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

survey

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Earlier this year, I started the ‘WORST PAPER OF 2022 COMPETITION’. As a prize, I am offering the winner (that is the lead author of the winning paper) one of my books that best fits his/her subject. I am sure this will overjoy him or her. I hope to identify about 10 candidates for the prize, and towards the end of the year, I let my readers decide democratically on who should be the winner. In this spirit of democratic voting, let me suggest to you entry No 9. Here is the unadulterated abstract:

Background

With the increasing popularity of traditional Chinese medicine (TCM) by the global community, how to teach basic knowledge of TCM to international students and improve the teaching quality are important issues for teachers of TCM. The present study was to analyze the perceptions from both students and teachers on how to improve TCM learning internationally.

Methods

A cross-sectional national survey was conducted at 23 universities/colleges across China. A structured, self-reported on-line questionnaire was administered to 34 Chinese teachers who taught TCM course in English and to 1016 international undergraduates who were enrolled in the TCM course in China between 2017 and 2021.

Results

Thirty-three (97.1%) teachers and 900 (88.6%) undergraduates agreed Chinese culture should be fully integrated into TCM courses. All teachers and 944 (92.9%) undergraduates thought that TCM had important significance in the clinical practice. All teachers and 995 (97.9%) undergraduates agreed that modern research of TCM is valuable. Thirty-three (97.1%) teachers and 959 (94.4%) undergraduates thought comparing traditional medicine in different countries with TCM can help the students better understand TCM. Thirty-two (94.1%) teachers and 962 (94.7%) undergraduates agreed on the use of practical teaching method with case reports. From the perceptions of the undergraduates, the top three beneficial learning styles were practice (34.3%), teacher’s lectures (32.5%), case studies (10.4%). The first choice of learning mode was attending to face-to-face teaching (82.3%). The top three interesting contents were acupuncture (75.5%), Chinese herbal medicine (63.8%), and massage (55.0%).

Conclusion

To improve TCM learning among international undergraduates majoring in conventional medicine, integration of Chinese culture into TCM course, comparison of traditional medicine in different countries with TCM, application of the teaching method with case reports, and emphasization of clinical practice as well as modern research on TCM should be fully considered.

I am impressed with this paper mainly because to me it does not make any sense at all. To be blunt, I find it farcically nonsensical. What precisely? Everything:

  • the research question,
  • the methodology,
  • the conclusion
  • the write-up,
  • the list of authors and their affiliations: Department of Chinese Integrative Medicine, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, China, Department of Traditional Chinese Medicine, School of Basic Medicine, Qingdao University, Qingdao, China, Department of Chinese Integrative Medicine, The Second Affiliated Hospital of Kunming Medical University, Kunming, China, Department of Traditional Chinese Medicine, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China, Department of Traditional Chinese Medicine, Medical College, China Three Gorges University, Yichang, China, Basic Teaching and Research Department of Acupuncture and Moxibustion, College of Traditional Chinese Medicine, Xinjiang Medical University, Urumqi, China, Institute of Integrative Medicine, Dalian Medical University, Dalian, China, Department of Chinese and Western Medicine, Chongqing Medical University, Chongqing, China, Department of Chinese and Western Medicine, North Sichuan Medical College, Nanchong, China, Department of Chinese and Western Medicine, School of Medicine, Xiamen University, Xiamen, China, School of Traditional Chinese Medicine, Capital Medical University, Beijing, China, School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, China, Department of Traditional Chinese Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China, Department of Traditional Chinese Medicine, School of Medicine, Xiamen University, Xiamen, China, Department of Chinese Medicine/Department of Chinese Integrative Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China, Department of Traditional Chinese Medicine, Shengjing Hospital Affiliated to China Medical University, Shenyang, China, Department of Acupuncture, Affiliated Hospital of Jiangsu University, Zhenjiang, China, Teaching and Research Section of Traditional Chinese Medicine, The Second Affiliated Hospital of Soochow University, Suzhou, China, Department of Traditional Chinese Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, China, Department of Chinese Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, China, Department of Chinese Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, China, Department of Traditional Chinese Medicine, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China, Department of Chinese Medicine, The First Affiliated Hospital of Jinzhou Medicine University, Jinzhou, China, Department of Integrated Traditional and Western Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China, Department of Chinese Medicine, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China, Department of Traditional Chinese Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
  • the journal that had this paper peer-reviewed and published.

