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

risk/benefit

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The usage of so-called alternative medicine (SCAM) in pediatric settings has been high for some time. However, the risks of pediatric SCAM use remain under-investigated. Almost 20 years ago, I published this systematic review:

Unconventional therapies have become popular in paediatric and adolescent populations. It is therefore important to define their risks. The aim of this systematic review was to summarise the recent evidence. Computerised literature searches were carried out in five databases to identify all recent reports of adverse events associated with unconventional therapies in children. The reports were summarised in narrative and tabular form. The results show that numerous case reports and several case series have been published since 1990. Investigations of a more systematic nature are, however, rare. Most of the adverse events were associated with herbal medications. Inadequately regulated herbal medicines may contain toxic plant material, be contaminated with heavy metals, or be adulterated with synthetic drugs. The adverse events included bradycardia, brain damage, cardiogenic shock, diabetic coma, encephalopathy, heart rupture, intravascular haemolysis, liver failure, respiratory failure, toxic hepatitis and death. A high degree of uncertainty regarding a causal relationship between therapy and adverse event was frequently noted. The size of the problem and its importance relative to the well-documented risks of conventional treatments are presently unknown. Several unconventional therapies may constitute a risk to the health of children and adolescents. At present, it is impossible to provide reliable incidence figures. It seems important to be vigilant and investigate this area more systematically.

Nothing much has happened since in terms of systematic investigation. But now, a 3-year survey was carried out at the Dutch Pediatric Surveillance Unit. Pediatricians were asked to register cases of adverse events associated with pediatric SCAM usage.

In 3 years, 32 unique adverse events were registered. Twenty-two of these adverse events were indirect and not related to the specific SCAM therapy but due to delaying, changing, or stopping of regular treatment, a deficient or very restrictive diet, or an incorrect diagnosis by a SCAM therapist. These events were associated with many different SCAM therapies.

Nine events were deemed direct adverse events like bodily harm or toxicity and one-third of them occurred in infants. Only supplements, manual therapies, and (Chinese) herbs were involved in these nine events. In one case, there was a risk of a serious adverse event but the harm had not yet occurred.

The authors concluded that relatively few cases of adverse events associated with pediatric SCAM usage were found, mostly due to delaying or stopping conventional treatment. Nevertheless, parents, pediatricians, and SCAM providers should be vigilant for both direct and indirect adverse events in children using SCAM, especially in infants.

The number of cases seems small indeed, but there may be many further adverse events that went unreported. Here are 4 of the documented cases of severe and life-threatening consequences:

  • An 8-year-old child with autoimmune hypothyroidism had his prescribed replaced with an ineffective herbal remedy.
  • A 14-year-old child developed septic shock with multiple organ failure after receiving homeopathy for acute appendicitis.
  • A 14-year-old child needed colectomy after ineffective naturopathic treatments for colitis.
  • A 5-year-old developed secondary adrenal insufficiency after his eczema was treated with Chinese herbal remedies adulterated with large doses of corticosteroids.

In view of the risks – even if small – I suggest that, in pediatric settings, we employ only those SCAMs that are supported by solid evidence. And those are very few indeed.

Many people believe that homeopathy is essentially plant-based – but they are mistaken! Homeopathic remedies can be made from anything: Berlin wall, X-ray, pus, excrement, dental plaque, mobile phone rays, poisons … anything you can possibly think of. So, why not from vaccines?

This is exactly what a pharmacist specialized in homeopathy thought.

It has been reported that the ‘Schloss-Apotheke’ in Koblenz, Germany offered for sale a homeopathic remedy made from the Pfizer vaccine. This has since prompted not only the Chamber of Pharmacists but also the Paul Ehrlich Institute and Pfizer to issue statements. On Friday (30/4/2021) morning, the pharmacy had advertised homeopathic remedies based on the Pfizer/Biontech vaccine. The Westphalia-Lippe Chamber of Pharmacists then issued an explicit warning against it. “We are stunned by this,” said a spokesman. The offer has since disappeared from the pharmacy’s website.

