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

survey

1 2 3 6

About 85% of German children are treated with herbal remedies. Yet, little is known about the effects of such interventions. A new study might tell us more.

This analysis accessed 2063 datasets from the paediatric population in the PhytoVIS data base, screening for information on indication, gender, treatment, co-medication and tolerability. The results suggest that the majority of patients was treated with herbal medicine for the following conditions:

  • common cold,
  • fever,
  • digestive complaints,
  • skin diseases,
  • sleep disturbances
  • anxiety.

The perceived effect of the therapy was rated in 84% of the patients as very good or good without adverse events.

The authors concluded that the results confirm the good clinical effects and safety of herbal medicinal products in this patient population and show that they are widely used in Germany.

If you are a fan of herbal medicine, you will be jubilant. If, on the other hand, you are a critical thinker or a responsible healthcare professional, you might wonder what this database is, why it was set up and how exactly these findings were produced. Here are some details:

The data were collected by means of a retrospective, anonymous, one-off survey consisting of 20 questions on the user’s experience with herbal remedies. The questions included complaints/ disease, information on drug use, concomitant factors/diseases as well as basic patient data. Trained interviewers performed the interviews in pharmacies and doctor’s offices. Data were collected in the Western Part of Germany between April 2014 and December 2016. The only inclusion criterion was the intake of herbal drugs in the last 8 weeks before the individual interview. The primary endpoint was the effect and tolerability of the products according to the user.

And who participated in this survey? If I understand it correctly, the survey is based on a convenience sample of parents using herbal remedies. This means that those parents who had a positive experience tended to volunteer, while those with a negative experience were absent or tended to refuse. (Thus the survey is not far from the scenario I often use where people in a hamburger restaurant are questioned whether they like hamburgers.)

So, there are two very obvious factors other than the effectiveness of herbal remedies determining the results:

  1. selection bias,
  2. lack of objective outcome measure.

This means that conclusions about the clinical effects of herbal remedies in paediatric patients are quite simply not possible on the basis of this survey. So, why do the authors nevertheless draw such conclusions (without a critical discussion of the limitations of their survey)?

Could it have something to do with the sponsor of the research?

The PhytoVIS study was funded by the Kooperation Phytopharmaka GbR Bonn, Germany.

Or could it have something to do with the affiliations of the paper’s authors:

1 Institute of Pharmacy, University of Leipzig, Brüderstr. 34, 04103, Leipzig, Germny. nieberkaren@gmx.de.

2 Kooperation Phytopharmaka GbR, Plittersdorfer Str. 218, 573, Bonn, Germany. nieberkaren@gmx.de.

3 Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.

4 ClinNovis GmbH, Genter Str. 7, 50672, Cologne, Germany.

5 Bayer Consumer Health, Research & Development, Phytomedicines Supply and Development Center, Steigerwald Arzneimittelwerk GmbH, Havelstr. 5, 64295, Darmstadt, Germany.

6 Kooperation Phytopharmaka GbR, Plittersdorfer Str. 218, 53173, Bonn, Germany.

7 Institute of Pharmaceutical Biology, Goethe University Frankfurt, Max-von-Laue-Str. 9, 60438, Frankfurt, Germany.

8 Chair of Naturopathy, University Medicine Rostock, Ernst-Heydemann Str. 6, 18057, Rostock, Germany.

WHAT DO YOU THINK?

There are no representative studies using a probability sample examining whether US physicians recommend so-called alternative medicines (SCAMs) to their patients. This article fills a void in the current literature for robust data on recommendations for SCAMs by office-based physicians in the US.

Descriptive statistics and multivariable regression analyses of physician-level data were from the 2012 Physician Induction Interview of the National Ambulatory Medical Care Survey (NAMCS PII), a nationally representative survey of office-based physicians. Weighted response rate among eligible physicians sampled for the 2012 NAMCS PII was 59.7%.