But what impressed me most with this paper is the way the authors managed to avoid even the slightest hint of critical thinking. They even included a short paragraph in the discussion section where they elaborate on the limitations of their work without ever discussing the true flaws in the conception and execution of this extraordinary example of pseudoscience.

The Sunday Times reported yesterday reported that five NHS trusts currently offer moxibustion to women in childbirth for breech babies, i.e. babies presenting upside down. Moxibustion is a form of Traditional Chinese Medicine (TCM) where mugwort is burned close to acupuncture points. The idea is that this procedure would stimulate the acupuncture point similar to the more common way using needle insertion. The fifth toe is viewed as the best traditional acupuncture point for breech presentation, and the treatment is said to turn the baby in the uterus so that it can be delivered more easily.

At least four NHS trusts are offering acupuncture and reflexology with aromatherapy to help women with delayed pregnancies, while 15 NHS trusts offer hypnobirthing classes. Some women are asked to pay fees of up to £140 for it. These treatments are supposed to relax the mother in the hope that this will speed up the process of childbirth.

The Nice guidelines on maternity care say the NHS should not offer acupuncture, acupressure, or hypnosis unless specifically requested by women. The reason for the Nice warning is simple: there is no convincing evidence that these therapies are effective.

Campaigner Catherine Roy who compiled the list of treatments said: “To one degree or another, the Royal College of Midwives, the Care Quality Commission and parts of the NHS support these pseudoscientific treatments.

“They are seen as innocuous but they carry risks, can delay medical help and participate in an anti-medicalisation stance specific to ‘normal birth’ ideology and maternity care. Nice guidelines are clear that they should not be offered by clinicians for treatment. NHS England must ensure that pseudoscience and non-evidence based treatments are removed from NHS maternity care.”

Birte Harlev-Lam, executive director of the Royal College of Midwives (RCM), said: “We want every woman to have as positive an experience during pregnancy, labour, birth and the postnatal period as possible — and, most importantly, we want that experience to be safe. That is why we recommend all maternity services to follow Nice guidance and for midwives to practise in line with the code set out by the Nursing and Midwifery Council.”

A spokeswoman for Nice said it was reviewing its maternity guidelines. NHS national clinical director for maternity and women’s health, Dr Matthew Jolly, said: “All NHS services are expected to offer safe and personalised clinical care and local NHS areas should commission core maternity services using the latest NICE and clinical guidance. NHS trusts are under no obligation to provide complementary or alternative therapies on top of evidence-based clinical care, but where they do in response to the wishes of mothers it is vital that the highest standards of safety are maintained.”

On this blog, we have repeatedly discussed the strange love affair of midwives with so-called alternative medicine (SCAM), for instance, here. In 2012, we published a summary of 19 surveys on the subject. It showed that the prevalence of SCAM use varied but was often close to 100%. Much of it did not seem to be supported by strong evidence for efficacy. We concluded that most midwives seem to use SCAM. As not all SCAMs are without risks, the issue should be debated openly. Today, there is plenty more evidence to show that the advice of midwives regarding SCAM is not just not evidence-based but also often dangerous. This, of course, begs the question: when will the professional organizations of midwifery do something about it?

This study described osteopathic practise activity, scope of practice and the osteopathic patient profile in order to understand the role osteopathy plays within the United Kingdom’s (UK) health system a decade after the authors’ previous survey.

