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

risk/benefit

The WHO has just released guidelines for non-surgical management of chronic primary low back pain (CPLBP). The guideline considers 37 types of interventions across five intervention classes. With the guidelines, WHO recommends non-surgical interventions to help people experiencing CPLBP. These interventions include:

  • education programs that support knowledge and self-care strategies;
  • exercise programs;
  • some physical therapies, such as spinal manipulative therapy (SMT) and massage;
  • psychological therapies, such as cognitive behavioural therapy; and
  • medicines, such as non-steroidal anti-inflammatory medicines.

The guidelines also outline 14 interventions that are not recommended for most people in most contexts. These interventions should not be routinely offered, as WHO evaluation of the available evidence indicate that potential harms likely outweigh the benefits. WHO advises against interventions such as:

  • lumbar braces, belts and/or supports;
  • some physical therapies, such as traction;
  • and some medicines, such as opioid pain killers, which can be associated with overdose and dependence.

As you probably guessed, I am particularly intrigued by the WHO’s positive recommendation for SMT. Here is what the guideline tells us about this specific topic:

Considering all adults, the guideline development group (GDG) judged overall net benefits [of spinal manipulation] across outcomes to range from trivial to moderate while, for older people the benefit was judged to be largely uncertain given the few trials and uncertainty of evidence in this group. Overall, harms were judged to be trivial to small for all adults and uncertain for older people due to lack of evidence.

The GDG commented that while rare, serious adverse events might occur with SMT, particularly in older people (e.g. fragility fracture in people with bone loss), and highlighted that appropriate training and clinical vigilance concerning potential harms are important. The GDG also acknowledged that rare serious adverse events were unlikely to be detected in trials. Some GDG members considered that the balance of benefits to harms favoured SMT due to small to moderate benefits while others felt the balance did not favour SMT, mainly due to the very low certainty evidence for some of the observed benefits.

The GDG judged the overall certainty of evidence to be very low for all adults, and very low for older people, consistent with the systematic review team’s assessment. The GDG judged that there was likely to be important uncertainty or variability among people with CPLBP with respect to their values and preferences, with GDG members noting that some people might prefer manual
therapies such as SMT, due to its “hands-on” nature, while others might not prefer such an approach.

Based on their experience and the evidence presented from the included trials which offered an average of eight treatment sessions, the GDG judged that SMT was likely to be associated with moderate costs, while acknowledging that such costs and the equity impacts from out-of-pocket costs would vary by setting.

The GDG noted that the cost-effectiveness of SMT might not be favourable when patients do not experience symptom improvements early in the treatment course. The GDG judged that in most settings, delivery of SMT would be feasible, although its acceptability was likely to vary across
health workers and people with CPLBP.

The GDG reached a consensus conditional recommendation in favour of SMT on the basis of small to moderate benefits for critical outcomes, predominantly pain and function, and the likelihood of rare adverse events.

The GDG concluded by consensus that the likely short-term benefits outweighed potential harms, and that delivery was feasible in most settings. The conditional nature of the recommendation was informed by variability in acceptability, possible moderate costs, and concerns that equity might be negatively impacted in a user-pays model of financing.

___________________________

This clearly is not a glowing endorsement or recommendation of SMT. Yet, in my view, it is still too positive. In particular, the assessment of harm is woefully deficient. Looking into the finer details, we find how the GDG assessed harms:

WHO commissioned quantitative systematic evidence syntheses of randomized controlled
trials (RCTs) to evaluate the benefits and harms (as reported in included trials) of each of the
prioritized interventions compared with no care (including trials where the effect of an
intervention could be isolated), placebo or usual care for each of the critical outcomes (refer to Table 2 for the PICO criteria for selecting evidence). Research designs other than RCTs
were not considered.

That explains a lot!

It is not possible to establish the harms of SMT (or any other therapy) on the basis of just a few RCTs, particularly because the RCTs in question often fail to report adverse events. I can be sure of this phenomenon because we investigated it via a systematic review:

Objective: To systematically review the reporting of adverse effects in clinical trials of chiropractic manipulation.

Data sources: Six databases were searched from 2000 to July 2011. Randomised clinical trials (RCTs) were considered, if they tested chiropractic manipulations against any control intervention in human patients suffering from any type of clinical condition. The selection of studies, data extraction, and validation were performed independently by two reviewers.

