FOUR QUESTIONS TO DC + CRITICAL CHIRO (CC):
1) what does the law say about informed consent for Australian chiros?
2) what info exactly do you have to provide?
3) who monitors it?
4) what published evidence do we have about compliance?
CC then posted this reply:
Here we go again you demand evidence while providing little if any for your own assumptions (poor case studies do not count. The pleural of anecdote does not equal evidence whether it’s from chiro’s or you).
We have been over this many times over many years, I cite research/provide links yet you still find it challenging to take it onboard. It is human nature to feel obligated once making a public statement to defend it no matter how much evidence is sent your way. So not surprising.
“1) what does the law say about informed consent for Australian chiros?”
It is all freely available on the national regulators website (as you know and as I have referenced in the past):
Some research by chiropractors on this topic (cited many times in the past):
Risk Management for Chiropractors and Osteopaths. Informed consent
A Common Law Requirement (2004):
Quick advanced PubMed with filters set to “Chiropractic” AND “Informed consent”.
Not rocket science
Latest paper that you wrote an ill informed blog on and the comments were not going as you expected (So I expected you to double down like Donald Trump with a new blog within days. Your getting predictable).
This paper questions the legal implications of vertebral subluxations with high powered legal input and is a broadside by evidence based chiropractors against vitalistic chiropractors. You respond a snide fantasy informed consent dialogue when you should be supporting the authors:
“2) what info exactly do you have to provide?”
“4) what published evidence do we have about compliance?”
We have discussed this as well. It is a common law requirement for every profession and is checked upon re-registration by AHPRA every year and by the professional indemnity insurers every year. No informed consent, no registration and no professional indemnity insurance.
Checked AHPRA’s panel decisions and went back 5 YEARS and found ONE decision relating to informed consent:
“3) who monitors it?”
Another of your tired old arguments that we have discussed many times over the years.
In the UK there is the “‘Chiropractic Reporting and Learning System’ (CRLS)” but this is set up by the association representing chiropractors and not the registration board that advocates for patients. Right idea and step in the right direction, wrong organization.
Here years ago there was a trial of an adverse event reporting system in a Melbourne emergency department systematically collected relevant AE information on all professions which was sent to the relevant board for investigation.
It was supported by doctors and chiropractors while physio’s were not involved. A doctor involved told me it was killed off by ER doctors who “snivelled” about the extra paperwork.
There is no AE reporting system for physio’s, chiro’s, osteo’s, GP’s in private practice etc.
Over the years you have harped on and on about this topic as if it is a failing purely of the chiropractic profession when we have supported initiatives for its implementation.
You have also kept up with the research even commenting on an chiropractic researcher on AE’s Charlotte Leboeuf-Yde (who you highly regard) yet ignored until you could take issue with two sentences written in a blog then you wrote this hatchet blog:
So you are asking for evidence yet willfully ignore an author who “I have always thought highly of Charlotte’s work”.
Stop the cynical cherry picked blogs and start supporting the researchers and reformers otherwise you are just someone standing on the sidelines blindly throwing grenades. You do not care who you hit or the damage you do to the chiropractors leading the reform you demand yet consistently fail to support.
I thought the tone of this response was oddly aggressive and found that CC had failed to understand some of my questions. Yet the link to the chiro’s code of conduct https://www.chiropracticboard.gov.au/Codes-guidelines/Code-of-conduct.aspx was useful. This is what it says about informed consent:
- the chiro suggests a manipulation of the neck;
- this often involves forcing a spinal joint beyond its physiological range of motion;
- the treatment will be short but needs repeating several times during the coming weeks;
- the expected benefits are a reduction of pain and improvement of motion;
- the total cost of the treatment series will be xy;
- there are many other treatment options for neck pain;
- most of these have a better risk/benefit profile than neck manipulation;
- having no treatment for neck pain at all is likely to lead to full resolution of the problem over time.
Apart from any doubts that chiropractors would actually comply with these requirements, the question remains: is the listed information sufficient? Does it outline a truly a fully informed consent? I think that essential aspects of informed consent are missing.
- The code does not explicidly require an explanation about the possible harms of spinal manipulation (i.e. 50% of all patients will suffer mild to moderate adverse effects lasting 2-3 days, and occasionally patients will have a stroke of which some have died).
- Moreover, the code mentions EXPECTED benefits, but not benefits supported by evidence. Chiros may well EXPECT their treatment to work, but what does the evidence show? As often discussed on this blog, the evidence is negative or very week, depending how you want to interpret it. The code does not require a chiro to inform his patients about this fact.
So, the way I see it, the code does not expressedly demand the chiro to explain his patient that the treatment he is being asked to consent to is
- not supported by sound evidence for effectiveness,
- nor that the treatment is burdened with significant risks.
And what about the other questions listed above? An Australian chiropractor who will remain anonymous gave me the following answers:
Yet, Australian chiropractors claim that they abide by the ethical imperative of informed consent. Are they taking the Mickey?
Perhaps not. Perhaps they are merely trying to make sure they do not lose the majority of their clientele. As I already pointed out in my previous post, fully informed consent would make most chiropractic patients turn round and run a mile.
This study assessed the patterns of dietary supplement usage among cancer survivors in the United States in a population-based setting. National Health and Nutrition Examination Survey (NHANES) datasets (1999-2016) were accessed, and adult respondents (≥ 20 years old) with a known status of cancer diagnosis and a known status of dietary supplements intake were included. Multivariable logistic regression analysis was then used to assess factors associated with dietary supplements intake. Moreover, and to evaluate the impact of dietary supplements on overall survival among respondents with cancer, multivariable Cox regression analysis was conducted.
A total of 49,387 respondents were included in the current analysis, including a total of 4,575 respondents with cancer. Among respondents with cancer, 3,024 (66.1%) respondents reported the use of dietary supplements; while 1,551 (33.9%) did not report the use of dietary supplements. Using multivariable logistic regression analysis, factors associated with the use of dietary supplements included:
- older age (OR: 1.028; 95% CI: 1.027-1.030);
- white race (OR for black race vs. white race: 0.67; 95% CI: 0.63-0.72);
- female gender (OR for males vs. females: 0.56; 95% CI: 0.53-0.59),
- higher income (OR: 1.13; 95% CI: 1.11-1.14),
- higher educational level (0.59; 95% CI: 0.56-0.63),
- better self-reported health (OR: 1.36; 95% CI: 1.17-1.58),
- health insurance (OR: 1.35; 95% CI: 1.27-1.44),
- history of cancer (OR: 1.20; 95% CI: 1.10-1.31).
