Edzard Ernst

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

Some experts concede that chiropractic spinal manipulation is effective for chronic low back pain (cLBP). But what is the right dose? There have been no full-scale trials of the optimal number of treatments with spinal manipulation. This study was aimed at filling this gap by trying to identify a dose-response relationship between the number of visits to a chiropractor for spinal manipulation and cLBP outcomes. A further aim was to determine the efficacy of manipulation by comparison with a light massage control.

The primary cLBP outcomes were the 100-point pain intensity scale and functional disability scales evaluated at the 12- and 24-week primary end points. Secondary outcomes included days with pain and functional disability, pain unpleasantness, global perceived improvement, medication use, and general health status.

One hundred patients with cLBP were randomized to each of 4 dose levels of care: 0, 6, 12, or 18 sessions of spinal manipulation from a chiropractor. Participants were treated three times per week for 6 weeks. At sessions when manipulation was not assigned, the patients received a focused light massage control. Covariate-adjusted linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 18, 24, 39, and 52 weeks.

For the primary outcomes, mean pain and disability improvement in the manipulation groups were 20 points by 12 weeks, an effect that was sustainable to 52 weeks. Linear dose-response effects were small, reaching about two points per 6 manipulation sessions at 12 and 52 weeks for both variables. At 12 weeks, the greatest differences compared to the no-manipulation controls were found for 12 sessions (8.6 pain and 7.6 disability points); at 24 weeks, differences were negligible; and at 52 weeks, the greatest group differences were seen for 18 visits (5.9 pain and 8.8 disability points).

The authors concluded that the number of spinal manipulation visits had modest effects on cLBP outcomes above those of 18 hands-on visits to a chiropractor. Overall, 12 visits yielded the most favorable results but was not well distinguished from other dose levels.

This study is interesting because it confirms that the effects of chiropractic spinal manipulation as a treatment for cLBP are tiny and probably not clinically relevant. And even these tiny effects might not be due to the treatment per se but could be caused by residual confounding and bias.

As for the optimal dose, the authors suggest that, on average, 18 sessions might be the best. But again, we have to be clear that the dose-response effects were small and of doubtful clinical relevance. Since the therapeutic effects are tiny, it is obviously difficult to establish a dose-response relationship.

In view of the cost of chiropractic spinal manipulation and the uncertainty about its safety, I would probably not rate this approach as the treatment of choice but would consider the current Cochrane review which concludes that “high quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain” Personally, I think it is more prudent to recommend exercise, back school, massage or perhaps even yoga to cLBP-sufferers.

Some sceptics are convinced that, in alternative medicine, there is no evidence. This assumption is wrong, I am afraid, and statements of this nature can actually play into the hands of apologists of bogus treatments: they can then easily demonstrate the sceptics to be mistaken or “biased”, as they would probably say. The truth is that there is plenty of evidence – and lots of it is positive, at least at first glance.

Alternative medicine researchers have been very industrious during the last two decades to build up a sizable body of ‘evidence’. Consequently, one often finds data even for the most bizarre and implausible treatments. Take, for instance, the claim that homeopathy is an effective treatment for cancer. Those who promote this assumption have no difficulties in locating some weird in-vitro study that seems to support their opinion. When sceptics subsequently counter that in-vitro experiments tell us nothing about the clinical situation, apologists quickly unearth what they consider to be sound clinical evidence.

An example is this prospective observational 2011 study of cancer patients from two differently treated cohorts: one cohort with patients under complementary homeopathic treatment (HG; n = 259), and one cohort with conventionally treated cancer patients (CG; n = 380). Its main outcome measures were the change of quality life after 3 months, after one year and impairment by fatigue, anxiety or depression. The results of this study show significant improvements in most of these endpoints, and the authors concluded that we observed an improvement of quality of life as well as a tendency of fatigue symptoms to decrease in cancer patients under complementary homeopathic treatment.

Another, in some ways even better example is this 2005 observational study of 6544 consecutive patients from the Bristol Homeopathic Hospital. Every patient attending the hospital outpatient unit for a follow-up appointment was included, commencing with their first follow-up attendance. Of these patients 70.7% (n = 4627) reported positive health changes, with 50.7% (n = 3318) recording their improvement as better or much better. The authors concluded that homeopathic intervention offered positive health changes to a substantial proportion of a large cohort of patients with a wide range of chronic diseases.

