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

research

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A study by an international team of researchers estimated the proportion of healthcare interventions tested within Cochrane Reviews that are effective according to high-quality evidence.

They selected a random sample of 2428 (35%) of all Cochrane Reviews published between 1 January 2008 and 5 March 2021 and extracted data about interventions within these reviews that were compared with placebo, or no treatment, and whose outcome quality was rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). They then calculated the proportion of interventions whose effectiveness was based on high-quality evidence according to GRADE, had statistically significant positive effects and were judged as beneficial by the review authors. They also calculated the proportion of interventions that suggested harm.

Of 1567 eligible interventions, 87 (5.6%) had high-quality evidence on first-listed primary outcomes, positive, statistically significant results, and were rated by review authors as beneficial. Harms were measured for 577 (36.8%) interventions, 127 of which (8.1%) had statistically significant evidence of harm. Our dependence on the reliability of Cochrane author assessments (including their GRADE assessments) was a potential limitation of our study.

The authors drew the following conclusions: While many healthcare interventions may be beneficial, very few have high-quality evidence to support their effectiveness and safety. This problem can be remedied by high-quality studies in priority areas. These studies should measure harms more frequently and more rigorously. Practitioners and the public should be aware that many frequently used interventions are not supported by high-quality evidence.

Proponents of so-called alternative medicine (SCAM) are fond of the ‘strawman’ fallacy; meaning they like to present a picture of conventional medicine that is overtly negative in order for SCAM to appear more convincing (Prince Charles, for instance, uses this trick every single time he speaks about SCAM). Therefore I am amazed that this paper has not been exploited in that way by them. I was expecting headlines such as

Evidence-based medicine is not supported by evidence

or

Less than 6% of all conventional treatments are supported by sound evidence.

etc.

Why did they not have a field day with this new paper then?

As the article is behind a paywall, it took me a while to get the full paper (thanks Paul). Now that I have read it, I think I understand the reason.

In the article, the authors provide figures for specific types of treatments. Let me show you some of the percentages of interventions that met the primary outcome (high quality, statistically significant effect, and authors interpret as effective):

  • pharmacological 73.8%
  • surgical 4.6%
  • exercise 5.8%
  • diet 1.2%
  • alternative 0.0%
  • manual therapies 0.0%

So, maybe the headlines should not be any of the above but:

No good evidence to support SCAM?

or

SCAM is destroying the evidence base of medicine.

 

An epidemiological study from the US just published in the BMJ concluded that “the mortality gap in Republican voting counties compared with Democratic voting counties has grown over time, especially for white populations, and that gap began to widen after 2008.”

In a BMJ editorial, Steven Woolf comments on the study and provides further evidence on how politics influence health in the US. Here are his concluding two paragraphs:

Political influence on US mortality rates became overt during the covid-19 pandemic, when public health policies, controlled by states, were heavily influenced by party affiliation. Republican politicians, often seeking to appeal to President Trump and his supporters, challenged scientific evidence and opposed enforcement of vaccinations and safety measures such as masking. A macabre natural experiment occurred in 2021, a year marked by the convergence of vaccine availability and contagious variants that threatened unvaccinated populations: states led by governors who promoted vaccination and mandated pandemic control measures experienced much lower death rates than the “control” group, consisting of conservative states with lax policies and large unvaccinated populations. This behavior could explain why US mortality rates associated with covid-19 were so catastrophic, vastly exceeding losses in other high income countries.

Observers of health trends in the US should keep their eye on state governments, where tectonic shifts in policy are occurring. While gridlock in Washington, DC incapacitates the federal government, Republican leaders in dozens of state capitols are passing laws to undermine health and safety regulations, ban abortion, limit LGBT+ rights, and implement more conservative policies on voting, school curriculums, and climate policy. To understand the implications for population health, researchers must break with custom; although scientific literature has traditionally avoided discussing politics, the growing influence of partisan affiliation on policies affecting health makes this covariate an increasingly important subject of study.

