pain
Yes, this was the (rather sensationalist) headline of a recent article in the Daily Mail that I allegedly wrote. Its unusual genesis might interest some of you.
I was contacted by a journalist who asked for a telephone interview on the subject of chiropractic as well as my recent book. I agreed under the condition that we do this not over the phone but in writing via email. So, he sent me his questions and I supplied the responses; here they are:
· What’s the absolute worst case scenario of seeing a chiropractor?
The worst that can happen is that you die. Certain manipulations that chiropractors regularly do can injure an artery that supplies part of the brain. This would then result in a stroke; and a stroke can of course be fatal. This is what happened, for example, to the American model Katie May. She had pinched a nerve in her neck on a photoshoot and consulted a chiropractor who manipulated her neck. This caused a tear to an artery in her upper spine. The result was a massive stroke of which she died a few days later.
· How did you first become interested in the topic?
I learned hands on spinal manipulation as a junior doctor. Later, as the head of the department of Physical Medicine and Rehabilitation at the University of Vienna, we used such techniques routinely. In 1993, I became chair of Complementary Medicine in Exeter, and my task was to scientifically investigate alternative therapies such as chiropractic. Recently, I decided to summarize all our research in a book.
· What did you learn from your research?
In essence, our investigations found that almost all the claims that chiropractors make are unsubstantiated. Their manipulations are not nearly as effective as they claim. More worryingly, they are also not free of risks. About 50% of patients who see a chiropractor suffer from side effects after spinal manipulation. These are usually not severe and disappear after 2 or 3 days. But, in addition, very serious complications like stroke, death, bone fractures, paralysis can also occur. Chiropractors say that these are rare, and I hope they are right, but the truth is that nobody knows because there is no system of monitoring such events. We once asked British neurologists to report cases of neurological complications occurring within 24 hours of cervical spine manipulation over a 12-month period. This unearthed a total of 35 cases. Particularly striking was the fact that none of these cases had previously been reported anywhere. So, the underreporting was exactly 100%. This tells me that, when chiropractors claim there are just a few such incidents, in truth there might be a few hundred or even thousand.
· Is there an especially shocking finding?
What I find particularly unnerving is the way chiropractors regularly disregard medical ethics. Take the issue of informed consent, for example. It means that we all have to fully inform patients about the treatment we plan to give. In the case of chiropractic spinal manipulation, it would need to include that the therapy is of doubtful effectiveness, that other options are more likely to help, and that the treatment carries very frequent minor as well as probably rare major risks. I do understand why chiropractors do often not provide this information – it would chase away most patients and thus impact of their income. At the same time, I feel that chiropractors should not be allowed to violate fundamental principles of medical ethics. This is not in the interest of patients!!!
· Why do you think patients are so keen on chiropractors?
I am not sure that they really are so keen; some are but the vast majority are not. Our own research suggests that, depending on the country, between 7 and 33% of the population see chiropractors. This means that between 93 and 67% have enough sense to avoid chiropractors.
· But what does the evidence actually show about the efficacy of chiropractic?
As it happens our most recent summary has just been published. It concluded that “it is uncertain if chiropractic spinal manipulation is more effective than sham, control, or deep friction massage interventions for patients with headaches” [Is chiropractic spinal manipulation effective for the treatment of cervicogenic, tension-type, or migraine headaches? A systematic review – ScienceDirect]. For other conditions the evidence tends to be even less convincing. The only exception might be chronic low back pain, according to another recent summary [Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials | BMJ Evidence-Based Medicine]. But here too, I would argue that other treatments are safer and cheaper.
· Are some chiropractors worse than others?
The profession is divided into 2 groups, the ‘straights’ and the ‘mixers’. The former believe in all the nonsense their founding father, DD Palmer, proclaimed 120 years ago, including that spinal manipulation is the only treatment for virtually all our ailments, and that vaccinations must be avoided at all cost. The mixers have realized that Palmer was a charlatan of the worst kind, focus on musculoskeletal conditions and use treatments borrowed from physiotherapy. Needless to say that the mixers might be bad, but the straights are even worse.
· What can patients do to keep safe?
Avoid chiropractors, go to a library and read my book.
· If you have backpain or joint pain what can you do instead?