On Friday afternoon, the manufacturer of the original vaccine also intervened. The Paul Ehrlich Institute released a statement making it clear that a vaccine is only safe “if it is administered in accordance with the marketing authorization.”

The Schloss-Apotheke had advertised the product in question with the following words:

“We have Pfizer/BioNTech Covid-19-Vaccine in potentized form up to D30 as globules or dilution (for discharge) in stock.”

The chamber of pharmacists countered with a warming under the heading “Facts instead of Fake News” on Facebook and Instagram:

“Whatever they might contain: These remedies are no effective protection against Covid-19.”

Pharmacy manager, Annette Eichele, of the Schloss-Apotheke claimed she had not sold homeopathic Corona vaccines and stressed that effective vaccines of this kind do not exist. According to Eichele, only an additional “mini drop” of the original Biontech vaccine had been used and “highly potentized” and prepared homeopathically. According to Eichele, Corona vaccinations that had already been administered were thus to have a “better and more correct effect with this supplementary product, possibly without causing side effects … but this is not scientifically proven”. The homeopathic product had been produced only on customer request and had been sold less than a dozen times in the past weeks. Ten grams of the remedy were sold for about 15 Euros. On Twitter, Eichele stated: „Wir haben nichts Böses getan, wir wollten nur Menschen helfen!“ (We have done nothing evil, we only wanted to help people). I am reminded yet again of Bert Brecht who observed:

“The opposite of good is not evil but good intentions”.

 

Thread embedding acupuncture therapy (TEAT) involves the insertion of thread at specific points on the body surface. The claim is that TEAT provides a sustained stimulation of acupoints and is therefore superior to needle acupuncture. Initially, TEAT was used in China to treat obesity, today it is employed to treat many conditions, including musculoskeletal conditions such as ankle sprain, shoulder pain, lumbar intervertebral disc herniation, and plantar fasciitis. Its effectiveness is, however, doubtful and so is its safety.

This review evaluated the safety of thread embedding acupuncture therapy (TEAT) and discuss the prevention and treatment of some adverse events (AEs).

Databases, including China National Knowledge Infrastructure (CNKI), CBMdisc, Wanfang, VIP databases and PubMed, MEDLINE, EMBASE, and Web of Science, were searched from their inception to January 2020. Included were randomized controlled trials (RCTs) and case reports in which AEs with TEAT were reported. Cochrane Collaboration’s tool and RevMan V.5.3.3 software were used to evaluate the quality of the studies.

A total of 61 articles (45 RCTs and 16 case reports) with a total of 620 cases of AEs were included in this review. These studies were published in two countries: China and South Korea. Twenty-eight kinds of AEs were noted. The most common AEs were induration, bleeding and ecchymosis, redness and swelling, fever, and pain. They accounted for 75.35% of all AEs.  Most AEs were mild.; The rarest AEs were epilepsy, irregular menstruation, skin ulcer, thread malabsorption, and fat liquefaction, with 1 case each. Not all of them had a clear causal relationship with TEAT. Most of the AEs were local reactions and systemic reactions accounted for only 1.27%. Although the included studies showed that AEs were very commonly encountered (11.09%), only 5 cases of severe AEs reported from 2013 to 2017 (0.1%) by using catgut thread, which is rarely employed nowadays with new absorbable surgical suture being more popular. All of the patients with severe AEs were recovered after symptomatic treatment with no sequelae.

The authors concluded that the evidence showed that TEAT is a relatively safe and convenient therapy especially since application of new absorbable surgical suture. Improving practitioner skills, regulating operations, and paying attention to the patients’ conditions may reduce the incidence of AEs and improve safety of TEAT.