Recommendations by physicians to their patients were recorded for any SCAM, and the following individual SCAMs: massage therapy, herbs/nonvitamin supplements, chiropractic/osteopathic manipulation, yoga, acupuncture, and mind–body therapies.

Massage therapy was the most commonly recommended SCAM (30.4%), followed by chiropractic/osteopathic manipulation (27.1%), herbs/nonvitamin supplements (26.5%), yoga (25.6%), and acupuncture (22.4%). The most commonly recommended SCAMs by general/family practice physicians were chiropractic/osteopathic manipulation (54.0%) and massage therapy (52.6%). Of all U.S. physicians, 53.1% recommended at least one SCAM to patients during the previous 12 months. Multivariable analyses found physician’s sex, race, specialty, and U.S. region to be significant predictors of SCAMrecommendations. Female physicians were more likely than male physicians to recommend massage therapy, herbs/nonvitamin supplements, yoga, acupuncture, and mind–body therapies to patients. Psychiatrists, OB/GYNs, and paediatricians were all less likely to recommend chiropractic/osteopathic manipulation than general and family practitioners.

The authors concluded that, overall, more than half of office-based physicians recommended at least one SCAM to their patients. Female physicians recommended every individual SCAM at a higher rate than male physicians except for chiropractic and osteopathic manipulation. These findings may enable consumers, physicians, and medical schools to better understand potential differences in use of SCAMs with patients.

Yes, I know!

Who cares what type of SCAMs US physicians recommended to their patients 7 years ago?

And who knows what the true figures would have looked like, if the ~40% who did not respond would have been included?

Such surveys usually tell us little of relevance. What is worse, they are misused for exploiting the ‘appeal to authority’ fallacy which hold that, if physicians recommend SCAMs, they must be fine. That this is a fallacy becomes obvious, if we remind ourselves that US physicians also are the main cause for the current opioid crisis in the US (if physicians recommend opioids, they must be fine???).

More importantly, I think, this survey also suggests the following:

  1. 73% of US physicians do NOT recommend chiropractic/osteopathic manipulations.
  2. 73% of them do NOT recommend herbal medicine.
  3. 74% of them do NOT recommend yoga.
  4. 77% of them do NOT recommend acupuncture.

I wonder why!

 

This survey investigated how many chiropractors in the Canadian province of Alberta promote a theory of subluxation, which health ailments or improvements were linked to subluxation, and whether the subluxation discourse was used to promote chiropractic for particular demographics.

Using the search engine on the Canadian Chiropractic Associations’ website, the researchers made a list of all clinics in Alberta. They then used Google searches to obtain a URL for each clinic with a website, totalling 324 URLs for 369 clinics. They then searched on each website for “subluxation” and performed content analysis on the related content.

One hundred twenty-one clinics’ websites (33%) presented a theory of vertebral subluxation. The ailments and improvements discussed in relation to subluxation were wide-ranging; they included the following:

  • ADHD,
  • allergies,
  • asthma,
  • autism,
  • back pain,
  • bed wetting
  • blood pressure,
  • cold,
  • colitis,
  • constipation,
  • diarrhoea,
  • dizziness,
  • ear infection,
  • epilepsy,
  • fatigue,
  • fever,
  • flu,
  • headache,
  • heart disease,
  • hormonal imbalance,
  • inflammation,
  • learning problems,
  • menstrual cramps,
  • MS,
  • nausea,
  • pain,
  • Parkinson’s disease,
  • problems with hearing,
  • problems with vision,
  • prostate cancer,
  • respiratory disease,
  • sciatica,
  • scoliosis,
  • sleeping problems,
  • spinal decay,
  • sudden infant death syndrome,
  • and many more.

The marketing of chiropractic for children was observed on 8% of the clinic websites.

The researchers concluded that, based on the controversy surrounding vertebral subluxation, the substantial number of clinic websites aligning their practice with vertebral subluxation should cause concern for regulatory bodies.