There is lots people can do but advice has to be individualized. By far the best is to prevent back pain from happening. Here advice might include more exercise, loosing weight, changing your mattress, avoiding certain things like heavy lifting, etc. If you are acutely suffering, see a physio or a doctor, keep moving and be aware that over 90% of back pain disappears within a few days regardless of what you do.
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I had insisted that I see his edits before this gets published, and a little while later I received the edited version. To my big surprise, the journalist had transformed the interview into an article allegedly authored by me. I told him that I was uncomfortable with this solution, and we agreed that he would make it clear that the article was merely based on an interview with me. I then revised the article in question and the result was the mentioned article published still naming me as its author but with a footnote: “As told in an interview with Ethan Ennals”
Never a dull day when you research so-called alternative medicine!
I has been reported that a man is pleading to steer clear of chiropractors. Last year, Tyler Stanton endured “the worst pain I had ever experienced in my life,” a hospital stay, and the beginning of an ongoing struggle that has left him unable to work. All started immediately after a chiropractor cracked his neck — and something popped.
After adjusting Stanton’s back, the chiropractor moved on to his neck. “It didn’t crack on the first time. On the second time where he tried to crack my neck, he put a lot of force behind it, and I heard one huge and painful pop. I knew immediately that something was wrong.” Stanton recalled that when he tried to sit up, the room began to spin. “My equilibrium was just completely f—ked. I was instantly, profusely sweating.”
After laying on the table for half an hour, Stanton made the short trip back to his home, where he became “violently ill.” Throwing up uncontrollably and unable to see straight, he got into bed, hoping rest would alleviate his symptoms. The following morning, Stanton woke up to “the worst pain I had ever experienced in my life. The entire right side of my body was numb. It was really scary.”
He was taken to the hospital, where he was diagnosed with a herniated disc between the C5 and C6 vertebrae in his neck. Due to the acute pain he was experiencing, he stayed in the hospital for several weeks. “They ended up giving me epidural injections into my spine, and they didn’t even make a dent into the pain,” he said. Ultimately, doctors gave him two choices: spinal fusion therapy or physical therapy to manage his discomfort.
Fearful of the consequences of surgery, Stanton opted for PT. “I had a pharmacy of pain medication to help the nerves be less inflamed so I can get mobility and feeling back into the right side of my body. Essentially, I just had to go home and lay down for about two more months.”
Unable to work, Stanton burned through his savings, and six months into his recovery, he is just beginning to regain sensation in his right arm. “I still deal with pain. I’m still limited in what I can do physically. It just destroyed me. Mentally, financially, physically, all of it.” With limited mobility and mounting medical bills, Stanton is consulting with lawyers and considering legal action. “I kinda feel like I just don’t have another choice because this really just derailed my entire life overnight,” he said.
While proponents say chiropractors help alleviate pain, many doctors describe the field as pseudoscience — and warn that it can actually lead to serious problems. ““There are reports of severe side effects with chiropractic treatment, including blood clot formation, herniated discs, fractures, artery dissection, stroke, paralysis, and death,” explained Gbolahan Okubadejo, MD, a spinal surgeon and the head of The Institute for Comprehensive Spine Care. Dr. Charles R. Wira III, an emergency medicine doctor at Yale Medicine, told the Huffington Post that there’s a known link between chiropractic neck manipulations and major artery tears that can cause strokes. “Thankfully, overall the incidence of neck dissections are small,” he said. “But intentional and aggressive manipulations of the neck merits strong consideration for concern.” Cardiologist Dr. Danielle Belardo said she was “heartbroken” to see a young patient with “dissection of the vertebral artery” following a neck adjustment. “How can we live in a world where it’s legal to perform something with zero evidence for benefit (neck adjustment from a chiro) when there are such incredibly dangerous and life changing risks?” she wrote on Twitter. “[My patient] trusted a licensed healthcare practitioner to provide care that has more benefit than harm. This is a disgrace.”
Stanton hopes his story can serve as a warning for others. “I think it’s important that I share this story because I just don’t want what happened to me to happen to someone else,” he said. “Please don’t go to the chiropractor, OK? If I can do anything with my platform to share the story and save somebody from experiencing what I had to experience, then hopefully, something positive can come out of what I went through. Please hear me when I say this: Please be careful. This is the last thing that you want to experience.”
