research
The BBC has repeatedly misled the public on matters related to so-called alternative medicine (SCAM). Examples include:
- Dangerous BS from the BBC
- The BBC, Michael Mosely, air ionization, depression, and an appalling lack of critical thinking.
Recently the BBC published an article about Ashwagandha. Here it is in its untouched beauty:
Ashwagandha is a herb (Withania somnifera) in the nightshade family, which also includes tomatoes and chilli peppers. It has been used in traditional Indian medicine (Ayurveda) for thousands of years to make preparations for treating various ailments, from infectious diseases, like tuberculosis, to pain and inflammation, baldness and hiccups. In classic Ayurvedic texts, it’s also described as a ‘mental strength promoter’ (or ‘Balya’).
While lots of research has been done on ashwagandha, studies for specific conditions can be sparser. Perhaps the most recent assessment of its use for stress and anxiety comes from a 2022 review of studies by the Cochrane Collaboration, which is internationally recognised for its high-standard medical reviews. Although the Cochrane researchers were only able to find 12 studies on the subject, which together tested the herb on just 1,002 participants, their findings did suggest that ashwagandha can lower stress and anxiety. The researchers rated the ‘certainty’ of the evidence as ‘low’ and called for more detailed studies, though.
The benefits of ashwagandha are thought to be related to natural steroids called withanolides, but this group includes hundreds of compounds, with tens having been isolated from ashwagandha so far. As with any herbal remedy, the combination of compounds and the exact concoction you get depends on how and where the plant is grown, and how it’s prepared. This means that not all supplements based on the same plant are equal.
Remember, too, that herbal doesn’t mean risk-free. For some people, ashwagandha causes drowsiness and more serious side effects aren’t unknown. It’s best to treat it like a drug and not ‘just’ a herb.
The review cited in the article is this one:
Clinical trial studies revealed conflicting results on the effect of Ashwagandha extract on anxiety and stress. Therefore, we aimed to evaluate the effect of Ashwagandha supplementation on anxiety as well as stress. A systematic search was performed in PubMed/Medline, Scopus, and Google Scholar from inception until December 2021. We included randomized clinical trials (RCTs) that investigate the effect of Ashwagandha extract on anxiety and stress. The overall effect size was pooled by random-effects model and the standardized mean difference (SMD) and 95% confidence interval (CIs) for outcomes were applied. Overall, 12 eligible papers with a total sample size of 1,002 participants and age range between 25 and 48 years were included in the current systematic review and meta-analysis. We found that Ashwagandha supplementation significantly reduced anxiety (SMD: −1.55, 95% CI: −2.37, −0.74; p = .005; I2 = 93.8%) and stress level (SMD: −1.75; 95% CI: −2.29, −1.22; p = .005; I2 = 83.1%) compared to the placebo. Additionally, the non-linear dose–response analysis indicated a favorable effect of Ashwagandha supplementation on anxiety until 12,000 mg/d and stress at dose of 300–600 mg/d. Finally, we identified that the certainty of the evidence was low for both outcomes. The current systematic review and dose–response meta-analysis of RCTs revealed a beneficial effect in both stress and anxiety following Ashwagandha supplementation. However, further high-quality studies are needed to firmly establish the clinical efficacy of the plant.
This review is NOT a Cochrane Review; what is more (and more important), it seem rather uncritical.
The BBC article seems to down-play the safety issue related to Ashwagandha. As we have discussed on this blog, Ashwagandha is far from harmless. In fact, Ashwagandha has been shown to be a herb with a high risk of hepatobiliary toxicity as well as heart problems.
So, why does the BBC misinform the public?
Search me.
A new market report predicts that the worldwide market for so-called alternative medicine (SCAM) will grow from $100 billion in 2022 to $438 billion by 2032.
According to the report, the SCAM market is expected to see innovation and expansion through mergers, acquisitions, and partnerships among large companies. Companies that are capitalizing on these trends include health supplement companies, companies that specialize in Ayurvedic health, those that offer TCM solutions, and those that offer more general holistic solutions to health. Major supplement brands include Herb Pharm LLC, Gaia Herbs, NOW Foods, Life Extension, Pure Encapsulations, Douglas Laboratories, Nordic Naturals, Nordic Nutraceuticals, Quality of Life Labs, Nature’s Bounty Co., Valensa International, Herbo Nutra, and Emerson Ecologics.
Other major players mentioned in the report are:
- AYUSH Ayurvedic Pte Ltd, Dabur India Ltd., Himalaya Global Holdings Ltd., Banyan Botanicals, and Arya Vaidya Pharmacy offer Ayurvedic health and wellness products while aiming to advance the science behind Ayurveda.
- Sheng Chang Pharmaceutical Company produces traditional Chinese medicines and herbal products that is one of the largest TCM pharma companies.
- All and One Medical provides healthcare solutions that combine conventional medicine with complementary and alternative therapies to promote overall wellness and preventive care.
- The John Schumacher Unity Woods Yoga Center is another that focuses on enhancing physical and mental well-being through the practice of Iyengar Yoga and offers classes and workshops.
- New Life Chiropractic aims to improve overall health and well-being by providing comprehensive chiropractic care that focuses on spinal health and preventive wellness.
- The Chicago Body Works offers a range of therapies and treatments designed to enhance physical and mental well-being, including massage and bodywork services.
- Weleda AG aims to connect people with nature by producing natural organic products that support health, beauty, and overall wellness while practicing sustainability and social responsibility.