Why do so many chiropractors cling so tightly to the long obsolete concept of subluxation? The way I see it there are at least three reasons:

  1.  If they abandoned subluxation, they would quickly become physiotherapists, only with a much reduced scope of practice.
  2. Using the subluxation myth avoids the need of the knowledge of any complicated pathophysiology.
  3.  Subluxation is ever so good for business, as it renders chiropractic manipulation a cure all.

D. D. Palmer, the magnetic healer who invented chiropractic about 120 years ago, claimed that a vital energy, which he called the “innate”, controls all body functions. In the presence of “vertebral subluxation,” it cannot work adequately, he postulated. In other words, subluxations block the flow of the innate which, in turn, is the cause of all disease. Palmer therefore developed spinal manipulations to correct such subluxations and de-block the flow of the innate. Palmer defined chiropractic as a system of healing based on the premise that the body requires unobstructed flow through the nervous system of innate intelligence. This effectively makes the adjustment of subluxation a panacea.

To put it simply: subluxation is the carte blanche required for making unlimited bogus claims, while ripping off the public.

 

On this blog and elsewhere, I have repeatedly claimed that as early as 2002 I published data to show that UK homeopaths advise their patients against vaccinations.

So sorry, but this not entirely true!

The truth is that I had forgotten about this article published 1995 in the British Journal of General Practice. As it is quite short and reveals several interesting facts, allow me to provide it here in full:

Homoeopathic remedies are believed by doctors and patients to be almost totally safe. Is homoeopathic advice safe, for example on the subject of immunization? In order to answer this question, a questionnaire survey was undertaken in 1995 of all 45 homoeopaths listed in the Exeter ‘yellow pages’ business directory. A total of 23 replies (51%) were received, 10 from medically qualified and 13 from non-medically qualified homoeopaths.

The homoeopaths were asked to suggest which conditions they perceived as being most responsive to homoeopathy. The three most frequently cited conditions were allergies (suggested by 10 respondents), gynaecological problems (seven) and bowel problems (five). They were then asked to estimate the proportion of patients that were referred to them by orthodox doctors and the proportion that they referred to orthodox doctors. The mean estimated percentages were 1 % and 8%, respectively. The 23 respondents estimated that they spent a mean of 73 minutes on the first consultation.

The homoeopaths were asked whether they used or recommended orthodox immunization for children and whether they only used and recommended homoeopathic immunization. Seven of the 10 homoeopaths who were medically qualified recommended orthodox immunization but none of the 13 non-medically qualified homoeopaths did. One non-medically qualified homoeopath only used and recommended homoeopathic immunization.

Homoeopaths have been reported as being against orthodox immunization and advocating homoeopathic immunization for which no evidence of effectiveness exists. As yet there has been no attempt in the United Kingdom to monitor homoeopaths’ attitudes in this respect. The above findings imply that there may be a problem.

The British homoeopathic doctors’ organization (the Faculty of Homoeopathy) has distanced itself from the polemic of other homoeopaths against orthodox immunization, and editorials in the British Homoeopathic Journal call the abandonment of mass immunization ‘criminally irresponsible’ and ‘most unfortunate, in that it will be seen by most people as irresponsible and poorly based’.’ Homoeopathic remedies may be safe, but do all homoeopaths merit this attribute?

Yes indeed! These findings indicate that there may be a problem with non-medically trained homeopaths in the UK. It is good to see that now (24 years later) the NHS has taken note of it. At the same time, it is not at all good to see that non-medically trained homeopaths and their professional organisations have managed to remain in complete denial of it.

As reported, the Bavarian government has set aside almost half a million Euros for research to determine whether the over-use of antibiotics can be reduced by replacing them with homeopathic remedies. Homeopaths in and beyond Germany were delighted, of course, but many experts were bewildered (see also this or this, if you read German).

While the Bavarians are entering the planning stage of this research, I want to elaborate on the question what methodology might be employed for this task. As far as I can see, there are, depending on the precise research questions, various options.