In a disturbing parallel, a young woman who felt a “crack to her neck” during a gym workout in 2021 died weeks later after going to a chiropractor to treat her neck pain. In 2022, a Georgia woman became paralyzed after a routine neck adjustment ended up rupturing her spinal arteries in several spots. In 2023, an Australian man suffered a stroke after cracking his neck in an ill-advised attempt to cure his chronic back pain.
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None of these are proper case reports in a medical sense, of course. Such publications are relatively rare.
I wonder why.
Could it be related to the fact that many chiropractors are in denial and, as a profession, they still have no adequate monitoring system for adverse event?
Patients with headaches often seek so-called alternative medicine (SCAM), including chiropractic care. Chiropractic spinal manipulation is one of the most commonly used techniques for these patients; however, its effectiveness remains unclear. This systematic review aimed to evaluate the effectiveness of chiropractic spinal manipulation in reducing headache days, episode duration, episode intensity, and medication intake in patients with headaches.
MEDLINE (Pubmed), PEDro, SCOPUS, Cochrane Library and Web of Science databases were searched from inception to April 2024. PICO search strategy was used to identify randomized controlled trials applying chiropractic spinal manipulations versus sham manipulation, no additional intervention, or other conservative non-pharmacological interventions in patients with headaches. Eligible studies and data extraction were conducted independently by two reviewers. Quality of the studies was assessed with Physiotherapy Evidence Database scale, and risk of bias with Cochrane Collaboration tool. Certainty of the evidence was evaluated using GRADE approach.
Eight studies ranging from low to high methodological quality were included. The results were categorized into three subgroups: chiropractic manipulation versus sham, chiropractic manipulation versus control, and chiropractic manipulation versus deep friction massage. Among the five studies comparing chiropractic manipulation to sham, two found a significant reduction in the number of headache days. Of the three studies comparing chiropractic manipulation to another control, one reported a decrease in headache episode duration. No significant differences were observed for any other variable across the subgroups. The certainty of evidence was downgraded to very low.
We concluded that it is uncertain if chiropractic spinal manipulation is more effective than sham, control, or deep friction massage interventions for patients with headaches.
These conclusions might not surprise many readers. Yet, in at least one way, they are quite surprising: the version of the article we submitted to the ‘European Journal of Integrative Medicine’ had a substantially different conclusion; it was as follows:
What happened?
You may well ask!
The journal wanted us to change our conclusion! Because the main authors of our paper needed, for academic reasons, to publish without any further delay, they agreed to the demand. As far as I remember, such a thing is unprecedented in my ~50 years of publishing research in medical journals.
PS
It is also the last time I will have any dealings with the European Journal of Integrative Medicine
In a recent post, I mentioned a new report which allegedly claimed that “employing chiropractors in the [English] health service could save £1.5 billion“. Thanks to ‘Blue Wode’, we can now read the original report, and I had a critical look at it. Here are some quotes of crucial passages from the report:
The objective of this analysis was to establish how chiropractors could help to address the unmet need of people with MSK [musculoskeletal] conditions, who are currently absent from work due to these conditions, on NHS MSK physiotherapy waiting lists …
To assess the available evidence on the relative effectiveness of chiropractors, physiotherapists and osteopaths a pragmatic literature review was undertaken. This consisted of a rapid, pragmatic search of existing literature evidence to explore the effectiveness of chiropractic interventions (in terms of productivity/return to work) compared with physiotherapists and/or osteopaths … The strategies were not designed to be ‘comprehensive’ but focused to target records for relevant studies whilst retrieving record numbers that were manageable within the project timescales and available resources…
The results of the analysis are based on the assumption that there are equivalent work-related outcomes associated with MSK physiotherapy and chiropractic care…
1,270 records were retrieved from the database searches and 41 records were sent by the BCA. 101 duplicates were removed, and the remaining 1,210 references were screened for inclusion. 18 studies met the eligibility criteria and were included in data extraction (see Appendix B for the study flow diagram). Included studies had the following study designs: five systematic reviews [29-32] (of which one was only a summary [33]), three non-systematic reviews [34, 35] with one running a meta analysis [36], five randomised controlled trials [37-41], three cohort studies [42-44], and two case series studies [26, 45]…
A pragmatic review of literature found that evidence of the effectiveness of chiropractors in helping people with MSK conditions to get back to work is sparse and poor quality. There is weak evidence to suggest that chiropractors treating MSK conditions would be able to achieve equivalent return-to-work outcomes as physiotherapists. If more robust evidence could be developed, it is feasible that chiropractors could be used to address supply shortages in treatment for MSK conditions. This would require the NHS to consider closely the clinical governance arrangements it would need to put in place to ensure patient safety. It would also need to review the type of treatment and advice that chiropractors were able to provide for people with MSK conditions.