- Quantum-Touch Inc. teaches energy healing techniques that promote physical, emotional, and spiritual health.
- Spectrum Chemical Manufacturing Corporation focuses on delivering high-quality chemicals and laboratory supplies to support scientific research and innovation across various industries, including health and wellness.
I must admit, I do like these market reports. They never fail to amuse me – for two main reasons:
- They are as reliable as reading tea leafs.
- The only reliable info they do provide is that the SCAM proponents’ often-voiced argument, “we are very different from BIG PHARMA” is pure nonsense.
Some papers on homeopathy are bad, others are very bad and others again create a new dimension of bad. Here is an example of the latter category (Research, Society and Development, v. 13, n. 7, e1413746050, 2024
(CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v13i7.46050 ):
Objective: To research, through literature review, the use of homeopathy as an alternative treatment for many pathologies involved in dentistry field. Methodology: online searches using databases available at PUBMED Central and VHL/BIREME. Other platforms such as Web of Science, Science Direct and Google Academy. Results: Our search resulted in 25 articles. Conclusion: Despite the mysticism that surrounds it, the use of homeopathic medicines in dental treatments is, in fact, a scientifically proven alternative treatment, which helps in various pre and post surgical procedures, which has a low financial cost and great effectiveness, enabling a contribution to dental care. Scientific study in this area requires more research and clinical evidence, so that this practice is more widespread and used by dental surgeons, in addition to the application of homeopathy as a discipline in dentistry.
But that’s merely the abstract. Perhaps the article itself offers some convincing evidence. See for yourself; here is the only section of the paper that provides something akin to evidence:
In dentistry, homeopathic remedies have been proposed for a variety of conditions including oral ulcers, sialorrhea (excessive salivation), neuralgia, temporomandibular joint disorders (TMJ), xerostomia (dry mouth), lichen planus, bruxism (teeth grinding), minor acute illnesses, chronic pathologies, atypical facial pain, burning mouth syndrome, postoperative osteitis, and anxiety related to dental treatment (Steinchler, 2015; Fischer, 2005). They are often used as adjuncts to conventional treatments, especially in cases where traditional approaches have failed or are contraindicated (Amaral, 2021).
Homeopathic medicines for these conditions come in various forms such as tablets, pills, drops, liquids, granules, and creams (Darby, 2011). Some are designed to dissolve on or under the tongue for quick absorption. The instructions typically advise placing the medicine directly in the mouth, where it can be sucked or chewed to facilitate absorption (Darby, 2011).
The use of homeopathic remedies in dentistry offers several potential benefits, including cost-effectiveness, versatility across different dental specialties (such as orthodontics, stomatology, endodontics, pediatric dentistry, periodontics, and surgery), relative efficacy, safety, and ease of use (Eleutério, 2011; Mendonça, 2022; Almeida et al., 2023). This makes them a valuable option in integrative dental care, where they can complement conventional treatments and provide additional therapeutic options for patients.
______________________
As the Brazilian authors of the article fail to say it, allow me to do so:
The place of homeopathy in dentistry is nowhere! There is no reliable evidence that homeopathy is effective for any of the conditions listed above.
PS
This paper is nonetheless notable: it is certainly amongst the worst I have seen for a very long time.
International guidelines have recommended cognitive behavioural therapy, including acceptance and commitment therapy (ACT), as it offers validated benefits for managing fibromyalgia; however, it is inaccessible to most patients. This study aimed to evaluate the effect of a 12-week, self-guided, smartphone-delivered digital ACT programme on fibromyalgia management.
In the PROSPER-FM randomised clinical trial conducted at 25 US community sites, adult participants aged 22–75 years with fibromyalgia were recruited and randomly assigned (1:1) to the digital ACT group or an active control group that offered daily symptom tracking and monitoring and access to health-related and fibromyalgia-related educational materials. Randomisation was done with a web-based system in permuted blocks of four at the site level. We used a blind-to-hypothesis approach in which participants were informed they would be randomly assigned to one of two potentially effective therapies under evaluation. Research staff were not masked to group allocation, with the exception of a masked statistics group while preparing statistical programming for the interim analysis. The primary endpoint was patient global impression of change (PGIC) response rate at week 12. Analyses were by intention to treat. The trial was registered with ClinicalTrials.gov, NCT05243511 (now fully closed).
Between Feb 8, 2022, and Feb 2, 2023, 590 individuals were screened, of whom 275 (257 women and 18 men) were randomly assigned to the digital ACT group (n=140) and the active control group (n=135). At 12 weeks, 99 (71%) of 140 ACT participants reported improvement on PGIC versus 30 (22%) of 135 active control participants, corresponding to a difference in proportions of 48·4% (95% CI 37·9–58·9; p<0·0001). No device-related safety events were reported.
The authors concluded that digital ACT was safe and efficacious compared with digital symptom tracking in managing fibromyalgia in adult patients.
___________________
These conclusions might well be valid – but then again, they might not!
Here is why I have my doubts:
- The patients treated with digital ACT knew that they were getting a novel and thus exciting treatment.
- The patients randomised to the control group, on the other hand, would most likely be disappointed not to receive this therapy. In other words, there were high expectations in the experimental group and disappointment in the control group.
- In addition, the unmasked researchers would have had the ambition that their innovation would be successful. Thus they would have used verbal and non-verbal communications with the ACT patients to bring about the desired result.
It is therefore conceivable – I think even likely – that these factors would add up to generate a false-positive finding, particularly since the endpoint was entirely subjective.