Using multivariable Cox regression analysis and within the subgroup of respondents with a history of cancer, the use of dietary supplements was not found to be associated with a difference in overall survival (HR: 1.13; 95% CI: 0.98-1.30).
The authors concluded that dietary supplement use has increased in the past two decades among individuals with cancer in the United States, and this increase seems to be driven mainly by an increase in the use of vitamins. The use of dietary supplements was not associated with any improvement in overall survival for respondents with cancer in the current study cohort.
Many cancer patients, when they first get diagnosed, are tested for vitamin D levels and found to be low or borderline. Consequently, they get a prescription for supplements. Other than this, there is rarely an indication to take any vitamins or other dietary supplements. Yet, cancer patients take them because they think these ‘natural’ preparations can do no harm (and because the industry can be persuasive [there is big money at stake] and the odd breed of ‘integrated’ oncologists might even recommend them). Sadly, this assumption is not correct. The biggest danger, in my view, is the possibility of supplements to interact with one of the many drugs that cancer patients need to take. So, in a way, it is reassuring that, on average, there is no detrimental effect on overall survival.
The paper will probably also reignite the perennial discussion about the effects of vitamin C on the natural history of cancer. My understanding is that there is none (and this verdict seems to be supported by the findings reported here). But I am, of course, aware that this is a ‘hot potato’ and that some readers will think differently. To them I say: please show me the evidence.
It would be interesting, I thought, to get some information on what type of books on so-called alternative medicine (SCAM) are being most frequently sold and read in different countries. In particular, it would be relevant to see how many of them are books that one might recommend.
But how would one go about researching this?
The simplest solution, I guessed, would be to go on the Amazon sites of various countries and have a look. And that’s precisely what I did a few days ago. I decided to scan the first 100 books that are listed under ‘alternative medicine’ and pick out the ones that are non-promotional, factual or critical. I did this little research in 4 countries: USA, UK, France and Germany.
Here are my findings:
Not one of the 100 books seems to offer a critical assessment of SCAM. That means the percentage of what I might call recommendable books (books that do not promote unproven or disproven SCAMs to the unsuspecting public) seems to be precisely zero.
On place 6, I was delighted to find my recent book Alternative Medicine: A Critical Assessment of 150 Modalities. On place 14 was You Are the Placebo: Making Your Mind Matter. And on place 70 Trick or Treatment?: Alternative Medicine on Trial.
That makes the percentage 3.
Surprisingly, there are hardly any books in French listed in the SCAM category. Place 4 is my SCAM: So-Called Alternative Medicine, place 7 More Harm than Good?: The Moral Maze of Complementary and Alternative Medicine, place 9 Trick or Treatment: The Undeniable Facts about Alternative Medicine, and place 64 Killing Us Softly: The Sense and Nonsense of Alternative Medicine.
The percentage is thus 4.
Not a single book met the inclusion criteria which makes the percentage a proud zero.
In 1998, we assessed for the first time books on SCAM ( Int J Risk Safety Med 1998, 11: 209-215. [the article is not Medline-listed]). We chose a random sample of 6 such books published in 1997, and assessed their contents according to pre-defined criteria. The findings showed that the advice given in these volumes was frequently misleading, not based on good evidence and often inaccurate. If followed, it would have caused significant harm to patients.
In 2006, we conducted a similar investigation which we then reported in the first and second editions of our book THE DESKTOP GUIDE TO COMPLEMENTARY AND ALTERNATIVE MEDICINE (now out of print, but the German and French translations are still available, I think). This time, we selected 7 best-sellers in SCAM and scrutinised them in much the same way. Our findings showed that almost every form of SCAM was recommended for almost every condition. There was no agreement between the 7 books which SCAM might be effective for which condition. Some treatments were even named as indications for a certain condition in one book, while, in other books, they were listed as contra-indications for the same problem. A bewildering plethora of treatments was recommended for most conditions, for instance:
- addictions: 120 different SCAMs
- arthritis: 131 different SCAMs
- asthma: 119 different SCAMs
- cancer: 133 different SCAMs
- etc. etc.
Even though, it included a much larger range of SCAM books, I do not consider my new investigation into this area to be a reliable piece of research. There are many reasons why, it can provide merely a very rough impression, e.g.:
- The lists included lots of misclassifications, i. e. books that have nothing to do with SCAM.
- Nobody seems to know by what rank order Amazon lists these books; I had hoped that it would be by sales figures, but I am not sure that this is so.
- Amazon is just one of many book sellers.
- My categorising can be criticised for being highly subjective.
Nonetheless, this little exercise, together with my previous research, might tell us something valuable after all. There are now between 30 000 and 60 000 SCAM books listed on the national Amazon sites, and even the most useless forms of SCAM are thus being promoted as though they were evidence-based forms of healthcare. Consumer demand for SCAM books is evidently substantial. The vast majority of these books are dangerously uncritical.
I believe that consumers deserve better.