TEAT was initially used in China only but recently it has become popular elsewhere as well. Therefore the question about its risks has become relevant. The present paper is interesting in that it demonstrates that AEs do occur with some regularity. The authors’ conclusion that TEAT is “relatively safe” is, however, not justified because:

  1. the total sample size was not large enough for a generalizable conclusion;
  2. only RCTs and case reports were included, whereas case series and case-control studies (which would provide more relevant data) were excluded or might not even exist;
  3. RCTs of acupuncture often fail to mention or under-report AEs;
  4. acupuncture papers from China are notoriously unreliable.

So, all we can conclude from the evidence presented here is that AEs after TEAT do occur and do not seem to be all that rare. As the efficacy of TEAT has not been shown beyond doubt, this must inevitably lead to the conclusion that the risk-benefit balance of TEAT is not positive. In turn, that means that TEAT cannot be recommended as a treatment for any condition.

 

Some time ago, I published ‘The 10 commandments of quackery’. Since then, I discovered that there are several errors that occur with such regularity in the comment section of this blog as well as in most other discussions about so-called alternative medicine (SCAM), that – in the hope to improve the logical reasoning of my readers (and often times my own) – it seems timely to publish the

10 ‘commandments’ of rational thought

  1. Thou shalt not confuse popularity of a therapy with its efficacy or safety (appeal to popularity).
  2. Thou shalt not assume that the test of time is a valid substitute for evidence (appeal to tradition).
  3. Thou shalt not believe that natural therapies are necessarily harmless (appeal to nature).
  4. Thou shalt not think that those who question your claim need to prove that you are wrong (reversal of the burden of proof).
  5. Thou shalt not assume that a therapy administered before a symptomatic improvement was necessarily the cause of that outcome (post hoc ergo propter hoc).
  6. Thou shalt not suppose that, because you do not know or understand an issue, it cannot be true (appeal to ignorance).
  7. Thou shalt not misrepresent your opponent’s position in order to make it easier for you to defeat it (straw man fallacy).
  8. Thou shalt not argue that, because others do wrong, you are permitted to do the same (tu quoque fallacy).
  9. Thou shalt not assume that your argument is correct because some authority agrees with you (appeal to authority).
  10. Thou shalt not attack your opponents instead of their arguments (ad hominem).

Yes, I know, one could add a lot more. But these 10 ‘commandments’ relate to the errors in rational thought that I feel would, if taken on board, be most useful in our discussions about SCAM.

Recently, I came across a newspaper asking: “Which vaccine do you trust most?” It turned out that there was a clear favourite according to public opinion. In the present climate of heated debates about COVID vaccines, this seems to make sense.

Or doesn’t it?

What determines public opinion?

There are probably many determinants, but most are dominated by what the public is being told about a subject. If, for instance, the press incessantly reports bad things about a certain vaccine and mostly good news about another, public opinion will reflect exactly that.

What I am trying to point out is this: the man and woman in the street have no expertise in vaccines. They mostly think what they are being told about them. So, public opinion is largely determined by journalists who write about the subject. If then a newspaper presents the public opinion about a vaccine, it is all but a foregone conclusion. The paper might as well just repeat what they have been telling their readers. By presenting a ‘public opinion’ about vaccines they actually go one step further: they amplify their own opinion by pretending it is not of their making but that of the public.

All this seems fairly obvious, once you start thinking about it.

So, why do I go on about it?

If this phenomenon occurs with vaccines, it also occurs with other issues, for instance, so-called alternative medicine (SCAM). We often hear that the public is in favour of this or that type of SCAM. It is supposed to convince us and politicians that SCAM is good. If thousands or even millions are in favour of it, it must be good! Who am I to disagree with the public?

But, as we have just seen with the example of the vaccines, public opinion is merely a reflection of what the press tells people. The man and the woman in the street are not competent to reliably estimate the risk-benefit ratios of St John’s wort, Arnica, glucosamine, acupuncture, etc. etc. They can judge such issues as little as they can judge the risk-benefit balance of a vaccine. They rely on information from the outside, and that information usually reaches them by the press.

What am I aiming at?