The initial analysis carried out for this study estimated that there are almost 1.6 million people unable to work due to an MSK condition in the UK. Spare capacity in the chiropractic profession indicates that around 114,000 more people per year could be treated by chiropractors. This represents around 7% of the current waiting list. Chiropractors have an average waiting time of 1.5 weeks compared with a minimum of 11 weeks for physiotherapists.
If the spare chiropractor capacity was used to address MSK conditions preventing people from working, then this could improve workforce productivity by reducing the time people are waiting for treatment. Adopting a simple analysis, assuming that all of the spare capacity could be used in the most efficient way, the estimated value of the improvement in productivity is £612 million per year. Using the Markov model to factor in a wider range of potential outcomes provides a more conservative, more robust estimated value of £399 million per year. If minimum rather that median wages are used to value the productivity gain based on an 11 week wait then it would reduce to £258 million.
A range of factors may increase or decrease the potential productivity gains. If the 11-week waiting time for physiotherapists is an under-estimate and the waiting times are 18 or 24 weeks, then the productivity gain would increase to £713 million and £1 billion respectively.
This analysis focused on productivity costs only, but people may also potentially have better health outcomes and lower treatment costs if they are treated more quickly.
Recommendations
Key recommendations emerging from this research are:
- The NHS should consider commissioning pilot research studies to generate evidence to make the case for the use of chiropractors in providing treatment for people with MSK conditions to allow them to return to work more quickly.
- The NHS should consider how the potential use of chiropractors to provide treatment and advice for people with MSK conditions can help to address the demand, capacity and financial challenges facing the health and social care system. This would need to be within the constraints of clinical guidelines and governance, to ensure safety and effective outcomes.
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And here are a few critical points:
- What on earth is a “pragmatic literature review”; was the term invented to disguise tha fact that the review is not systematic and thus is a bonanza in cherry-picking? I had a look at the cited literature and can confirm that any critical assessment of chiropractic has been excluded.
- “The results of the analysis are based on the assumption that there are equivalent work-related outcomes associated with MSK physiotherapy and chiropractic care.” Are you kidding me? I thought the aim was to “assess the available evidence on the relative effectiveness of chiropractors, physiotherapists and osteopaths”. How can you then assume equivalent outcomes as a basis for conducting the research?
- “Included studies had the following study designs: five systematic reviews [29-32] (of which one was only a summary [33]), three non-systematic reviews [34, 35] with one running a meta analysis [36], five randomised controlled trials [37-41], three cohort studies [42-44], and two case series studies [26, 45].” So, just 5 RCTs are the basis of the evaluations? What did you do with the dozens of other RCTs in this area? Did they perhaps not fit your conclusions?
- “If more robust evidence could be developed, it is feasible that chiropractors could be used to address supply shortages in treatment for MSK conditions.” However, I predict that more robust evidence will show the opposite of what you seem to wish!
- “Ensure patient safety”. Yes, thanks for mentioning safety. The report neglects safety completely. In view of the known risks of chiropractic this seems a serious mistake!
- “The estimated value of the improvement in productivity is £612 million per year.” From my comments above, it follows that this wild and largely unsubstantiated estimate was guided by little more than wishful thinking.
- “This analysis focused on productivity costs only, but people may also potentially have better health outcomes and lower treatment costs if they are treated more quickly.” More likely people experience health outcomes that are very similar to those of doing nothing at all. In this case, it would follow that a lot of money might be saved if we scrap MSK treatments altogether.
