systematic review
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:
- randomized trials,
- had at least one conservative treatment arm,
- 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.1
- 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.
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.
_____________________________
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 “.
Certain aspects of yoga can be used as a non-pharmacological conservative therapeutic approach to the management of chronic low back pain (CLBP). This overview summarized and evaluated data from current systematic reviews (SRs) on the use of yoga for CLBP.
The researchers searched SRs on the use of yoga for CLBP in nine electronic databases from inception to September 2023. The methodological quality was evaluated using the Assessment of Multiple Systematic Review Scale-2 (AMSTAR-2). The reporting quality of the included SRs was evaluated using the Preferred Reporting Item for Systematic Review and Meta-Analysis-2020 (PRISMA-2020), and the quality of data was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Two independent researchers performed the screening, data extraction, and quality assessment process of SRs.
A total of 13 SRs were included. The results of the AMSTAR-2 indicated that the methodological quality of the included studies was relatively low. The PRISMA-2020 checklist evaluation results indicated that methodological limitations in reporting, especially regarding data processing and presentation, were the main weaknesses. The GRADE assessment indicated that 30 outcomes were rated moderate, 42 were rated low level, and 20 were rated very low level. Downgrading factors were mainly due to the limitations of the included studies.
The authors concluded that yoga appears to be an effective and safe non-pharmacological therapeutic modality for the Management of CLBP. Currently, it may exhibit better efficacy in improving pain and functional disability associated with CLBP. However, the methodological quality and quality of evidence for SRs/MAs in the included studies were generally low, and these results should be interpreted cautiously.
Sorry, but I beg to differ!
- The safety of a therapy cannot be ascertained on the basis of such small sample sizes.
- The effectiveness of yoga has not been demonstrated by these data.
- All that has been shown with this review is that the quality of the research in this area is too poor for drawing conclusions.
I was alerted to a new book entitled “Handbook of Space Pharmaceuticals“. It contains a chapter on “Homeopathy as a Therapeutic Option in Space” (yes, I am not kidding!). Here is its abstract (the numbers were inserted by me and refer to the short comments below):
Homeopathy is one of the largest used unorthodox medicinal systems having a wide number of principles and logic to treat and cure various diseases [1]. Many successful concepts like severe dilution to high agitation have been applied in the homeopathic system [2]. Though many concepts like different treatment for same diseases and many more are contradictory to the allopathic system [3], homeopathy has proved its worth in decreasing drug-related side effects in many arenas [4]. Various treatments and researches are carried out on various diseases; mostly homeopathic treatment is used in joint diseases, respiratory diseases, cancer, and gastrointestinal tract diseases [5]. In this chapter, readers will have a brief idea about many meta-analysis results of most common respiratory diseases, i.e., asthma, incurable hypertension condition, rheumatoid arthritis, and diarrhea and a megareview of all the diseases to see their unwanted effects, uses of drugs, concepts, and issues related to homeopathy [6]. Various limitations of homeopathic treatments are also highlighted which can give a clear idea about the future scope of research [7]. Overall, it can be concluded that placebo and homeopathic treatments give almost the same effect [8], but the less severe side effects of homeopathic drugs in comparison to all other treatment groups catch great attention [9].
Apart from the very poor English of the text and the fact that it has as good as nothing to do with the subject of ‘Homeopathy as a Therapeutic Option in Space’, I have the following brief comments:
- I did not know that homeopathy has ‘a wide number of logic’ and had alwas assumed that there is only one logic.
- Successful concepts? Really?
- So, homeopaths believe that the ‘allopathic system’ treats the same diseases uniformly? In this case, they should perhaps read up what conventional medicine really does.
- I am not aware of good evidence showing that homeopathy reduces drug related adverse effects.
- No, homeopathy is used for all symptoms – Hahnemann did not believe in treating disease entities – and mostly for those that are self-limiting.
- I love the term ‘incurable hypertension condition’; can somebody please explain what it is?
- The main limitation is that homeopathy is nonsense and, as such, does not really require further research.