Public opinion sounds impressive, and in the realm of SCAM, it often determines much. If the public opinion is in favour of homoeopathy, for instance, politicians are likely to lend their support to it. Yet, public opinion is just OPINION! It cannot be used as an indicator for the efficacy or safety of medical interventions, and it cannot be the reason for using or rejecting them.

It follows, I think, that journalists have a huge responsibility to inform the public correctly on SCAM (and any other matter). On this blog, we have seen numerous instances of journalists who could have done better, e.g.:

Public opinion, it seems to me, can only be meaningful, if the information fed to the public is sound. And when it comes to SCAM, this condition is often not met.

 

 

After yesterday’s post entitled ‘What does a holistic doctor do that a traditional doctor doesn’t?‘, I thought it would only be fair to turn the question around and ask: What does a proper doctor do that a holistic healer doesn’t? The answers will upset a lot of practitioners of alternative medicine (SCAM), but so be it.

So, what does a proper doctor do that a holistic healer doesn’t?

I suggest several answers and hope that the readers of this blog will contribute to further points. Many of them center around safeguarding the public:

  • Proper doctors avoid confusing or misleading the public with titles they do not have.
  • They do have rigorous education and training.
  • They avoid making false therapeutic claims.
  • They adhere to the ethical standards of their profession.
  • They resist the temptation to advertise their services to the consumer.
  • They do their best to identify the cause of their patient’s symptoms.
  • They treat the causes of disease whenever possible.
  • They avoid pretending that they always have all the answers.
  • They abide by the rules of evidence-based medicine.
  • They are aware that almost any effective treatment comes with adverse effects.
  • They try to keep abreast with the rapid advances in medicine.
  • They know that a patient is more than a diagnostic label.
  • They try to treat patients holistically.

At this stage, I can hear some readers shout in anger:

  • Ahh, but that is rubbish!
  • I know doctors who are not at all like that!
  • You are idealizing your profession!
  • This is little more than wishful thinking!

Yes, I know that many patients are disappointed and have had a bad experience with conventional medicine. That is one of the reasons many try SCAM. I know that many doctors occasionally fail to live up to the ideal that I depicted above. And I fear that some do so more often than just occasionally.

This is regrettable and occasionally it is unacceptable. Medicine is populated not by perfect people; it is run by humans like you and me. Humans are fallible. Doctors have bad days just like you and me. If that happens regularly, we need to address the problems that may the cause of the deficit. If necessary, the case has to go before a disciplinary hearing. There are thousands of experts who are dedicated to improving healthcare in the hope of generating progress.

The point I was trying to make is that there is such a thing as an ideal physician. It relies on:

  • rigorous training,
  • ethical codes,
  • post-graduate education,
  • supervision,
  • governance,
  • swift disciplinary procedures,
  • advances brought about through colossal research efforts,
  • etc., etc.

Do ‘holistic healers’ offer all of these safeguards?

The sad answer is no.

For those who disagree, let’s briefly look at a recent example.

John Lawler died in 2017 after being treated by a chiropractor (as discussed on this blog before).

  • Mr. Lawler died because of a tear and dislocation of the C4/C5 intervertebral disc caused by a considerable external force.
  • The pathologist’s report also showed that the deceased’s ligaments holding the vertebrae of the upper spine in place were ossified.
  • This is a common abnormality in elderly patients and limits the range of movement of the neck.
  • There was no adequately informed consent by Mr. Lawler.
  • Mr. Lawler seemed to have been under the impression that the chiropractor, who used the ‘Dr’ title, was a medical doctor.
  • There is no reason to assume that the treatment of Mr. Lawler’s neck would be effective for his pain located in his leg.
  • The chiropractor used an ‘activator’ that applies only little and well-controlled force. However, she also employed a ‘drop table’ which applies a larger and not well-controlled force.