IN VITRO TESTS OF HOMEOPATHICS

The most straight forward way to find out whether homeopathics are an alternative to antibiotics would be to screen them for antibiotic activity. For this, we would take all homeopathic remedies in several potencies that are commonly used, for instance D12 and C30, and add them to bacterial cultures. To cover even part of the range of homeopathic remedies, several thousand such tests would be required. The remedies that show activity in vitro would then be candidates for further clinical tests.

I doubt that this will generate meaningful findings. As homeopaths would probably point out quickly, they never claimed that their remedies have any antibiotic effects. Homeopathics work not via pharmacological mechanisms (there is none), they stimulate the vital force, the immune system, or whatever mystical force you fancy. Faced with the inevitably negative results of in vitro tests, homeopaths would merely shrug their shoulders and say: ‘we told you so’.

ANIMAL MODELS

Thus it might be more constructive to go directly into animal models. Such tests could take several shapes and forms. For instance, scientists could infect animals with a bacterium and subsequently treat one group with a high potency homeopathic remedy and the control group with a placebo. If the homeopathic animals survive, while the controls die, the homeopathic treatment was effective.

Such concepts would run into problems on at least two levels. Firstly, any ethics committee worth its name would refuse to pass such a protocol and argue that it is not ethical to infect and then treat animals with two different types of placebo. Secondly, the homeopathic fraternity would explain that homeopathy must be individualised which cannot be done properly in animals. Faced with the inevitably negative results of such animal studies, homeopaths would merely shrug their shoulders and say: ‘we told you so’.

CLINICAL TRIALS

Homeopathy may, according to some homeopaths, defy in vitro and animal tests, but it is most certainly amenable to being tested in clinical trials. The simplest version of a clinical study would entail randomising a group of patients with bacterial infections – say pneumonia – into receiving either individualised homeopathy or placebo. Possibly, one could add a third group of patients being treated with appropriate antibiotics.

The problem here would again be the ethics; no proper ethic committee would pass such a concept (see above). Another problem might be that even the homeopathic fraternity would oppose such a study. Why? Because all but the most deluded homeopaths know only too well that the result of such a trial would be devastatingly negative for homeopathy.

Therefore, homeopaths are likely to go for a different study design, for instance, one where patients suspected to have a bacterial infection are randomised to two groups of GPs. One group of ‘normal’ GPs would proceed as usual, while the other group are also trained in homeopathy and would be free to give whatever they feel is right for each individual patient. With a bit of luck, the ‘normal’ GPs would over-prescribe antibiotics (because that’s what they are apparently doing routinely), while the homeopathic GPs would often use homeopathics instead.

Such a study would indeed generate a result alleging that the use of homeopathy reduces the use of antibiotics. Of course, to be truly ‘positive’ it would need to exclude any clinical outcome such as time to recovery, because that might not be in favour of homeopathy.

The problem might again be the ethics committee. Assuming they are scientifically switched on, they will see through the futility of a trial designed to produce the desired result. They might also argue that science is not for testing one faulty approach (over-prescribing) against another (homeopathy) and insist that science is about finding the best treatment (which is neither of the two).

There are, of course, many other study designs that could be considered. Generally, they fall into two different categories: if they are rigorous tests of a hypothesis, they are sure to produce a result unfavourable to homeopathy. Such studies will therefore be opposed to by the powerful homeopathic fraternity. If, however, studies are flimsily designed to generate a positive finding, they might be liked by homeopaths, yet rejected by scientists and ethicists.

SURVEYS

A much easier solution to the question ‘does the use of homeopathy reduce the use of antibiotics’ might be to not do a trial at all, but to run a simple survey. For instance, one could retrospectively assess how many antibiotics 100 homeopathic GPs have prescribed during the last year and compare this to the figure of 100 over-prescribing, ‘normal’ GPs. This type of ‘research’ is a sure winner for the homeopaths. Therefore, I predict that they will advocate this or a similarly flawed concept.