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What has this to do with so-called alternative medicine (SCAM)?

Not a lot.

Except, of course, that Trump has been quite sympathetic to both quackery and quacks (see, for instance, here and here). Moreover, the embarrassing Dr. Oz, America’s charlatan-in-chief, is now a Republican candidate for the US senate. And the creation of the NHI office for alternative medicine, currently called NCCIH, was the idea of the Republican senator, Tom Harkin.

I think we get the drift: on the US political level, SCAM seems to be a right-wing thing.

Am I claiming that SCAM is the cause of the higher mortality in Republican counties?

No.

Do I feel that both are related to irresponsible attitudes towards healthcare issues?

Yes.

Alan Gaby, the assistant editor of the journal Integr Med has written an interesting commentary about widespread fraud in natural health products research. Here is an excerpt of his article:

During the past 49 years, I have reviewed and analyzed more than 50 000 papers from the biomedical literature, most of which were related to the field of nutritional medicine. Doing this work has given me some understanding of how to assess the reliability of a study. Over the past 10 to 15 years, an uncomfortably large and growing number of published papers related to my area of expertise have left me wondering whether the research was fabricated; that is, whether people were writing papers about research that had not actually been conducted. If the studies were not actually conducted, the publishing of this research is an affront to all who value integrity in science, and it has the potential to harm practitioners and patients who rely on its findings.

The studies that have raised concerns have come primarily from Iran and to a lesser extent from Egypt, China, India, Japan, and a few other countries. Characteristics of these concerning studies typically include one or more of the following:

  1. The study comes from an investigator or research group that has published an enormous number of randomized clinical trials in a relatively short period of time.
  2. The number of participants in the trial is unusually large, when considering the resources that appear to be available to the researchers.
  3. The recruitment period for the trial is unusually short.
  4. The paper is submitted to a journal unusually rapidly after the study is completed, or in some cases before it would have been possible to have completed the trial.
  5. A randomized double-blind trial is conducted before there is any preliminary evidence of efficacy in humans (such as case reports or uncontrolled trials). Because double-blind trials are expensive to conduct, such trials are generally reserved for treatments for which there is some evidence of efficacy.
  6. The magnitude of the reported improvement is much larger than is typically seen in trials using just one or two nutrients.
  7. No funding source is listed or the study is listed as self-funded. This is of particular concern when the sample size or study design suggests that the study was expensive.
  8. The design of the study raises ethical issues, such as participants not being permitted to use treatments that are known to be effective.
  9. One or more baseline characteristics of the study group appear to be implausible.
  10. The research was conducted by a student as part of a graduate school thesis, and the magnitude of the project seems to have been beyond the capabilities and resources of a student.

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What Gaby alludes to is a problem indeed. I have previously posted about the Chinese aspect of this story. What Gaby does not mention is the fact that even many studies of so-called alternative medicine (SCAM) which seem to be not overtly fraudulent are nevertheless highly suspect. I am referring to trials that are fatally flawed and/or studies that draw unwarranted conclusions. These are, of course, the types of studies that are the main target of this blog. Because they are so numerous, I feel that the damage they do is much bigger than that of the more overtly fraudulent papers.

This systematic review evaluated individualized homeopathy as a treatment for children with attention deficit and hyperactivity disorder (ADHD) when compared to placebo or usual care alone.

Thirty-seven online sources were searched up to March 2021. Studies investigating the effects of individualized homeopathy against any control in ADHD were eligible. Data were extracted to a predefined excel sheet independently by two reviewers.

Six studies were analyzed:

  • 5 were RCTs
  • 2 were controlled against standard treatments;
  • 4 were placebo-controlled and double-blinded.

The meta-analysis revealed a significant effect size across studies of Hedges’ g = 0.542 (95% CI 0.311-0.772; z = 4,61; p < 0.001) against any control and of g = 0.605 (95% CI 0.05-1.16; z = 2.16, p = 0.03) against placebo. The effect estimations are based on studies with an average sample size of 52 participants.