This report is a transparent and dilettante attempt to push more chiropractic on the NHS, a move that would not improve much and could even put a few patients in wheelchairs.
This “randomized controlled clinical trial” (has anyone ever seen a randomized trial without a control group? – No, therefore, the correct term is “ramdomized clinical trial (RCT)”) aimed to compare the effectiveness of wet cupping therapy (WCT) and Acupuncture in treating migraine patients. It was conducted between 01.03.2022 and 01.10.2023 in a Traditional and Complementary Medicine Center of a tertiary hospital. Patients diagnosed with migraine were included in the study and randomized into three groups.
- The WCT group received wet cupping 3 times, once a month.
- The acupuncture group received 10 sessions of acupuncture once a week.
- The waiting list group served as the control group.
VAS and MIDAS scales were used for all groups at the beginning and the end of the treatment, and the results were compared.
Initially, 168 patients were enrolled. However, there were some dropouts throughout the study period. In the acupuncture group, 11 patients did not attend subsequent sessions, with one dropout occurring due to adverse effects. In the wet cupping (WCT) group, three patients discontinued their participation following the initial treatment. Ultimately, a total of 153 patients were included.
The findings show that all three groups were similar regarding age and sex. Migraine Disability Assessment Scale (MIDAS) and Visual Analogue Scale (VAS) pain scores decreased significantly in both treatment groups after the applications, while they remained similar for the same period in the control group. Additionally, the post-treatment values of MIDAS and VAS in both the WCT and acupuncture groups were significantly lower compared to controls, while they were similar when compared in between.
The authors concluded that both of these applications were found to be similarly effective in improving disability status and pain intensity in patients with migraine.
I beg to differ!
Apart from all other flaws of this trial, it did not control for placebo effects. Both WCT and acupuncture are invasive treatments that are bound to cause sizeable placebo responses. The waiting list control might account for the natural history of the disease and for regression towards the mean, but it is not a method for allowing for placebo effects. In view of this fundamental limitation of the study, its conclusions should be re-written as follows:
Both of these applications were similarly effective in producing sizeable placebo effects which in turn improved disability status and pain intensity in patients with migraine.
For migraine patients, this means that neither of these therapies are likely to be the best available option.
Recently, several papers reported about PP353 as a new ‘wonder drug’ for chronic low back pain (cLBP). The reason is that Persica Pharmaceuticals Limited (Persica) announced positive results of a randomised, double-blind, placebo-controlled clinical trial assessing the safety and efficacy of PP353 as a treatment for patients with chronic low back pain (cLBP). PP353 is a specifically formulated combination of linezolid, iohexol and a thermosensitive gel that is injected into the degenerate lumbar disc, delivering prolonged exposure of a high concentration at the site of infection. A 2-dose regime (dosed 4 days apart) is said to eliminate the infection, thus addressing the underlying cause of cLBP which is claimed to be an infection.
Intradiscal administration of 3 mL of PP353 has been reported to be well-tolerated and based on the pharmacokinetics following a single injection, a two-dose regimen of PP353 (150 mg linezolid) on Day 1 and Day 5 ± 1 was selected to explore safety, tolerability, pharmacokinetics, and efficacy in Part B of the Persica 002 study.
The abovementioned efficacy trial enrolled 44 patients who had suffered from cLBP for more than 6 months (mean duration of 5.5 years) and had not been helped by existing non-surgical treatments. They were randomized to receive either PP353 or placebo injected into intervertebral discs. The results of the study demonstrated statistically significant and clinically meaningful results in patients with cLBP. Compared to placebo, the verum led to a 30% reduction of pain after 12 months. The placebo group did not achieve clinically meaningful change from baseline. The PP353 group also reported statistically significant and clinically meaningful reductions in disability with a within-group reduction of 9.4-points (63%) and a between-group reduction of 3.9-points (39%) from placebo in the Full Analysis Set of subjects at 12 months.
The manufacturer claims to provide an alternative, non-opioid, treatment for cLBP patients by replacing the 100-day high-dose oral antibiotics course to treat cLBP with an injectable antibiotic formulation that will achieve high local concentration and adequate duration of exposure in the spine to effect the sterilisation of the infected disc.