The researchers used a retrospective questionnaire survey design to ask about osteopathic practice and audit patient case notes. All UK-registered osteopaths were invited to participate in the survey. The survey was conducted using a web-based system. Each participating osteopath was asked about themselves, and their practice and asked to randomly select and extract data from up to 8 random new patient health records during 2018. All patient-related data were anonymized.

The survey response rate was 500 osteopaths (9.4% of the profession) who provided information about 395 patients and 2,215 consultations. Most osteopaths were:

  • self-employed (81.1%; 344/424 responses),
  • working alone either exclusively or often (63.9%; 237/371),
  • able to offer 48.6% of patients an appointment within 3 days (184/379).

Patient ages ranged from 1 month to 96 years (mean 44.7 years, Std Dev. 21.5), of these 58.4% (227/389) were female. Infants <1 years old represented 4.8% (18/379) of patients. The majority of patients presented with musculoskeletal complaints (81.0%; 306/378) followed by pediatric conditions (5%). Persistent complaints (present for more than 12 weeks before the appointment) were the most common (67.9%; 256/377) and 41.7% (156/374) of patients had co-existing medical conditions.

The most common treatment approaches used at the first appointment were:

  • soft-tissue techniques (73.9%; 292/395),
  • articulatory techniques (69.4%; 274/395),
  • high-velocity low-amplitude thrust (34.4%; 136/395),
  • cranial techniques (23%).

The mean number of treatments per patient was 7 (mode 4). Osteopaths’ referral to other healthcare practitioners amounted to:

  • GPs 29%
  • Other complementary therapists 21%
  • Other osteopaths 18%

The authors concluded that osteopaths predominantly provide care of musculoskeletal conditions, typically in private practice. To better understand the role of osteopathy in UK health service delivery, the profession needs to do more research with patients in order to understand their needs and their expected outcomes of care, and for this to inform osteopathic practice and education.

What can we conclude from a survey that has a 9% response rate?

Nothing!

If I ignore this fact, do I find anything of interest here?

Not a lot!

Perhaps just three points:

  1. Osteopaths use high-velocity low-amplitude thrusts, the type of manipulation that has most frequently been associated with serious complications, too frequently.
  2. They also employ cranial osteopathy, which is probably the least plausible technique in their repertoire, too often.
  3. They refer patients too frequently to other SCAM practitioners and too rarely to GPs.

To come back to the question asked in the title of this post: What do UK osteopaths do? My answer is

ALMOST NOTHING THAT MIGHT BE USEFUL.

Have you ever wondered how good or bad the education of chiropractors and osteopaths is? Well, I have – and this new paper promises to provide an answer.

The aim of this study was to explore Australian chiropractic and osteopathic new graduates’ readiness for transition to practice concerning their clinical skills, professional behaviors, and interprofessional abilities. Phase 1 explored final-year students’ self-perceptions, and this part uncovered their opinions after 6 months or more in practice.

Interviews were conducted with a self-selecting sample of phase 1 participant graduates from 2 Australian chiropractic and 2 osteopathic programs. Results of the thematic content analysis of responses were compared to the Australian Chiropractic Standards and Osteopathic Capabilities, the authority documents at the time of the study.

Interviews from graduates of 2 chiropractic courses (n = 6) and 2 osteopathic courses (n = 8) revealed that the majority had positive comments about their readiness for practice. Most were satisfied with their level of clinical skills, verbal communication skills, and manual therapy skills. Gaps in competence were identified in written communications such as case notes and referrals to enable interprofessional practice, understanding of professional behaviors, and business skills. These identified gaps suggest that these graduates are not fully cognizant of what it means to manage their business practices in a manner expected of a health professional.

The authors concluded that this small study into clinical training for chiropractic and osteopathy suggests that graduates lack some necessary skills and that it is possible that the ideals and goals for clinical education, to prepare for the transition to practice, may not be fully realized or deliver all the desired prerequisites for graduate practice.