As far as I can see, most of the safeguards and standards that apply to conventional medicine were not in place to safeguard Mr. Lawler. And that includes a timely disciplinary hearing of the case. Mr. Lawler died in 2017! The CCG has been dragging its feet ever since, and, as far as I know, the chiropractor was meanwhile allowed to practise. The HEARING BEFORE THE PROFESSIONAL CONDUCT COMMITTEE OF THE GENERAL CHIROPRACTIC COUNCIL has now been scheduled to commence on 19 April 2021.

I know, it’s just an example. But it should make us think.

The Chinese have made several attempts to persuade us that their traditional remedies are effective for COVID-19 infections. Here is yet another one. This review summarised the evidence of the therapeutic effects and safety of Chinese herbal medicine (CHM) used with or without conventional western therapy for COVID-19. All clinical studies of the therapeutic effects and safety of CHM for COVID-19 were included. The authors

  • summarized the general characteristics of included studies,
  • evaluated the methodological quality of the randomized controlled trials (RCTs) using the Cochrane risk of bias tool,
  • analyzed the use of CHM,
  • used Revman 5.4 software to present the risk ratio (RR) or mean difference (MD) and their 95% confidence interval (CI) to estimate the therapeutic effects and safety of CHM.

A total of 58 clinical studies were identified including;

  • 10 RCTs,
  • 1 non-randomized controlled trials,
  • 11 retrospective studies with a control group,
  • 12 case-series,
  • 24 case-reports.

All of the studies had been performed in China. No RCTs of high methodological quality were identified. The most frequently tested oral Chinese patent medicine, Chinese herbal medicine injection, or prescribed herbal decoction were:

  • Lianhua Qingwen granule/capsule,
  • Xuebijing injection,
  • Maxing Shigan Tang.

The pooled analyses showed that there were statistical differences between the intervention group and the comparator group (RR 0.42, 95% CI 0.21 to 0.82, six RCTs; RR 0.38, 95% CI 0.23 to 0.64, five retrospective studies with a control group), indicating that CHM plus conventional western therapy appeared to be better than conventional western therapy alone in reducing aggravation rate.

In addition, compared with conventional western therapy, CHM plus conventional western therapy had the potential advantages in increasing the recovery rate and shortening the duration of fever, cough, and fatigue, improving the negative conversion rate of nucleic acid test, and increasing the improvement rate of chest CT manifestations and shortening the time from receiving the treatment to the beginning of chest CT manifestations improvement.

For adverse events, the pooled data showed that there were no statistical differences between the CHM and the control groups.

The authors concluded that current low certainty evidence suggests that there maybe a tendency that CHM plus conventional western therapy is superior to conventional western therapy alone. The use of CHM did not increase the risk of adverse events.

One of the principles to remember here is this: RUBBISH IN, RUBBISH OUT. If you meta-analyze primary data that are rubbish, your findings can only be rubbish as well.

All one needs to know about the primary data entered into the present analysis is that there were no rigorous RCTs… not one! That means the evidence is, as the authors rightly but modestly conclude of LOW CERTAINTY. My conclusions would have been a little different:

  1. In terms of safety, the dataset is too small and unreliable to make any judgment.
  2. In terms of efficacy, there is no sound data that CHM has a positive effect.

The COMPLEMENTARY AND NATURAL HEALTHCARE COUNCIL describe themselves as follows:

We were set up by the government to protect the public. We do this by providing an independent UK register of complementary healthcare practitioners. Protection of the public is our sole purpose.

We set the standards that practitioners need to meet to get onto and then stay on the register. All CNHC registrants have agreed to be bound by the highest standards of conduct and have registered voluntarily. All of them are professionally trained and fully insured to practise.

We investigate complaints about alleged breaches of our Code of Conduct, Ethics and Performance. We impose disciplinary sanctions that mirror those of the statutory healthcare regulators.

We make the case to government and a wide range of organisations for the use of complementary healthcare to enhance the UK’s health and wellbeing. We raise awareness of complementary healthcare and seek to influence policy wherever possible to increase access to the disciplines we register.