The principle that is being followed here is simple:

  • believers in a bogus therapy conduct a clinical trial which is designed to generate an apparently positive finding;
  • the fact that the study cannot tell us anything about cause and effect is cleverly hidden or belittled;
  • they publish their findings in one of the many journals that specialise in this sort of nonsense;
  • they make sure that advocates across the world learn about their results;
  • the community of apologists of this treatment picks up the information without the slightest critical analysis;
  • the researchers conduct more and more of such pseudo-research;
  • nobody attempts to do some real science: the believers do not truly want to falsify their hypotheses, and the real scientists find it unreasonable to conduct research on utterly implausible interventions;
  • thus the body of false or misleading ‘evidence’ grows and grows;
  • proponents start publishing systematic reviews and meta-analyses of their studies which are devoid of critical input;
  • too few critics point out that these reviews are fatally flawed – ‘rubbish in, rubbish out’!
  • eventually politicians, journalists, health care professionals and other people who did not necessarily start out as believers in the bogus therapy are convinced that the body of evidence is impressive and justifies implementation;
  • important health care decisions are thus based on data which are false and misleading.

So, what can be done to prevent that such pseudo-evidence is mistaken as solid proof which might eventually mislead many into believing that bogus treatments are based on reasonably sound data? I think the following measures would be helpful:

  • authors should abstain from publishing over-enthusiastic conclusions which can all too easily be misinterpreted (given that the authors are believers in the therapy, this is not a realistic option);
  • editors might consider rejecting studies which contribute next to nothing to our current knowledge (given that these studies are usually published in journals that are in the business of promoting alternative medicine at any cost, this option is also not realistic);
  • if researchers report highly preliminary findings, there should be an obligation to do further studies in order to confirm or refute the initial results (not realistic either, I am afraid);
  • in case this does not happen, editors should consider retracting the paper reporting unconfirmed preliminary findings (utterly unrealistic).

What then can REALISTICALLY be done? I wish I knew the answer! All I can think of is that sceptics should educate the rest of the population to think and analyse such ‘evidence’ critically…but how realistic is that?

To write an AT FAP seems far from easy. The reason for this is simple: the reality of alternative medicine is often more fantastic than what our fantasy can make up. I hope you give it a try nevertheless and send me your stories. Here are AT FAPs 10, 11 and 12.

AT FAP No 10 (by Edzard Ernst)

IMPORTANT NEW ARTICLE IN ‘SOS’

A little-known but nevertheless important monthly journal called ‘Snake-Oil Salesman’ (SOS) has just published a remarkable article which, I think, deserves a mention here. The paper entitled HOW TO BE SUCCESSFUL IN HARD TIMES – A ROAD-MAP TO HEALTH AND WEALTH was authored by the chief executive of ‘Dutchy Originals Herbal Tinctures’ (DOHT) but the grapevine has it that Prince Charles had important input as well. The article explains that, during recessions, snake-oil salesmen are the ones who suffer most. People are just not educated enough to realise the importance of snake oil to public health and wealth, the paper stated. The sale figures for Dutchy Originals Herbal Detox Tincture, for instance, have been declining steadily ever since the world financial crisis started. And that during a time when people need our products most, the SOS-paper stressed. In view of this dire situation, the experts at DOHT have conducted a multi-facetted research project funded by HRH with the aim of designing an effective strategy that will boost sale figures of any snake-oil product, even during hard times. The main part of the SOS-article goes into the strategy point by point. Here I take the liberty of listing from the executive summary the main landmarks on the road to snake-oil success:

  • snake-oil is natural and natural means good, effective and foremost safe
  • synthetic medicines have none of these qualities, on the contrary, they are amongst the leading causes of death in most countries
  • snake-oils have stood the test of time; they were used much before today’s pharmaceuticals were even invented; in other words, they have been field tested for hundreds of years on millions of patients, and that is certainly more important than a few clinical trials
  •  snake-oils are thus supported by thousands of anecdotes and satisfied customers
  • highly respected pharmacies like Boots sell snake-oil and some are even available on the NHS
  • famous people, politicians and other pillars of society regularly use snake-oil; some even have a Royal warrant!
  • several Nobel-prize winners endorse snake-oil
  • compared to some modern drugs, snake-oil is cheap
  • snake-oil is not just for one or two conditions, it is a ‘cure all’
  • snake-oil is holistic, i.e. it takes care not just of your physical symptoms, like conventional drugs might do, it also increases wellness on the emotional and spiritual levels
  • snake-oil is in tune with the current emphasis on patient choice in health care

The SOS-article concludes with the advice for snake-oil manufacturers to employ the above-listed elements for an effective sales-strategy wisely. Do not use all you ammunition at once, writes the paper states, if you adapt a small selection of them carefully to optimally suit your product, you will be able to sell your snake-oil well, and your customers will be delighted forthwith. It really is a win/win situation.

AT FAP No 11 (by Edzard Ernst)

THE ‘NO BRAIN DRAIN’

At a recent meeting of the ‘International Medical Research Standard Panel’ (IMRSP), a governance body of major research funding bodies across the globe aimed at watching over, as well as increasing the quality of medical research, members surprised the world of science: in an official statement, they expressed their pleasure with and approval of alternative medicine.

The panel had commissioned an investigation into the impact on research standards of the plethora of alternative medicine research groups (AMRGs). The investigators applied powerful statistical methods and demonstrated an unexpected but consistent effect: In regions where particularly many AMRGs had emerged, the quality of mainstream medical research seemed to improve; there was even something akin to a dose-effect relationship: the more AMRGs, the larger the improvement in quality.

The panel concluded that alternative medicine seems to attract those researchers who are “perhaps not the brightest buttons in the drawer”, as they elegantly put it. This ‘no brain drain’, they argued, has the effect that the less gifted scientists are drawn away from mainstream research which, in turn, means that the quality of mainstream science increases. A spokesman said: “we are pleased that so many AMRGs are emerging these days and hope the trend continues for the benefit of real medicine”.

AT FAP No 12 (submitted by ‘stopthequacks’)

CASE REPORT:

Homeopathy successfully treats heart attack

As part of the intensive on-going research effort in the School of Homeopathy Education and Denialism (Shed) in our garden we’re delighted to report another success for homeopathy.

One of our leading researchers Del Usional was investigating homeopathic preparations of mains voltage alternating current. In these highly technical and detailed scientific experiments Del first cut the end off a kettle lead and  removed the shielding from the live and neutral wires. He then plugged in the cable and put the exposed copper ends into some fresh tap water in a clean jam jar.

This resulted in Del being thrown backwards and landing on the lawnmower and suffering a cardiac arrest. Luckily a colleague witnessed this and called the paramedics. However, with great presence of mind, he began to succus and dilute the water that remained in the jar. The paramedics arrived and despite defibrillating Del were having no success, the race was on. !0, 20, 30C and Del was still in problems, chest compressions and oxygen  were doing nothing. Finally 200C, we’d need a really potent remedy for this situation.

Just as the paramedics shocked Del again some of the 200C Alt Curr preparation was dripped on Del’s lips. Instantly he coughed and opened his eyes. He made a full recovery and the burns on his hands were successfully treated with homeopathic preparations (after skin grafting).

This clear and unequivocal result shows the power of homeopathy. The sceptics may well say we “don’t know” that it wasn’t quantum nano-bollock particles of copper from the wire rather than the electricity itself. But that’s just stupid – like cures like so it couldn’t be the copper, it is obviously the memory of the electricity in the water that had the effect.

We offered some of this highly potent medicine to the paramedic crew but they mysteriously declined, we can only assume they are in the pay of big Pharma.

HRH, The Prince of Wales has supported quackery on uncounted occasions. Several years ago, Charles even began selling his very own line of snake-oil. Now he surprises the British public with a brand new product: the ‘Baby Organic Hamper’. It is being sold for £195 under Prince Charles’ Highgrove-label and advertised with the following words:

A limited edition, hand-numbered hamper box packed with our new gentle organic bath and body products and a Highgrove Baby Bear. An ideal gift for new babies and parents. The blend of organic Roman chamomile and mandarin has been developed to be calm and gentle on delicate skin.