Their conclusions in the actual paper finish with these sentences, in the main, graduate participants and the final year students were unable to articulate what professional behaviors were expected of them. The identified gaps suggest these graduates are not fully cognizant of what it means to manage their business practices in a manner expected of a health professional.

In several ways, this is a remarkable paper – remarkably poor, I hasten to add. Apart from the fact that its sample size was tiny and the response rate was low, it has many further limitations. Most notably, the clinical skills, professional behaviors, and interprofessional abilities were not assessed. All the researchers did was ask the participants how good or bad they were at these skills. Is this method going to generate reliable evidence? I very much doubt it!

Imagine, these guys have just paid tidy sums for their ‘education’ and they have no experience to speak of. Are they going to be in a good position to critically evaluate their abilities? No, I fear not!

Considering these flaws and the fact that chiropractors and osteopaths are not exactly known for their skills of critical thinking, I find it amazing that important deficits in their abilities nevertheless emerge. If I had to formulate a conclusion from all this, I might therefore suggest this:

A dismal study seems to suggest that chiropractic and osteopathic schooling is dismal. 

PS

Come to think of it, there might be another fitting option:

Yet another team of chiro- and osteos demonstrate that they don’t know how to do science.

Traditional, complementary, and alternative medicine (TCAM) – as most of my readers know, I prefer the abbreviation SCAM for so-called alternative medicine – refers to a broad range of health practices and products typically not part of the ‘conventional medicine’ system. Its use is substantial among the general population. TCAM products and therapies may be used in addition to, or instead of, conventional medicine approaches, and some have been associated with adverse reactions or other harms.

The aims of this systematic review were to identify and examine recently published national studies globally on the prevalence of TCAM use in the general population, to review the research methods used in these studies, and to propose best practices for future studies exploring the prevalence of use of TCAM.

MEDLINE, Embase, CINAHL, PsycINFO, and AMED were searched to identify relevant studies published since 2010. Reports describing the prevalence of TCAM use in a national study among the general population were included. The quality of included studies was assessed using a risk of bias tool developed by Hoy et al. Relevant data were extracted and summarised.

Forty studies from 14 countries, comprising 21 national surveys and one cross-national survey, were included. Studies explored the use of TCAM products (e.g. herbal medicines), TCAM practitioners/therapies, or both. Included studies used different TCAM definitions, prevalence time frames and data collection tools, methods and analyses, thereby limiting comparability across studies. The reported prevalence of use of TCAM (products and/or practitioners/therapies) over the previous 12 months was 24–71.3%.

The authors concluded that the reported prevalence of use of TCAM (products and/or practitioners/therapies) is high, but may underestimate use. Published prevalence data varied considerably, at least in part because studies utilise different data collection tools, methods and operational definitions, limiting cross-study comparisons and study reproducibility. For best practice, comprehensive, detailed data on TCAM exposures are needed, and studies should report an operational definition (including the context of TCAM use, products/practices/therapies included and excluded), publish survey questions and describe the data-coding criteria and analysis approach used.

[Trends in prevalence of TCAM use by country for countries with at least two data collection waves from a nationally representative study. For data collected over several years (e.g. 2007–2009), the prevalence data are plotted at the end of the data collection period (e.g. 2009). Solid and perforated lines between consecutive points are for illustrative purposes only and are not intended to represent linearity. NHANES National Health and Nutrition Examination Survey, NHIS National Health and Interview Survey, SLAN Survey of Lifestyle, Attitudes and Nutrition.]

The review discloses that the prevalence reported across countries ranges from 24 to 71%. This huge variability is not very surprising; some of the many reasons for this phenomenon include:

  • different TCAM definitions,
  • different prevalence time frames,
  • different data collection tools,
  • different methods of analyzing the data.

Despite these problems, the information summarized in the review is fascinating in several respects. For me, the most interesting message here is this: the plethora of claims that SCAM use is increasing are not supported by sound evidence.