Most politicians are scientifically illiterate to such a degree that they might actually agree to finance such a survey and then confuse correlation with causation by triumphantly stating that the use of homeopathy reduces over-prescribing of antibiotics. Few, I fear, will realise that there is only one method for reducing the over-prescribing of antibiotics: remind doctors what they all learnt in medical school, namely to prescribe antibiotics only in cases where they are indicated. And for that we evidently need no homeopathy or other SCAM.

The use of so-called alternative medicine (SCAM) are claimed to be associated with preventive health behaviors. However, the role of SCAM use in patients’ health behaviors remains unclear.

This survey aimed to determine the extent to which patients report that SCAM use motivates them to make changes to their health behaviours. For this purpose, a secondary analysis of the 2012 National Health Interview Survey data was undertaken. It involved 10,201 SCAM users living in the US who identified up to three SCAM therapies most important to their health. Analyses assessed the extent to which participants reported that their SCAM use motivated positive health behaviour changes, specifically: eating healthier, eating more organic foods, cutting back/stopping drinking alcohol, cutting back/quitting smoking cigarettes, and/or exercising more regularly.

Overall, 45.4% of SCAM users reported being motivated by SCAM to make positive health behaviour changes, including exercising more regularly (34.9%), eating healthier (31.4%), eating more organic foods (17.2%), reducing/stopping smoking (16.6% of smokers), or reducing/stopping drinking alcohol (8.7% of drinkers). Individual SCAM therapies motivated positive health behaviour changes in 22% (massage) to 81% (special diets) of users. People were more likely to report being motivated to change health behaviours if they were:

  • aged 18-64 compared to those aged over 65 years;
  • of female gender;
  • not in a relationship;
  • of Hispanic or Black ethnicity, compared to White;
  • reporting at least college education, compared to people with less than high school education;
  • without health insurance.

The authors concluded that a sizeable proportion of respondents were motivated by their SCAM use to undertake health behavior changes. CAM practices and practitioners could help improve patients’ health behavior and have potentially significant implications for public health and preventive medicine initiatives; this warrants further research attention.

This seems like an interesting finding! SCAM might be ineffective, but it motivates people to lead a healthier life. Thus SCAM has something to show for itself after all.

Great!

Except, there is another explanation of the results, one that might be much more plausible.

What if some consumers, particularly females who are well-educated and have no health insurance, one day decide that it’s time to do something for their health. Thus they initiate several things:

  • they start using SCAM;
  • they exercise more regularly;
  • they eat more healthily;
  • they consume organic food;
  • they stop smoking;
  • they stop boozing.

The motivation common to all these changes is their determination to do something about their health. Contrary to the authors’ wishful thinking, SCAM has little or even nothing to do with it. The notion was induced by SCAM practitioners who like to think that they play a role in disease prevention, by the leading questions of the interviewer, by recall bias, or by other factors..

What did the wise man say once upon a time?

CORRELATION IS NOT CAUSATION!

 

 

Many paediatric oncology patients report use of so-called alternative medicine (SCAM), and naturopathic ‘doctors’ (NDs) often provide supportive paediatric oncology care. However, little information exists to formally describe this clinical practice. This survey was aimed at filling the gap. It was conducted with members of the ‘Oncology Association of Naturopathic Physicians’ (OncANP.org) to describe recommendations across 4 therapeutic domains:

  1. natural health products (NHPs),
  2. nutrition,
  3. physical medicine,
  4. mental/emotional support.

The researchers received 99 responses from practitioners with a wide variance of clinical experience and aptitude to treat children with cancer. 52.5% of respondents stated that they did, in fact, not treat such children. The three primary reasons for this decision were:

  1. lack of public demand (45.1%),
  2. institutional or clinic restrictions (21.6%),
  3. personal reasons/comfort (19.6%).

The 10 most frequently considered NHPs by those NDs who did treat childhood cancer patients were:

  • fish-derived omega-3 fatty acid (83.3%),
  • vitamin D (83.3%),
  • probiotics (82.1%),
  • melatonin (73.8%),
  • vitamin C (72.6%),
  • homeopathic Arnica (69.0%),
  • turmeric/curcumin (67.9%),
  • glutamine (66.7%),
  • Astragalus membranaceus (64.3%),
  • Coriolus versicolor/PSK (polysaccharide K) extracts (61.9%).