Roman chamomile has been known for centuries for its calming and relaxing benefits and also acts as an anti-inflammatory. Mandarin, known as ‘happy-oil’, has been chosen for its antiseptic properties and ability to boost immunity. Combined, this blend of ingredients produces a calming, protective barrier helping babies to relax. The exclusive, fully jointed Highgrove Baby Bear in antique mohair is made by Merrythought.

Provenance The unique bath and body collection has been created with Daniel Galvin Jr. in collaboration with Alexandra Soveral. Daniel Galvin Jr. has pioneered and developed organic products for hair and beauty over the last decade and Alexandra Soveral is a renowned and highly respected aromatherapist and facialist.

This new collection has been formulated in accordance with The Soil Association’s standards for health and beauty products, ensuring the purity of the range. Hamper Contents Body Lotion 100ml. Bath and Massage Oil 100ml. Flower Water 100ml. Bath and Body Wash 100ml. Balm 50ml. Highgrove Baby Bear.

Terms like relaxing benefits … anti-inflammatory … antiseptic properties … ability to boost immunity … protective barrier … helping babies to relax do undoubtedly amount to medical/therapeutic claims which, by definition (and by English law), need to be supported by evidence. I fail to see any sound evidence that either chamomile or mandarin oil or their combination have any of these effects on babies when applied as a body lotion, bath oil, massage oil, flower water, body wash.

The only RCT for mandarin-oil I could find concluded that results do not support a benefit of ‘M’ technique massage with or without mandarin oil in these young postoperative patients. Several reasons may account for this: massage given too soon after general anaesthesia, young patients’ fear of strangers touching them, patients not used to massage. For Roman Chamomile, I also identified just one relevant study; its results do not seem to suggest that the oil is the decisive factor in producing relaxation: Massage with or without essential oils appears to reduce levels of anxiety. Neither of these trials were done with babies, and crucially, no clinical trial at all seems to exist of the combination of the two oils as used in the Charles’ products.

As Charles and his team are clearly not scientists or health care experts, they took advice from people who might know about such matters: Daniel Galvin Jr. in collaboration with Alexandra Soveral. Daniel Galvin Jr. has pioneered and developed organic products for hair and beauty over the last decade and Alexandra Soveral is a renowned and highly respected aromatherapist and facialist.

This might look responsible at first glance; at closer scrutiny, Daniel Galvin turns out to be more an expert in cosmetics than in medicine; his own website explains: Born into the country’s most influential hairdressing dynasty, Daniel Galvin Jr, has been instrumental in the growth of the organic beauty market for the past 12 years and has been in the industry for 27 years. As a salon owner and creator of natural, organic professional haircare, he is at the forefront of colour expertise, with a client list including a ‘who’s who’ of TV personalities, British actors, royalty and London’s most beautiful socialites.

Alexandra Soveral might have once worked as an aromatherapist, but today she is the co-owner of a firm marketing natural beauty products; her website explains: We use rare & organic ingredients of the highest quality to create products that work in synergy with nature. We work towards a synthetic chemical free world. The scents from our essential oils evoke mind, body and soul reactions that promote well-being. We aim to continue our journey by always ensuring we source out new ways to improve our products and be kind to the planet.

At this point, two questions emerge in my mind: 1) is this just foolish nonsense or is it more sinister than that? 2) Why on earth does Charles venture into this sort of thing?

Ad 1

I would be inclined to file Charles’ baby-hamper under the category of ‘foolish nonsense’. Ok, it exploits the love of parents for their new-borns – £195 per item is not exactly cheap (even considering that it is HAND-NUMBERED!) – but the type of customer who might buy this product is probably not on the brink of financial hardship. The ‘foolish nonsense’ does, however, acquire a more sinister significance through the fact that the heir to the throne, who arguably should be an example to us all, yet again is responsible for unsubstantiated therapeutic claims. So, on balance, I think this is more than just foolish nonsense; in fact, it is yet another example of Charles misguiding the public through his passion for quackery.

