sentenced to death at the Nuremberg trials.
  • Hitler committed suicide.
  • Heydrich was assassinated.
  • Eichmann was sentenced to death in Israel.

Only Rademacher survived. After the war, he was imprisoned by British military police who mistook him for ‘small fry’ and promptly released him. In 1952, he was put on trial in West Germany for the murders of Jews he had supervised in Serbia. Yet, aided by a network of Nazi sympathizers, he managed to flee to Syria. The German court then convicted him in his absence and sentenced him to 3 years and 5 months imprisonment. In 1962, an Israeli spy delivered a letter bomb to Rademacher in Syria who, however, remained unharmed. In 1966, Rademacher returned voluntarily to West Germany and was promptly re-arrested. This time, he was sentenced to five and half years, but never actually served a prison sentence. In 1971, the German high court overruled the former judgment and ordered a new trial to take place. However, Rademacher died on 17 March 1973, before it could take place.[3]

I hope that I am wrong and that the UK government’s plan is not similar to the Nazi’s “Madagascar Project”. Maybe it is just a PR stunt of our PM to distract from his very own lawbreaking, and the ‘Rwanda project’ will never be implemented. In any case, we should urgently remind everyone of George Santayana’s wise words: “Those who cannot remember the past are condemned to repeat it.”

 

 

[1] https://www.independent.co.uk/news/uk/politics/priti-patel-asylum-ascensi on-island-atlantic-immigration-process-centre-b703625.html

[2] https://www.haaretz.com/jewish/.premium-1940-eichmann-plans-to-deport-jews-to-madagascar-1.5424692

[3] https://en.wikipedia.org/wiki/Franz_Rademacher

The Anglo-European College of Chiropractic (AECC) has been promoting pediatric chiropractic for some time, and I have posted about the subject before  (see, for instance, here). Now the AECC has gone one decisive step further. On the website, the AECC announced an MSc ‘Musculoskeletal Paediatric Health‘:

The MSc Musculoskeletal Paediatric Health degree is designed to develop your knowledge and skills in the safe and competent care of children of all ages. Our part-time, distance-based course blends live online classes with ready to use resources through our virtual learning environment. In addition, you will have the opportunity to observe in the AECC University College clinical services at our Bournemouth campus. The course covers topics in paediatric musculoskeletal practice with specific units on paediatric development, paediatric musculoskeletal examination, paediatric musculoskeletal interventions, and paediatric musculoskeletal management. You will address issues such as risk factors and public health, including breastfeeding, supine sleep in infancy, physical activity in children and conditions affecting the musculoskeletal health of children from birth. The paediatric specific topics are completed by other optional units such as professional development, evidence-based practice, and leadership and inter-professional collaboration. In the dissertation unit you will conduct a study relevant to musculoskeletal paediatric health.

Your learning will happen through a mix of live and recorded lectures, access to online reading materials, and access to the literature through our learning services. You will also engage with the contents taught through guided activities with your peers and staff. Clinical paediatric experience is recommended to fully engage with the course. For students with limited access to a suitable clinical environment to support their studies, or for student who wants to add to their clinical experience, we are able to offer a limited number of opportunities to observe and work alongside our clinical educators within the AECC University College clinical services. Assessments are tailor made to each unit and may include a variety of methods such as critical reviews, reflective accounts, portfolios and in the last year a research dissertation.

___________________________

The AECC emphasizes its commitment to being a leading higher education institution in healthcare disciplines, nationally and internationally recognised for quality and excellence. Therefore, it seems only fair to have another look at the science behind pediatric chiropractic. Specifically, is there any good science to show that would justify a Master of Science in ‘Musculoskeletal Paediatric Health’?

So, let’s have a look and see whether there are any good review articles supporting such a degree. Here is what I found with several Medline searches (date of the review on chiropractic for any pediatric conditions, followed by its conclusion + link [so that the reader can look up the evidence]):

2008

I am unable to find convincing evidence for any of the above-named conditions. 

2009

Previous research has shown that professional chiropractic organisations ‘make claims for the clinical art of chiropractic that are not currently available scientific evidence…’. The claim to effectively treat otitis seems to
be one of them. It is time now, I think, that chiropractors either produce the evidence or abandon the claim.

2009

The … evidence is neither complete nor, in my view, “substantial.”

2010

Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system.

2018

Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action. Manual therapy appears relatively safe.

