I have often felt that practitioners of so-called alternative medicine (SCAM) tend to be foolishly overconfident, often to the point of being dangerous. In a word, they are plagued by hubris.
Here is an example of osteopathic hubris:
The aim of this study was to determine the impact of visceral osteopathy on the incidence of nausea/vomiting, constipation and overall quality of life (QoL) in women operated for breast cancer and undergoing adjuvant chemotherapy in Centre Georges François Leclerc, CGFL.
Ninety-four women operated for a breast cancer stage 1-3, in complete resection and to whom a 3 FEC 100 chemotherapy was prescribed, were randomly allocated to experimental or placebo group. Experimental group underwent a visceral osteopathic technique and placebo group was subjected to a superficial manipulation after each chemotherapy cycle. Rate of grade ≥1 nausea/vomiting or constipation, on the first 3 cycles of FEC 100, were reported. QoL was evaluated using the EORTC QLQ-C30 questionnaire.
Rate of nausea/vomiting episodes of grade ≥1 was high in both experimental and placebo group. Constipation episodes of grade ≥1 were also frequent. No significant differences were found between the two groups concerning the rate of nausea/vomiting (p = 0.569) or constipation (p = 0.204) according to clinician reported side-effects but patient reported impact of constipation and diarrhoea on quality of life was significantly lower in experimental group (p = 0.036 and p = 0.038, respectively).
The authors concluded that osteopathy does not reduce the incidence of nausea/vomiting in women operated for breast cancer and undergoing adjuvant chemotherapy. In contrast, patient reported digestive quality of life was significantly ameliorated by osteopathy.
Several studies have assessed the diagnostic reliability of the techniques involved. The totality of this evidence fails to show that they are sufficiently reliable to be of practical use.
Other studies have tested whether the therapeutic techniques used in visceral osteopathy are effective in curing disease or alleviating symptoms. The totality of this evidence fails to show that visceral osteopathy works for any condition.
The treatment itself is probably safe, yet the risks of visceral osteopathy are nevertheless considerable: if a patient suffers from symptoms related to her inner organs, a visceral osteopath is likely to misdiagnose them and subsequently mistreat them. If the symptoms are due to a serious disease, this would amount to medical neglect and could, in extreme cases, cost the patient’s life.
The key message here should be that visceral osteopathy lacks plausibility. So why test its effectiveness for any condition, especially chemo-induced nausea where there is no conceivable mechanism of action and no hint that it might work?
The answer, I am afraid, might be quite simple: osteopathic hubris!
Dr Gabriella Day is a GP in England who describes herself and her beliefs as follows: “I began training in homeopathy as it is clear that for many conditions conventional treatment options are not effective and can have unwanted side effects. It seemed to me that there must be another way to help people suffering from symptoms such as these… I believe in whole person medicine. No illness exists in isolation. The human body is immensely sophisticated and complicated and we do not understand it fully. Therefore the illness cannot be separated from the person suffering the disease. This may be as simple as stress impairing the immune system to far more complex interactions. Homeopathic treatment seeks to match the underlying disturbance in the system and stimulate the body to correct itself.”
I do not know Dr Day, but she caught my attention recently when she published an article in THE HIPPOCRATIC POST (I had never heard of this publication before!). It is, I think, sufficiently noteworthy to show you some excerpts (the references [in square brackets] were added by me, and they refer to my comments below):
START OF QUOTES
…Homeopathy can be helpful for pretty much any condition , whether as the main treatment , as a complement to a conventional treatment  to speed up the healing process , or to lessen the side-effects of a pharmacological medication . It can be helpful in the treatment of emotional problems , physical problems  and for multi-morbidity patients . I find it an invaluable tool in my GP’s toolbox and regularly see the benefits of homeopathy in the patients I treat …
There are many conditions for which I have found homeopathy to be effective … There are, however, a multitude of symptomatic treatments available to suppress symptoms, both on prescription and over-the-counter. Most symptoms experienced by patients in this context result from the body’s attempt to eliminate the infection. Our immune systems have spent thousands of years refining this response; therefore it seems counter-intuitive to suppress it .