- Not ‘almost’ but ‘exactly’! But thanks for pointing it out.
- Wishful thinking and not true. Firstly, the author forgot about ‘homeopathic aggravations’ in which homeopaths so strongly believe. Secondly, I know of many non-homeopathic treatments that are free of adverse effects when done properly.
Altogether, I am as disappointed by this article as you must be: we were probably all hoping to hear about the discovery showing that homeopathy works splendidly in space – not least because we have known for a while that homeopaths seem to be from a different planet.
NICE helps practitioners and commissioners get the best care to patients, fast, while ensuring value for the taxpayer. Internationally, NICE has a reputation for being reliable and trustworthy. But is that also true for its recommendations regarding the use of acupuncture? NICE currently recommends that patients consider acupuncture as a treatment option for the following conditions:
- chronic (long-term) pain
- chronic tension-type headaches
- migraines
- prostatitis symptoms
- hiccups
Confusingly, on a different site, NICE also recommends acupuncture for retinal migraine, a very specific type of migraine that affect normally just one eye with symptoms such as vision loss lasting up to one hour, a blind spot in the vision, headache, blurred vision and seeing flashing lights, zigzag patterns or coloured spots or lines, as well as feeling nauseous or being sick.
I think this perplexing situation merits a look at the evidence. Here I quote the conclusions of recent, good quality, and (where possible) independent reviews:
- Chronic pain: Acupuncture is efficacious for reducing pain in patients with LBP… Further research needs to be done to evaluate acupuncture’s efficacy in these conditions, especially for abdominal pain, as many of the current studies have a risk of bias due to lack of blinding and small sample size.
- Chronic tension-type headaches (TTH): Acupuncture may be an effective and safe treatment for TTH patients. Due to low or very low certainty of evidence and high heterogeneity, more rigorous RCTs are needed to verify the effect and safety of acupuncture in the management of TTH.
- Migraines: Many studies suggest that acupuncture is a safe, helpful and available alternative therapy that may be beneficial to certain migraine patients. Nevertheless, further large-scale RCTs are warranted to further consolidate these findings and provide further support for the clinical value of acupuncture. Despite previous studies that have analyzed the effects of acupuncture on migraine, there is still a need for further investigation to ensure that the incorporation of acupuncture into migraine treatment management will have a positive outcome on patients.
- Prostatitis: This meta-analysis indicated that acupuncture has measurable benefits on CP/CPPS, and security has also been ensured. However, this meta-analysis only included 10 RCTs; thus, RCTs with a larger sample size and longer-term observation are required to verify the effectiveness of acupuncture further in the future.
- Hiccups: All of these studies sought to determine the effectiveness of different acupuncture techniques in the treatment of persistent and intractable hiccups. All four studies had a high risk of bias, did not compare the intervention with placebo, and failed to report side effects or adverse events for either the treatment or control groups.
- Retinal migraine: no evidence
So, what do we make of this? I think that, on the basis of the evidence:
- a positive recommendation for all types of chromic pain is not warranted;
- a positive recommendation for the treatment of TTH is questionable;
- a positive recommendation for migraine is questionable;
- a positive recommendation for prostatitis is questionable;
- a positive recommendation for hiccups is not warranted;
- a positive recommendation for retinal migraine is not warranted.
But why did NICE issue positive recommendations despite weak or even non-existent evidence?
SEARCH ME!
.
Omega-3 fatty acids (fish oil) supplementation reduces the occurrence of cardiovascular disease (CVD) and CVD-related mortality in patients at high-risk of CVD and in patients with elevated plasma triglyceride level. Yet, some studies have found an increased risk of atrial fibrillation (AF). AF is the most common sustained cardiac arrhythmia worldwide. It is associated with high morbidity and mortality rates and significant public health burden. Previous studies of the effect of omega-3 fatty acids on AF occurrence have reported contradictory results.