The top 5 nutritional recommendations were:

  • anti-inflammatory diets (77.9%),
  • dairy restriction (66.2%),
  • Mediterranean diet (66.2%),
  • gluten restriction (61.8%),
  • and ketogenic diet (57.4%).

The top 5 physical interventions were

  • exercise (94.1%),
  • acupuncture (77.9%),
  • acupressure (72.1%),
  • craniosacral therapy (69.1%),
  • and yoga (69.1%).

The top 5 mental/emotional interventions were:

  • meditation (79.4%),
  • art therapy (77.9%),
  • mindfulness-based stress reduction (70.6%),
  • music therapy (70.6%),
  • and visualization therapy (67.6%).

The Canadian authors concluded that the results of our clinical practice survey highlight naturopathic interventions across four domains with a strong rationale for further inquiry in the care of children with cancer.

Personally, I don’t see a ‘strong rationale’ for anything here. I was, however, struck by the fact that about half of the naturopaths (they are NOT doctors!) dare to treat children with cancer. Equally, I was impressed by the list of treatments they use for this purpose; most are pure quackery! Finally, I was struck by the reasons given by those naturopaths who laudably abstained from treating cancer: they did not take this decision because of the lack of evidence that naturopaths and the treatments they like to employ fail to do more good than harm.

Altogether, this survey confirmed my view that naturopaths should not be allowed near children, especially those suffering from cancer.

I live (most of my time) in the UK, a country where the media interest in so-called alternative medicine (SCAM) is considerable. Years ago, the UK press used to be very much in favour of SCAM. In 2000, we showed that the level of interest was huge and the reporting was biased. Here is our short BMJ paper on the subject:

The media strongly influences the public’s view of medical matters. Thus, we sought to determine the frequency and tone of reporting on medical topics in daily newspapers in the United Kingdom and Germany. The following eight newspapers were scanned for medical articles on eight randomly chosen working days in the summer of 1999: the Times, the Independent, the Daily Telegraph, and the Guardian in the United Kingdom, and Frankfurter Allgemeine Zeitung, Süddeutsche Zeitung, Frankfurter Rundschau, and Die Welt in Germany. All articles relating to medical topics were extracted and categorised according to subject, length, and tone of article (critical, positive, or neutral).

A total of 256 newspaper articles were evaluated. The results of our analysis are summarised in the table. We identified 80 articles in the German newspapers and 176 in the British; thus, British newspapers seem to report on medical topics more than twice as often as German broadsheets. Articles in German papers are on average considerably longer and take a positive attitude more often than British ones. Drug treatment was the medical topic most frequently discussed in both countries (51 articles (64%) in German newspapers and 97 (55%) in British). Surgery was the second most commonly discussed medical topic in the UK newspapers (32 articles; 18%). In Germany professional politics was the second most commonly discussed topic (11 articles; 14%); this category included articles about the standing of the medical profession, health care, and social and economic systems—that is, issues not strictly about treating patients.

Because our particular interest is in complementary medicine, we also calculated the number of articles on this subject. We identified four articles in the German newspapers and 26 in the UK newspapers. In the United Kingdom the tone of these articles was unanimously positive (100%) whereas most (3; 75%) of the German articles on complementary medicine were critical.

This analysis is, of course, limited by its small sample size, the short observation period, and the subjectivity of some of the end points. Yet it does suggest that, compared with German newspapers, British newspapers report more frequently on medical matters and generally have a more critical attitude (table). German newspapers frequently discuss medical professional politics, a subject that is almost totally absent from newspapers in the United Kingdom.