In this second part of my series ‘Heedless Homeopathy‘, I want to introduce you to some remedies that are based on mother tinctures which might be viewed as less than appetising by some of the more faint-hearted of my readers. Some time ago, we had already discussed that the urethral discharge of a male patient suffering from gonorrhoea is used to make a popular remedy sold under the name of Medorrhinum. But in the ‘revolting range’, homeopathy has more – much more – to offer. Here is a selection of my personal favourites:
- Chimpanzee Urine (Urina pan troglodytes)
- Cimex lectularius (Bed bug)
- Dental Plaque
- Frog spawn (Common frog, Rana temporaria)
- New Forest Eye (Infectious bovine keratoconjunctivitis)
- Pig Scabies
- Pigeon Blood (Columba livia) (Common pigeon. Rock Dove)
- Placenta (Eberle) (Placenta Humana)
- Placenta Humana (Placenta Humana (welsh))
- Rabbit’s Blood (Sanguis Oryctolagi cuniculiRabbit’s blood)
- Sang. Panthera tigris alt. (Amur Tiger, Siberian Tiger (Blood))
- Sang. Suilla. Scroph. Fem.. (Sanguis suilla scropha feminae)
- Sang. Suilla. Scroph. Masc. (Sanguis suilla scropha masculinae)
- Sanguis Acinonyx Jubati (Cheetah’s blood)
- Sanguis bos taurus (Ox blood)
- Sanguis Didelphis (Virginia opossum blood)
- Sanguis Odocoilei Virg. (White tailed deer’s blood)
- Sanguis panthera uncia (Snow leopard (blood))
- Sanguis Soricis (Rat’s blood)
- Sanguis Ursa Arctos (Brown Bear (Blood))
- Sanguis Vulpes (Vulpes vulpes, Red Fox blood)
- Sanicula aqua (Sanicula Spring water)
- Semen humanum
- Tiger’s Urine
- Umbilical cord (Guild)
- Umbilicus humanus (Umbilical Cord Humanus)
- Urini Leopardus pardalis (Ocelot’s Urine)
- Urinum Equinum (Horse’s Urine)
Did I put you off homeopathy, because you find these substances disgusting?
Sorry (perhaps some Nux vomica C30?)! But you really need not worry: as with practically all homeopathic remedies, there will be not a single molecule of what it says on the bottle left in the remedy you buy.
Or did I put you off homeopathy, because you find such remedies ridiculous?
No, I am not sorry for that!
In fact, I think it is time that the public learn how silly homeopathy truly is.
I do hope they pay a good salary to the man who has to collect the tiger urine!
About one in three individuals have elevated blood pressure. This is bad news because hypertension is one of the most important risk factors for cardiovascular events like strokes and heart attacks. Luckily, there are many highly effective approaches for treating elevated blood pressure (diet, life-style, medication, etc.), and the drug management of hypertension has improved over the last few decades.
But unfortunately all anti-hypertensive drugs have side-effects and some patients look towards so-called alternative medicine (SCAM) to normalise their blood pressure. Therefore, we have to ask: are SCAMs effective treatments for hypertension? Because of the prevalence of hypertension, this is a question of great importance for public health.
In 2005, I addressed the issue by publishing a review entitled ‘Complementary/alternative medicine for hypertension: a mini-review‘. Here is its abstract:
Many hypertensive patients try complementary/alternative medicine for blood pressure control. Based on extensive electronic literature searches, the evidence from clinical trials is summarised. Numerous herbal remedies, non-herbal remedies and other approaches have been tested and some seem to have antihypertensive effects. The effect size is usually modest, and independent replications are frequently missing. The most encouraging data pertain to garlic, autogenic training, biofeedback and yoga. More research is required before firm recommendations can be offered.
Since the publication of this paper, more systematic reviews have become available. In order to get an overview of this evidence, I conducted a few simple Medline searches for systematic reviews (SRs) of SCAM published between 2005 and today. I included only SRs that were focussed on just one specific therapy as a treatment of just one specific condition, namely hypertension (omitting SRs with titles such as ‘Alternative treatments for cardiovascular conditions’). Reviews on prevention were also excluded. Here is what I found (the conclusions of each SR is quoted verbatim):
- A 2020 SR of auricular acupressure including 18 RCTs: The results demonstrated a favorable effect of auricular acupressure to reduce blood pressure and improve sleep in patients with hypertension and insomnia. Further studies to better understand the acupoints and intervention times of auricular acupressure are warranted.
- A 2020 SR of Chinese herbal medicines (CHM) including 30 studies: CHM combined with conventional Western medicine may be effective in lowering blood pressure and improving vascular endothelial function in patients with hypertension.
- A 2020 SR of Tai chi including 28 RCTs: Tai Chi could be recommended as an adjuvant treatment for hypertension, especially for patients less than 50 years old.
- A 2020 SR of Tai chi including 13 trials: Tai chi is an effective physical exercise in treating essential hypertension compared with control interventions.
- A 2020 SR of Tai chi including 31 controlled clinical trials: Tai Ji Quan is a viable antihypertensive lifestyle therapy that produces clinically meaningful BP reductions (i.e., 10.4 mmHg and 4.0 mmHg of SBP and DBP reductions, respectively) among individuals with hypertension.
- A 2020 SR of pycnogenol including 7 trials: the present meta-analysis does not suggest any significant effect of pycnogenol on BP.
- A 2019 SR of Policosanol including 19 studies: Policosanol could lower SBP and DBP significantly; future long term studies are required to confirm these findings in the general population.
- A 2019 SR of dietary phosphorus including 14 studies: We found no consistent association between total dietary phosphorus intake and BP in adults in the published literature nor any randomized trials designed to examine this association.
- A 2019 SR of ginger including 6 RCTs: ginger supplementation has favorable effects on BP.
- A 2019 SR of corn silk tea (CST) including 5 RCTs: limited evidence showed that CST plus antihypertensive drugs might be more effective in lowering blood pressure compared with antihypertensive drugs alone.
- A 2019 SR of blood letting including 7 RCTs: no definite conclusions regarding the efficacy and safety of BLT as complementary and alternative approach for treatment of hypertension could be drew due to the generally poor methodological design, significant heterogeneity, and insufficient clinical data.
- A 2019 SR of Xiao Yao San (XYS) including 17 trials: XYS adjuvant to antihypertensive drugs maybe beneficial for hypertensive patients in lowering BP, improving depression, regulating blood lipids, and inhibiting inflammation.
- A 2019 SR of Chinese herbal medicines including 9 RCTs: Chinese herbal medicine as complementary therapy maybe beneficial for postmenopausal hypertension.
- A 2019 Cochrane review of guided imagery including 2 trials: There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy.
- A 2019 Cochrane review of acupuncture including 22 RCTs: At present, there is no evidence for the sustained BP lowering effect of acupuncture that is required for the management of chronically elevated BP.
- A 2019 SR of wet cupping including 7 RCTs: no firm conclusions can be drawn and no clinical recommendations made.
- A 2019 SR of transcendental meditation (TM) including 9 studies: TM was associated with within-group (but not between-groups) improvements in BP.
- A 2019 SR of yoga including 49 trials: yoga is a viable antihypertensive lifestyle therapy that produces the greatest BP benefits when breathing techniques and meditation/mental relaxation are included.