What seems to emerge is rather disappointing:

  1. There are no really new reviews.
  2. Most of the existing reviews are not on musculoskeletal conditions.
  3. All of the reviews cast considerable doubt on the notion that chiropractors should go anywhere near children.

But perhaps I was too ambitious. Perhaps there are some new rigorous clinical trials of chiropractic for musculoskeletal conditions. A few further searches found this (again year and conclusion):

2019

We found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant.

2018

Adding manipulative therapy to other conservative care in school children with spinal pain did not result in fewer recurrent episodes. The choice of treatment-if any-for spinal pain in children therefore relies on personal preferences, and could include conservative care with and without manipulative therapy. Participants in this trial may differ from a normal care-seeking population.

I might have missed one or two trials because I only conducted rather ‘rough and ready’ searches, but even if I did: would this amount to convincing evidence? Would it be good science?

No! and No!

So, why does the AECC offer a Master of Science in ‘Musculoskeletal Paediatric Health’?

Search me!

It wouldn’t have something to do with the notion that it is good for business?

Or perhaps they just want to give science a bad name?

Today is the start of chiropractic awareness week 2022. On this occasion the BCA states most categorically: First and foremost, chiropractic is a statutorily regulated healthcare profession, supported by evidence, which offers a safe form of treatment for patients with a range of conditions.  Here I am tempted to cite my friend Simon Singh:

THEY HAPPILY PROMOTE BOGUS TREATMENTS

I am, of course, particularly impressed by the BCA’s assurance of safety. In my view, the safety issue needs to be addressed more urgently than any other in the realm of chiropractic. So, to make a meaningful contribution to the current chiropractic awareness week, I conducted a few Medline searches to identify all publications of 2022 on chiropractic/spinal manipulation risks.

This is what I found:

paper No 1

Objective: Patients can be at risk of carotid artery dissection and ischemic stroke after cervical chiropractic manipulation. However, such risks are rarely reported and raising awareness can increase the safety of chiropractic manipulations.

Case report: We present two middle-aged patients with carotid artery dissection leading to ischemic stroke after receiving chiropractic manipulation in Foshan, Guangdong Province, China. Both patients had new-onset pain in their necks after receiving chiropractic manipulations. Excess physical force during chiropractic manipulation may present a risk to patients. Patient was administered with recombinant tissue plasminogen activator after radiological diagnoses. They were prescribed 100 mg and clopidogrel 75 mg daily for 3 months as dual antiplatelet therapy. There were no complications over the follow-up period.

Conclusion: These cases suggest that dissection of the carotid artery can occur as the result of chiropractic manipulations. Patients should be diagnosed and treated early to achieve positive outcomes. The safety of chiropractic manipulations should be increased by raising awareness about the potential risks.

paper No 2

Spontaneous intracranial hypotension (SIH) still remains an underdiagnosed etiology of new-onset headache. Important risk factors include chiropractic manipulation (CM). We present a case of a 36-year-old Filipino woman who presented with severe bifrontal and postural headache associated with dizziness, vomiting, and doubling of vision. A cranial computed tomography scan was done which showed an acute subdural hematoma (SDH) at the interhemispheric area. Pain medications were given which afforded minimal relief. On history, the headaches occurred 2 weeks after cervical CM. Cranial and cervical magnetic resonance imaging revealed findings supportive of intracranial hypotension and neck trauma, respectively. The patient improved with conservative management. We found 12 articles on SIH and CM after a systematic review of literature. Eleven patients (90.9%) initially presented with orthostatic headache. Eight patients (66.7%) were initially treated conservatively but only 5 (62.5%) had complete recovery. Recovery was achieved within 14 days from start of supportive therapy. Among the 3 patients who failed conservative treatment, 2 underwent non-directed epidural blood patch and one required neurosurgical intervention. This report highlights that a thorough history is warranted in patients with new onset headache. A history of CM must be actively sought. The limited evidence from the case reports showed that patients with SIH and SDH but with normal neurologic examination and minor spinal pathology can be managed conservatively for less than 2 weeks. This review showed that conservative treatment in a closely monitored environment may be an appropriate first line treatment.

paper No 3

Introduction: Cranio-cervical artery dissection (CeAD) is a common cause of cerebrovascular events in young subjects with no clear treatment strategy established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement.

Methods: COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center observational, retrospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥ 18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1 year evaluating MACE as the primary endpoint.