In view of all this, I am surprised that a journal like THE LANCET has published such a flimsy study with such a over-optimistic conclusion, and I suggest re-phrasing the conclusions as follows:
Digital ACT seemed safe and effective compared with digital symptom tracking in managing fibromyalgia in adult patients. However, due to the design of the study, it is possible that digital ACT is entirely ineffective and the positive outcome is caused by a number of context effects.
Yesterday, I stumbled across this remarkable notice. As it is in German, I took the libery of translating it for you:
Am 6. April 2024 war es wieder soweit: Die ÖGHM und die Schwabe Austria GmbH luden zur Verleihung des mit 4.000,- Euro dotierten Dr. Peithner Preises ein.
Dieses Mal wurde der Forschungspreis für die zwei eingereichte Arbeiten „Recommendations in the design and conduction of randomized controlled trials in human and veterinary homoeopathic medicine“ und „Recommendations for Designing, Conducting and Reporting Clinical Observational Studies in Homeopathic Veterinary Medicine“ an Katharina Gaertner, Klaus von Ammon, Philippa Fibert, Michael Frass, Martin Frei-Erb, Christien Klein-Laansma, Susanne Ulbrich-Zuerni und Petra Weiermayer vergeben.
Wir freuen uns sehr und gratulieren den Preisträger:innen zum verdienten Erfolg. Ein herzliches Dankeschön geht auch an die ÖGHM und die Schwabe Austria, die nicht nur mit diesem traditionellen Forschungspreis die Wissenschaft unterstützt.
Here is my translation:
On 6 April 2024, the time had come again: the ‘Austrian Society for Homeopathic Medicine’ (ÖGHM) and Schwabe Austria GmbH hosted the award ceremony for the Dr Peithner Prize, which is endowed with 4,000 euros.
This time, the research prize was awarded to Katharina Gaertner, Klaus von Ammon, Philippa Fibert, Michael Frass, Martin Frei-Erb, Christien Klein-Laansma, Susanne Ulbrich-Zuerni and Petra Weiermayer for the two submitted papers “Recommendations in the design and conduction of randomised controlled trials in human and veterinary homoeopathic medicine” and “Recommendations for Designing, Conducting and Reporting Clinical Observational Studies in Homeopathic Veterinary Medicine”.
We are delighted and congratulate the prizewinners on their well-deserved success. A big thank you also goes to the ÖGHM and Schwabe Austria, who support science with this traditional research prize.
______________________________
And where is the irony?
Firstly, homeopaths are not exactly the experts on how to conduct research.
Secondly, there are recommendations and guidelines for conducting clinical research (e.g. here), and there is no reason for homeopathy to not to adopt those.
Thirdly, and most importantly, to award a prize to Michael Frass for telling us how to do research is more than a little ironic. If anything, Frass could teach us a thing or two about how to falsify, fabricate and manipulate research results!
For many years, Dale Thompson has been one of our most loyal commentators, often defending the indefensible, or willfully misleading us, or deliberately distracting us from the topic at hand. He has made his comments under several names or pseudomyms, sometimes with and sometines without using the doctor-title, sometimes disclosing that he is a chiropractor and someimes not disclosing either this information or his most obvious conflicts of interest.
Recently, several readers became more interested in Dale and his activities. I therefore thought it would be relevant to find out how he is being presented on the Internet. Here are the mentions I found that include some relevant information about Dale:
- Dr. Dale Thompson. Over 20 years of delivering a conservative approach to muscle and joint issues. Trained in approaches that don’t require the typical adjustment but it is available when needed. Use a whole body approach and consider other factors that may be contributing to problems such as diet, ergonomics, lifestyles, etc.
- Dr. Dale Thompson is a Stratford, Iowa based male chiropractor with 22 years of experience in General Chiropractor. He completed his graduation from Logan College Of Chiropractic in 2002. He accepts the Medicare-approved amount. Patients will not be billed for any more than the Medicare deductible and coinsurance. Active license number of Dr. Dale Thompson as General Chiropractor is 06631 in Iowa. Dr. Dale Thompson is qualified as a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems.
- Dr. Thompson graduated from the Logan College of Chiropractic in 2002. He works in Stratford, IA and specializes in Chiropractor.
- DALE THOMPSON, D.C. practices at 813 SHAKESPEARE AVE, STRATFORD, IA 50249. Chiropractors diagnose and treat common spinal misalignments that can occur from lifestyle or injuries causing pain, discomfort and degenerative conditions. DALE THOMPSON, D.C. may be able to treat; back pain, sciatica, neck pain, shoulder pain, headaches, sports injuries, and auto accident injuries.
- Dr. Dale Thompson – Why I Like Being An Evidence-Based Chiropractor. Today we’re going to talk about being an evidence-based chiropractor. What does it mean to be practicing evidence-based chiropractic and we’re going to be talking about with Dr. Dale Thompson from Iowa. USA.
As we see, these texts are not always entirely clear about the fact that Dale has no medical degree. Dale recently posted: “Here in the USA it would be a board violation to ‘conceal’ that one is a doctor of chiropractic.” And in August 2021, he made this comment: “There are several professions that use the title doctor which aren’t earned from a medical college: dentists, optometrists, physical therapists. Within chiropractic, when we advertise, at least in the USA, we are required to identify that we are a doctor of chiropractic. Of course the word doctor originally was used by a religious sect but the medical profession decided they wanted it … “Several authors have recently lamented the continued chiropractic inclination to use outdated and anatomically incorrect language to describe the nature of the manipulable lesion (“subluxation”) and the method of treatment (“adjustment”).2,3,11 J Chiropr Educ. 2020 Oct; 34(2): 172–176.”