Local administration of antibiotic has the potential to elicit a faster response because an effective drug concentration in the infected tissue is immediately achieved. It also significantly reduces the amount of drug required, reducing the likelihood of systemic side effects, especially those associated with perturbation of the gut microbiome.
Intradiscal administration of therapeutics to treat cLBP is an established but mostly ineffective route. Persica believes that an effective treatment must address the underlying cause of disease – the infection. An effective antibacterial therapeutic should reduce the inflammatory stimuli in the intervertebral space and adjacent bone and allow repair over time, leading to a reduction in pain.
During the development of PP353, Persica tested several generic antibiotics in vitro and in vivo to find an antibiotic with the required properties: active against the bacteria identified in disc and herniated tissue samples, little to no resistance in clinical isolates, and the ability to be formulated to provide a depot to extend the duration of exposure.
To enable administration of the antibiotic, Persica developed a unique formulation which delivers the antibiotics to the site of infection and ensures that it remains within the infected area.
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Sounds good?
Yes, perhaps even a little too good to be true!
Here are some of my concerns:
- The manufacturer has, as far as I can see, not published the findings in a peer-reviewed journal and thus wants us to believe the findings without scrutinizing the methodology.
- Even if they eventually do publish the study in full, and even if it turns out to be rigorous, one would still want independent preplications.
- There is an undenialble and very substantial financial interest in the matter (anyone who comes out with an effective and safe pill against cLBP, will quickly make billions!), and one might therefore wonder how objective the manufacturer can be about the merits of PP353.
- The assumption that many cases of cLBP are caused by a disc infection is a well-known theory, but it remains largely unproven.
- As we dicuseed only recently, antibiotics have not been shown to be effective for cLBP.
Clearly, we have to wait and see – but my advice is to take PP353 with a healthy pinch of salt.
A long article on chiropractic casts doubt that chiropractic is useful. Here is an abbreviated version of it:
The chemistry and biology graduate from the University of Georgia, 28-year-old Caitlin Jensen, visited a chiropractor to sort out her lower back pain. During the session, the therapist performed an adjustment. It severed four arteries in her neck. She collapsed shortly after, unable to speak or move. The injury had caused her to suffer a series of strokes. Today, she has regained some movement in her head, legs and arms but she is still unable to speak, is partially blind and relies on a wheelchair.
- One 66-year-old grandmother said a visit to a chiropractor to treat her sore shoulder left her covered in bruises, hearing ringing in her ears and with a splitting pain in her jaw. She was later diagnosed by doctors with trigeminal neuralgia – a chronic pain disorder caused by a trapped or irritated nerve in the neck that causes sudden, electric shock-like pain in the face. She believes the condition – which, three years later, still sometimes leaves her unable to open her mouth wide enough to speak to her grandchildren – was triggered by a chiropractic adjustment of her neck.
- A 55-year-old woman was left with chronic neck and shoulder pain after visiting a chiropractor for a sore back. The pain was so bad she once spent 72 hours immobile and unable to sleep despite taking a concoction of painkillers.
- And a 66-year-old man says his back went into spasm as he was leaving his first chiropractor appointment – which left him hospitalised and bedbound for weeks. The intense treatment, he later learned, had pushed one of the discs of his spine out of place, causing him to lose feeling in his right leg for ever.
The aim of this recent review was to investigate the efficacy of non-surgical and non-interventional treatments for adults with low back pain compared with placebo. It included all randomised controlled trials evaluating non-surgical and non-interventional treatments compared with placebo or sham in adults (≥18 years) suffering from non-specific low back pain.
Random effects meta-analysis was used to estimate pooled effects and corresponding 95% confidence intervals on outcome pain intensity (0 to 100 scale) at first assessment post-treatment for each treatment type and by duration of low back pain—(sub)acute (<12 weeks) and chronic (≥12 weeks). Certainty of the evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.