Results: One-hundred ten patients were enrolled (age 53 ± 15.9, 56% Caucasian, and 50% male, BMI 28.9 ± 9.2). Grade I, II, III, and IV blunt vascular injury was noted in 16%, 33%, 19%, and 32%, respectively. Predisposing factors were noted in the majority (78%), including sneezing, carrying heavy load, chiropractic manipulation. Stent was placed in 10 (10%) subjects (extracranial carotid n = 9; intracranial carotid n = 1; extracranial vertebral n = 1) at the physician’s discretion along with medical management. Reasons for stent placement were early development of high-grade stenosis or expanding pseudoaneurysm. Stented patients experienced no procedural or in-hospital complications and no MACE between discharge and 1 year follow up. CeAD patients treated with medical management only had 14% MACE at 1 year.

Conclusion: In this single high-volume center cohort of CeAD patients, stenting was found to be beneficial, particularly with development of high-grade stenosis or expanding pseudoaneurysm. These results warrant confirmation by a randomized clinical trial.

paper No 4

Background: Manipulation and mobilisation for low back pain are presented in an evidence-based manner with regard to mechanisms of action, indications, efficacy, cost-effectiveness ratio, user criteria and adverse effects. Terms such as non-specific or specific are replaced by the introduction of “entities” related to possible different low back pain forms.

Efficacy: MM is effective for acute and chronic low back pain in terms of pain relief, recovery of function and relapse prevention. It is equally effective but less risky compared to other recommended therapies. MM can be used alone in acute cases and not only in the case of chronic low back pain where it is always and necessarily part of a multimodal therapy programme, especially in combination with activating measures. The users of MM should exclusively be physician specialists trained according to the criteria of the German Medical Association (Bundesärztekammer) with an additional competence in manual medicine or appropriately trained certified therapists. The application of MM follows all rules of Good Clinical Practice.

Adverse effects: Significant adverse effects of MM for low back pain are reported in the international literature with a frequency of 1 per 50,000 to 1 per 3.7 million applications, i.e. MM for low back pain is practically risk-free and safe if performed according to the rules of the European Training Requirements of the UEMS.

paper No 5

Studies have reported that mild adverse events (AEs) are common after manual therapy and that there is a risk of serious injury. We aimed to assess the safety of Chuna manipulation therapy (CMT), a traditional manual Korean therapy, by analysing AEs in patients who underwent this treatment. Patients who received at least one session of CMT between December 2009 and March 2019 at 14 Korean medicine hospitals were included. Electronic patient charts and internal audit data obtained from situation report logs were retrospectively analysed. All data were reviewed by two researchers. The inter-rater agreement was assessed using the Cohen’s kappa coefficient, and reliability analysis among hospitals was assessed using Cronbach’s Alpha coefficient. In total, 2,682,258 CMT procedures were performed in 289,953 patients during the study period. There were 50 AEs, including worsened pain (n = 29), rib fracture (n = 11), falls during treatment (n = 6), chest pain (n = 2), dizziness (n = 1), and unpleasant feeling (n = 1). The incidence of mild to moderate AEs was 1.83 (95% confidence interval [CI] 1.36-2.39) per 100,000 treatment sessions, and that of severe AEs was 0.04 (95% CI 0.00-0.16) per 100,000 treatment sessions. Thus, AEs of any level of severity were very rare after CMT. Moreover, there were no instances of carotid artery dissection or spinal cord injury, which are the most severe AEs associated with manual therapy in other countries.

_______________________________

This is not too bad after all!

Five papers are clearly better than nothing.

What conclusions might be drawn from my mini-review?

I think it might be safe to say:

  1. There is not much but at least some research going on in this area.
  2. The risks of chiropractic/spinal manipulation are real and are being recognized.
  3. BUT NOT BY CHIROPRACTORS! The most remarkable feature of the 5 papers, I think, is that none originates from a chiropractic team.

Thus, allow me to make a suggestion to chiropractors worldwide: Instead of continuing with HAPPILY PROMOTING BOGUS TREATMENTS, what about using the ‘chiropractic awareness week’ to raise awareness of the urgent necessity to research the safety of your treatments?

This paper is an evaluation of the relationship between chiropractic spinal manipulation and medical malpractice. The legal database VerdictSearch was queried using the terms “chiropractor” OR “spinal manipulation” under the classification of “Medical Malpractice” between 1988 and 2018. Cases with chiropractors as defendants were identified. Relevant medicolegal characteristics were obtained, including legal outcome (plaintiff/defense verdict, settlement), payment amount, nature of plaintiff claim, and type and location of the alleged injury.