Next, I looked on Medline to find out wether Dale has ever published any research on his subject. I failed to find a single article in his name. This is remarkable because, all too often, he presents himself as THE expert in research.
Subsequently, I looked at some of the claims made by Dale. Here are a few of them:
- I can go to a conference and know if the speaker is generally telling the truth or is trying to sell a lie.
- I can read a research paper and know if it’s good or bad and how it may apply to what I do.
- I can take the best evidence and apply it and yet also have the freedom to find novel ways to approach a problem.
- I can take a seemly complex problem and find a simple solution as well as understand the complexity of an apparently simple problem.
- I know my clinical strengths and limitations as well as the strengths and limitations of other healthcare professionals.
- I do not have to jump on board the latest health fad but I can, and may, scrutinize it using logic, reasoning and supporting evidence.
- I can respect my colleagues desire to practice different than me but I still demand they do so in an evidence-based chiropractor and ethical manner.
- My patients come first, my profession second and I am last.
So, what should we conclude about Dale Thompson?
I don’t know about you, but I get the impression that Dale lacks the ability to be critical of his own abilities and of the value of chiropractic. He likes to post comments that are aimed at misleading us. He might not be a ‘straight chiropractor‘ in the usual sense of the term, but in my view he also is still far from straight. Personally, I have not taken much notice of his deeply biased, often pompous and smug comments for some time. I suggest you consider doing the same.
But Dale is just one chiro!
He hardly has any wider significance.
So, why even bother and write a whole blog post about him?
I certainly agree that such a man does not deserve the attention we have been giving him. But Dale stand for so many of his colleagues. In fact, he is a prime example of a chiro victim of the ‘Dunning Kruger Effect‘. These people have a thin veneer of respectability which allows them to pretend to be veritable ‘know alls’. They remain entirely oblivious to the fact that they have been brain-washed at chiro school and have become a life-time members of a cult unable to see how deluded they truly are. As such they are dangerous, and I feel that the public needs to be aware of the danger.
And here you have the true reason why I am writing these lines.
The objective of this paper was to review the 10 most recent case reports of cervical spine manipulation and cervical artery dissection for convincing evidence of the causation of cervical artery dissection by cervical spine manipulation. The author, Steven P. Brown, a chiropractor (who is quoted as “the authors have declared that no competing interests exist”), lists the following 10 cases:
Case 1: Yeung et al. (2023) [17]
Yeung et al. [17] reported that a “48-year-old female went to a chiropractor for chronic neck pain and developed right-sided weakness, nausea, dizziness, and vomiting immediately after neck manipulation.” Imaging showed occlusion of the V1 segment of the right vertebral artery and cerebellar stroke.
The adverse event immediately following cervical spine manipulation (CSM) was the cerebellar stroke, not the cerebral artery dissection (CAD). Right-sided weakness, nausea, dizziness, and vomiting are symptoms of cerebellar ischemia, not right VAD. The neck pain prior to the CSM is consistent with a CAD being present prior to CSM, not caused by CSM.
Even if CSM had caused the CAD, it is not biologically possible for a thrombus large enough to occlude the vertebral artery to form immediately [6]. Therefore, the CAD was likely pre-existing to CSM. While an existing thrombus may have been aggravated by the CSM, it was not caused by the CSM. In this case, it is plausible that CSM may have suddenly repositioned an already large thrombus in such a way that it blocked the V1 segment of the right vertebral artery, resulting in thrombotic ischemic stroke from vascular occlusion [26]. The practitioner failed to exclude CAD and performed CSM when it was contraindicated [7]. So, while thrombotic stroke may have been causally related to the CSM, the CAD was not.
Cases 2 and 3: Chen et al. (2022) [18]
Chen et al. [18] reported that “a 51-year-old man with a history of mild hypertension noted new-onset right neck pain two days following chiropractic manipulation.” Imaging revealed dissection of the C3 segment of the right ICA and right-sided stroke.
Chen et al. [18] also reported a second case in which “a 55-year-old man with a history of cigarette smoking, no other cerebrovascular risk factors, received chiropractic cervical manipulation 1 day prior to presentation to the emergency department with new onset of left hemiparesis, facial paralysis, right neck pain, and dysarthria lasting for 5 hours.” Imaging revealed dissection of the C3 segment of the right ICA and right-sided cerebral stroke.
In these two case reports, the symptoms that prompted the patients to seek CSM were not documented. In the first case, neck pain started two days after CSM. In the second case, neck pain started 19 hours after CSM.
In these two cases, there was no adverse event immediately following CSM. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the ICA dissection or the stroke. Furthermore, the C3 segment of the ICA is intracranial and has not been identified as an area for strain by CSM.
Case 4: Arning et al. (2022) [19]
Arning et al. [19] reported the case of a 47-year-old female with a two-week history of non-traumatic right neck pain who had increased, severe right neck pain immediately after CSM, and paresis of the right deltoid muscle and hypalgesia in the right C3 and right C4 dermatomes. MRI revealed a dissection of the V2 segment of the right vertebral artery.
The adverse event immediately following CSM was a stroke, not a CAD. Paresis and hypalgesia are symptoms of brain ischemia, not right VAD. The right neck pain prior to the CSM is consistent with a right VAD being present prior to CSM, not caused by CSM.