This review evaluated the effect of omega-3 fatty acids on the risk of AF. The results suggest that omega-3 fatty acids supplementation is associated with increased AF risk, particularly in trials that used high doses. Therefore, several factors should be considered before prescribing omega-3 fatty acids, including their dose, type, and formulation (fish, dietary fish oil supplements, and purified fatty acids), as well as patient-related factors and atrial mechanical milieu. Because the benefits of omega-3 fatty acids are dose-dependent, the associated AF risk should be balanced against the benefit for CVD. Patients who take omega-3 fatty acids, particularly at high doses, should be informed of the risk of AF and followed up for the possible development of this common and potentially hazardous arrhythmia.
Another recent review included 54,799 participants from 17 cohorts. A total of 7,720 incident cases of AF were ascertained after a median 13.3 years of follow-up. In multivariable analysis, EPA levels were not associated with incident AF, HR per interquintile range (ie, the difference between the 90th and 10th percentiles) was 1.00 (95% CI: 0.95-1.05). HRs for higher levels of DPA, DHA, and EPA+DHA, were 0.89 (95% CI: 0.83-0.95), 0.90 (95% CI: 0.85-0.96), and 0.93 (95% CI: 0.87-0.99), respectively.
The authors concluded that in vivo levels of omega-3 fatty acids including EPA, DPA, DHA, and EPA+DHA were not associated with increased risk of incident AF. Our data suggest the safety of habitual dietary intakes of omega-3 fatty acids with respect to AF risk. Coupled with the known benefits of these fatty acids in the prevention of adverse coronary events, our study suggests that current dietary guidelines recommending fish/omega-3 fatty acid consumption can be maintained.
Faced with contradictory results based on non-RCT evidence, we clearly need an RCT. Luckily such a trial has recently been published. It was an ancillary study of a 2 × 2 factorial randomized clinical trial involving 25 119 women and men aged 50 years or older without prior cardiovascular disease, cancer, or AF. Participants were recruited directly by mail between November 2011 and March 2014 from all 50 US states and were followed up until December 31, 2017.
Participants were randomized to receive EPA-DHA (460 mg/d of EPA and 380 mg/d of DHA) and vitamin D3 (2000 IU/d) (n = 6272 analyzed); EPA-DHA and placebo (n = 6270 analyzed); vitamin D3 and placebo (n = 6281 analyzed); or 2 placebos (n = 6296 analyzed). The primary outcome was incident AF confirmed by medical record review.
Among the 25 119 participants who were randomized and included in the analysis (mean age, 66.7 years; 50.8% women), 24 127 (96.1%) completed the trial. Over a median 5.3 years of treatment and follow-up, the primary end point of incident AF occurred in 900 participants (3.6% of study population). For the EPA-DHA vs placebo comparison, incident AF events occurred in 469 (3.7%) vs 431 (3.4%) participants, respectively (hazard ratio, 1.09; 95% CI, 0.96-1.24; P = .19). For the vitamin D3 vs placebo comparison, incident AF events occurred in 469 (3.7%) vs 431 (3.4%) participants, respectively (hazard ratio, 1.09; 95% CI, 0.96-1.25; P = .19). There was no evidence for interaction between the 2 study agents (P = .39).
The authors concluded that among adults aged 50 years or older, treatment with EPA-DHA or vitamin D3, compared with placebo, resulted in no significant difference in the risk of incident AF over a median follow-up of more than 5 years. The findings do not support the use of either agent for the primary prevention of incident AF.
So, does the regular supplementation with omega-3 fatty acids increase the risk of atrial fibrillation? The evidence is not entirely clear but, on balance, I conclude that the risk is low or even non-existent.
Congratulations to Joseph Prahlow, MD, who is the winner of the Excellence in Homeopathy Award! Here are the conclusions of his winning essay. Special thanks to Hermeet Singh and Boiron for their prize donation.
Despite the many obstacles and challenges which face homeopathy in the 21st century, the homeopathic community should be emboldened and encouraged by the fact that there are also many opportunities for the advancement of homeopathy as an alternative choice in health care.