At present, the CNHC are looking for new board members:

Are you interested in setting standards in the public interest? CNHC is the independent regulatory body for complementary healthcare practitioners, established in 2008 with support and funding from the Department of Health. Our public register of over 6,300 qualified therapists provides confirmation that individuals have met UK standards for safe and competent practice.

The Board meets for a half-day four times a year. In normal circumstances meetings are held in London. There is no remuneration but travel costs are reimbursed.

We have vacancies for one Lay and two Registrant Board members.

Although not essential, CNHC are particularly interested in applications from individuals with a background in financial management or accounting.

Deadline for applications is 26 March 2021. Interviews for a Lay member will be held via Zoom on 15 April and for Registrant members on 14 April.

Full information about the work of CNHC is available on our website.

I think it would be desirable for new members to be rational thinkers. I, therefore, encourage all skeptics and rationalists to apply via their website … but expect the job to be a challenge!

Therapeutic touch (TT) is a form of paranormal or energy healing developed by Dora Kunz (1904-1999), a psychic and alternative practitioner, in collaboration with Dolores Krieger, a professor of nursing. According to Kunz, TT has its origins in ancient Yogic texts. TT is popular and practiced predominantly by US nurses; it is currently being taught in more than 80 colleges and universities in the U.S., and in more than seventy countries. According to one TT-organisation, TT is a holistic, evidence-based therapy that incorporates the intentional and compassionate use of universal energy to promote balance and well-being. It is a consciously directed process of energy exchange during which the practitioner uses the hands as a focus to facilitate the process.

The assumptions that form the basis for TT are not biologically plausible. But that does not necessarily mean it is ineffective.

This study was conducted to assess the effect of therapeutic touch on stress, daytime sleepiness, sleep quality, and fatigue among students of nursing and midwifery.

A total of 96 students were randomized into three groups: the therapeutic touch (TT) group, the sham therapeutic touch (STT) group, and the control group. The TT group was subjected to therapeutic touch twice a week for 4 weeks with each session lasting 20 min.

When the TT group was compared to the STT and control groups following the intervention, the decrease in the levels of stress, fatigue, and daytime sleepiness, as well as the increase in the sleep quality were found to be significant.

The authors concluded that TT, which is one form of complementary therapy, was relatively effective in decreasing the levels of stress, fatigue and daytime sleepiness, and in increasing the sleep quality of university students of nursing and midwifery.

Several previous trials and reviews of TT are available. However, many of them were conducted ardent proponents of TT, seriously flawed, and thus less than reliable. One rigorous pre-clinical study, co-designed by a 9-year-old girl, found that experienced TT practitioners were unable to detect the investigator’s “energy field.” Their failure to substantiate TT’s most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified.

In my recent book, I concluded that there are no reasons to assume that TT causes any meaningful effects beyond placebo. One could, however, argue that, like all forms of paranormal healing, it undermines rational thinking.

Does the new study change my judgment?

I am afraid not!

This recent article is truly remarkable:

There is a faction within the chiropractic profession passionately advocating against the routine use of X-rays in the diagnosis, treatment and management of patients with spinal disorders (aka subluxation). These activists reiterate common false statements such as “there is no evidence” for biomechanical spine assessment by X-ray, “there are no guidelines” supporting routine imaging, and also promulgate the reiterating narrative that “X-rays are dangerous.” These arguments come in the form of recycled allopathic “red flag only” medical guidelines for spine care, opinion pieces and consensus statements. Herein, we review these common arguments and present compelling data refuting such claims. It quickly becomes evident that these statements are false. They are based on cherry-picked medical references and, most importantly, expansive evidence against this narrative continues to be ignored. Factually, there is considerable evidential support for routine use of radiological imaging in chiropractic and manual therapies for 3 main purposes: 1. To assess spinopelvic biomechanical parameters; 2. To screen for relative and absolute contraindications; 3. To reassess a patient’s progress from some forms of spine altering treatments. Finally, and most importantly, we summarize why the long-held notion of carcinogenicity from X-rays is not a valid argument.