For these types of acute conditions homeopathy can work with the body to support it . For instance, homeopathic Arsenicum album (arsenic) is a classic remedy for diarrhoea and vomiting that can be taken alongside essential oral rehydration . And in influenza I’ve found Eupatorium perfoliatum (ague or feverwort) to be very helpful if the patient is suffering with bony pain .
…Unless it is clinically imperative for a pharmacological intervention, I will always consider homeopathy first  and have successfully prescribed the homeopathic remedy Nux vomica (strychnine) for women suffering from morning sickness . Problems associated with breastfeeding such as mastitis have also responded well to the classic remedies Belladonna (deadly nightshade) and Phytolacca (pokeweed), while I have found Urtica urens (dog nettle) effective in switching off the milk supply to prevent engorgement when the mother stops breastfeeding .
…“heart sink” patients are clearly suffering from pain and discomfort, which is blighting their lives. This is understandably frustrating for them, for they know full well something is awry but there is no medical evidence for this… Homeopathy affords me another approach in trying to help these patients [1,3]. It doesn’t work for them all, but I’m frequently surprised at how many it does help .
The beauty of homeopathy is that it combines mental and emotional symptoms with physical symptoms . When the right remedy is found it appears to stimulate the body to recognise how it is being dysfunctional and corrects this, with no suppression, just a correction of the underlying disturbance . Thus homeopathy not only eliminates unwanted symptoms , it dramatically improves a patient’s overall well-being .
…homeopathy… enables me to reduce the number of painkillers and other drugs I’m prescribing [1,3]. This is particularly true for older multi-morbidity, polypharmacy patients  who are often taking huge amounts of medication.
Contrary to what most homeopaths will tell you, I believe homeopathic treatment does have side-effects – positive side-effects!  It fosters an enhanced doctor patient relationship . The process of eliciting the relevant information to select a remedy enables me to better understand the patient’s condition and helps me to get to know them better . And the patient, seeing that the doctor is interested in the idiosyncrasies and detail of their disease, finds themselves heard and understood . In short, since training in homeopathy I enjoy my job as a GP and my relationship with patients so much more .
Dr Gabriella Day BSc, MBBS, MRCP, DCH, MRCGP, MFHom
END OF QUOTES
- statement without good evidence,
- Hahnemann was vehemently against combining homeopathy with other treatments and called clinicians who disregarded this ‘traitors’,
- statement of belief,
- wrong assumption,
- questionable ethics.
I have recently attempted to slip into the brain of lay-homeopaths and shown how illogical, misguided and wrong the arguments of such enthusiasts really are. Surely, the logic of a doctor homeopath must be better, I then thought. Once you have studied medicine, you have learnt an awful lot of things about the body, disease, therapy, etc., etc., I felt.
Judging from the above article, I might have been wrong.
Acupuncture is little more than a theatrical placebo! If we confront an acupuncture fan with this statement, he/she is bound to argue that there are some indications for which the evidence is soundly positive. One of these conditions, they would claim, is nausea and vomiting. But how strong are these data? A new study sheds some light on this question.
The objective of this RCT was to evaluate if consumption of antiemetics and eating capacity differed between patients receiving verum acupuncture, sham acupuncture, or standard care only during radiotherapy. Patients were randomized to verum (n = 100) or sham (n = 100) acupuncture (telescopic blunt sham needle) (12 sessions) and registered daily their consumption of antiemetics and eating capacity. A standard care group (n = 62) received standard care only.
The results show that more patients in the verum and the sham acupuncture group did not need any antiemetic medications, as compared to the standard care group after receiving 27 Gray dose of radiotherapy. More patients in the verum and the sham acupuncture group were capable of eating as usual, compared to the standard care group. Patients receiving acupuncture had lower consumption of antiemetics and better eating capacity than patients receiving standard antiemetic care, plausible by nonspecific effects of the extra care during acupuncture.