The authors concluded that individualized homeopathy showed a clinically relevant and statistically robust effect in the treatment of ADHD.

This is a counter-intuitive result (to put it mildly), and it is, therefore, wise to have a look at the 6 included studies:

1.Frei, H. et al. Homeopathic treatment of children with attention deficit hyperactivity disorder: a randomised, double blind, placebo controlled crossover trial. Eur. J. Pediatr. 164, 758–767 (2005).

This was a trial with just 62 patients who had previously responded to homeopathy. The study was conducted by known proponents of homeopathy and had a highly unusual design. The results suggested that homeopathy was better than placebo.

2. Oberai, P. et al. Homoeopathic management of attention deficit hyperactivity disorder: a randomised placebo-controlled pilot trial. Indian J. Res. Homoeopathy 7, 158–167 (2013).

This one was published in an obscure journal that I could not access.

3. Jacobs, J., Williams, A. L., Girard, C., Njike, V. Y. & Katz, D. Homeopathy for attention-deficit/hyperactivity disorder: a pilot randomized-controlled trial. J. Altern. Complement. Med. 11, 799–806 (2005)

This study showed that there were no statistically significant differences between homeopathic remedy and placebo groups on the primary or secondary outcome variables.

4. Jones, M. The efficacy of homoeopathic simillimum in the treatment of attention-deficit/hyperactivity disorder (AD/HD) in schoolgoing children aged 6-11 years (2009).

This was a small unpublished (and not peer-reviewed) thesis. Its results showed no statistically significant effect of treatment.

5. Lamont, J. Homoeopathic treatment of attention deficit hyperactivity disorder. Br. Homeopathic J. 86, 196–200 (1997)

This was a small (n=46) trial with an unusual design. Its results suggested that homeopathy was better than placebo.

6. von Ammon, K. et al. Homeopathic RCT embedded in a long-term observational study of children with ADHD—a successful model of whole systems CAM research. Eur. J. Integr. Med. 1, 27 (2008).

Even though the journal is Medline-listed, I was unable to find this paper. I did, however, find a paper by the same authors with the same title. It turned out to be a duplication of the paper by Frei et al listed above.

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All in all, this brief analysis of the available abstracts (most full papers are behind paywalls) leaves many questions as to the trustworthiness of this systematic review unanswered. The fact that H. Walach (and other apologists of homeopathy) is its senior author does not inspire me with overwhelming confidence. In any case, I very much doubt that the authors’ conclusion is correct. I therefore would encourage someone with access to all full papers to initiate a more thorough analysis; the abstracts obviously leave many questions unanswered. For instance, it would be crucial to know how many of the trials followed an A+B versus B design (I suspect most studies did, and this would completely invalidate the review’s conclusion). I am more than happy to co-operate with such an evaluation.

I know only too well that some readers will interpret this post as pompous and self-congratulatory, but I nevertheless feel like telling my readers that I have become a member of the ACADEMIA EUROPAEA. In case you don’t know what this is, Wikipedia provides the following information:

Membership of the Academia Europaea (MAE) is an award conferred by the Academia Europaea to individuals that have demonstrated “sustained academic excellence”.[2] Membership is by invitation only by existing MAE only and judged during a peer review selection process.[3] Members are entitled to use the post-nominal letters MAE.[4]

New members are announced annually, every year since 1988.[5][6] For a more complete list see Category:Members of Academia Europaea..[7][8][9][10][11] Some Members of the Academia Europaea have received very prestigious awards, medals and prizes, such as:

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The Academia Europaea was founded in 1988, on the initiative of the UK’s Royal Society and other National Academies in Europe. It is a `Not for Profit’ Charity registered in the UK. The Academia Europaea is the only Academy with individual members from the Council of Europe states and from other nations across the world. Currently, there are some 5000 members who cover the full range of academic disciplines.