Prior to CSM, cervical spine disc herniation had been ruled out by MRI. Upon review, the pre-CSM MRI also showed dissection of the right V2 segment, which had initially been overlooked by the radiologist. The practitioner performed CSM when it was contraindicated. Therefore, while the CSM may have caused the ischemic stroke by a thromboembolic mechanism, the CSM did not cause the CAD.
Case 5: Abidoye et al. (2022) [20]
Abidoye et al. [20] reported, “This is a 40-year-old male with a medical history of migraine headaches and cervicalgia, evaluated for a sudden onset of headache, associated with nausea, vomiting, blurred vision, and dizziness, two months after a chiropractic manipulation. He also reported rigorous exercise and sexual intercourse prior to the headache onset. Vital sign is significant for a 10/10, non-radiating right-sided headache. Neurological examination revealed right ptosis and miosis. Labs were unremarkable. CTA of neck showed tapering of the right ICA with near occlusion at the skull base.” No imaging evidence or diagnosis of stroke was documented. However, with ischemic symptoms of nausea, vomiting, blurred vision, dizziness, right ptosis, and right miosis, it is likely that this patient suffered a stroke.
In this case, there was no adverse event immediately following CSM, and the most recent CSM was two months prior to the onset of symptoms. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the ICA dissection or the stroke.
The patient’s medical history of neck pain and headaches are risk factors for CAD. If there was existing right ICA dissection, it is plausible that rigorous exercise and sexual intercourse could have dislodged a loosely adherent ICA thrombus and caused immediate stroke by a thromboembolic mechanism. However, this is not possible to determine as the temporality from exercise and intercourse to ischemic symptoms of stroke was vaguely documented as “prior to.”
Case 6: Yap et al. (2021) [21]
Yap et al. [21] reported a 35-year-old male who presented with a two-day history of expressive dysphasia and a one-day history of right-sided weakness. The patient reported having CSM for pain relief sometime in the prior two weeks. Imaging showed left ICA dissection and left middle cerebral artery stroke. The dissected segment of the left ICA was not documented.
In this case, there was no adverse event immediately following CSM. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the ICA dissection or the stroke.
Case 7: Xia et al. (2021) [22]
Xia et al. [22] reported a case of a 44-year-old male with chronic neck pain who reported sudden-onset left homonymous hemianopia after CSM a few days prior. The patient reported progression from a left homonymous hemianopia to a left homonymous inferior quadrantanopia. Imaging revealed bilateral VAD at the left V2 and right V3 segments, and right medial occipital lobe stroke. The authors noted that a right posterior communicating artery stroke was likely embolic from the right V3 and left V2 dissections. They also noted that the patient likely had a migrating embolus as evidenced by the progression from a homonymous hemianopia to a quadrantanopia.
The adverse event immediately following CSM was the stroke, not the CAD. Left homonymous hemianopia is a symptom of brain ischemia, not VAD. The neck pain prior to the CSM is consistent with VAD being present prior to CSM, not caused by CSM.
Even if CSM had caused the CAD, it is not biologically possible for a thrombus to instantly form and dislodge to cause sudden-onset thromboembolic stroke [6]. Therefore, the CAD was likely pre-existing to CSM. While an existing thrombus may have been aggravated by the CSM, it was not caused by the CSM. In this case, it is possible that CSM dislodged a loosely adherent vertebral artery thrombus to cause thromboembolic stroke [26]. The practitioner failed to exclude CAD and performed CSM when it was contraindicated [7]. So, while thromboembolic stroke may have been causally related to the CSM, the CAD was not.
Case 8: Lindsay et al. (2021) [23]
Lindsay et al. [23] reported a case of a 47-year-old male who presented with left neck pain and headache. His medical history was notable for dyslipidemia and a cerebellar stroke six years prior. Imaging revealed dissections of the left vertebral artery extending from the origin of the artery to the V3 segment. The patient also had a dissection of his right renal artery. There was no evidence of a stroke.
Six years prior, the patient had presented with a one-week history of left neck pain and headache, as well as left facial numbness and dizziness. The pain was not relieved with ibuprofen and previously been evaluated and treated by a chiropractor. Imaging done six years prior showed no evidence of CAD but did show a left cerebellar stroke.
There is no plausible biological mechanism by which CSM six years prior could cause a current VAD. Therefore, it is not likely that there was a causal relationship between CSM and CAD in this case.
Ultimately, the patient was diagnosed with vascular Ehlers-Danlos syndrome, a disorder that causes connective tissue weakness and makes a patient susceptible to arterial dissection. This diagnosis is consistent with the left VAD and right renal artery dissection.
Case 9: Monari et al. (2021) [24]
Monari et al. [24] reported a case of a 39-year-old pregnant female with a history of tension headaches presenting with vertigo, vomiting, nystagmus, dizziness, and hindrance in the execution of fine movements of the right arm. The patient reported having CSM by an osteopathic specialist “in the days preceding the beginning of the symptoms.” Imaging showed a dissection of the V2 segment of the right vertebral artery and a right-sided stroke.
In this case, there was no adverse event immediately following CSM. As there was no neck pain, headache, or ischemic symptoms noted immediately after CSM, it is not likely that CSM caused the right vertebral artery dissection or the stroke. Medical history of headache prior to the CSM is consistent with a VAD being present prior to CSM, not caused by CSM. Pregnancy is also a risk factor for CAD.