An article in THE TIMES seems worth mentioning. Here are some excerpts:

… Maternity care at Nottingham University Hospitals NHS Trust (NUH) is the subject of an inquiry, prompted by dozens of baby deaths. More than 450 families have now come forward to take part in the review, led by the expert midwife Donna Ockenden. The trust now faces further scrutiny over its use of aromatherapy, after experts branded guidelines at the trust “shocking” and not backed by evidence. Several bereaved families have said they recall aromatherapy being heavily promoted at the trust’s maternity units.

It is being prosecuted over the death of baby Wynter Andrews just 23 minutes after she was born in September 2019. Her mother Sarah Andrews wrote on Twitter that she remembered aromatherapy being seen as “the answer to everything”. Internal guidelines, first highlighted by the maternity commentator Catherine Roy, suggest using essential oils if the placenta does not follow the baby out of the womb quickly enough…  the NUH guidelines say aromatherapy can help expel the placenta, and suggest midwives ask women to inhale oils such as clary sage, jasmine, lavender or basil, while applying others as an abdominal compress. They also describe the oils as “extremely effective for the prevention of and, in some cases, the treatment of infection”. The guidelines also suggest essential oils to help women suffering from cystitis, or as a compress on a caesarean section wound. Nice guidelines for those situations do not recommend aromatherapy…

The NUH adds frankincense “may calm hysteria” and is “recommended in situations of maternal panic”. Roy said: “It is shocking that dangerous advice seemed to have been approved by a team of healthcare professionals at NUH. There is a high tolerance for pseudoscience in NHS maternity care … and it needs to stop. Women deserve high quality care, not dangerous quackery.” …

________________________________

The journalist who wrote the article also asked me for a comment, and I emailed her this quote: “Aromatherapy is little more than a bit of pampering; no doubt it is enjoyable but it is not an effective therapy for anything. To use it in medical emergencies seems irresponsible to say the least.” The Times evidently decided not to include my thoughts.

Having now read the article, I checked again and failed to find good evidence for aromatherapy for any of the mentioned conditions. However, I did find an article and an announcement both of which are quite worrying, in my view:

Aromatherapy is often misunderstood and consequently somewhat marginalized. Because of a basic misinterpretation, the integration of aromatherapy into UK hospitals is not moving forward as quickly as it might. Aromatherapy in UK is primarily aimed at enhancing patient care or improving patient satisfaction, and it is frequently mixed with massage. Little focus is given to the real clinical potential, except for a few pockets such as the Micap/South Manchester University initiative which led to a Phase 1 clinical trial into the effects of aromatherapy on infection carried out in the Burns Unit of Wythenshawe Hospital. This article discusses the expansion of aromatherapy within the US and follows 10 years of developing protocols and policies that led to pilot studies on radiation burns, chemo-induced nausea, slow-healing wounds, Alzheimers and end-of-life agitation. The article poses two questions: should nursing take aromatherapy more seriously and do nurses really need 60 hours of massage to use aromatherapy as part of nursing practice?

My own views on aromatherapy are expressed in our now not entirely up-to-date review:

Aromatherapy is the therapeutic use of essential oil from herbs, flowers, and other plants. The aim of this overview was to provide an overview of systematic reviews evaluating the effectiveness of aromatherapy. We searched 12 electronic databases and our departmental files without restrictions of time or language. The methodological quality of all systematic reviews was evaluated independently by two authors. Of 201 potentially relevant publications, 10 met our inclusion criteria. Most of the systematic reviews were of poor methodological quality. The clinical subject areas were hypertension, depression, anxiety, pain relief, and dementia. For none of the conditions was the evidence convincing. Several SRs of aromatherapy have recently been published. Due to a number of caveats, the evidence is not sufficiently convincing that aromatherapy is an effective therapy for any condition.