Proclaim the Truth: Homeopathy Actually Works
Notwithstanding the challenges involved (especially for a student) in arriving at the correct simillimum for a case, let alone the appropriate follow-up and case management, the truth of the matter is that homeopathy does, in fact, work! Those of us who have been the beneficiaries of homeopathic care, or who have seen the benefits in others, know with no doubt whatsoever that homeopathy represents a truly amazing form of alternative medicine that is able to successfully treat patients having a wide range of health concerns, including some very ill individuals. And it’s not just based on “experience” or “perception,” although such evidence should not be discounted. Numerous studies show the effectiveness of homeopathy.6-9 The fact that homeopathy actually works represents one of the biggest and most important opportunities for homeopathy. The corresponding challenge relates to “getting the word out” into the general community as well as the medical community. Instead of homeopathy being the “last resort,” it should increasingly become the “first choice” amongst patients. Only by “spreading the word” of its success can this become a reality.
What intrigued me here was the evidence that an award-winning homeopath believes might justify the claim that
“Numerous studies show the effectiveness of homeopathy”
6. Mathie RT, Lloyd SM, Legg LA, et al. Randomised placebo-controlled trials of individualized homeopathic treatment: systematic review and meta-analysis. Syst Rev. 2014 Dec 6;3:142. doi: 10.1186/2046-4053-3-142.
As we have discussed previously that meta-analysis is phoney and created a false-positive result by omitting at least two negative studies.
7. Taylor JA, Jacobs J. Homeopathic ear drops as an adjunct in reducing antibiotic usage in children with otitis media. Glob Pediatr Health 2014 Nov 21;1:2333794X14559395. doi: 10.1177/2333794X14559395.
This study had the notorious A+B versus B design and thus was unable to test for specific effects of homeopathy. Moreover, the lead author, Dr Jennifer Jacobs, was a paid consultant to Standard Homeopathic Company.
8. Sorrentino L, Piraneo S, Riggio E, et al. Is there a role for homeopathy in breast cancer surgery? A first randomized clinical trial on treatment with Arnica montana to reduce post-operative seroma and bleeding in patients undergoing total mastectomy. J Intercult Ethnopharmacol 2017 Jan 3;6(1):1-8. doi: 10.5455/jice.20161229055245.
This study showed no significant result in the intention to treat analysis. The positive conclusion seems to be based on data dredging only.
9. Frass M, Lechleitner P, Grundling C, et al. Homeopathic treatment as an add-on therapy may improve quality of life and prolong survival in patients with non-small cell lung cancer: a randomized, placebo-controlled, double-blind, three-arm, multic0-e1955enter study. Oncologist 2020 Dec 25(12):e1930-e1955. doi: 10.1002/onco.13548.
This study is since months under investigation for fraud. The reasons for this have been discussed previously.
Perhaps the award winning author should chance the crucial sentence into something like:
Numerous studies have shown how homeopaths try to mislead the public?
In any case, please do not let this stop you from reading the full paper by the award-winning author. I promise you that it will create much hilarity.
What does homeopathy offer our modern ailing world?
NOTHING!
The concept that the outcomes of spinal manipulation therapy (SMT) – the hallmark intervention of chiropractors which they use on practically every patient – are optimized when the treatment is aimed at a clinically relevant joint is commonly assumed and central to teaching and clinical use of chiropractic. But is the assumption true?
This systematic review investigated whether clinical effects are superior when this is the case compared to SMT applied elsewhere. Eligible study designs were randomized controlled trials that investigated the effect of SMT applied to candidate versus non-candidate sites for spinal pain.
The authors obtained studies from four different databases. Risk of bias was assessed using an adjusted Cochrane risk of bias tool, adding four items for study quality. Between-group differences were extracted for any reported outcome or, when not reported, calculated from the within-group changes. Outcomes were compared for SMT applied at a ‘relevant’ site to SMT applied elsewhere. The authors prioritized methodologically robust studies when interpreting results.
Ten studies were included. They reported 33 between-group differences; five compared treatments within the same spinal region and five at different spinal regions.