Ad 2

Why does he do it? Does Charles need the money? No, unlike other quacks, he is not motivated by commercial interests. Is it for boosting his public image? Charles has certainly had an alternative bee under his royal bonnet for a very long time; in his quest to spread his abstruse notions of integrated health care, he has aquired an image to live up to. This new foray into quackery seems nevertheless baffling, in my view, because it is so obviously and cynically disregarding the law, regulations and evidence.

The way I see it, there are only two explanations for all this: either Charles is less aware of reality than one might have hoped, or he delegates trivial matters of this nature to one of his many sycophants without caring about the embarrassing details. Both of these possibilities are neither flattering for him nor reassuring for us…GOD SAVE THE QUEEN!

According to its authors, this RCT was aimed at investigating the 1) specific effect of individualized homeopathic Q-potencies compared to placebo and 2) the effect of an extensive homeopathic case taking (case history I) compared to a shorter, rather conventional one (case history II) in the treatment of acute major depression. In particular the second research question is intriguing, I think – so let’s have a closer look at this trial.

The study was designed as a randomized, partially double-blind, placebo-controlled, four-armed, 2×2 factorial trial with a 6-week study duration. A total of 44 patients were randomized (2∶1∶2∶1 randomization: 16 homeopathic Q-potencies/case history I, 7 placebo/case history I, 14 homeopathic Q-potencies/case history II, 7 placebo/case history II). Because of recruitment problems, the study was terminated prior to full recruitment, and was thus underpowered for the pre-planned confirmatory hypothesis testing. Exploratory data analyses showed heterogeneous and inconclusive results with large variance. The mean difference for the Hamilton-D after 6 weeks was 2.0 (95%CI -1.2;5.2) for Q-potencies vs. placebo, and -3.1 (-5.9;-0.2) for case history I vs. case history II. Overall, no consistent or clinically relevant results between homeopathic Q-potencies versus placebo and homeopathic versus conventional case taking were observed. The frequency of adverse events was comparable for all groups.

The conclusions were remarkable: although our results are inconclusive, given that recruitment into this trial was very difficult and we had to terminate early, we cannot recommend undertaking a further trial addressing this question in a similar setting.

Alright, the authors encountered problems in recruiting enough patients and they therefore decided to stop the trial early. This sort of thing happens. Most researchers would then not publish any data at all. This team, however, did publish a report, and the decision to do so might be perfectly fine: other investigators might learn from the problems which led to early termination of the study.

But why do they conclude that the results were INCONCLUSIVE? I think the results were not inconclusive but non-existent; these were no results to report other than those related to the recruitment problems. And even if one insists on presenting outcome data as an exploratory analysis, one cannot honestly say they were INCONCLUSIVE, all one might state in this case is that the results failed to show an effect of the remedy or the consultation. This is far less favourable for homeopathy than stating the results were INCONCLUSIVE.

And why on earth do the authors conclude “we cannot recommend undertaking a further trial addressing this question in a similar setting”? This does not make the slightest sense to me. If the trialists encountered recruitment problems, others might find ways of overcoming them. The research question asking whether the effects of an extensive homeopathic case taking differ from those of a shorter conventional one seems important. If answered accurately, it could disentangle much of the confusion that surrounds clinical trials of homeopathy.

I have repeatedly commented on the odd conclusions drawn by proponents of alternative medicine on the basis of data that did not quite fulfil their expectations, and I often ask myself at what point this ‘prettification’ of the results via false positive conclusions crosses the line to scientific misconduct. My theory is that these conclusions appear odd to those capable of critical analysis because the authors bend over backwards in order to conclude more positively than the data would seem to permit. If we see it this way, such conclusions might even prove useful as a fairly sensitive ‘bullshit-detector’.

We have probably all fallen into the trap of thinking that something which has stood the ‘test of time’, i.e. something that has been used for centuries with apparent success, must be ok. In alternative medicine, this belief is extremely wide-spread, and one could argue that the entire sector is built on it. Influential proponents of ‘traditional’ medicine like Prince Charles do their best to strengthen this assumption. Sadly, however, it is easily disclosed as a classical fallacy: things that have stood the ‘test of time’ might work, of course, but the ‘test of time’ is never a proof of anything.