In this context, it might also be worth mentioning that we warned about the frequent usage of quackery in midwifery years ago. Here is our systematic review of 2012 published in a leading midwifery journal:

Background: in recent years, several surveys have suggested that many midwives use some form of complementary/alternative therapy (CAT), often without the knowledge of obstetricians.

Objective: to systematically review all surveys of CAT use by midwives.

Search strategy: six electronic databases were searched using text terms and MeSH for CAT and midwifery.

Selection criteria: surveys were included if they reported quantitative data on the prevalence of CAT use by midwives.

Data collection and analysis: full-text articles of all relevant surveys were obtained. Data were extracted according to pre-defined criteria.

Main results: 19 surveys met the inclusion criteria. Most were recent and from the USA. Prevalence data varied but were usually high, often close to 100%. Much use of CATs does not seem to be supported by strong evidence for efficacy.

Conclusion: most midwives seem to use CATs. As not all CATs are without risks, the issue should be debated openly.

I am tired of saying ‘I TOLD YOU SO!’ but nevertheless find it a pity that our warning remained (yet again) unheeded!

The US Food and Drug Administration created the Tainted Dietary Supplement Database in 2007 to identify dietary supplements adulterated with active pharmaceutical ingredients (APIs). This article compared API adulterations in dietary supplements from the 10-year time period of 2007 through 2016 to the most recent 5-year period of 2017 through 2021. Its findings are alarming:

  • From 2007 through 2021, 1068 unique products were found to be adulterated with APIs.
  • Sexual enhancement and weight-loss dietary supplements are the most common products adulterated with APIs.
  • Phosphodiesterase-5 inhibitors are commonly included in sexual enhancement dietary supplements.
  • A single product can include up to 5 APIs.
  • Sibutramine, a drug removed from the market due to cardiovascular adverse events, is the most included adulterant API in weight loss products.
  • Sibutramine analogues, phenolphthalein (which was removed from the US market because of cancer risk), and fluoxetine were also included.
  • Muscle-building dietary supplements were commonly adulterated before 2016, but since 2017 no additional adulterated products have been identified.

The authors concluded that the lack of disclosure of APIs in dietary supplements, circumventing the normal procedure with clinician oversight of prescription drug use, and the use of APIs that are banned by the Food and Drug Administration or used in combinations that were never studied are important health risks for consumers.

The problem of adulterated supplements is by no means new. A similar review published 4 years ago already warned that “active pharmaceuticals continue to be identified in dietary supplements, especially those marketed for sexual enhancement or weight loss, even after FDA warnings. The drug ingredients in these dietary supplements have the potential to cause serious adverse health effects owing to accidental misuse, overuse, or interaction with other medications, underlying health conditions, or other pharmaceuticals within the supplement.”

These papers relate to the US where supplement use is highly prevalent. The harm done by adulterated products is thus huge. If we focus on Chinese or Ayurvedic supplements, the problem might even be more serious. In 2002, my own review concluded that adulteration of Chinese herbal medicines with synthetic drugs is a potentially serious problem which needs to be addressed by adequate regulatory measures. Twenty years later, we seem to be still waiting for effective regulations that protect the consumer.

Progress in medicine, they say, is made funeral by funeral!

 

The purpose of this study was to examine the trends in the expenditure and utilization of chiropractic care in a representative sample of children and adolescents in the United States (US) aged <18 years.

The researchers evaluated serial cross-sectional data (2007-2016) from the Medical Expenditure Panel Survey. Weighted descriptive statistics were conducted to derive national estimates of expenditure and utilization, and linear regression was used to determine trends over time. Sociodemographic and clinical characteristics of chiropractic users were also reported.