Forty-eight cases involving chiropractic management in the US were reported. Of these, 93.8% (n = 45) featured allegations involving spinal manipulation. The defense (practitioner) was victorious in 70.8% (n = 34) of cases, with a plaintiff (patient) victory in 20.8% (n = 10) (mean payment $658,487 ± $697,045) and settlement in 8.3% (n = 4) (mean payment $596,667 ± $402,534).

Over-aggressive manipulation was the most frequent allegation (33.3%; 16 cases). A majority of cases alleged neurological injury of the spine as the reason for litigation (66.7%, 32 cases) with 87.5% (28/32) requiring surgery. C5-C6 disc herniation was the most frequently alleged injury (32.4%, 11/34, 83.3% requiring surgery) followed by C6-C7 herniation (26.5%, 9/34, 88.9% requiring surgery). Claims also alleged 7 cases of stroke (14.6%) and 2 rib fractures (4.2%) from manipulation therapy.

The authors concluded that litigation claims following chiropractic care predominately alleged neurological injury with consequent surgical management. Plaintiffs primarily alleged overaggressive treatment, though a majority of trials ended in defensive verdicts. Ongoing analysis of malpractice provides a unique lens through which to view this complicated topic.

The fact that the majority of trials ended in defensive verdicts does not surprise me. I once served as an expert witness in a trial against a UK chiropractor. Therefore, I know how difficult it is to demonstrate that the chiropractic intervention – and not anything else – caused the problem. Even cases that seem medically clear-cut, often allow reasonable doubt vis a vis the law.

Apologists will be quick and keen to point out that, in the US, there are many more successful cases brought against real doctors (healthcare professionals who have studied medicine). They are, of course, correct. But, at the same time, they miss the point. Real doctors treat real diseases where the outcomes are sadly often not as hoped. Litigation is then common, particularly in a litigious society like the US. Chiropractors predominantly treat symptoms like back troubles that are essentially benign. To create a fair comparison of litigations against doctors and chiros, one would therefore need to account for the type and severity of the conditions. Such a comparison has – to the best of my knowledge – not been done.

What has been done, however – and I did previously report about it – are comparisons between chiros, osteos, and physios (which seems to be a more level playing field). They show that complaints against chiros top the bill.

No 10-year follow-up study of so-called alternative medicine (SCAM) for lumbar intervertebral disc herniation (LDH) has so far been published. Therefore, the authors of this paper performed a prospective 10-year follow-up study on the integrated treatment of LDH in Korea.

One hundred and fifty patients from the baseline study, who initially met the LDH diagnostic criteria with a chief complaint of radiating pain and received integrated treatment, were recruited for this follow-up study. The 10-year follow-up was conducted from February 2018 to March 2018 on pain, disability, satisfaction, quality of life, and changes in a herniated disc, muscles, and fat through magnetic resonance imaging.

Sixty-five patients were included in this follow-up study. Visual analogue scale score for lower back pain and radiating leg pain were maintained at a significantly lower level than the baseline level. Significant improvements in Oswestry disability index and quality of life were consistently present. MRI confirmed that disc herniation size was reduced over the 10-year follow-up. In total, 95.38% of the patients were either “satisfied” or “extremely satisfied” with the treatment outcomes and 89.23% of the patients claimed their condition “improved” or “highly improved” at the 10-year follow-up.

The authors concluded that the reduced pain and improved disability was maintained over 10 years in patients with LDH who were treated with nonsurgical Korean medical treatment 10 years ago. Nonsurgical traditional Korean medical treatment for LDH produced beneficial long-term effects, but future large-scale randomized controlled trials for LDH are needed.

This study and its conclusion beg several questions:

WHAT DID THE SCAM CONSIST OF?