Results: Sixty RCTs had been published. Twenty-nine RCTs did not mention adverse effects at all. Sixteen RCTs reported that no adverse effects had occurred. Complete information on incidence, severity, duration, frequency and method of reporting of adverse effects was included in only one RCT. Conflicts of interests were not mentioned by the majority of authors.

Conclusions: Adverse effects are poorly reported in recent RCTs of chiropractic manipulations.

The GDG did not cite our review (or any other of our articles on the subject) but, as it was published in a very well-known journal, they must have been aware of it. I am afraid that this wilfull ignorance caused the WHO guideline to underestimate the level of harm of SMT. As there is no post-marketing surveillance system for SMT, a realistic assessment of the harm is far from easy and needs to include a carefully weighted summary of all the published reports (such as this one).

The GDG seems to have been aware of (some of) these problems, yet they ignored them and simply assumed (based on wishful thinking?) that the harms were small or trivial.

Why?

Even the most cursory look at the composition of the GDG, begs the question: could it be that the GDG was highjacked by chiropractors and other experts biased towards SMT?

The more I think of it, the more I feel that this might actually be the case. One committee even listed an expert, Scott Haldeman, as a ‘neurologist’ without disclosing that he foremost is a chiropractor who, for most of his professional life, has promoted SMT in one form or another.

Altogether, the WHO guideline is, in my view, a shameful example of pro-chiropractic bias and an unethical disservice to evidence-based medicine.

 

As promised, here is my translation of the article published yesterday in ‘Le Figaro’ arguing in favour of integrating so-called alternative medicine (SCAM) into the French healthcare system [the numbers in square brackets were inserted by me and refer to my comments listed at the bottom].

So-called unconventional healthcare practices (osteopathy, naturopathy, acupuncture, homeopathy and hypnosis, according to the Ministry of Health) are a cause for concern for the health authorities and Miviludes, which in June 2023 set up a committee to support the supervision of unconventional healthcare practices, with the task of informing consumers, patients and professionals about their benefits and risks, both in the community and in hospitals. At the time, various reports, surveys and press articles highlighted the risks associated with NHPs, without pointing to their potential benefits [1] in many indications, provided they are properly supervised. There was panic about the “booming” use of these practices, the “explosion” of aberrations, and the “boost effect” of the pandemic [2].

But what are the real figures? Apart from osteopathy, we lack reliable data in France to confirm a sharp increase in the use of these practices [3]. In Switzerland, where it has been decided to integrate them into university hospitals and to regulate the status of practitioners who are not health professionals, the use of NHPs has increased very slightly [4]. With regard to health-related sectarian aberrations, referrals to Miviludes have been stable since 2017 (around 1,000 per year), but it should be pointed out that they are a poor indicator of the “risk” associated with NHPs (unlike reports). The obvious contrast between the figures and the press reports raises questions [5]. Are we witnessing a drift in communication about the risks of ‘alternative’ therapies? [6] Is this distortion of reality [7] necessary in order to justify altering the informed information and freedom of therapeutic choice of patients, which are ethical and democratic imperatives [8]?

It is the inappropriate use of certain NHPs that constitutes a risk, more than the NHPs themselves! [9] Patients who hope to cure their cancer with acupuncture alone and refuse anti-cancer treatments are clearly using it in a dangerous alternative way [10]. However, acupuncture used to relieve nausea caused by chemotherapy, as a complement to the latter, is recommended by the French Association for Supportive Care [11]. The press is full of the dangers of alternative uses, but they are rare: less than 5% of patients treated for cancer according to a European study [12]. This is still too many. Supervision would reduce this risk even further [13].

Talking about risky use is therefore more relevant than listing “illusory therapies”, vaguely defined as “not scientifically validated” and which are by their very nature “risky” [14]. What’s more, it suggests that conventional treatments are always validated and risk-free [15]. But this is not true! In France, iatrogenic drug use is estimated to cause over 200,000 hospital admissions and 10,000 deaths a year [16]. Yes, some self-medication with phytotherapy or aromatherapy does carry risks… just like any self-medication with conventional medicines [17]. Yes, acupuncture can cause deep organ damage, but these accidents occur in fewer than 5 out of every 100,000 patients [18]. Yes, cervical manipulations by osteopaths can cause serious or even fatal injuries, but these exceptional situations are caused by practitioners who do not comply with the decree governing their practice.[19] Yes, patients can be swindled by charlatans, but there are also therapeutic and financial abuses in conventional medicine, such as those reported in dental and ophthalmology centres. [20]