A statistically significant increasing trend was observed for the number of children receiving chiropractic care (P <.05) and chiropractic utilization rate (P < .05). Increases in chiropractic expenditure and the number of chiropractic visits were also observed over time but were not statistically significant (P > .05). The mean annual number of visits was 6.4 visits, with a mean expenditure of $71.49 US dollars (USD) per visit and $454.08 USD per child. Children and adolescent chiropractic users in the United States were primarily 14 to 17 years old (39.6%-61.6%), White (71.5%-76.9%), male (50.6%-51.3%), and privately insured (56.7%-60.8%). Chiropractic visits in this population primarily involved low back conditions (52.4%), spinal curvature (14.0%), and head and neck complaints (12.8%).

The authors concluded that the number of children visiting a chiropractor and percent utilization showed a statistically significant, increasing trend from 2007 to 2016; however, total expenditure and the number of chiropractic visits did not significantly differ during this period. These findings provide novel insight into the patterns of chiropractic utilization in this understudied age group.

Why are these numbers increasing?

Is it because of increasing and sound evidence showing that chiropractors do more good than harm to kids?

No!

A recent systematic review of the evidence for effectiveness and harms of specific spinal manipulation therapy (SMT) techniques for infants, and children suggests the opposite.

Its authors searched electronic databases up to December 2017. Controlled studies, describing primary SMT treatment in infants (<1 year) and children/adolescents (1–18 years), were included to determine effectiveness. Controlled and observational studies and case reports were included to examine harms. One author screened titles and abstracts and two authors independently screened the full text of potentially eligible studies for inclusion. Two authors assessed the risk of bias in included studies and the quality of the body of evidence using the GRADE methodology. Data were described according to PRISMA guidelines and CONSORT and TIDieR checklists. If appropriate, a random-effects meta-analysis was performed.

Of the 1,236 identified papers, 26 studies were eligible. In all but 3 studies, the therapists were chiropractors. Infants and children/adolescents were treated for various (non-)musculoskeletal indications, hypothesized to be related to spinal joint dysfunction. Studies examining the same population, indication, and treatment comparison were scarce. Due to very low-quality evidence, it is uncertain whether gentle, low-velocity mobilizations reduce complaints in infants with colic or torticollis, and whether high-velocity, low-amplitude manipulations reduce complaints in children/adolescents with autism, asthma, nocturnal enuresis, headache or idiopathic scoliosis. Five case reports described severe harms after HVLA manipulations in 4 infants and one child. Mild, transient harms were reported after gentle spinal mobilizations in infants and children and could be interpreted as a side effect of treatment.

The authors concluded that, based on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents. Outcomes in the included studies were mostly parent or patient-reported; studies did not report on intermediate outcomes to assess the effectiveness of SMT techniques in relation to the hypothesized spinal dysfunction. Severe harms were relatively scarce, poorly described and likely to be associated with underlying missed pathology. Gentle, low-velocity spinal mobilizations seem to be a safe treatment technique in infants, children and adolescents. We encourage future research to describe effectiveness and safety of specific SMT techniques instead of SMT as a general treatment approach.

But chiros do more than just SMT, I hear some say.

Yes, they do!

But they nevertheless manipulate virtually every patient, and the additional treatments they use are merely borrowed from other disciplines.

So, why are the numbers increasing then?

I suggest this as a main reason:

chiropractors are systematically misleading the public about the value of their trade.

This study used a US nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided.

NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. The investigators examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for a health visit. They ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide the development of logistic regression models.

Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem.

The authors concluded that these data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

The authors used the same dataset for a 2nd paper which examined the reasons why office-based physicians do or do not recommend four selected complementary health approaches to their patients in the context of the Andersen Behavioral Model. Descriptive estimates were employed of physician-level data from the 2012 National Ambulatory Medical Care Survey (NAMCS) Physician Induction Interview, a nationally representative survey of office-based physicians (N = 5622, weighted response rate = 59.7%). The endpoints were the reasons for the recommendation or lack thereof to patients for:

  • herbs,
  • other non-vitamin supplements,
  • chiropractic/osteopathic manipulation,
  • acupuncture,
  • mind-body therapies (including meditation, guided imagery, and progressive relaxation).