Case 10: Ramos et al. (2021) [25]
Ramos et al. [25] reported a case of a 48-year-old female with a history of chronic neck pain who experienced sudden neck pain and generalized weakness during CSM. Imaging showed bilateral VAD and occlusion and bilateral acute cerebellar stroke. There was also tetraplegia noted at the C5 sensory level, C5 and C6 vertebral fracture, spinal cord injury, epidural hematoma, and acute disc herniation.
There is convincing evidence that CSM caused CAD and stroke in this case. This case is exceptional as the CSM was contraindicated by pre-existing cervical spine pathology. Cervical spine bony ankylosis was noted which existed prior to the CSM. The CSM appears to have been a posterior-anterior manipulation of the cervical spine at the level of C5-C6, which was contraindicated due to the presence of the bony ankylosis [27].
The practitioner failed to exclude cervical spine pathology and performed CSM when it was contraindicated. The spinal pathology in this case could have been diagnosed with a cervical spine X-ray examination.
As the Ramos et al. [25] study provided limited case information, a case report from Macêdo et al. [28] provides additional information on this exceptional case.
“A 47-year-old Afro-Brazilian woman with long-standing back pain sought chiropractic care for symptomatic relief. Until then, she had never consulted a doctor to treat her axial pain and was not aware of having any specific spinal pathology. Since childhood, she had a moderate cognitive deficit, which probably compromised her ability to adequately describe the pain and, thus, led the family to seek medical advice. During her last session of spinal manipulation, she mentioned new-onset paresthesia beginning on the upper limbs and progressing to the lower limbs. Her complaint was disregarded, and the session continued, at the end of which she was unable to stand. Urinary retention ensued a little after. The patient was referred to our service only a week after, completely bedridden. Spine MRI revealed a transdiscal fracture at C5-C6, resulting in critical stenosis and compressive myelopathy. CT angiography revealed traumatic thrombosis of the vertebral arteries emerging on this level. Whole spine-imaging evidenced multiple syndesmophytes giving a characteristic bamboo spine appearance, as well as ankylosis in sacroiliac joints, uncovering the diagnosis of ankylosing spondylitis. She underwent laminectomy from C2 to C6 and arthrodesis from C2 to T2 for spine stabilization but did not recover mobility. Even though a systematic review did not find an increased risk of significant adverse events related to spine manipulation therapy, there have been descriptions of vertebral fracture following a session on patients with ankylosing spondylitis and unsuspected multiple myeloma.”
The author concluded that nine out of the 10 case reports of CSM and CAD did not provide convincing evidence of the causal relationship between CSM and CAD. Only one case report provided convincing evidence of a causal relationship between CAD and CSM. This case was exceptional as the CSM was contraindicated by pre-existing cervical spine pathology. Therefore, we conclude that practitioners of CSM should exclude cervical spine pathology before performing CSM.
I must say that I find it difficult or even impossible to follow most of the arguments of Mr Brown. Do they teach them a different kind of physiology and pathophysiology in chiro-school? Foremost, he seems to think that case-reports can/should establish cause and effect. Do they teach research methodology at all in chiro-school?
Here is what Wiki tells us, for instance:
In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases. Case reports are professional narratives that provide feedback on clinical practice guidelines and offer a framework for early signals of effectiveness, adverse events, and cost.
So, case reports “offer a framework for early signals of adverse events”. To expect that they demonstrate a causal link is ill-informed. Their significance in relation to risks lies mostly in providing a signal, particularly if the signal becomes loud and clear due to numerous repetitions, as is the case in chiropractic manipulations. Once the signal is noted, it needs further investigation to determine its nature. In the absence of conclusive further studies, a signal that has emerged hundreds of times, as in chiropractic, it has to be taken seriously. In fact, the precautionary principle demands that we then assume causality until proven otherwise.
As to the research effort of Mr Brown in assembling 10 case reports, I must say it is frightfully daft for the following reasons:
- Most cases do probably not get connected to a CSM at all.
- Many lead to litigation and are not published.
- In the end, very few get published in the medical literature.
- Being retrospective, they all lack important detail and are thus incomplete.
- None prove causation and only some render it likely.
- A sample size of 10 is laughable.
- Brown’s desire to white-wash chiropractic is plapable.
- So is his naivety.
This study aimed to investigate the clinical effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention to prevent the recurrence of low back pain.
WalkBack was a two-armed, randomised clinical trial, which recruited adults (aged 18 years or older) from across Australia who had recently recovered from an episode of non-specific low back pain that was not attributed to a specific diagnosis, and which lasted for at least 24 h. Participants were randomly assigned to an individualised, progressive walking and education intervention facilitated by six sessions with a physiotherapist across 6 months or to a no treatment control group (1:1). The randomisation schedule comprised randomly permuted blocks of 4, 6, and 8 and was stratified by history of more than two previous episodes of low back pain and referral method. Physiotherapists and participants were not masked to allocation. Participants were followed for a minimum of 12 months and a maximum of 36 months, depending on the date of enrolment. The primary outcome was days to the first recurrence of an activity-limiting episode of low back pain, collected in the intention-to-treat population via monthly self-report. Cost-effectiveness was evaluated from the societal perspective and expressed as incremental cost per quality-adjusted life-year (QALY) gained. The trial was prospectively registered (ACTRN12619001134112)
Between Sept 23, 2019, and June 10, 2022, 3206 potential participants were screened for eligibility, 2505 (78%) were excluded, and 701 were randomly assigned (351 to the intervention group and 350 to the no treatment control group). Most participants were female (565 [81%] of 701) and the mean age of participants was 54 years (SD 12). The intervention was effective in preventing an episode of activity-limiting low back pain (hazard ratio 0·72 [95% CI 0·60–0·85], p=0·0002). The median days to a recurrence was 208 days (95% CI 149–295) in the intervention group and 112 days (89–140) in the control group. The incremental cost per QALY gained was AU$7802, giving a 94% probability that the intervention was cost-effective at a willingness-to-pay threshold of $28 000. Although the total number of participants experiencing at least one adverse event over 12 months was similar between the intervention and control groups (183 [52%] of 351 and 190 [54%] of 350, respectively, p=0·60), there was a greater number of adverse events related to the lower extremities in the intervention group than in the control group (100 in the intervention group and 54 in the control group).