Are patients really that naive? No. 56% are aware that “natural” remedies can have harmful side-effects, and 70% know that there is a risk of sectarian aberrations or of patients being taken in by a sect [21]. In view of the strong demand from patients, we believe that guaranteeing safe access to certain NHPs is an integral part of their supervision, based on regulation of the training and status of practitioners who are not health professionals, transparent communication, appropriate research, the development of hospital services and outpatient networks of so-called “integrative” medicine combining conventional practices and NHPs, structured care pathways with qualified professionals, precise indications and a safe context for treatment.[22] This pragmatic approach to reducing risky drug use [17] has demonstrated its effectiveness in addictionology [23]. It should inspire decision-makers in the use of NHPs”.

  1. Reports about things going wrong usually do not include benefits. For instance, for a report about rail strikes it would be silly to include a paragraph on the benefits of rail transport. Moreover, it is possible that the benefits were not well documented or even non-existent.
  2. No, there was no panic but some well-deserved criticism and concern.
  3. Would it not be the task of practitioners to provide reliable data of their growth or decline?
  4. The situation in Switzerland is often depicted by enthusiasts as speaking in favour of SCAM; however, the reality is very different.
  5. Even if reports were exaggerated, the fact is that the SCAM community does as good as nothing to prevent abuse.
  6. For decades, these therapies were depicted as gentle and harmless (medicines douces!). As they can cause harm, it is high time that there is a shift in reporting and consumers are informed responsibly.
  7. What seems a ‘distortion of reality’ to enthusiasts might merely be a shift to responsible reporting akin to that in conventional medicine where emerging risks are taken seriously.
  8. Are you saying that informing consumers about risks is not an ethical imperative? I’d argue it is an imperative that outweighs all others.
  9. What if both the inappropriate and the appropriate use involve risks?
  10.  Sadly, there are practitioners who advocate this type of usage.
  11. The recommendation might be outdated; current evidence is far less certain that this treatment might be effective (“the certainty of evidence was generally low or very low“)
  12. The dangers depend on a range of factors, not least the nature of the therapy; in case of spinal manipulation, for instance, about 50% of all patients suffer adverse effects which can be severe, even fatal.
  13. Do you have any evidence showing that supervision would reduce this risk, or is this statement based on wishful thinking?
  14. As my previous comments demonstrate, this statement is erroneous.
  15. No, it does not.
  16. Even if this figure is correct, we need to look at the risk/benefit balance. How many lives were saved by conventional medicine?
  17. Again: please look at the risk/benefit balance.
  18. How can you be confident about these figures in the absence of any post-marketing surveillance system? The answer is, you cannot!
  19. No, they occur even with well-trained practitioners who comply with all the rules and regulations that exist – spoiler: there hardly are any rules and regulations!
  20. Correct! But this is a fallacious argument that has nothing to do with SCAM. Please read up about the ‘tu quoque’ and the strawman’ fallacies.
  21. If true, that is good news. Yet, it is impossible to deny that thousands of websites try to convince the consumer that SCAM is gentle and safe.
  22. Strong demand is not a substitute for reliable evidence. In any case, you stated above that demand is not increasing, didn’t you?
  23. Effectiveness in addictionology? Do you have any evidence for this or is that statement also based on wishful thinking?

My conclusion after analysing this article in detail is that it is poorly argued, based on misunderstandings, errors, and wishful thinking. It cannot possibly convince rational thinkers that SCAM should be integrated into conventional healthcare.

PS

The list of signatories can be found in the original paper.

“Le Figaro” has published two articles (one contra and one pro) authored by ‘NoFakeMed’ (an association of health professionals warning of the danger of fake medicine) signed by a long list of healthcare professionals (including myself) who argue that so-called alternative medicine (SCAM) should be excluded from public healthcare. It relates to the fact that, since last June, a committee set up by the French government has been bringing together opponents and supporters of SCAM. At the heart of the debate is the question of how SCAMs should be regulated, and the place they should occupy in the realm of healthcare. Should they be included or excluded?