None of the nine studies with low or moderate risk of bias reported statistically significant between-group differences for any outcome. The tenth study reported a small effect on pain (1.2/10, 95%CI – 1.9 to – 0.5) but had a high risk of bias. None of the nine articles of low or moderate risk of bias and acceptable quality reported that “clinically-relevant” SMT has a superior outcome on any outcome compared to “not clinically-relevant” SMT. This finding contrasts with ideas held in educational programs and clinical practice that emphasize the importance of joint-specific application of SMT.
The authors concluded that the current evidence does not support that SMT applied at a supposedly “clinically relevant” candidate site is superior to SMT applied at a supposedly “not clinically relevant” site for individuals with spinal pain.
I came across this study when I searched for the published work of Prof Stephen Perle, a chiropractor and professor at the School of Chiropractic, College of Health Sciences, University of Bridgeport, US, who recently started trolling me on this blog. Against my expectation, I find his study interesting and worthwhile.
His data quite clearly show that the effects of SMT are non-specific and mainly due to a placebo response. That in itself is not hugely remarkable and has been suspected to some time, e.g.:
- Chiropractic manipulation for migraine is a placebo therapy
- Chiropractic treatments are placebos
- Chiropractic spinal manipulation = placebo!
- Manual therapy (mainly chiropractic and osteopathy) does not have clinically relevant effects on back pain compared with sham treatment
- Manual therapies for back pain: not better than a placebo
- Is spinal manipulation a placebo therapy?
What is remarkable, however, is the fact that Perle and his co-authors offer all sorts of other explanation for their findings without even seriously considering what is stareing in their faces:
SPINAL MANIPULATIONS ARE PLACEBOS
CHIROPRACTIC IS A PLACEBO THERAPY
This might be almost acceptable, if chiropractic would not also be burdened with significant risks (as we have discussed ad nauseam on this blog) – another fact of which chiros like Perle are in denial.
What does all that mean for patients?
The practical implication is fairly straight forward: the risk/benefit balance of chiropractic is negative. And this surely means the only responsible advice to patients is this:
NEVER CONSULT A CHIRO!
The BBC has a popular program entitled JUST ONE THING presented by Dr, Michael Mosely. In each of these short broadcasts, Mosely presents JUST ONE THING that will make your life more healthy. Whenever I listen to them, I get slightly irritated. Mosely is clearly a very skilled presenter and makes complicated things easy to understand; but for my taste his approach is totally devoid of critical thinking. This is obviously the point of the series and probably one reason for its success. So, maybe it needs to be tolerated – perhaps, but surely not if it seriously misleads the public on important health issues.
The most recent broadcast was entitled EMBRACE THE RAIN and, in my view, it did cross this crucial line. Mosely explained that after it has rained, the air is full of negative ions and these ions are effective against depression. The center piece was his interview with Prof Michael Terman who explained some of his research on the subject, in particular a clinical trial which showed that intensely ionized air was effective against depression. Terman explained that this was more than a placebo effect, that it worked even for serious chronic depressed patients, and that the effect was better than standard treatments.
At no stage was there an even mildly critical question from Mosely. Consequently many depressed patients might now abandon their standard treatments and opt for air ionizers in their homes or walks in the rain which was deemed to be just as effective. In view of the fact that chronic depression, through its suicide risk, can be a life-threatening condition, I find this rather concerning.
My concerns were not exactly alleviated when I did a quick search for the evidence. The most recent review on the subject states that there has been considerable interest in the potential effects of negative air ions (NAIs) on human health and well-being, but the conclusions have been inconsistent and the mechanisms remain unclear. So, why does Terman promote NAIs as though they are the best thing since sliced bread? It took me less than a minute to find a possible answer: he holds a patent for a NEGATIVE ION GENERATOR!
It is laudable of the BBC and Michael Mosely to present aspects of healthcare in a simple, understandable way. Yet, it would be even more laudable, if they did their homework a bit better and, crucially, tried to also educate the public in critical thinking. After all ’embracing the rain’ will not change lives but critical thinking most certainly does!