A recent study brought this message home loud and clear. This trial tested the efficacy of Rhodiola crenulata (R. crenulata), a traditional remedy which has been used widely in the Himalayan areas and in Tibet to prevent acute mountain sickness . As no scientific studies of this traditional treatment existed, the researchers conducted a double-blind, placebo-controlled crossover RCT to test its efficacy in acute mountain sickness prevention.

Healthy adult volunteers were randomized to two treatment sequences, receiving either 800 mg R. crenulata extract or placebo daily for 7 days before ascent and two days during mountaineering. After a three-month wash-out period, they were crossed over to the alternate treatment. On each occasion, the participants ascended rapidly from 250 m to 3421 m. The primary outcome measure was the incidence of acute mountain sickness with headache and at least one of the symptoms of nausea or vomiting, fatigue, dizziness, or difficulty sleeping.

One hundred and two participants completed the trial. No significant differences in the incidence of acute mountain sickness were found between R. crenulata extract and placebo groups. If anything, the incidence of severe acute mountain sickness with Rhodiola extract was slightly higher compared to the one with placebo: 35.3% vs. 29.4%.

R. crenulata extract was not effective in reducing the incidence or severity of acute mountain sickness as compared to placebo.

Similar examples could be found by the dozen. They demonstrate very clearly that the notion of the ‘test of time’ is erroneous: a treatment which has a long history of usage is not necessarily effective (or safe) – not only that, it might be dangerous. The true value of a therapy cannot be judged by experience, to be sure, we need rigorous clinical trials. Acute mountain sickness is a potentially life-threatening condition for which there are reasonably effective treatments. If people relied on the ‘ancient wisdom’ instead of using a therapy that actually works, they might pay for their error with their lives. The sooner alternative medicine proponents realise that, the better.

A most excellent comment by Donald Marcus on what many now call ‘quackademia‘ (the disgraceful practice of teaching quackery (alternology) such as homoeopathy, acupuncture or chiropractic at universities as if they were legitimate medical professions) has recently been published in the BMJ.

Please allow me to quote extensively from it:

A detailed review of curriculums created by 15 institutions that received educational grants from the National Center for Complementary and Alternative Medicine (NCCAM) showed that they failed to conform to the principles of evidence based medicine. In brief, they cited many poor quality clinical trials that supported the efficacy of alternative therapies and omitted negative clinical trials; they had not been updated for 6-7 years; and they omitted reports of serious adverse events associated with CAM therapies, especially with chiropractic manipulation and with non-vitamin, non-mineral dietary supplements such as herbal remedies. Representation of the curriculums as “evidence based” was inaccurate and unjustified. Similar defects were present in the curriculums of other integrative medicine programs that did not receive educational grants….

A re-examination of the integrative medicine curriculums reviewed previously showed that they were essentially unchanged since their creation in 2002-03…Why do academic centers that are committed to evidence based medicine and to comparative effectiveness analysis of treatments endorse CAM? One factor may be a concern about jeopardizing income from grants from NCCAM, from CAM clinical practice, and from private foundations that donate large amounts of money to integrative medicine centers. Additional factors may be concern about antagonizing faculty colleagues who advocate and practice CAM, and inadequate oversight of curriculums.

By contrast to the inattention of US academics and professional societies to CAM education, biomedical scientists in Great Britain and Australia have taken action. At the beginning of 2007, 16 British universities offered 45 bachelor of science degrees in alternative practices. As the result of a campaign to expose the lack of evidence supporting those practices, most courses in alternative therapies offered by public universities in Britain have been discontinued. Scientists, physicians, and consumer advocates in Australia have formed an organization, Friends of Science in Medicine, to counter the growth of pseudoscience in medicine.

The CAM curriculums violate every tenet of evidence based medicine, and they are a disservice to learners and to the public. It could be argued that, in the name of academic freedom, faculty who believe in the benefits of CAM have a right to present their views. However, as educators and role models they should adhere to the principles of medical professionalism, including “a duty to uphold scientific standards.” Faculty at health profession schools should urge administrators to appoint independent committees to review integrative medicine curriculums, and to consider whether provision of CAM clinical services is consistent with a commitment to scholarship and to evidence based healthcare.