Here is the piece arguing for EXCLUSION (my translation):

They’re called alternative medicine, complementary medicine, parallel medicine, alternative medicine, SCAM, and other fancy words. The authorities prefer to call them “non-conventional healthcare practices” (NCSP), or “non-conventional health practices” (NCHP). The choice of terminology is more than just a parochial quarrel: it’s a question of knowing what quality of medicine we want, and whether we agree to endorse illusory techniques whose main argument is their popularity. This raises the question of how to regulate these practices. Some people want to force them into the healthcare system, hospitals, health centres and nursing homes. And they are prepared to use all manner of oratory and caricature to legitimise questionable practices.

Unconventional healthcare practices are on the up, and the number of practitioners and practices has been rising steadily since the 2000s; there are now around 400 therapeutic NHPs. But their success is often due to a lack of understanding of the philosophy behind them, and their lack of effectiveness beyond context effects. This was seen in the debate surrounding homeopathy, which lost much of the confidence placed in it as soon as it stopped to be reimbursed in France and was confronted with the work of popularising it on its own merits among the general public. The ethical imperative of respect for patients means providing them with reliable information so that they can make a free and informed choice.

This raises the question of the place or otherwise to be given to NHPs within the healthcare system. Although there are many different names for them, they are all practices that claim to relate to care and well-being, without having been proven to be effective, and based on theories that are not supported by scientific evidence. Admittedly, the evidence is evolving, and a practice can demonstrate its usefulness in healthcare. This is true, for instance, of hypnosis, whose usefulness as a tool in certain situations is no longer debated since it has become possible to measure and explain both its benefits and its limitations.

However, there is no question of legitimising the entire range of NHPs on the pretext that they are supposedly harmless. Many of them do have adverse effects, sometimes serious, either directly or because they lead to a lack of care. These effects also exist with conventional treatments, but the risks must always be weighed against the proven benefits. The risks associated with NHPs are therefore unacceptable, given their ineffectiveness.

Furthermore, there are abuses associated with NHPs, even if (fortunately!) they are not frequent. Sectarian aberrations are not systematically linked to NHPs, but here again the risk is unacceptable. In its 2021 activity report, Miviludes indicates that 25% of referrals concern the field of health, and that 70% of these relate to SCAM. The number of health-related referrals has risen from 365 in 2010 to 842 in 2015, and exceed 1,000 in 2021.

Conventional medicine is of course not immune to such aberrations, and Miviludes estimates that 3,000 doctors are linked to a sectarian aberration. But the health professional associations have tackled the problem head-on, notably by setting up a partnership with Miviludes and multiple safeguards (verification of diplomas and authorisation to practise, obligation to undergo continuing training, codes of ethics and public health codes, professional justice, declaration of links of interest, etc.). The professional associations have raised awareness of sexual and gender-based violence, universities are providing training in critical reading of scientific articles, and community initiatives are flourishing to improve public information.

We agree that the choices of our patients must be respected, and everyone has recourse to the wellness practices of their choice. But, at the same time, patients have the right when they consult a healthcare professional, a hospital or a health centre, to know that they will be looked after by healthcare professionals offering conscientious, dedicated, evidence-based care.

In view of the current challenges facing our healthcare system, the response must not be to offer more pseudo-medicine on the pretext that people are already using it. The real answer is to rely on evidence, to provide resources for more research, to continue with research, to rely on social work, not to neglect mental health, to improve disease prevention, and to keep pressure groups at bay, whether they come from pharmaceutical companies or the promoters of esoteric, costly and sometimes dangerous practices.

___________________________

Tomorrow, I will translate and comment on the pro-piece that ‘Le Figaro’ today published alongside this article.

 

PS

The list of signatories can be found in the origninal paper.

In Germany, two doctors, Dr. Christian Denné (from Vechta), Dr. Hans-Werner Bertelsen (from Bremen), and myself have initiated a petition. Here is my translation of its full text:

We, the undersigned, demand that the “homeopathy” training certificates be revoked. After the deletion from the further training regulations of the vast majority of state medical associations (13 out of 17), as well as the deletion from the model further training regulations (MWBO), it is no longer acceptable that medical fees are paid from the solidarity community pot for a sham therapy. The clear vote of the German Medical Association must be followed by consequences for doctors in private practice in order to avoid continuing to support the organised self-deception of a minority that clings to outdated and thus dangerous forms of medical practice.