The authors concluded that an individualised, progressive walking and education intervention significantly reduced low back pain recurrence. This accessible, scalable, and safe intervention could affect how low back pain is managed.
Rigorous clinical trials of excercise therapy are difficult to conceive and conduct because of a range of methodological issues. For instance, there is no obvious placebo and thus it is hardly possible to control for placebo effects. Nonetheless, the benefits of exercise therapy for back pain is undoubted. As previously discussed on this blog, a recent systematic review concluded that “the relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance.”
I have always been convinced of the health benefits of excercise. In fact, 40 years ago, when I did my inaugural lecture at the University of Munich (LMU), excercise was its topic and I concluded that, if exercise were a pharmaceutical product, it would out-sell any drug. The new study only confirms my view. It adds to our knowledge by suggesting that exercise also reduces the risk of recurrences.
Forget about spinal manipulation, acupuncture, etc., despite the undeniable weaknesses in the evidence, exercise is by far the most promissing treatment for back pain
This study tested the efficacy and safety of individualized homeopathic medicines (IHMs) in treating hemorrhoids compared with placebo. The double-blind, randomized (1:1), two parallel arms, placebo-controlled trial was conducted at the surgery outpatient department of the State National Homoeopathic Medical College and Hospital, Lucknow, Uttar Pradesh, India.
Patients were 140 women and men, aged between 18 and 65 years, with a diagnosis of primary hemorrhoids grades I-III for at least 3 months. Excluded were the patients with grade IV hemorrhoids, anal fissure, and fistula, hypertrophic anal papillae, inflammatory bowel disease, coagulation disorders, rectal malignancies, obstructed portal circulation, patients requiring immediate surgical intervention, and vulnerable samples.
Patients were randomized to Group 1 (n = 70; IHMs plus concomitant care; verum) and Group 2 (n = 70; placebos plus concomitant care; control). Primary-the anorectal symptom severity and quality-of-life (ARSSQoL) questionnaire, and secondary-the EuroQol 5-dimensions 5-levels (EQ-5D-5L) questionnaire and EQ visual analogue scale (VAS); all of them were measured at baseline, and every month, up to 3 months.
Out of the 140 randomized patients, 122 were protocol compliant. Intention-to-treat sample (n = 140) was analyzed. The level of significance was set at p < 0.05 two tailed. Statistically significant between-group differences were elicited in the ARSSQoL total (Mann-Whitney U [MWU]: 1227.0, p < 0.001) and EQ-5D-5L VAS (MWU: 1228.0, p = 0.001) favoring homeopathy against placebos. Sulfur was the most frequently prescribed medicine. No harm or serious adverse events were reported from either of the groups.
The authors concluded that IHMs demonstrated superior results over placebo in the short-term treatment of hemorrhoids of grades I-III. The findings are promising, but need to be substantiated by further phase 3 trials.
Yes, I know: it is not easy to keep a straight face when reading such a paper. And the task is not made easier when considering the affiliations of its authors:
- 1East Bishnupur State Homoeopathic Dispensary, Chandi Daulatabad Block Primary Health Centre, Under Department of Health & Family Welfare, Government of West Bengal, India, South 24 Parganas, India.
- 2Department of Organon of Medicine and Homoeopathic Philosophy, State National Homoeopathic Medical College and Hospital, Lucknow, India.
- 3Department of AYUSH, Government of Uttar Pradesh, Lucknow, India.
- 4State National Homoeopathic Medical College and Hospital, Lucknow, India.
- 5Department of Materia Medica, State National Homoeopathic Medical College and Hospital, Lucknow, India.
- 6Department of Pathology & Microbiology, D. N. De Homoeopathic Medical College & Hospital, Government of West Bengal, Kolkata, India.
- 7Department of Pathology & Microbiology, Mahesh Bhattacharyya Homoeopathic Medical College & Hospital, Government of West Bengal, Howrah, India.
- 8Department of Repertory, D. N. De Homoeopathic Medical College and Hospital, Kolkata, India.
Let’s nevertheless ask three serious questions:
- According to classical homeopathy, for a cure, one needs a remedy that, when given to a healthy volunteer, causes the symptom one wants to treat. So, does sulfur etc.cause the symptoms of hemorrhoids?
- According to classical homeopathy, the remedy is supposed to cure the condition, not alleviate the symptoms. Is that what the results show?
- Is it plausible that homeopathy can have any effects on hemorrhoids?
I am confident that the answers are: no, no and no.
And this leads me to ask my final question: do we believe these findings?
I let you answer this one!
An article in ‘METRO’ caught my eye – not least because it quotes me. Here are a few edited excerpts:
Peter Stott lost his first wife to cancer in 1998. Her death, he believes, was due to geopathic stress (GS) – harmful energies that originate from the Earth. ‘I found out that the house where we had lived had a serious GS problem,’ he says. The discovery prompted him to become a professional ‘dowser’, devoting his life to finding and managing geopathic stress.