- A 2018 SR of mindfulness-based stress reduction (MBSR) including 5 studies: The MBSR program is a promising behavioral complementary therapy to help people with hypertension lower their blood pressure
- A 2018 SR of beetroot juice (BRJ) including 11 studies: BRJ supplementation should be promoted as a key component of a healthy lifestyle to control blood pressure in healthy and hypertensive individuals.
- A 2018 SR of taurine including 7 studies: ingestion of taurine at the stated doses and supplementation periods can reduce blood pressure to a clinically relevant magnitude, without any adverse side effects.
- A 2018 SR of acupuncture including 30 RCTs: there is inadequate high quality evidence that acupuncture therapy is useful in treating hypertension.
- A 2018 SR of co-enzyme Q10 including 17 RCTs: CoQ10 supplementation may result in reduction in SBP levels, but did not affect DBP levels among patients with metabolic diseases.
- A 2018 SR of a traditional Chinese formula Longdanxiegan decoction (LDXGD) including 9 trials: Due to poor methodological quality of the included trials, as well as potential reporting bias, our review found no conclusive evidence for the effectiveness of LDXGD in treating hypertension.
- A 2018 SR of viscous fibre including 22 RCTs: Viscous soluble fiber has an overall lowering effect on SBP and DBP.
- A 2017 SR of yoga breathing exercise (pranayama) including 13 studies: The pranayama’s effect on BP were not robust against selection bias due to the low quality of studies. But, the lowering BP effect of pranayama is encouraging.
- A 2017 SR of dietary nitrate supplementation including 13 trials: Positive effects of medium-term dietary nitrate supplementation on BP were only observed in clinical settings, which were not corroborated by more accurate methods such as 24-h ambulatory and daily home monitorings.
- A 2017 SR of Vitamin D supplementation including 8 RCTs: vitamin D is not an antihypertensive agent although it has a moderate SBP lowering effect.
- A 2017 SR of pomegranate including 8 RCTs: The limited evidence from clinical trials to date fails to convincingly show a beneficial effect of pomegranate on blood pressure
- A 2017 SR of ‘forest bathing’ including 20 trials: This systematic review shows a significant effect of Shinrin-yoku on reduction of blood pressure.
- A 2017 SR of Niuhuang Jiangya Preparation (NHJYP) including 12 RCTs: Our review indicated that NHJYP has some beneficial effects in EH patients with liver-yang hyperactivity and abundant phlegm-heat syndrome.
- A 2017 SR of Chinese medicines (CM) including 24 studies: CM might be a promising approach for the elderly with isolated systolic hypertension, while the evidence for CM employed alone was insufficient.
- A 2017 SR of beetroot juice including 22 RCTs: Our results demonstrate the blood pressure-lowering effects of beetroot juice and highlight its potential NO3-independent effects.
- A 2017 SR of blueberry including 6 RCTs: the results from this meta-analysis do not favor any clinical efficacy of blueberry supplementation in improving BP
- A 2016 Cochrane review of co-enzyme Q10 including 3 RCTs: This review provides moderate-quality evidence that coenzyme Q10 does not have a clinically significant effect on blood pressure.
- A 2016 SR of Nigella sativa including 11 RCTs: short-term treatment with N. sativa powder can significantly reduce SBP and DBP levels.
- A 2016 SR of vitamin D3 supplementation including 30 RCTs: Supplementation may be beneficial at daily doses >800 IU/day for <6 months in subjects ≥50 years old.
- A 2016 SR of anthocyanin supplementation including 6 studies: results from this meta-analysis do not favor any clinical efficacy of supplementation with anthocyanins in improving blood pressure.
- A 2016 SR of flaxseed including 15 trials: This meta-analysis of RCTs showed significant reductions in both SBP and DBP following supplementation with various flaxseed products.
- A 2016 SR of massage therapy including 9 RCTs: This systematic review found a medium effect of massage on SBP and a small effect on DBP in patients with hypertension or prehypertension.
- A 2015 SR of massage therapy including 24 studies: There is some encouraging evidence of massage for essential hypertension.
- A 2015 SR of transcendental meditation (TM) including 12 studies: an approximate reduction of systolic and diastolic BP of -4.26 mm Hg (95% CI=-6.06, -2.23) and -2.33 mm Hg (95% CI=-3.70, -0.97), respectively, in TM groups compared with control groups.
- A 2015 SR of Zhen Wu Decoction (ZWD) including 7 trials: This systematic review revealed no definite conclusion about the application of ZWD for hypertension due to the poor methodological quality, high risk of bias, and inadequate reporting on clinical data.
- A 2015 SR of acupuncture including 23 RCTs: Our review provided evidence of acupuncture as an adjunctive therapy to medication for treating hypertension, while the evidence for acupuncture alone lowing BP is insufficient.
- A 2015 SR of xuefu zhuyu decoction (XZD) including 15 studies: This meta-analysis provides evidence that XZD is beneficial for hypertension.
- A 2015 SR of Shenqi pill including 4 RCTs: This systematic review firstly provided no definite evidence for the efficacy and safety of Shenqi pill for hypertension based on the insufficient data.
- A 2015 SR of Jian Ling Decoction (JLD) including 10 trials: Owing to insufficient clinical data, it is difficult to draw a definite conclusion regarding the effectiveness and safety of JLD for essential hypertension.
- A 2015 SR of Chinese herbal medicines (CHM) including 5 trials: No definite conclusions about the effectiveness and safety of CHM for resistant hypertension could be drawn.
- A 2015 SR of Chinese medicines (CM) including 27 RCTs: When combined with Western medines, CM as a complementary treatment approach has certain effects for the control of hypertension and protection of target organs.
- A 2015 SR of berberine including 17 RCTs: This study indicates that berberine has comparable therapeutic effect on type 2 DM, hyperlipidemia and hypertension with no serious side effect.
- A 2015 SR of garlic including 9 double-blind trials: Although evidence from this review suggests that garlic preparations may lower BP in hypertensive individuals, the evidence is not strong.
- A 2015 SR of chlorogenic acids (CGAs) including 5 studies: CGA intake causes statistically significant reductions in systolic and diastolic blood pressures.