1. Dubious cash flows – parallel shadow financing

In addition to the payments made to doctors via the associations of statutory health insurance physicians, there is a second method of cash flow that enables the doctors who bill to generate funds for “homeopathy”, bypassing any control functions of the associations of statutory health insurance physicians (plausibility checks, time profiles). The selective contracts concluded for this purpose with the participating health insurance funds, which were concluded directly by many statutory health insurance funds with the “German Central Association of Homeopathic Doctors” (DZVhÄ), above all Barmer GEK, Techniker Krankenkasse and DAK, are not suitable for building trust, but rather enable medical billing fraud due to the lack of any independent control functions on the part of the health insurance KV.

Enabling parallel billing channels while bypassing the KV’s control function means that the important instrument of billing control is boycotted because neither plausibility checks nor time profiles can be created. The Barmer GEK and Techniker Krankenkasse were informed of the criticism of the implementation of this dubious and non-transparent shadow financing. The management boards of both health insurance funds firmly rejected any interest in changing this situation, for example by cancelling the contracts concluded with the DZVhÄ.

2. Dubious therapies instead of talking medicine

It is no longer acceptable that “homeopathy” will still be used in 2023 to pay for sham therapies in a medical context with annual amounts of up to €530 per patient, while talking medicine remains remunerated with single-digit amounts. Talking medicine must no longer be associated with esotericism in order to generate medical fees. The organised self-deception of inclined sections of the medical profession must be stopped for ethical reasons.

3 Dubious social consequences and dangers

It is no longer acceptable that doctors allow themselves to be conditioned into self-deception by participating in expensive, so-called “advanced training courses” and ignore elementary scientific laws in order to fulfil the need for causality of their patient clientele. Numerous – sometimes fatal – consequences, such as missing an indicated therapeutic time window, have been documented. In addition to serious individual medical consequences, social effects such as denial of science, refusal to vaccinate, etc. are increasingly becoming a problem with far-reaching, unforeseeable consequences.


You can go to the petition here.

The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR), a painful condition caused by the compression or irritation of the nerves that supply the shoulders, arms and hands.

A multidisciplinary team autors searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were:

  1. randomized trials,
  2. had at least one conservative treatment arm,
  3. diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests.

Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.

Of the 2561 records identified, 59 trials met the inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively.

There is very-low certainty evidence supporting the use of:

  • acupuncture,
  • prednisolone,
  • cervical manipulation,
  • low-level laser therapy

for pain and disability in the immediate to short-term, and

  • thoracic manipulation,
  • low-level laser therapy

for improvements in cervical range of motion in the immediate term.

There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion.

There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.

The authors concluded that there is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

I agree!

Yet, to patients suffering from CR, this is hardly constructive advice. What should they do vis a vis such disappointing evidence?

They might speak to a orthopedic surgeon; but often there is no indication for an operation. What then?

Patients are bound to try some of the conservative options – but which one?

  • Acupuncture?
  • Prednisolone?
  • Cervical manipulation,?
  • Low-level laser therapy?

My advice is this: be patient – the vast majority of cases resolves spontaneously regardless of therapy – and, if you are desperate, try any of them except cervical manipulation which is burdened with the risk of serious complications and often makes things worse.

So-called alternative medicine (SCAM) interventions are often being discussed as possible treatments for long COVID symptoms. However, comprehensive analysis of current evidence in this setting is still lacking. This review aims to review existing published studies on the use of SCAM interventions for patients experiencing long COVID through a systematic review.

A comprehensive electronic literature search was performed in multiple databases and clinical trial registries from September 2019 to January 2023. RCTs evaluating efficacy and safety of SCAM for long COVID were included. Methodological quality of each included trial was appraised with the Cochrane ‘risk of bias’ tool. A qualitative analysis was conducted due to heterogeneity of included studies.

A total of 14 RCTs with 1195 participants were included in this review. Study findings demonstrated that SCAM interventions could benefit patients with long COVID, especially those suffering from neuropsychiatric disorders, olfactory dysfunction, cognitive impairment, fatigue, breathlessness, and mild-to-moderate lung fibrosis. The main interventions reported were self-administered transcutaneous auricular vagus nerve stimulation, neuro-meditation, dietary supplements, olfactory training, aromatherapy, inspiratory muscle training, concurrent training, and an online breathing and well-being program.

The authors concluded that SCAM interventions may be effective, safe, and acceptable to patients with symptoms of long COVID. However, the findings from this systematic review should be interpreted with caution due to various methodological limitations. More rigorous trials focused on SCAM for long COVID are warranted in the future.