The proportion of articles about complementary medicine seems to be considerably larger in the United Kingdom (15% v 5%), and, in contrast to articles on medical matters in general, reporting on complementary medicine in the United Kingdom is overwhelmingly positive. In view of the fact that both healthcare professionals and the general public gain their knowledge of complementary medicine predominantly from the media, these findings may be important.2,3

Table

Reporting on medical topics by daily newspapers in the United Kingdom and Germany, 1999

Country

United Kingdom (n=176) Germany (n=80)
Mean No articles/day 5.5 2.5
Mean (SD) No words/article 130 (26) 325 (41)
Ratio of positive articles to critical articles* 1.0 3.2

Even though I have no new data on this, my impression is that things have since changed. It seems that the UK press has become more objective and are now reporting more critical comments on SCAM. While this is most welcome, of course, one feature is still deplorable, in my view: journalists’ obsession with ‘balance’.

A recent example might explain this best. The ‘i’ newspaper published an article about homeopathy which was well-written and thoroughly researched. It explained the current best evidence on the subject and made it quite clear why homeopathy is not a reasonable therapy for any condition. But then, towards the end of the article, the journalist added this section:

Dr Lise Hansen, a veterinary homeopath based in London and author of a forthcoming book, The Complete Book of Cat and Dog Health, argues that scientists have shown how homeopathy works. She cites a paper by Luc Montagnier, the French virologist who won a Nobel Prize in 2008 for his role in discovering HIV. The following year, he published evidence of his discovery of “electromagnet signals that are produced by nanostructures derived from bacterial DNA at high aqueous dilutions”. “Mainstream medicine is about chemistry, homeopathy is physics and scientists have only recently begun to study these nanostructures,” Hansen says.

Basically, the reader is left with the impression that homeopathy might be fine after all, and that science will soon be able to catch up with it. In the interest of balance, the journalist thus confused her readers and misled the public.

Why?

Journalists are obviously taught to always cover ‘both sides’ of their stories, and they adhere to this dogma no matter what. In most instances, this works out well, because in most cases there are two sides.

But not always!

When there is a strong consensus supported by facts, science and reproducible findings, the other side ceases to have a reasonable point. There simply is no reasonable ‘other side’ when we consider global warming, evolution, the Holocaust, and many other subjects. Of course, one can always find some loon who claims the earth is flat, or that cancer is a Jewish plot against public health. But these arguments lack reason and integrity – to dish them out without anything remotely resembling a ‘fact check’ is not just annoying but harmful.

Journalists should, in my view, be more responsible, check the facts, and avoid false balance. I know this will often entail much more work, but they owe it to their readers and to the reputation of their profession.

“There is a ton of chiropractor journals. If you want evidence then read some.”

This was the comment by a defender of chiropractic to a recent post of mine. And it’s true, of course: there are quite a few chiro journals, but are they a reliable source of information?

One way of quantifying the reliability of medical journals is to calculate what percentage of its published articles arrive at negative conclusion. In the extreme instance of a journal publishing nothing but positive results, we cannot assume that it is a credible publication. In this case, it would be not a scientific journal at all, but it would be akin to a promotional rag.

Back in 1997, we published our first analysis of journals of so-called alternative medicine (SCAM). It showed that just 1% of the papers published in SCAM journals reported findings that were not positive. In the years that followed, we confirmed this deplorable state of affairs repeatedly, and on this blog I have shown that the relatively new EBCAM journal is similarly dubious.

But these were not journals focussing specifically on chiropractic. Therefore, the question whether chiro journals are any different from the rest of SCAM is as yet unanswered. Enough reason for me to bite the bullet and test this hypothesis. I thus went on Medline and assessed all the articles published in 2018 in two of the leading chiro journals.

  1. JOURNAL OF CHIROPRACTIC MEDICINE (JCM)
  2. CHIROPRACTIC AND MANUAL THERAPY (CMT)

I evaluated them according to

  1. TYPE OF ARTICLE
  2. DIRECTION OF CONCLUSION

The results of my analysis are as follows:

  1. The JCM published 39 Medline-listed papers in 2018.
  2. The CMT published 50 such papers in 2018.
  3. Together, the 2 journals published:
  • 18 surveys,
  • 17 case reports,
  • 10 reviews,
  • 8 diagnostic papers,
  • 7 pilot studies,
  • 4 protocols,
  • 2 RCTs,
  • 2 non-randomised trials,
  • 2 case-series,
  • the rest are miscellaneous types of articles.