The objectives of the Academia Europaea are the advancement and propagation of excellence in scholarship in the humanities, law, the economic, social, and political sciences, mathematics, medicine, and all branches of natural and technological sciences anywhere in the world for the public benefit and for the advancement of the education of the public of all ages.

The Academy organizes meetings and workshops, provides scientific and scholarly advice, and publishes the international journal the ‘European Review’ and is associated with Biology Direct. It operates regional knowledge hubs out of Barcelona, Bergen, Budapest, Cardiff, Munich, Tbilisi, and Wroclaw, hosted by Universities and National academies.

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I am both proud and thankful that I have been honored in this way.

For quite some time now, I have had the impression that the top journals of general medicine show less and less interest in so-called alternative medicine. So, I decided to do some Medline searches to check. Specifically, I searched for 4 different SCAMs:

  • homeopathy
  • acupuncture
  • chiropractic
  • herbal medicine

I  wanted to see how often 7 leading medical journals from the US, UK, Australia, Germany, and Austria carried articles indexed under these headings:

  • JAMA – US
  • NEJM – US
  • BMJ – UK
  • Lancet – UK
  • Aust J Med – Australia
  • Dtsch Med Wochenschrift – Germany
  • Wien Med Wochenschrift – Austria

This is what I found (the 1st number is the total number of articles ever listed; the 2nd number is the maximum number in any year; the 3rd number in brackets is the year when that maximum occurred)

JAMA

Homeopathy: 17, 3 (1998)

Acupuncture: 176, 21 (2017)

Chiropractic: 49, 4 (1998)

Herbal medicine: 43, 5 (2001)

NEJM

Homeopathy: 6, 3 (1986)

Acupuncture: 49, 8 (1974)

Chiropractic: 43, 13 (1980)

Herbal medicine: 29, 12 (1999)

BMJ

Homeopathy: 122, (10, 1995)

Acupuncture: 405, 31 (2021)

Chiropractic: 99, 11 (2021)

Herbal medicine: 158, 13 (2018)

Lancet

Homeopathy: 75, 11 (2005)

Acupuncture: 93, 12 (1973)

Chiropractic: 20, 5 (1993)

Herbal medicine: 46, 6 (1993)

Aust J Med

Homeopathy: 9, 2 (2010)

Acupuncture: 78, 13 (1974)

Chiropractic: 34, 4 (1985)

Herbal medicine: 20, 2 (2017)

Deutsche Medizinische Wochenschrift

Homeopathy: 27, 4 (1999)

Acupuncture: 34, 6 (1978)

Chiropractic: 14, 3 (1972)

Herbal medicine: 6, 1 (2020)

Wiener Medizinische Wochenschrift

Homeopathy: 11, 4 (2005)

Acupuncture: 32, 8 (1998)

Chiropractic: 8, 2 (1956)

Herbal medicine: 16, 3 (2002)

These figures need, of course, to be taken with a rather large pinch of salt. There are many pitfalls in interpreting them, e.g. misclassifications by Medline. Yet they are, I think, revealing in that they suggest several interesting trends.

  1. All in all, my suspicion that the top journals of various countries are less and less keen on SCAM seems to be confirmed. The years where the maximum of papers on specific SCAMs was published are often long in the past.
  2. The UK journals seem to be by far more open to SCAM that the publications from other countries. This is mostly due to the BMJ – in fact, it turns out to be the online journal ‘BMJ-open’. And this again is to a great part caused by the BMJ-open carrying a sizable amount of acupuncture papers in recent months.
  3. The two US journals seem particularly cautious about SCAM papers. When looking at the type of articles in the US journals (and especially the NEJM), one realizes that most of them are ‘letters to the editor’ which seems to confirm the dislike of these journals for publishing original research into SCAM. Another interpretation of this phenomenon, of course, would be that only very few SCAM studies are of a high enough quality to make it into these two top journals.
  4. I was amazed to see how little SCAM was published in the two German-language journals. Vis a vis the high popularity of SCAM in these countries, I find this not easy to understand. Perhaps, one also needs to consider that these two journals publish considerably less original research than the other publications
  5. If we look at the differences between the 4 types of SCAM included in my assessment, we find that acupuncture is by far the most frequently published modality. The other 3 are on roughly the same level, with chiropractic being the least frequent – which I thought was surprising.
  6. Overall, the findings do not generate the impression that – despite the many billions spent on SCAM research during the last decades – SCAM has made important inroads into science or medicine.