The review’s aim is, in my view, nonsense. SCAM is a diverse field which means that the review must capture a wide range of therapies each represented by just one or two primary studies. In turn, this means that general conclusions across all SCAM will be highly questionable, if not misleading.

Furthermore, I find these conclusions odd and irresponsibly misleading. My main reason for this is the poor methodological quality of the primary studies:

  • Four trials were considered to have unknown bias risk for generating the random sequence due to insufficient information about the specific method of randomization used.
  • Only 5 of the trials provided appropriate random allocation concealment.
  • Only 5 trials were blinded to both participants and personnel.
  •  Three trials were rated as unknown risk of bias since insufficient information was provided.
  • Four trials failed to performed outcome assessment blinding.
  • One trial did not report detailed information about drop-out cases and was defined as high risk of bias. 
  • Three study protocols were unavailable and had relevant outcomes that were not reported in the pre-specified way.

Moreover, safety cannot possibly be reliably estimated on the basis of the data. And finally, the statement that SCAM interventions may be effective, as the authors put it, is in my view not a valid conclusion but a silly platitude.

I therefore suggest to re-formulate the conclusion of this review as follows:

At present there is no sound evidence to assume that any SCAM intervention is effective in the management of long COVID.

I was alerted to the updated and strengthened guidance to ensure safer practice by chiropractors who treat children under the age of 12 years that has recently been published by the Chiropractic Board of Australia after considering the recommendations made by the Safer Care Victoria independent review. The Board also considered community needs and expectations, and specifically the strong support for consumer choice voiced in the public consultation of the independent review.

The Board examined how common themes in the independent review’s recommendations align with its existing regulatory guidance, and used these insights to inform a risk-based approach to updating its Statement on paediatric care. This includes updated advice reinforcing the need to ensure that parents or guardians fully understand their rights and the evidence before treatment is provided to children. ‘Public safety is our priority, and especially so when we consider the care of children’, Board Chair Dr Wayne Minter said.

According to the statement, the Board expects chiropractors to various things, including the following [the numbers in the following passage were added by me and refer to my brief comments below]:

  • inform the patient and their parent/guardian about the quality of the acceptable evidence and explain the basis for the proposed treatment [1]
  • provide the patient and their parent/guardian with information about the risks and benefits of the proposed treatment and the risks of receiving no treatment [2]
  • appropriately document consent, including considering the need for written consent for high-risk procedures [3]
  • refer patients when they have conditions or symptoms outside a chiropractor’s area of competence, for example ‘red flags’ such as the presence of possible serious pathology that requires urgent medical referral to the care of other registered health practitioners [4]

______________________________

  1. I know what is meant by the ‘quality of the evidence’ but am not sure what to make of the ‘quality of the acceptable evidence]. Acceptable by whom? In any case, who checks whether this information is being provided?
  2. Imagine the scenatio following this guidance: Chiro informs that there is a serious risk and no proven benefit – which parent would then procede with the treatment? In any case, the informed consent is incomplete because it also requires information as to which conventional treatment is effective for the condition at had [information that chiros are not competent to provide].
  3. Who checks whether this is done properly?
  4. Arguably, all pediatric conditions or symptoms are outside a chiropractor’s area of competence!

In view of these points, I fear that the updated guidance is a transparent attempt of window dressing, yet unfit for purpose. Most certainly, it does not ensure safer practice by chiropractors who treat children under the age of 12 years.

Mushrooms are somewhat neglected in medical research, I often feel. This systematic review focused on clinical studies testing the effectiveness of mushrooms in cancer care. A total of 39 met the authors’ inclusion criteria. The studies included 12 different mushroom preparations. Some of the findings were encouraging:

  • A survival benefit was reported using Huaier granules (Trametes robiniophila Murr) in 2 hepatocellular carcinoma studies and 1 breast cancer study.
  • A survival benefit was also found in 4 gastric cancer studies using polysaccharide-K (polysaccharide-Kureha; PSK) as an adjuvant therapy.
  • Eleven studies reported a positive immunological response.
  • Quality-of-life (QoL) improvement and/or reduced symptom burden was reported in 14 studies using various mushroom supplements.
  • Most studies reported adverse effects of grade 2 or lower, mainly nausea, vomiting, diarrhea, and muscle pain.