The authors concluded that patients receiving acupuncture had lower consumption of antiemetics and better eating capacity than patients receiving standard antiemetic care, plausible by nonspecific effects of the extra care during acupuncture.
I find these conclusions odd because they seem to state that acupuncture was more effective than standard care. Subsequently – almost as an afterthought – they mention that its effects are brought about by nonspecific effects. This is grossly misleading, in my view.
The study was designed as a comparison between real and sham acupuncture, and the standard care group was not a randomised comparison group. Therefore, the main result and conclusion has to focus on the comparison between verum and sham acupuncture. This comparison shows that the two did not produce different result. Therefore, the study shows that acupuncture was not effective.
A much more reasonable conclusion would have been: THIS STUDY FAILED TO FIND SIGNIFICANT EFFECTS OF ACUPUNCTURE BEYOND PLACEBO.
It is almost 10 years ago that Prof Kathy Sykes’ BBC series entitled ALTERNATIVE MEDICINE was aired. I had been hired by the BBC as their advisor for the programme and had tried my best to iron out the many mistakes that were about to be broadcast. But the scope for corrections turned out to be narrow and, at one stage, the errors seemed too serious and too far beyond repair to continue with my task. I had thus offered my resignation from this post. Fortunately this move led to some of my concerns being addressed after all, and they convinced me to remain in post.
The first part of the series was on acupuncture, and Kathy presented the opening scene of a young women undergoing open heart surgery with the aid of acupuncture. All the BBC had ever shown me and asked me to advise on was the text – I had never seen the images. Kathy’s text included the statement that the patient was having the surgery “with only needles to control the pain.” I had not objected to this statement in the firm belief that the images of the film would back up this extraordinary claim. As it turned out, it did not; the patient clearly had all sorts of other treatments given through intra-venous lines and, in the film, these were openly in the view of Kathy Sykes.
This overt contradiction annoyed not just me but several other people as well. One of them was Simon Singh who filed an official complaint against the BBC for misleading the public, and eventually won his case.
The notion that acupuncture can serve as an alternative to anaesthesia or other surgical conditions crops up with amazing regularity. It is important not least because is often used as a promotional tool with the implication that, IF ACUPUNCTURE CAN ACHIVE SUCH DRAMATIC EFFECTS, IT MUST BE AN INCREDIBLY USEFUL TREATMENT! It is therefore relevant to ask what the scientific evidence tells us about this issue.
This was the question we wanted to address in a recent publication. Specifically, our aim was to summarise recent systematic reviews of acupuncture for surgical conditions.
Thirteen electronic databases were searched for relevant reviews published since 2000. Data were extracted by two independent reviewers according to predefined criteria. Twelve systematic reviews met our inclusion criteria. They related to the prevention or treatment of post-operative nausea and vomiting as well as to surgical or post-operative pain. The reviews drew conclusions which were far from uniform; specifically for surgical pain the evidence was not convincing. We concluded that “the evidence is insufficient to suggest that acupuncture is an effective intervention in surgical settings.”
So, Kathy Sykes’ comment was misguided in more than just one way: firstly, the scene she described in the film did not support what she was saying; secondly, the scientific evidence fails to support the notion that acupuncture can be used as an alternative to analgesia during surgery.
This story has several positive outcomes all the same. After seeing the BBC programme, Simon Singh contacted me to learn my views on the matter. This prompted me to support his complaint against the BBC and helped him to win this case. Furthermore, it led to a co-operation and friendship which produced our book TRICK OR TREATMENT.
Acupressure is a treatment-variation of acupuncture; instead of sticking needles into the skin, pressure is applied over ‘acupuncture points’ which is supposed to provide a stimulus similar to needling. Therefore the effects of both treatments should theoretically be similar.