I have often commented on the dismal state of the many SCAM journals; these days, they seem to publish almost exclusively poor-quality papers with misleading conclusions. It can therefore be expected that these journals will be more and more discarded by everyone (except the few SCAM advocates who publish their rubbish in them) as some sort of cult publications. In turn, this means that only SCAM studies published in mainstream journals will have the potential of generating any impact at all.

For this reason, my little survey might be relevant. It is far from conclusive, of course, yet it might provide a rough picture of what is happening in the area of SCAM research.

WARNING: SATIRE

This is going to be a very short post. Yet, I am sure you agree that my ‘golden rules’ encapsulate the collective wisdom of so-called alternative medicine (SCAM):

  1. Conventional treatments are dangerous
  2. Conventional doctors are ignorant
  3. Natural remedies are by definition good
  4. Ancient wisdom knows best
  5. SCAM tackles the roots of all health problems
  6. Experience trumps evidence
  7. People vote with their feet (SCAM’s popularity and patients’ satisfaction prove SCAM’s effectiveness)
  8. Science is barking up the wrong tree (what we need is a paradigm shift)
  9. Even Nobel laureates and other VIPs support SCAM
  10. Only SCAM practitioners care about the whole individual (mind, body, and soul)
  11. Science is not yet sufficiently advanced to understand how SCAM works (the mode of action has not been discovered)
  12. SCAM even works for animals (and thus cannot be a placebo)
  13. There is reliable evidence to support SCAM
  14. If a study of SCAM happens to yield a negative result, it is false-negative (e.g. because SCAM was not correctly applied)
  15. SCAM is patient-centered
  16. Conventional medicine is money-orientated
  17. The establishment is forced to suppress SCAM because otherwise, they would go out of business
  18. SCAM is reliable, constant, and unwavering (whereas conventional medicine changes its views all the time)
  19. SCAM does not need a monitoring system for adverse effects because it is inherently safe
  20. SCAM treatments are individualized (they treat the patient and not just a diagnostic label like conventional medicine)
  21. SCAM could save us all a lot of money
  22. There is no health problem that SCAM cannot cure
  23. Practitioners of conventional medicine have misunderstood the deeper reasons why people fall ill and should learn from SCAM

QED

I am sure that I have forgotten several important rules. If you can think of any, please post them in the comments section.

S-adenosyl methionine – SAMe for short – is a popular dietary supplement available freely via the Internet. It is a naturally occurring methyl radical donor involved in enzymatic transmethylation reactions in humans and animals. It has been used for treating postpartum depression, cholestatic jaundice, osteoarthritis, and numerous other conditions. SAM-e has poor oral bioavailability. SAM-e has so far been thought of as safe. The most frequent adverse effects reported were gastrointestinal, such as nausea, and skin rashes.

I have been involved in two systematic reviews that produced positive evidence for the effectiveness of SAMe:

Now the safety of SAMe has been questioned by new research. A team from Manchester and Kyoto universities reported that the supplement can break down inside the body into substances that cause a wide range of medical problems, including kidney and liver damage. Their study showed that “excess S-adenosylmethionine disrupts rhythms and, rather than promoting methylation, is catabolized to adenine and methylthioadenosine, toxic methylation inhibitors.”