The authors caution that limitations included small sample size and not using randomized controlled trial design. Many of the reviewed studies were observational. Most showed favorable effects of mushroom supplements in reducing the toxicity of chemotherapy, improving QoL, favorable cytokine response, and possibly better clinical outcomes.

The authors concluded that the evidence is inconclusive to recommend the routine use of mushrooms for cancer patients. More trials are needed to explore mushroom use during and after cancer treatment.

The use of mushrooms for medicinal purposes has a long history in many cultures. Some mushrooms are known to be highly poisonous, some have hallucinogenic effects, and some are assumed to have pharmacological effects that have therapeutic potential. Some mushrooms possess pharmacologic properties such as anti-tumour, immunomodulating, antioxidant, cardiovascular, anti-hypercholesterolemic, anti-viral, anti-bacterial, anti-parasitic, anti-fungal, detoxification, hepatoprotective, and anti-diabetic effects.

Many modern medicines were derived from fungi. The best-known example is penicillin; others include several cancer drugs, statins and immunosuppressants. In Traditional Chinese Medicine, numerous herbal mixtures contain mushrooms; examples are reishi, maitake and shiitake which are all assumed to have anti-cancer properties.

As the review authors point out, there is a paucity of clinical trials testing the effectiveness of mushrooms, and the existing studies tend to be of poor quality. At present, most of our knowledge comes from traditional use or test-tube studies. The adverse effects depend on the specific mushroom in question and, can in some instances, be serious.

Considering the potential and the complexity of mycomedicine, I find it surprising to not see much more research into this subject.

It has been reported that a man has been charged after the death of a woman attending a slapping therapy workshop run by Hongchi Xiao. Danielle Carr-Gomm died aged 71 at Cleeve House in Seend, Wiltshire, on 20 October 2016. Hongchi Xiao (60), an alternative healer who advocates a technique known as “slapping therapy”, living in Cloudbreak in California, has now been charged with manslaughter by gross negligence, after being extradited back to the UK.

Xiao promotes paida lajin therapy, also called slapping therapy, in which patients are slapped or slap themselves repeatedly, ostensibly to release toxins from the body. Patients often end up with bruises or bleeding. The technique has its roots in Chinese medicine, but critics say it has no scientific basis. Xiao, who is originally from China and runs the California-based Pailala Institute, has led paida lajin workshops around the world.

Carr-Gomm’s son Matthew said after his mother’s death that she had sought “alternative methods of treating and dealing with her diabetes” because she struggled to inject insulin due to a fear of needles. “I know she was desperate to try and cure herself of this disease,” he said. “She always maintained a healthy lifestyle and was adamant that nothing would stop her from living a full life.”

A warrant for Mr Xiao’s arrest was originally issued in October 2019. He has now been arrested after returning to the United Kingdom from Australia on an extradition warrant and was taken to Gablecross custody in Swindon where he was charged with manslaughter by gross negligence. Police said Xiao, 60, is due to appear in court in Salisbury, southwest England, on Friday.

The Pailala Institute claims to be  a non-profit organization incorporated in California. It is managed by a team of non-paying volunteers to promote and support the self-healing practice of Paida Lajin, led by Mr. HongChi Xiao. Their mission is to “transform our world into a healthier place, by enabling every one of us to awaken our self-healing power, we were born with, to heal ourselves, reducing medical cost and its related potential side effects.”

The institute also claims that “based on Traditional Chinese Medicine, the practice of PaidaLajin helps you to relieve from chronic pain, hypertension or diabetes, without equipment or medication. It can quickly improve your circulation and let your body heal itself. PaidaLajin has facilitated the healing of over 210 different illnesses worldwide. Join millions of practitioners in China, Taiwan, Hong Kong, Bulgaria, Germany, Indonesia, India, South Africa, Australia, etc. Just Google and following their witnesses.”

It goes almost without saying that the evidence for slapping therapy’s effectiveness is non-existent.

That proponents of anthroposophic medicine have strange attitudes towards established and effective immunizations is hardly a secret. The authors of this review defined anthroposophic communities as people following some/certain views more or less loosely connected to the philosophies of anthroposophy. Their systematic review firstly collated evidence documenting outbreaks linked to anthroposophic communities.