- A 2014 SR of omega-3 fatty acid supplementation including 70 RCTs: provision of EPA+DHA reduces systolic blood pressure, while provision of ≥2 grams reduces diastolic blood pressure.
- A 2014 SR of green tea including 20 RCTs: Green tea intake results in significant reductions in systolic blood pressure
- A 2014 SR of probiotics including 9 studies: consuming probiotics may improve BP by a modest degree, with a potentially greater effect when baseline BP is elevated, multiple species of probiotics are consumed, the duration of intervention is ≥8 weeks, or daily consumption dose is ≥10(11) colony-forming units.
- A 2014 SR of yoga including 17 trials: The evidence for the effectiveness of yoga as a treatment of hypertension is encouraging but inconclusive.
- A 2014 SR of yoga including 7 RCTs: very low-quality evidence was found for effects of yoga on systolic and diastolic blood pressure.
- A 2014 SR of yoga including 120 studies: yoga is an effective adjunct therapy for HPT and worthy of inclusion in clinical guidelines.
- A 2014 SR of moxibustion: a beneficial effect of using moxibustion interventions on KI 1 to lower blood pressure compared to antihypertensive drugs.
- A 2014 SR of acupuncture including 4 sham-controlled RCTs: acupuncture significantly lowers blood pressure in patients taking antihypertensive medications.
- A 2014 SR of Tuina including 7 RCTs: The findings from our review suggest that Tuina might be a beneficial adjuvant for patients with EH
- A 2014 SR of ‘kidney tonifying’ (KT) Chinese herbal mixture including 6 studies: Compared with antihypertensive drugs alone, KT formula combined with antihypertensive drugs may provide more benefits for patients with SH.
- A 2014 SR of Tongxinluo capsule including 25 studies : There is some but weak evidence about the effectiveness of TXL in treating patients with hypertension.
- A 2014 SR of moxibustion including 5 RCTs: no confirm conclusion about the effectiveness and safety of moxibustion as adjunctive treatment for essential hypertension could be made
- A 2013 SR of Qi Ju Di Huang Wan (QJDHW) including 10 RCTs: QJDHW combined with antihypertensive drugs might be an effective treatment for lowering blood pressure and improving symptoms in patients with essential hypertension.
- A 2013 SR of yoga including 17 studies: Yoga can be preliminarily recommended as an effective intervention for reducing blood pressure.
- A 2013 SR of Tianma Gouteng Yin (TGY) including 22 RCTs: No confirmed conclusion about the effectiveness and safety of TGY as adjunctive treatment for essential hypertension … could be made.
- A 2013 SR of Zhen Gan Xi Feng Decoction (ZGXFD) including 6 RCTs: ZGXFD appears to be effective in improving blood pressure and hypertension-related symptoms for EH
- A 2013 SR of Tianmagouteng decoction including 9 RCTs: Tianmagouteng decoction can decrease both systolic and diastolic blood pressure.
- A 2013 SR of fish oil including 17 RCTs: The small but statistically significant effects of fish-oil supplements in hypertensive participants in this review have important implications for population health and lowering the risk of stroke and ischaemic heart disease.
- A 2013 SR of acupuncture including 35 RCTs: While there are some evidences that suggest potential effectiveness of acupuncture for hypertension, the results were limited by the methodological flaws of the studies.
- A 2013 SR of yoga including 6 studies: There is some encouraging evidence of yoga for lowering SBP and DBP.
- A 2012 SR of spinal manipulation therapy (SMT) including 10 studies: There is currently a lack of low bias evidence to support the use of SMT as a therapy for the treatment of
- A 2012 SR of vitamin C including 29 trials: In short-term trials, vitamin C supplementation reduced SBP and DBP.
- A 2012 SR of magnesium supplementation including 22 trials: magnesium supplementation appears to achieve a small but clinically significant reduction in BP, an effect worthy of future prospective large randomised trials using solid methodology.
- A 2012 SR of Banxia Baizhu Tianma Decoction (BBTD) including 16 RCTs: There is encouraging evidence of BBTD for lowering SBP, but evidence remains weak.
- A 2012 SR of Liu Wei Di Huang Wan (LWDHW) including 6 RCTs: LWDHW combined with antihypertensive drugs appears to be effective in improving blood pressure and symptoms in patients with essential hypertension.
- A 2012 SR of aromatherapy including 5 studies: The existing trial evidence does not show convincingly that aromatherapy is effective for hypertension.
- A 2012 empty Cochrane review: As no trials could be identified, no conclusions can be made about the role of TGYF in the treatment of primary hypertension.
- A 2012 SR of yoga including 10 studies: Not only does yoga reduce high BP but it has also been demonstrated to effectively reduce blood glucose level, cholesterol level, and body weight, major problems affecting the American society.
- A 2011 SR of L-arginine including 11 RCTs: This meta-analysis provides further evidence that oral L-arginine supplementation significantly lowers both systolic and diastolic BP.
- A 2011 SR of soy isoflavones including 14 RCTs: Soy isoflavone extracts significantly decreased SBP but not DBP in adult humans, and no dose-response relationship was observed.
- A 2010 SR of moxibustion including 4 RCTs: There is insufficient evidence to suggest that moxibustion is an effective treatment for hypertension.
- A 2010 SR of acupunctures including 20 studies: Because of the paucity of rigorous trials and the mixed results, these findings result in limited conclusions. More rigorously designed and powered studies are needed.
- A 2010 SR of cupping including 3 trials: the evidence is not significantly convincing to suggest cupping is effective for treating hypertension.
- A 2010 empty Cochrane review: There is insufficient evidence to support the benefit of Roselle for either controlling or lowering blood pressure in patients with hypertension.
- A 2009 SR of acupuncture including 11 RCTs: the notion that acupuncture may lower high BP is inconclusive.
- A 2008 SR of transcendental meditation including 9 studies: The regular practice of Transcendental Meditation may have the potential to reduce systolic and diastolic blood pressure by approximately 4.7 and 3.2 mm Hg, respectively.
- A 2008 SR of relaxation therapies including 25 trials: the evidence in favour of a causal association between relaxation and blood pressure reduction is weak.
- A 2007 SR of qigong including 12 RCTs: There is some encouraging evidence of qigong for lowering SBP, but the conclusiveness of these findings is limited.