But what exactly is this mysterious force erupting from the surface of the Earth – and can it really harm people?Geopathic stress is said to cause discomfort and health issues for certain individuals. These energies, also called ‘harmful Earth rays’ by believers, can be detrimental, beneficial or neutral according to those who think they are ‘in the know’.
The word ‘geopathic’ is derived from the Greek words ‘Geo’ meaning the Earth and ‘pathos’, meaning disease or suffering – hence the term pathogens, the medical terms for bugs that make us ill.
Dowsing, practitioners say, is a method used to detect the presence of various subtle Earth energies and assess their nature and quality. They argue that some of these energies can be linked to geomagnetic anomalies caused by flowing underground water, dry faults and fissures, subterranean cavities, or mineral and crystal deposits.
Dowsing is carried out by a dowser, practitioners who try to find the source of these energies using special tools, such as pendulums, rods, and bobbers – essentially sexed-up tree branches. The person holds the tool, waiting for it to move or react, which they take as a sign that they’ve found what they’re looking for. The odd practice can allegedly also be used to identify leaks, stress fractures, environmental pollutants, electromagnetic fields, nutritional deficiencies, black spots, and, rather oddly, sexing pigeons.
Peter claims that a skilled dowser effectively advises on the optimal placement of buildings and structures to mitigate the impact of geopathic stress, and often possesses the ability to reduce or eliminate it through the use of various methods. He emphasises the fact that GS ‘does not affect everybody in the same way. Cancer has been described as “a disease of location”,’ he says. ‘And if there is a family history of cancer – as there was in my late wife’s case – a person can be more susceptible to GS being a contributing factor in succumbing to the disease.’ Peter believes that GS impacts our immune system, depleting its resources and hindering its ability to function optimally. By eliminating GS from our surroundings, we allow our immune system to operate more efficiently, he contends. Our susceptibility to GS varies, he says, with some experiencing mild symptoms like sleep disturbances and fatigue, while others may face more severe health issues such as arthritis, multiple sclerosis and cancer.
In 2017, rather incredibly, a report revealed that 10 out of 12 water companies in the UK were employing the practice of water dowsing to identify and locate leaks. Even more incredibly, last year, it emerged that Thames Water and Severn Trent Water were still using this form of ‘witchcraft’ for leak detection, despite scientific research indicating its lack of efficacy.
But water companies aren’t the only ones turning to dowsers for help. Peter believes that ‘it is also possible to carry a token or amulet on your person that has been imbued with the powers of protection by someone who is proficient in [dowsing]’. ‘This can protect you from GS and other detrimental energies wherever you go anywhere throughout the world,’ he claims. ‘Other protection techniques can also offer a degree of protection.’
However, Dr Edzard Ernst, a man who has dedicated years of his life to examining questionable, science-based claims, won’t be enlisting the services of a GS specialist or house healer anytime soon. ‘Geopathic stress cannot cause health problems for the simple reason that it does not exist,’ says the retired physician. ‘It is a sly invention of quacks who exploit gullible consumers. The methods to diagnose GS are as bogus as the ones that allegedly treat it. But the quacks don’t mind – as long as the consumer pays.’
Peter fully acknowledges ‘that dowsing and this work in general is not a catch-all solution for every ailment or every person’s situation’. ‘However, often we are approached by people who are “at the end of their tether” due to their exasperation of experiencing events or circumstances in their lives that are not well catered for in the mainstream wellbeing sector,’ he says. ‘I can only speak personally, I cannot speak for the possibly tens of thousands of dowsers around the world. If our work can help ease a person’s experience of life then that is a good enough reason to continue to help where I can’. He adds that ‘we are never going to change the minds of people like Dr Edzard Ernst’, someone ‘who seems to focus exclusively on debunking anything for which there is not a scientific explanation’. Moreover, science, he notes, ‘is moving on with research done into quantum physics and the theory that everything in the universe is connected and is also accessible to everyone’.
_________________________
Oh, dear Peter!
Perhaps you should learn the difference between critical evaluation and debunking (this ‘debunker’ has shown more forms of so-called alternative medicine (SCAM) to be worthy of integrating into the NHS than anyone else).
Perhaps you should read up about the difference between evidence and belief?
And perhaps the chapter on dowsing in my book could help you in this endeavour:
Dowsing is a common but unproven method for divining water and other materials. In alternative medicine, it is sometimes used as a technique for diagnosing diseases or the causes of health problems.
-
-
- Dowsers employ a motor automatism, amplified through a pendulum, divining rod or similar device. The effect is that the device seemingly provides an independent, visible reaction, while the dowser is, in fact, its true cause.
- Dowsing is used by some homeopaths as an aid to prescribe the optimal remedy and as a tool for identify a miasm or toxin load.
- The assumptions upon which dowsing is based lack plausibility.
- Dowsing has not often been submitted to clinical trials.
- All rigorous attempts to test water dowsing have failed, and it is no longer considered a viable method for this purpose.
- The only randomized double-blind trial that has tested whether homeopaths are able to distinguish between a homeopathic remedy and placebo by dowsing failed to show that it is a valid method. Its authors (well-known homeopaths) drew the following conclusion: “These results, wholly negative, add to doubts whether dowsing in this context can yield objective information.”[1]
- If dowsing is employed for differentiating between truly effective treatments (rather than homeopathic remedies), the risk of false choices would be intolerably high, and serious harm would inevitably be the result.
-