Jean-Michel Fustin, of Manchester University, said experiments that he and his collaborators had carried out had revealed that SAMe breaks down into adenine and methylthioadenosine in the body. These substances are known to be toxic, he added. “This discovery came out of the blue,” Fustin said last week. “When we gave the supplement to mice we expected they would become healthier. But instead we found the opposite. We found that when SAMe breaks down in the body, it produces very toxic molecules, including adenine which causes gout, kidney disease and liver disease.” Fustin added that, although their study was carried out on mice, their results were relevant for humans. “We have not yet tested the supplement on men and women but we have added it to human cells in laboratory cultures and have found it had the same effect as it had on mice.”

Their study, which was funded by the Medical Research Council and the Japanese Society for the Promotion of Science, makes it clear that the health benefits of SAMe are questionable, to say the very least, Fustin added. “It is unclear what dose of it might be safe, so there is a good chance that a safe dose will be exceeded if someone takes this supplement – if a safe dose exists at all.”

An article in PULSE entitled ‘ Revolutionising Chiropractic Care for Today’s Healthcare System’ deserves a comment, I think. Here I give you first the article followed by my comments. The references in square brackets refer to the latter and were inserted by me; otherwise, the article is unchanged.

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This Chiropractic Awareness Week (4th – 10th April), Catherine Quinn, President of the British Chiropractic Association (BCA), is exploring the opportunity and need for a more integrated healthcare eco-system, putting the spotlight on how chiropractors can help alleviate pressures and support improved patient outcomes.

Chiropractic treatment and its role within today’s health system often prompts questions and some debate – what treatments fit under chiropractic care? Is the profession evidence based? How can it support primary health services, with the blend of public and private practice in mind? This Chiropractic Awareness Week, I want to address these questions and share the British Chiropractic Association’s ambition for the future of the profession.

The role of chiropractic today

The need for effective and efficient musculoskeletal (MSK) treatment is clear – in the UK, an estimated 17.8 million people live with a MSK condition, equivalent to approximately 28.9% of the total population.1 Lower back and neck pain specifically are the greatest causes of years lost to disability in the UK, with chronic joint pain or osteoarthritis affecting more than 8.75 million people.2 In addition to this, musculoskeletal conditions also account for 30% of all GP appointments, placing immense pressure on a system which is already under stress.3 The impact of the COVID-19 pandemic is still being felt by these patients and their healthcare professionals alike. Patients with MSK conditions are still having their care impacted by issues such as having clinic appointments cancelled, difficulty in accessing face-to-face care and some unable to continue regular prescribed exercise.

With these numbers and issues in mind, there is a lot of opportunity to more closely integrate chiropractic within health and community services to help alleviate pressures on primary care [1]. This is something we’re really passionate about at the BCA. However, we recognise that there are varying perceptions of chiropractic care – not just from the public but across our health peers too. We want to address this, so every health discipline has a consistent understanding.

First and foremost, chiropractic is a registered primary healthcare profession [2] and a safe form of treatment [3], qualified individuals in this profession are working as fully regulated healthcare professionals with at least four years of Masters level training. In the UK, chiropractors are regulated by law and required to adhere to strict codes of practice [4], in exactly the same ways as dentists and doctors [5]. At the BCA we want to represent the highest quality chiropractic care, which is encapsulated by a patient centred approach, driven by evidence and science [6].

As a patient-first organisation [7], our primary goal is to equip our members to provide the best treatment possible for those who need our care [8]. We truly believe that working collaboratively with other primary care and NHS services is the way to reach this goal [9].

The benefits of collaborative healthcare

As chiropractors, we see huge potential in working more closely with primary care providers and recognise there’s mutual benefits for both parties [10]. Healthcare professionals can tap into chiropractors’ expertise in MSK conditions, leaning on them for support with patient caseloads. Equally, chiropractors can use the experience of working with other healthcare experts to grow as professionals.

At the BCA, our aim is to grow this collaborative approach, working closely with the wider health community to offer patients the best level of care that we can [11]. Looking at primary healthcare services in the UK, we understand the pressures that individual professionals, workforces, and organisations face [12]. We see the large patient rosters and longer waiting times and truly believe that chiropractors can alleviate some of those stresses by treating those with MSK concerns [13].