The answer is not  provided in the paper; instead, the authors refer to 3 previous articles where they claim to have published the treatment schedule:

12. Park JJ, Shin J, Choi Y, Youn Y, Lee S, Kwon SR, et al. Integrative package for low back pain with leg pain in Korea: a prospective cohort study. Complement Ther Med. 2010;18(2):78–86. [PubMed[]
13. Shin JS, Lee J, Kim MR, Shin BC, Lee MS, Ha IH. The long-term course of patients undergoing alternative and integrative therapy for lumbar disc herniation: 3-year results of a prospective observational study. BMJ open. 2014;4(9) []
14. Shin JS, Lee J, Lee YJ, Kim MR, Ahn YJ, Park KB, et al. Long-term course of alternative and integrative therapy for lumbar disc herniation and risk factors for surgery: a prospective observational 5-year follow-up study. Spine. 2016;41(16):E955–EE63. [PubMed[]
I could only access the BMJ Open article, and it tells is this:

The treatment package included herbal medicine, acupuncture, bee venom pharmacopuncture and Chuna therapy (Korean spinal manipulation). Treatment was conducted once a week for 24 weeks, except herbal medication which was taken twice daily for 24 weeks; (1) Acupuncture: frequently used acupoints (BL23, BL24, BL25, BL31, BL32, BL33, BL34, BL40, BL60, GB30, GV3 and GV4)10 ,11 and the site of pain were selected and the needles were left in situ for 20 min. Sterilised disposable needles (stainless steel, 0.30×40 mm, Dong Bang Acupuncture Co., Korea) were used; (2) Chuna therapy12 ,13: Chuna is a Korean spinal manipulation that includes high-velocity, low-amplitude thrusts to spinal joints slightly beyond the passive range of motion for spinal mobilisation, and manual force to joints within the passive range; (3) Bee venom pharmacopuncture14: 0.5–1 cc of diluted bee venom solution (saline: bee venom ratio, 1000:1) was injected into 4–5 acupoints around the lumbar spine area to a total amount of 1 cc using disposable injection needles (CPL, 1 cc, 26G×1.5 syringe, Shinchang medical Co., Korea); (4) Herbal medicine was taken twice a day in dry powder (2 g) and water extracted decoction form (120 mL) (Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Peucedanum japonicum, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis and Atractylodes japonica). These herbs were selected from herbs frequently prescribed for LBP (or nerve root pain) treatment in Korean medicine and traditional Chinese medicine,15 and the prescription was further developed through clinical practice at Jaseng Hospital of Korean Medicine.9 In addition, recent investigations report that compounds of C. barometz inhibit osteoclast formation in vitro16 and A. japonica extracts protect osteoblast cells from oxidative stress.17 E. ulmoides has been reported to have osteoclast inhibitive,18 osteoblast-like cell proliferative and bone mineral density enhancing effects.19 Patients were given instructions by their physician at treatment sessions to remain active and continue with daily activities while not aggravating pre-existing symptoms. Also, ample information about the favourable prognosis and encouragement for non-surgical treatment was given.

The traditional Korean spinal manipulations used (‘Chuna therapy’ – the references provided for it do NOT refer to this specific way of manipulation) seemed interesting, I thought. Here is an explanation from an unrelated paper: Image result for chuna therapy

Chuna, which is a traditional manual therapy practiced by Korean medicine doctors, has been applied to various diseases in Korea. Chuna manual therapy (CMT) is a technique that uses the hand, other parts of the doctor’s body or other supplementary devices such as a table to restore the normal function and structure of pathological somatic tissues by mobilization and manipulation. CMT includes various techniques such as thrust, mobilization, distraction of the spine and joints, and soft tissue release. These techniques were developed by combining aspects of Chinese Tuina, chiropratic, and osteopathic medicine.[] It has been actively growing in Korea, academically and clinically, since the establishment of the Chuna Society (the Korean Society of Chuna Manual Medicine for Spine and Nerves, KSCMM) in 1991.[] Recently, Chuna has had its effects nationally recognized and was included in the Korean national health insurance in March 2019.[]

This almost answers the other questions I had. Almost, but not quite. Here are two more:

  • The authors conclude that the SCAM produced beneficial long-term effects. But isn’t it much more likely that the outcomes their uncontrolled observations describe are purely or at least mostly a reflection of the natural history of lumbar disc herniation?
  • If I remember correctly, I learned a long time ago in medical school that spinal manipulation is contraindicated in lumbar disc herniation. If that is so, the results might have been better, if the patients of this study had not received any SCAM at all. In other words, are the results perhaps due to firstly the natural history of the condition and secondly to the detrimental effects of the SCAM the investigators applied?

If I am correct, this would then be the 4th article reporting the findings of a SCAM intervention that aggravated lumbar disc herniation.

 

 

PS

I know that this is a mere hypothesis but it is at least as plausible as the conclusion drawn by the authors.

 

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