A total of 301 trials (377 comparisons) provided data on 56 different treatments or treatment combinations. One treatment for acute low back pain: (non-steroidal anti-inflammatory drugs (NSAIDs)), and five treatments for chronic low back pain:
- exercise,
- spinal manipulative therapy,
- taping,
- antidepressants,
- transient receptor potential vanilloid 1 (TRPV1) agonists)
were found to be efficacious. However, effect sizes were small and of moderate certainty. Three treatments for acute low back pain (exercise, glucocorticoid injections, paracetamol), and two treatments for chronic low back pain (antibiotics, anaesthetics) were not efficacious and are unlikely to be suitable treatment options; moderate certainty evidence. Evidence is inconclusive for remaining treatments due to small samples, imprecision, or low and very low certainty evidence.
The authors concluded that the current evidence shows that one in 10 non-surgical and non-interventional treatments for low back pain are efficacious, providing only small analgesic effects beyond placebo. The efficacy for the majority of treatments is uncertain due to the limited number of randomised participants and poor study quality. Further high-quality, placebo-controlled trials are warranted to address the remaining uncertainty in treatment efficacy along with greater consideration for placebo-control design of non-surgical and non-interventional treatments.
This is an important analysis, not least because of the fact that the research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The methodology is sound and the results thus seem reliable.
The findings are in keeping with what we have been discussing at nauseam here: no treatment works really well for back pain. For acute symptoms no so-called alternative medicine (SCAM) at all is efficacious. For chronic pain, spinal manipulation therapy (SMT) have small effects. As SMT is neither cheap nor free of risks, excercise is much preferable.
Considering that most SCAMs are heavily promoted for low back pain (e.g. acupuncture, Alexander technique, cupping, Gua Sha, herbal medicine, homeopathy, massage, mind-body therapies, reflexology, Reiki, yoga), this verdict is sobering indeed!
Qi-gong is a branch of Traditional Chinese Medicine that employs meditation, exercise, deep breathing and other techniques with a view of strengthening the assumed life force ‘qi’ and thus improving health and prolong life. Qi-gong has ancient roots in China and has recently also become popular in other countries. There are several distinct forms of qi-gong which can be categorized into two main groups, internal qi-gong and external qi-gong. Internal qi-gong refers to a physical and mental training method for the cultivation of oneself to achieve optimal health in both mind and body. Internal qi-gong is not dissimilar to tai chi but it also employs the coordination of different breathing patterns and meditation. External qi-gong refers to a treatment where qi-gong practitioners direct their qi-energy to the patient with the intention to clear qi-blockages or balance the flow of qi within that patient. According to Taoist and Buddhist beliefs, qi-gong allows access to higher realms of awareness.
The assumptions of qi-gong are not scientifically plausible. But this does not stop enthusiasts to submit it to clinical trials.
A quasi-experimental pretest-posttest study was conducted with 231 adolescent girls aged 13-17 years suffering from premenstrual syndrome (PMS). Participants underwent a 4-week Qi Gong therapy program, with five 45-minute sessions weekly. Data were collected using a demographic questionnaire and Modified PMS Scale, analysing pre- and post-intervention symptoms through descriptive statistics, paired t-tests and chi-square tests.
The intervention significantly reduced PMS severity, with mild PMS cases increasing from 48 (20.78%) to 166 (71.86%) post-intervention. Paired t-tests revealed a highly significant mean difference in PMS scores (T = 12.251, p < 0.001).
The authors concluded that Qi Gong therapy offers a holistic, non-invasive approach for managing PMS by addressing both physiological and emotional dimensions to the condition. Its ability to balance hormones, alleviate stress and improve overall quality of life makes it a valuable addition to PMS care.
This study originated from the Department of Obstetrics and Gynecological Nursing, Nootan college of Nursing, Sankalchand Patel university, Visnagar, Gujarat, India; the Department of Pediatric Nursing of the same institution and the Department of Psychiatric Nursing of the same institution. One would have hoped that its authors know better than to draw such conclusions from such a study. Here are some points of concern:
- There is no reason why the treatment should be holistic.
- The study did not have a control group; causal inferences are thus not waarranted.
- The study did not produce any evidence to show that the treatment addressed either physiological or emotional dimensions.
- The study did not produce any evidence to show that the treatment did anything to hormones.
- The study did not produce any evidence to show that the treatment alleviated stress.
- The study did not produce any evidence to show that the treatment improved quality of life.
- I see no resason why the treatment should be promoted as a valuable addition to PMS care.
- The PMS severity changed after the treatment and not necessarily because of it.