Acupressure could have several advantages over acupuncture:
- it can be used for self-treatment
- it is suitable for people with needle-phobia
- it is painless
- it is not invasive
- it has less risks
- it could be cheaper
But is acupressure really effective? What do the trial data tell us? Our own systematic review concluded that the effectiveness of acupressure is currently not well documented for any condition. But now there is a new study which might change this negative verdict.
The primary objective of this 3-armed RCT was to assess the effectiveness and cost-effectiveness of self-acupressure using wristbands compared with sham acupressure wristbands and standard care alone in the management of chemotherapy-induced nausea. 500 patients from outpatient chemotherapy clinics in three regions in the UK involving 14 different cancer units/centres were randomised to the wristband arm, the sham wristband arm and the standard care only arm. Participants were chemotherapy-naive cancer patients receiving chemotherapy of low, moderate and high emetogenic risk. The experimental group were given acupressure wristbands pressing the P6 point (anterior surface of the forearm). The Rhodes Index for Nausea/Vomiting, the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool and the Functional Assessment of Cancer Therapy General (FACT-G) served as outcome measures. At baseline, participants completed measures of anxiety/depression, nausea/vomiting expectation and expectations from using the wristbands.
Data were available for 361 participants for the primary outcome. The primary outcome analysis (nausea in cycle 1) revealed no statistically significant differences between the three arms. The median nausea experience in patients using wristbands (both real and sham ones) was somewhat lower than that in the anti-emetics only group (median nausea experience scores for the four cycles: standard care arm 1.43, 1.71, 1.14, 1.14; sham acupressure arm 0.57, 0.71, 0.71, 0.43; acupressure arm 1.00, 0.93, 0.43, 0). Women responded more favourably to the use of sham acupressure wristbands than men (odds ratio 0.35 for men and 2.02 for women in the sham acupressure group; 1.27 for men and 1.17 for women in the acupressure group). No significant differences were detected in relation to vomiting outcomes, anxiety and quality of life. Some transient adverse effects were reported, including tightness in the area of the wristbands, feeling uncomfortable when wearing them and minor swelling in the wristband area (n = 6). There were no statistically significant differences in the costs associated with the use of real acupressure band.
26 subjects took part in qualitative interviews. Participants perceived the wristbands (both real and sham) as effective and helpful in managing their nausea during chemotherapy.
The authors concluded that there were no statistically significant differences between the three arms in terms of nausea, vomiting and quality of life, although apparent resource use was less in both the real acupressure arm and the sham acupressure arm compared with standard care only; therefore; no clear conclusions can be drawn about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting. However, the study provided encouraging evidence in relation to an improved nausea experience and some indications of possible cost savings to warrant further consideration of acupressure both in practice and in further clinical trials.
I could argue about several of the methodological details of this study. But I resist the temptation in order to focus on just one single point which I find important and which has implications beyond the realm of acupressure.
Why on earth do the authors conclude that no clear conclusions can be drawn about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting? The stated aim of this RCT was to assess the effectiveness and cost-effectiveness of self-acupressure using wristbands compared with sham acupressure wristbands and standard care. The results failed to show significant differences of the primary outcome measures, consequently the conclusion cannot be “unclear”, it has to be that ACUPRESSURE WRIST BANDS ARE NOT MORE EFFECTIVE THAN SHAM ACUPRESSURE WRIST BANDS AS AN ADJUNCT TO ANTI-EMETIC DRUG TREATMENT (or something to that extent).
As long as RCTs of alternative therapies are run by evangelic believers in the respective therapy, we are bound to regularly encounter this lamentable phenomenon of white-washing negative findings with an inadequate conclusion. In my view, this is not research or science, it is pseudo-research or pseudo-science. And it is much more than a nuisance or a trivial matter; it is a waste of research funds, a waste of patients’ good will that has reached a point where people will lose trust in alternative medicine research. Someone should really do a systematic study to identify those research teams that regularly commit such scientific misconduct and ensure that they are cut off public funding and support.