4. None of these papers arrived at a conclusion that is negative or contrary to chiropractors’ current belief in chiropractic care. The percentage of publishing negative findings is thus exactly 0%, a figure that is almost identical to the 1% we found for SCAM journals in 1997.

I conclude: these results suggest that the hypothesis of chiro journals publishing reliable information is not based on sound evidence.

A chiro, a arms dealer and a Brexit donor meet in a bar.

The arms dealer: my job is so secret, I cannot tell my neighbour what I do.

The Brexit donor: I have to keep things so close to my chest that not even my wife knows what I am doing.

The chiro: that’s nothing; my work is so secret that not even I know what I am doing.

CHILDISH, I KNOW!

But I am yet again intrigued by a survey aimed at finding out what chiropractors are up to. One might have thought that, after 120 years, they know what they are doing.

This survey described the profiles of chiropractors’ practice and the reasons, nature of the care provided to their patients and extent of interprofessional collaborations in Ontario, Canada. The researchers randomly recruited chiropractors from a list of registered chiropractors (n=3978) in active practice in 2015. Of the 135 randomly selected chiropractors, 120 were eligible, 43 participated and 42 completed the study.

Each chiropractor recorded information for up to 100 consecutive patient encounters, documenting patient health profiles, reasons for encounter, diagnoses and care provided. Descriptive statistics summarised chiropractor, patient and encounter characteristics, with analyses accounting for clustering and design effects. Thus data on 3523 chiropractor-patient encounters became available. More than 65% of participating chiropractors were male, mean age 44 years and had practised on average 15 years. The typical patient was female (59% of encounters), between 45 and 64 years (43%) and retired (21%) or employed in business and administration (13%). Most (39.4%) referrals were from other patients, with 6.8% from physicians. Approximately 68% of patients paid out of pocket or claimed extended health insurance for care. Most common diagnoses were back (49%, 95% CI 44 to 56) and neck (15%, 95% CI 13 to 18) problems, with few encounters related to maintenance/preventive care (0.86%, 95% CI 0.2 to 3.9) and non-musculoskeletal problems (1.3%, 95% CI 0.7 to 2.3). The most common treatments included spinal manipulation (72%), soft tissue therapy (70%) and mobilisation (35%).

The authors concluded that this is the most comprehensive profile to date of chiropractic practice in Canada. People who present to Ontario chiropractors are mostly adults with a musculoskeletal condition. Our results can be used by stakeholders to make informed decisions about workforce development, education and healthcare policy related to chiropractic care.

I am so sorry to have mocked this paper. I shouldn’t have, because it actually does reveal a few interesting snippets:

  1. Only 7% of referrals come from real doctors.
  2. The vast majority of all patients receive spinal manipulations.
  3. About 6% of them are under 14 years of age.
  4. Chiropractors seem to dislike surveys; only 35% of those asked complied.
  5. 23% of all consultations were for general or unspecified problems,
  6. 8% for neurologically related problems,
  7. 5% for non-musculoskeletal problems (eg, digestive, ear, eye, respiratory, skin, urology, circulatory, endocrine and metabolic, psychological).
  8. Chiropractors rarely refer patients to other clinicians; this only happened in less than 3% of encounters.
  9. Apart from manipulation, chiropractors employ all sorts of other dubious therapies (ultrasound 3%, acupuncture 3%, , traction 1%, interferential therapy 3%, soft laser therapy 3%).
  10.  68% of patients pay out of their own pocket…

… NO WONDER, THEY DO NOT SEEM TO BE IN NEED OF ANY TYPE OF TREATMENT: 54% of all patients reported being in “excellent/very good overall health”!

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