A total of 18 measles outbreaks occurred between 1997 and 2011 in European countries. Eight out of 18 measles outbreaks started at Waldorf schools throughout Germany, Switzerland, Austria, Netherlands, and the UK. Although data from community reporting was limited, the measles cases at Waldorf schools were predominantly higher than in mainstream private or state schools across the five countries. Offering measles vaccination catch-ups by public health authorities (which is an effective way to manage a measles outbreak) was described in several articles but was largely refused by both parents and Waldorf schools. The most effective outbreak control strategy was the immediate closure of the Waldorf school and strict rules regarding entry to the school upon reopening.

Secondly, the review summarized the literature on vaccination coverage in anthroposophic communities. Six articles described vaccine coverage in anthroposophic communities, and one article described the personal belief exception (PBE) rate at Waldorf school in the USA. The papers focussed predominantly on diphtheria, pertussis, tetanus and poliomyelitis (DPTP), and mumps, measles and rubella (MMR) vaccines. Two studies studying the vaccination coverage at Waldorf pre-schools/schools, demonstrated overall low immunization coverage at those schools. One article focusing on PBE rates demonstrated a proportionally high rate at Waldorf schools in California. Three studies from the Netherlands measure vaccination coverage in general and focussed specifically on whether there were special groups that showed specifically low coverage. In these studies, anthroposophic communities were identified as showing low coverage. However, one study suggested that anthroposophic communities are not as significant in terms of low coverage as low-income groups. One paper described rates of vaccination refusal in Switzerland. It showed that complementary alternative medicine users, including people who draw on anthroposophic medicine, are more likely to refuse vaccination. However, the paper also shows that this group was more likely to vaccinate against tick-borne diseases and encephalitis than the general population.

Thirdly, the review discussed the literature that summarized theories and factors influencing vaccine decision-making in anthroposophic communities. Eight articles examining factors and theories influencing vaccine decision-making in anthroposophic communities were included. Five articles focused on parents of children attending Waldorf schools or who considered themselves part of an anthroposophic community. Three articles focused on the perspectives of anthroposophic healthcare providers, although two of those articles mixed and compared views with other alternative/complementary providers or allopathic health providers. Of the eight articles, two were quantitative and did not provide an in-depth discussion. The qualitative findings from six articles were summarized in-depth and revealed four themes.

The authors concluded that this systematic review showed that there have been several measles outbreaks linked to anthroposophic communities in Europe. Although studies on vaccination coverage in anthroposophic communities are limited, it appears that coverage is lower than in the general population. Monitoring outbreak numbers and vaccination coverage could be important. Popular beliefs about the anthroposophic communities’ vaccination beliefs are challenged in this review. As the evidence shows the communities are not categorically against vaccines. Moreover, there are a myriad of factors that influence vaccine decision-making of parents belonging to an anthroposophic community. The importance of experiencing childhood illnesses and concerns over long-term side effects were mentioned. Moreover, parents want to be able to individually select vaccines for their children. They consider themselves actively engaged in vaccine decision-making and well-informed. Stigma regarding vaccine choices was mentioned repeatedly mostly by people outside of the anthroposophic community but also by people within the community. This review calls for a better understanding of vaccine choices and beliefs for vaccines beyond MMR, in particular HPV vaccines. The review also highlights a potentially important research gap, which constitutes understanding not only a belief system but the role that stigma may play in making decisions about vaccines.

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If you ask where this strange anti-vaccination stance of anthroposophic medicine comes from, you don’t need to look far:

“In the future, we will eliminate the soul with medicine.

Under the pretext of a ‘healthy point of view’, there will be a vaccine by which the human body will be treated as soon as possible directly at birth,
(1) so that the human being cannot develop the thought of the existence of soul and Spirit.

To materialistic doctors, will be entrusted with the task of removing the soul of humanity.

As today, people are vaccinated against this disease or disease, so in the future, children will
(2) be vaccinated with a substance that can be produced precisely in such a way that people, thanks to this vaccination, will be immune to being subjected to the “madness” of spiritual life.

He would be extremely smart, but he would not develop a conscience, and that is the
(3) true goal of some materialistic circles.

With such a vaccine, you can easily make the etheric body loose in the physical body.
Once the etheric body is detached, the relationship between the universe and the etheric body would become extremely unstable, and man would become
(4) an automaton, for the physical body of man must be polished on this Earth by spiritual will.

So, the vaccine becomes a kind of arymanique [Ahrimanic] force; man can no longer get rid of a given materialistic feeling.
(5) He becomes materialistic of constitution and can no longer rise to the spiritual “.

Rudolf Steiner 

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