- A 2007 SR of co-enzyme Q10 including 12 trials: coenzyme Q10 has the potential in hypertensive patients to lower systolic blood pressure by up to 17 mm Hg and diastolic blood pressure by up to 10 mm Hg without significant side effects.
- A 2007 SR of stress reduction programs including 106 studies: Available evidence indicates that among stress reduction approaches, the Transcendental Meditation program is associated with significant reductions in BP.
- A 2006 Cochrance review of magnesium supplementation including 12 RCTs: the evidence in favour of a causal association between magnesium supplementation and blood pressure reduction is weak and is probably due to bias.
- A 2006 Cochrane review of calcium supplementation including 13 RCTs: evidence in favour of causal association between calcium supplementation and blood pressure reduction is weak and is probably due to bias.
ALMOST 100 NEW SRs!
To be honest, if I had known the volume of the material, I would probably not have tackled this task. Since the publication of my mini-review in 2005, there has been an explosion of similar papers:
- 1 in 2005
- 2 in 2006
- 3 in 2007
- 2 in 2008
- 1 in 2009
- 4 in 2010
- 2 in 2011
- 8 in 2012
- 8 in 2013
- 12 in 2014
- 12 in 2015
- 6 in 2016
- 9 in 2017
- 7 in 2018
- 12 in 2019
As this is based on very simple Medline searches, the list is certainly not complete. Despite this fact, several conclusions seem to emerge:
- There is no shortage of SCAMs that have been tested for hypertension.
- Most seem to have positive effects; in many cases, they seem too good to be true.
- Many of the SRs are of poor methodological quality, based on poor quality primary studies, published in less than reputable journals. Some SRs, for instance, include studies without a control group which is likely to lead to false-positive overall conclusions about the effectiveness of the SCAM in question.
- In recent years, there are more and more SRs by Chinese authors focussed on Chinese herbal mixtures that are unknown and unobtainable outside China. These SRs are invariably based on studies published in Chinese language in journals that are inaccessible. This means it is almost impossible for the reader, reviewer or editor to check their accuracy. The reliability of the conclusions of these SRs must therefore be doubted.
- Most of the primary studies included in the SRs lack long-term data. Thus the usefulness of the SCAM in question is questionable.
- With several of the SCAMs, the dose of the treatment and treatment schedule is less than clear. For instance, one might ask how frequently a patient should have acupuncture to control her hypertension.
- Some of the SCAMs assessed in these SRs seem of doubtful practicality. For instance, it might not be feasible nor economical for patients to receive regular acupuncture to manage their blood pressure.
- Several contradictions emerge from some of the SRs of the same modality. This is particularly confusing because SRs are supposed to be the most reliable type of evidence. In most instances, however, the explanation can easily be found by looking at the quality of the SRs. If SRs are based on uncontrolled studies, or if they fail to critically evaluate the reliability of the included primary trials, they are likely to arrive at conclusions that are too positive. Examples for such confusion are the multiple SRs of co-enzyme Q10 or the three yoga SRs of 2014.
- Because of this confusion, SCAM advocates are able to select false-positive SRs to support their opinion that SCAM is effective.
- Despite a substantial amount of positive evidence, none of the SCAMs have become part of the routine in the management of hypertension. A 2013 statement by the American Heart Association entitled Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the american heart association concluded that it is reasonable for all individuals with blood pressure levels >120/80 mm Hg to consider trials of alternative approaches as adjuvant methods to help lower blood pressure when clinically appropriate. A suggested management algorithm is provided, along with recommendations for prioritizing the use of the individual approaches in clinical practice based on their level of evidence for blood pressure lowering, risk-to-benefit ratio, potential ancillary health benefits, and practicality in a real-world setting.
What lessons might this brief overview of SRs teach us? I think the following points are worth considering:
- Systematic reviews are the best type of evidence we have for estimating the effectiveness of treatments. But it is essential that they include a strong element of CRITICAL evaluation of the primary studies. Without it, a SR is incomplete and potentially counter-productive.
- The primary studies of SCAM are far too often of poor quality. This means that researchers should thrive to improve the rigour of their investigations.
- Both poor-quality primary studies and uncritically conducted SRs are prone to yielding findings that are too good to be true.
- Editors and reviewers have a responsibility to prevent the publication of trials and SRs that are of poor quality and thus likely to mislead us.
- Those SCAMs that have shown promising effects on hypertension (for instance Tai chi) should now be submitted to further independent scrutiny to find out whether their efficacy and usefulness can be confirmed, for instance, by 24-h ambulatory and daily home blood pressure monitoring and studies testing their acceptability in real life settings. Subsequently, we ought to determine whether the SCAM in question can be reasonably integrated in routine blood pressure management.
- The adjunctive use of a SCAM that has been proven to be effective and practical seems a reasonable approach. Yet, it requires proper scientific scrutiny.
- There is a paucity of cost-effectiveness studies and investigations of the risks of SCAM which needs to be addressed before any SCAM is considered for routine care.
Steiner with his wife (right) and Ita Wegman, his lover (left).
Anthroposophic medicine was founded by Steiner and Ita Wegman in the early 20th century. Currently, it is being promoted as an extension of conventional medicine. Proponents claim that “its unique understanding of the interplay among physiological, soul and spiritual processes in healing and illness serves to bridge allopathy with naturopathy, homeopathy, functional/nutritional medicine and other healing systems.” Its value has repeatedly been questioned, and clinical research in this area is often less than rigorous.
Anthroposophic education was developed in the Waldorf school that was founded by Steiner in 1919 to serve the children of employees of the Waldorf-Astoria cigarette factory in Stuttgart, Germany. Pupils of Waldorf or Steiner schools, as they are also frequently called, are encouraged to develop independent thinking and creativity, social responsibility, respect, and compassion.
Waldorf schools implicitly infuse spiritual and mystic concepts into their curriculum. Like some other alternative healthcare practitioners – for instance, doctors promoting integrative medicine, chiropractors, homeopaths and naturopaths – some doctors of anthroposophic medicine take a stance against childhood immunizations. In a 2011 paper, I summarised the evidence which showed that in the UK, the Netherlands, Austria and Germany, Waldorf schools have been at the centre of measles outbreaks due to their stance regarding immunisations.