One way the industry is beginning to work in a more integrated way is through First Contact Practitioners (FCPs) [14]. These are healthcare professionals like chiropractors who provide the first point of contact to GP patients with MSK conditions [15]. We’ve already seen a lot of evidence showing that primary care services using FCPs have been able to improve quality of care [16]. Through this service MSK patients are also seeing much shorter wait times for treatment (as little as 2-3 days), so the benefits speak for themselves for both the patient and GP [17].

By working as part of an integrated care model, with chiropractors, GPs, physiotherapists and other medical professionals, we’re creating a system that provides patients with direct routes to the treatments that they need, with greater choice. Our role within this system is very much to contribute to the health of our country, support primary care workers and reinforce the incredible work of the NHS [18].

Overcoming integrated healthcare challenges

To continue to see the chiropractic sector develop over the coming years, it’s important for us to face some of the challenges currently impacting progress towards a more integrated healthcare service.

One example is that there is a level of uncertainty about where chiropractic sits in the public/private blend. This is something we’re ready to tackle head on by showing exactly how chiropractic care benefits different individuals, whether that’s through reducing pain, improving physical function or increasing mobility [19]. We also need to encourage more awareness amongst both chiropractors and other healthcare providers about how an integrated workforce could benefit medical professionals and patients alike [20]. For example, there’s only two FCP chiropractors to date, and that’s something we’re looking to change [14].

This is the start of a much bigger conversation and, at the BCA, we’ll continue to work on driving peer acceptance, trust and inclusion to demonstrate the value of our place within the healthcare industry [21]. We’re ready to support the wider health community and primary carers, alleviating some of the pressures already facing the NHS; we’re placed in the perfect position as we have the knowledge and experience to provide essential support [22]. My main takeaway from this year’s Chiropractic Awareness Week would be to simply start a conversation with us about how [23].

 

About the British Chiropractic Association:

The BCA is the largest and longest-standing association for chiropractors in the UK. As well as promoting international standards of education and exemplary conduct, the BCA supports chiropractors to progress and develop to fulfil their professional ambitions with honour and integrity, at every step [24]. This Chiropractic Awareness Week, the BCA is raising awareness about the rigour, relevance and evidence driving the profession and the association’s ambition for chiropractic to be more closely embedded within mainstream healthcare [25].

 

  1. https://bjgp.org/content/70/suppl_1/bjgp20X711497
  2. https://www.versusarthritis.org/about-arthritis/data-and-statistics/the-state-of-musculoskeletal-health/
  3. https://www.england.nhs.uk/elective-care-transformation/best-practice-solutions/musculoskeletal/#:~:text=Musculoskeletal%20(MSK)%20conditions%20account%20for,million%20people%20in%20the%20UK

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And here are my comments:

  1. Non sequitur = a conclusion or statement that does not logically follow from the previous argument or statement.
  2. A primary healthcare profession is a profession providing primary healthcare which, according to standard definitions, is the provision of health services, including diagnosis and treatment of a health condition, and support in managing long-term healthcare, including chronic conditions like diabetes. Thus chiropractors are not in that category.
  3. This is just wishful thinking. Chiropractic spinal manipulation is not safe!
  4. “Required to adhere to strict codes of practice”. Required yes, but how often do they not comply?
  5. This is not true.
  6. Chiropractic is very far from being “driven by evidence and science”.
  7. Platitude = a remark or statement, especially one with a moral content, that has been used too often to be interesting or thoughtful.
  8. Judging from past experience, the primary goal seems to be to protect chiropractors (see, for instance, here).
  9. Belief is for religion, in healthcare you need evidence. Have you looked at the referral rates of chiropractors to GPs, for instance?
  10. For chiropractors, the benefit is usually measured in £s.
  11. To offer the ” best level of care” you need research and evidence, not politically correct statements.
  12. Platitude = a remark or statement, especially one with a moral content, that has been used too often to be interesting or thoughtful.
  13. Belief is for religion, in healthcare you need evidence.
  14. First Contact Practitioners are “regulated, advanced and autonomous health CARE PROFESSIONALS who are trained to provide expert PATIENT assessment, diagnosis and first-line treatment, self-care advice and, if required, appropriate onward referral to other SERVICES.” I doubt that many chiropractors fulfill these criteria.
  15. Not quite; see above.
  16. “A lot of evidence”? Really? Where is it?
  17.  “The benefits speak for themselves” only if the treatments used are evidence-based.
  18. Platitude = a remark or statement, especially one with a moral content, that has been used too often to be interesting or thoughtful.
  19. Where is the evidence?
  20. Awareness is not needed as much as evidence?
  21. Platitude = a remark or statement, especially one with a moral content, that has been used too often to be interesting or thoughtful.
  22. Platitude = a remark or statement, especially one with a moral content, that has been used too often to be interesting or thoughtful.
  23. Fine, let’s start the conversation: where is your evidence?
  24. Judging from past experience honor and integrity seem rather thin on the ground (see, for instance here).

The article promised to ‘revolutionize chiropractic care and to answer questions like what treatments fit under chiropractic care? Is the profession evidence-based? Sadly, none of this emerged. Instead, we were offered politically correct platitudes, half-truths, and obscurations.

The revolution in chiropractic, it thus seems, is not in sight.

Spinal cord injury after manual manipulation of the cervical spine is rare and has never been described as resulting from a patient performing a self-manual manipulation on his own cervical spine. This seems to be the first well-documented case of this association.

A healthy 29-year-old man developed Brown-Sequard syndrome immediately after performing a manipulation on his own cervical spine. Brown-Sequard syndrome is characterized by a lesion in the spinal cord which results in weakness or paralysis (hemiparaplegia) on one side of the body and a loss of sensation (hemianesthesia) on the opposite side.

Imaging showed large disc herniations at the levels of C4-C5 and C5-C6 with severe cord compression. The patient underwent emergent surgical decompression. He was discharged to an acute rehabilitation hospital, where he made a full functional recovery by postoperative day 8.

The authors concluded that this case highlights the benefit of swift surgical intervention followed by intensive inpatient rehab. It also serves as a warning for those who perform self-cervical manipulation.

I would add that the case also serves as a warning for those who are considering having cervical manipulation from a chiropractor. Such cases have been reported regularly. Here are three of them:

A spinal epidural hematoma is an extremely rare complication of cervical spine manipulation therapy (CSMT). The authors present the case of an adult woman, otherwise in good health, who developed Brown-Séquard syndrome after CSMT. Decompressive surgery performed within 8 hours after the onset of symptoms allowed for complete recovery of the patient’s preoperative neurological deficit. The unique feature of this case was the magnetic resonance image showing increased signal intensity in the paraspinal musculature consistent with a contusion, which probably formed after SMT. The pertinent literature is also reviewed.

Another case was reported of increased signal in the left hemicord at the C4 level on T2-weighted MR images after chiropractic manipulation, consistent with a contusion. The patient displayed clinical features of Brown-Séquard syndrome, which stabilized with immobilization and steroids. Follow-up imaging showed decreased cord swelling with persistent increased signal. After physical therapy, the patient regained strength on the left side, with residual decreased sensation of pain involving the right arm.

A further case was presented in which such a lesion developed after chiropractic manipulation of the neck. The patient presented with a Brown-Séquard syndrome, which has only rarely been reported in association with cervical epidural hematoma. The correct diagnosis was obtained by computed tomographic scanning. Surgical evacuation of the hematoma was followed by full recovery.

Brown-Séquard syndrome after spinal manipulation seems to be a rare event. Yet, nobody can provide reliable incidence figures because there is no post-marketing surveillance in this area.

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