Not only is low dose radiation not detrimental, but it also protects us from cancer, according to the authors:

Exposures to low-dose radiation incites multiple and multi-hierarchical biopositive mechanisms that prevent, repair or remove damage caused mostly by endogenous reactive oxygen species (ROS) and H2O2 from aerobic metabolism. Indeed, non-radiogenic (i.e. naturally occurring) molecular damage occurs daily at rates many orders of magnitude greater than the rate of damage caused by low-dose radiation such as diagnostic X-rays. It is estimated that the endogenous genetic damage caused on a daily basis from simply breathing air is about one million times the damage initially resulting from an X-ray. We concur that “it is factually preposterous to have radiophobic cancer concerns from medical X-rays after considering the daily burden of endogenous DNA damage.”

And, of course, radiological imaging makes sense in cases of non-specific back pain due to ‘malalignment’ of the spine:

Pressures to restrict the use of “repeat” (i.e. follow-up) X-rays for assessing patient response to treatment shows a complete disregard for the evidence discussed that definitively illustrates how modern spine rehabilitation techniques and practices successfully re-align the spine and pelvis for a wide variety of presenting subluxation/deformity patterns. The continued anti-X-ray sentiment from “consensus” and opinion within chiropractic needs to stop; it is antithetical to scientific reality and to the practice of contemporary chiropractic practice. We reiterate a quote from the late Michael A. Persinger: “what is happening in recent years is that facts are being defined by consensus. If a group of people think that something is correct, therefore it’s true, and that’s contradictory to science.”

Thus, the authors feel entitled to conclude:

Routine and repeat X-rays in the nonsurgical treatment of patients with spine disorders is an evidence-based clinical practice that is warranted by those that practice spine-altering methods. The evidence supporting such practices is based on definitive evidence supporting the rationale to assess a patient’s spinopelvic parameters for biomechanical diagnosis, to screen for relative and absolute contraindications for specific spine care methods, and to re-assess the spine and postural response to treatment.

The traditional and underlying presumption of the carcinogenicity from X-rays is not a valid notion because the LNT is not valid for low-dose exposures. The ALARA radiation protection principle is obsolete, the threshold for harm is high, low-dose exposures prevent cancers by stimulating and upregulating the body’s innate adaptive protection mechanisms, the TCD concept in invalid, and aged cohort studies assumed to show cancers resulting from previous X-rays are not generalizable to the wider population because they represent populations predisposed to cancers.

Red flags, or suspected serious underlying disease is a valid consideration warranting screening imaging by all spine care providers. We contend, however, that as long as the treating physician or rehabilitation therapist is practicing evidence-based methods, proven to improve spine and postural parameters in order to provide relief for the myriad of spinal disorders, spinal X-rays are unequivocally justified. Non-surgical spine care guidelines need to account for proven and evolving non-surgical methods that are radiographically guided, patient-centered, and competently practiced by those specialty trained in such methods. This is over and above so-called “red flag only” guidelines. The efforts to universally dissuade chiropractors from routine and repeat X-ray imaging is neither scientifically justified nor ethical.

There seems to be just one problem here: the broad consensus is against almost anything these authors claim.

Oh, I almost forgot: this paper was authored and sponsored by CBP NonProfit.

“The mission of Chiropractic BioPhysics® (CBP®) Non-Profit is to provide a research based response to these changing times that is clinically, technically, and philosophically sound. By joining together, we can participate in the redefinition and updating of the chiropractic profession through state of the art spine research efforts. This journey, all of us must take as a Chiropractic health care profession to become the best we can be for the sake of the betterment of patient care. CBP Non-Profit’s efforts focus on corrective Chiropractic care through structural rehabilitation of the spine and posture. Further, CBP Non-Profit, Inc. has in its purpose to fund Chiropractic student scholarships where appropriate as well as donate needed chiropractic equipment to chiropractic colleges; always trying to support chiropractic advancement and education.”

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