Differences by physician sex and medical specialty were described.

For each of the four complementary health approaches, more than half of the physicians who made recommendations indicated that they were influenced by scientific evidence in peer-reviewed journals (ranging from 52.0% for chiropractic/osteopathic manipulation [95% confidence interval, CI = 47.6-56.3] to 71.3% for herbs and other non-vitamin supplements [95% CI = 66.9-75.4]). More than 60% of all physicians recommended each of the four complementary health approaches because of patient requests. A higher percentage of female physicians reported evidence in peer-reviewed journals as a rationale for recommending herbs and non-vitamin supplements or chiropractic/osteopathic manipulation when compared with male physicians (herbs and non-vitamin supplements: 78.8% [95% CI = 72.4-84.3] vs. 66.6% [95% CI = 60.8-72.2]; chiropractic/osteopathic manipulation: 62.3% [95% CI = 54.7-69.4] vs. 47.5% [95% CI = 42.3-52.7]).

For each of the four complementary health approaches, a lack of perceived benefit was the most frequently reported reason by both sexes for not recommending. Lack of information sources was reported more often by female versus male physicians as a reason to not recommend herbs and non-vitamin supplements (31.4% [95% CI = 26.8-36.3] vs. 23.4% [95% CI = 21.0-25.9]).

The authors concluded that there are limited nationally representative data on the reasons as to why office-based physicians decide to recommend complementary health approaches to patients. Developing a more nuanced understanding of influencing factors in physicians’ decision making regarding complementary health approaches may better inform researchers and educators, and aid physicians in making evidence-based recommendations for patients.

I am not sure what these papers really offer in terms of information that is not obvious or that makes a meaningful contribution to progress. It almost seems that, because the data of such surveys are available, such analyses get done and published. The far better reason for doing research is, of course, the desire to answer a burning and relevant research question.

A problem then arises when researchers, who perceive the use of so-called alternative medicine (SCAM) as a fundamentally good thing, write a paper that smells more of SCAM promotion than meaningful science. Having said that, I find it encouraging to read in the two papers that

  • the prevalence of SCAM remains quite low,
  • more than 60% of all physicians recommended SCAM not because they were convinced of its value but because of patient requests,
  • the lack of perceived benefit was the most frequently reported reason for not recommending it.

During the last two years, I have written more often than I care to remember about the numerous links between so-called alternative medicine (SCAM) and COVID-19 vaccination hesitancy. For instance:

Whenever I publish a post on these subjects, some enthusiasts of SCAM argue that, despite all this evidence, they are not really against COVID vaccinations. But who is correct? What proportions of SCAM practitioners are pro or contra? One way to find out is to check how they themselves behave. Do they get vaccinated or not?

Here are some recent data from Canada that seem to provide an answer.

A breakdown of vaccination rates among Canadian healthcare professions has been released, based on data gathered from 17 of B.C.’s 18 regulated colleges. The findings are most revealing:

  • dieticians, physicians, and surgeons lead the way, with vaccination rates of 98%,
  • occupational therapists were at 97%,
  • Chinese medicine practitioners and acupuncturists were at 79%,
  • chiropractors at 78%
  • naturopaths at 69%.

The provincial health officer Dr. Bonnie Henry said the province is still working with the colleges on how to notify patients about their practitioner’s vaccination status. “We are working with each college on how to build it into professional standards. The overriding principle is patient status,” she told a news conference. “It may be things like when you call to book, you are asked whether you would prefer to see a vaccinated or unvaccinated professional. We are trying to protect privacy and provide agency to make the decision.”

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As far as I am aware, these are unique data. It would be interesting to see additional evidence. If anyone knows about vaccination rates in other countries of acupuncturists, herbalists, homeopaths, osteopaths, Heilpraktiker, etc. I would love to learn more.

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