- The true reasons it changed might be multifold, e.g.: placebo, regression towards the mean, social desirability.
- Misleading the public by drawing far-reaching conclusions has the potential to do untold harm.
I have said it often, and it saddens me to have to say it again:
If the quality of research into so-called alternative medicine (SCAM) does not improve dramatically, nobody can blame the public to not take SCAM seriously any more.
On this blog, we have discussed all sorts of so-called alternative medicine (SCAM) but only rarely we scrutinize any of the many gadets and devices that are being promoted under the SCAM umbrella. Therefore, I will in future try to fill this gap.
This study investigated the effects of a magnetic pain relief patch (MPRP) on gait variability in adults. In 10 young men and women, MPRP was attached to 18 bilateral lower limb muscle areas (biceps femoris, gastrocnemius medialis, gastrocnemius lateralis, rectus femoris, soleus, semitendinosus, tibialis anterior, vastus medialis, and vastus lateralis) for 24 hours. Gait parameters collected from the accelerometer sensor were ground contact time, cadence, stance phase, swing phase, double support, stride length, and swing width, and were analyzed as gait variability. Data analysis was performed using the Wilcoxon signed-rank test.
Significant differences were found in the left and right gait cycle time coefficient of variation (CV) (p=0.047 in left, p=0.028 in right), cadence CV (p=0.047 in left and right), and double support CV (p=0.028 in left and right) before and after attachment of the MPRP.
The author concluded that MPRP enhances gait variability and can be utilized as a potential tool to complement noninvasive pain management and rehabilitation strategies. However, further studies are required to prove the long-term benefits and optimal application protocol of MPRP use.
My interpretation is very different!
Background: Static magnets are marketed with claims of effectiveness for reducing pain, although evidence of scientific principles or biological mechanisms to support such claims is limited. We performed a systematic review and meta-analysis to assess the clinical evidence from randomized trials of static magnets for treating pain.
Methods: Systematic literature searches were conducted from inception to March 2007 for the following data sources: MEDLINE, EMBASE, AMED (Allied and Complementary Medicine Database), CINAHL, Scopus, the Cochrane Library and the UK National Research Register. All randomized clinical trials of static magnets for treating pain from any cause were considered. Trials were included only if they involved a placebo control or a weak magnet as the control, with pain as an outcome measure. The mean change in pain, as measured on a 100-mm visual analogue scale, was defined as the primary outcome and was used to assess the difference between static magnets and placebo.
Results: Twenty-nine potentially relevant trials were identified. Nine randomized placebo-controlled trials assessing pain with a visual analogue scale were included in the main meta-analysis; analysis of these trials suggested no significant difference in pain reduction (weighted mean difference [on a 100-mm visual analogue scale] 2.1 mm, 95% confidence interval -1.8 to 5.9 mm, p = 0.29). This result was corroborated by sensitivity analyses excluding trials of acute effects and conditions other than musculoskeletal conditions. Analysis of trials that assessed pain with different scales suggested significant heterogeneity among the trials, which means that pooling these data is unreliable.
Interpretation: The evidence does not support the use of static magnets for pain relief, and therefore magnets cannot be recommended as an effective treatment. For osteoarthritis, the evidence is insufficient to exclude a clinically important benefit, which creates an opportunity for further investigation.
Our systematic review did evidently not stop the author to do his own study – good for him!
But what a study it is!!!
Alert readers will have noticed that the study has no control group. Others might have remarked that the notion of static magnets of this kind doing anything meaningful to our bodies lacks plausibility. Thus the observed effects cannot possibly attributed to the magnet therapy. Most likely they are due to the considerable attention the volunteers received.
Some might argue that such gadgets do no harm – so, why not use them? I would disagree with this notion. Firstly, they cost money and thus harm the finances of gullible consumers. Secondly, they distract people from effective treatments and thus have the potential to prolong the suffering of patients.
In view of all this, I feel I should rewrite the conclusions as follows:
Attention can improve pain and enhance gait variability. MPRP is neither biologically plausibe nor has it been shown to be clinically effective. Responsible clinicians should stop using MPRP and employ effective treatments instead. Future research on MPRP must be categorized as a waste of resources.