More recently, a study evaluated trends in rates of personal belief exemptions (PBEs) to immunization requirements for private kindergartens in California that practice alternative educational methods. The investigators used California Department of Public Health data on kindergarten PBE rates from 2000 to 2014 to compare annual average increases in PBE rates between schools.
Alternative schools had an average PBE rate of 8.7%, compared with 2.1% among public schools. Waldorf schools had the highest average PBE rate of 45.1%, which was 19 times higher than in public schools (incidence rate ratio = 19.1; 95% confidence interval = 16.4, 22.2). Montessori and holistic schools had the highest average annual increases in PBE rates, slightly higher than Waldorf schools (Montessori: 8.8%; holistic: 7.1%; Waldorf: 3.6%).
The authors concluded that Waldorf schools had exceptionally high average PBE rates, and Montessori and holistic schools had higher annual increases in PBE rates. Children in these schools may be at higher risk for spreading vaccine-preventable diseases if trends are not reversed.
As the world is hoping for the arrival of an effective vaccine against the corona virus, these figures should concern us.
I was notified via Twitter (thank you John) that the UK ‘United Lincolnshire Hospitals NHS Trust’ is looking to employ a spiritual healer or reiki therapist. For those who find this perhaps too hard to believe, I have copied a few excerpts from the advertisement:
- United Lincolnshire Hospitals NHS Trust
- Spiritual Healer / Reiki Therapist
- Lincoln County Hospital, Lincoln
- £21,892 – £24,157 per annum pro rata
An exciting opportunity has arisen for an Spiritual Healer / Reiki Therapist to join our friendly and energetic team on Waddington Unit. We are looking for a committed, enthusiastic and a self-motivated therapist to join our well established team.
Waddington Unit is a 26 bedded acute Haematology and Oncology ward that care for male and female patients. The ward has a high acuity, fast paced clinical admissions setting that cares for acutely unwell patients as a result of haematological and oncological conditions such as spinal cord compression and neutropenic sepsis as well as facilitating the delivery of chemotherapy.
We are passionate about improving patient experience and enhancing patients stay in hospital.
We are pleased to be working with The Sam Buxton Sunflower Healing Trust to offer this exciting opportunity on Waddington Unit.
If you are qualified and experienced as a Spiritual Healer /Reiki Therapist with 1 year or more of experience. To have completed the Healing In Hospital course, delivered by Angie Buxton-King and would like this opportunity to join this forward thinking team then please contact the co-ordinator for more information and an informal visit…
… ULHT is one of the largest hospital trusts in the country providing a comprehensive range of hospital based medical, surgical, paediatric, obstetric and gynaecological services to over 800,000 people across the county of Lincolnshire. The Trust’s core values are:
– Patient Centred
– Respect and
END OF QUOTE
The Sam Buxton Sunflower Healing Trust supports cancer patients and their families by providing funds to employ Complementary Therapists (Healers) in the NHS and Hospices. And Angie Buxton-King is a Reiki Master/ Teacher, Spiritual Healer, Author and Public Speaker. She also tells us this about her:
I am a fully qualified tutor of adults in the life learning sector and a Director/Trustee of our charity The Sam Buxton Sunflower Healing Trust ( SBSHT).
Since 2004 following the publication of my first book The NHS Healer; I have been invited to speak at many medical and holistic conferences. I am a past chair of The Doctor Healer Network and a former council member of The College of Medicine representing complementary therapies. Along with my husband Graham we created Energy Healing Training and Reiki Training that complies with National Occupational Standards. We have also created our unique ‘Healing in Hospitals & Hospices Training’ and ‘Delivering Complementary Therapy in a Statutory Setting Training’ to give healers and complementary therapists the necessary skills to work safely and competently in a more formal setting. I was employed by University College London Hospital (UCLH) as a Spiritual Healer to deliver healing to cancer patients as part of an integrated, holistic package of care for 12 years.
David Colquhoun published an excellent comment at the time about the UCLH work. All I want to add here is a list of suggestions to the ‘United Lincolnshire Hospitals NHS Trust’ regarding posts they might consider advertising in the future:
- ACUPUNCTURIST to run the department of anaesthesiology.
- FLYING CARPET MANAGER to relieve the over-worked Lincolnshire ambulance service.
- EXORCIST to deal with whistle blowers of all types.
- ALCHEMIST to turn lead into gold whenever the Trust runs into financial difficulties.
- HOMEOPATH to run the hospital pharmacy.
- QUANTUM PHYSICIST to maintain the ventilators of the IC unit.
- VIRTUAL SURGEON to head the department of surgery.
- VAMPIRE to organise the blood donation activities.
- DISCIPLE OF ANDREW WAKEFIELD to coordinate the Trust’s vaccination service.
- PRO-LIFE ACTIVIST to head the abortion service.
- SCIENTOLOGIST to run the spiritual well-being initiative.
- PSEUDOSCIENTIST to head the clinical trials unit.
- CAOS THEORIST to oversee the accounts.
- ELEPHANT to work in the porcelain shop.
In the interest of improving public health in Lincolnshire, I invite my readers to suggest further posts which might contribute profitably to the success of the ‘United Lincolnshire Hospitals NHS Trust’.
In response to the recommendation, the health ministry announced the formation of a working group of medical experts to suggest proposals for further regulation of homeopathy. A spokesman said that medicines whose efficiency is not clinically proven should not be procured using public funds, nor prescribed to treat the sick.
Russia has proved a profitable market for foreign suppliers of homeopathic medicine such as French company Boiron, which opened its Russian subsidiary in 2005. “Today, the Russian market is our company’s fourth largest in terms of turnover, after France, the US and Italy. Russia has always been interesting for Boiron because of the large population, and a relatively high incidence of illness and lower level of medicine consumption in comparison with Europe,” general director of Boiron in Russia Irina Nikulina said.
According to figures from Russian pharmaceutical market analysts DSM Group, Boiron sold 35 percent of all the homeopathic medicine sold in Russia last year, or 2.88 billion rubles (USD 49.5 million) worth of medicine. Boiron produces Russia’s most popular homeopathic medicine, called Oscillococcinum, which is marketed to relieve flu symptoms and accounted for 18.98 percent of all homeopathic medicines sold in 2016.
The many international initiatives aimed at minimising the harm done by homeopathy are slowly beginning to yield results. It took many years for politicians to realise that the supposedly harmless homeopathy is, in fact, not harmless at all. Homeopathy causes harm by:
- wasting people’s money,
- distracting patients from effective treatments,
- the ill-conceived advice homeopaths give to patients,
- making a mockery of evidence-based medicine,
- violating the principles of medical ethics,
- undermining rational thinking in society.
One therefore has to applaud Russia’s ‘Commission against Pseudoscience’, hope that the working group does produce robust advice, and support similar initiatives in other countries.
Michael Dixon LVO, OBE, MA, FRCGP has been a regular feature of this blog (and elsewhere). He used to be a friend and colleague until … well, that’s a long story. Recently, I came across his (rather impressive) Wikipedia page. To my surprise, it mentions that Dixon
“has been criticised by professor of complementary medicine and alternative medicine campaigner Edzard Ernst for advocating the use of complementary medicine. Ernst said that the stance of the NHS Alliance on complementary medicine was “misleading to the degree of being irresponsible.” Ernst had previously been sympathetic to building a bridge between complementary and mainstream medicine, co-writing an article with Michael Dixon in 1997 on the benefits of such an approach. Ernst and Dixon write “missed diagnoses by complementary therapists giving patients long term treatments are often cited but in the experience of one of the authors (MD) are extremely rare. It can also cut both ways. A patient was recently referred back to her general practitioner by an osteopath, who was questioning, as it turned out quite correctly, whether her pain was caused by metastates. Good communication between general practitioner and complementary therapist can reduce conflicts and contradictions, which otherwise have the potential to put orthodox medicine and complementary therapy in an either/or situation.”
31) February 2009, 24. “Academics and NHS Alliance clash over complementary medicine”. Pulse Today.
32) ^ Update – the journal of continuing education for General Practitioners, 7th May 1997
I have little recollection of the paper that I seem to have published with my then friend Michael, and it is not listed in Medline, nor can I find it in my (usually well-kept) files; the journal ‘Update’ does not exist anymore and was obviously not a journal good enough for keeping a copy. But I do not doubt that Wiki is correct.
In fact, it is true that, in 1997, I was still hopeful that bridges could be built between conventional medicine and so-called alternative medicine (SCAM). But I had always insisted that they must be bridges built on solid ground and with robust materials.
Put simply, my strategy was to test SCAM as rigorously as I could and to review the totality of the evidence for and against it. Subsequently, one could consider introducing those SCAMs into routine care that had passed the tests of science.
Dixon’s strategy differed significantly from mine. He had no real interest in science and wanted to use SCAM regardless of the evidence. Since the publication of our paper in 1997, he has pursued this aim tirelessly. On this blog, we find several examples of his activity.
And what happened to the bridges?
I’m glad you ask!
As it turns out, very few SCAMs have so far passed the test of science and hardly any SCAM has been demonstrated to generate more good than harm. The material to build bridges is therefore quite scarce, hardly enough for solid constructions. Dixon does still not seem to be worried about this indisputable fact. He thinks that INTEGRATED MEDICINE is sound enough for providing a way to the future. I disagree and still think it is ‘misleading to the degree of being irresponsible’.
Who is right?
Dixon or Ernst?
Opinions about this differ hugely.
Time will tell, I suppose.
Can I invite you to join me in a little thought experiment?
Think of a totally useless therapy. I would suggest homeopathy but there are always some who would disagree with this classification. I need a TOTALLY useless therapy, and one where we ALL can agree on the label.
What about ‘Potentised Toe-Nail Powder’ (PoToNaPo)?
PoToNaPo is made from nail clippings, thoroughly sterilised, ground to a powder, serially diluted and potentised. Does anyone claim this remedy to be effective for any condition?
So, we all agree that PoToNaPo is completely ineffective.
Now imagine some charlatan claiming that PoToNaPo is a highly effective cancer cure. Let’s furthermore imagine that he is very successful with his claim.
(No, this is not far fetched! Think of Laetrile, Essiac, etc.)
Imagine our charlatan makes millions with PoToNaPo.
There would soon be some opposition to his quackery. The FDA would issue a statement that PoToNaPo is unproven. Perhaps the NEJM would publish an editorial saying something similar. Ethicists would frown publicly. And many sceptics would head to the pubs where clever guys would give talks about ‘the scandal of PoToNaPo’.
We all know it would happen, because it has happened with PoToNaPo-like remedies many times before.
Now imagine a different scenario, namely one in which our charlatan does not claim that PoToNaPo is a cancer cure; imagine instead he had claimed that PoToNaPo is a holistic medicine that boosts your well-being via re-balancing your vital energies which, in turn, helps with anxiety which in turn might have positive effects on things like mild chronic pain, depressive mood, tension headache, insomnia, erectile dysfunction and many more symptoms of daily life.
Let’s furthermore imagine that our charlatan is very successful with these claims.
No, this is not far fetched! Think of … well … think of any SCAM really.
Imagine the charlatan makes millions with PoToNaPo.
What would happen?
- He would be invited to conferences on integrative medicine.
- Become an honorary member/sponsor of the ‘College of Medicine and Integrated Health’.
- He would be interviewed on the BBC.
- The Daily Mail would publish advertorials.
- HRH would perhaps invite him for tea.
- Trump might hint that PoToNaPo cures virus infections.
- Ainsworth might buy his patent.
- There could even be a gong waiting for him.
- And yes … some sceptics would mutter a bit, but the public would respond: what’s the harm?
We all know that things of this nature might happen, because they have happened before with PoToNaPo-like remedies.
So what’s the difference?
In both scenarios, our charlatan has marketed the same bogus remedy, PoToNaPo.
In both scenarios, he has made unsubstantiated, even fraudulent claims.
Why does he get plenty of stick in the 1st and becomes a hero in the 2nd case?
Yes, I know, the difference is the nature of the claims. But the invention, production, marketing and selling of a bogus treatment, the lying, the deceit, the fraud, the exploitation of vulnerable people are all the same.
Why then are we, as a society, so much kinder to the charlatan in the 2nd scenario?
I think we shouldn’t be; it’s not logical or consequent. I feel we should name, shame and punish both types of charlatans. They are both dangerous quacks, and it is our ethical duty to stop them.
END OF THOUGHT EXPERIMENT