One of the first who openly opposed science degrees without science was David Colquhoun; in an influential article published in Nature, he wrote:

The least that one can expect of a bachelor of science (BSc) honours degree is that the subject of the degree is science. Yet in December 2006 the UK Universities and Colleges Admissions Service advertised 61 courses for complementary medicine, of which 45 are BSc honours degrees. Most complementary and alternative medicine (CAM) is not science because the vast majority of it is not based on empirical evidence. Homeopathy, for example, has barely changed since the beginning of the nineteenth century. It is much more like religion than science. Worse still, many of the doctrines of CAM, and quite a lot of its practitioners, are openly anti-science.

More recently, Louise Lubetkin wrote in her post ‘Quackademia‘ that alternative medicine and mainstream medicine are absolutely not equivalent, nor are they by any means interchangeable, and to speak about them the way one might when debating whether to take the bus or the subway to work – both will get you there reliably – constitutes an assault on truth.

I think ‘quackademia’ is most definitely an assault on truth – and I certainly know what I am talking about. When, in 1993, I was appointed as Professor of Complementary Medicine at Exeter, I became the director of a pre-existing team of apologists teaching a BSc-course in alternative medicine to evangelic believers. I was horrified and had to use skill, diplomacy and even money to divorce myself from this unit, an experience which I will not forget in a hurry. In fact, I am currently writing it up for a book I hope to publish soon which covers not only this story but many similarly bizarre encounters I had while researching alternative medicine during the last two decades.

Here are 3 more short pieces of alternative medicine satire. if you like them, please consider to send me your own short articles.

AT FAP No 7 (sent in by ‘Ex-Acupuncturist’)

Heroin junkies are now putting another type of needle in their body to get high…  Acupuncture needles!  Acupuncturists have long theorized that an endorphin release is part of the clinical effect of acupuncture.  Endorphins are the body’s own painkillers.  They are in a group of chemicals called endogenous opioids.  While sceptics have pointed out that endorphin release is also a key part of the placebo effect, it seems that ancient Chinese wisdom wins this round of the battle.

“The key is to twirl the needle in the correct direction for each individual,” one experienced user reported.  “In general, men get clockwise, women counter-clockwise, but it reverses depending on the phase of the moon and whether the kidney pulse on the wrist is floating or deep.  It may sound strange, but once you hit the right point and twirl the right way, you’re talking to the rabbit on the moon for hours.”

Apparently, heroin-like effects aren’t the only drugs acupuncture can mimic.  Homeless researcher William S. Burrows reports point combinations which replicate cannabis, magic mushrooms, and even methamphetamines.  “We confirmed this with a double-blind test down in the park.  I drew the point combinations and labelled them with codes, then taught a few volunteers how to do the needling without telling them what combinations mimic each drug.  Then I hit the bar while they rolled dice and randomly did these combinations on hundreds of homeless addicts, who then were observed and interviewed by different volunteers who didn’t know what group they had been randomized to.  The differences between the meth points and the horse points were pretty obvious by behaviour, but we also gathered more objective data such as blood pressure, pupil size, and pre- and post- treatment urinalysis results.  Most of our volunteers are users of real drugs, but when you get the acupuncture right it the metabolites show up in urine.”

Science journal editor Dr. Edward Ernest was impressed.  “This acupuncture research carried out by homeless drug addicts, literally under a bridge, is better and more convincing than all previous acupuncture research combined.  What’s more impressive is that it’s being replicated as we speak in addicted populations around the world, all through grassroots efforts.”
When asked why his research was so well structured and recorded compared to previous acupuncture research, Burrows said, “I’m not sure, but it may have something to do with how important getting high is to addicts.  Regular acupuncturists are just telling people they can treat normal pain and diseases, and many of those go away on their own.  We are dealing with serious drug habits here, it’s not something to mess around with.  Regular people can be fooled with post hoc reasoning, regression to the mean, and a good bedside manner.  Junkies in withdrawal have a higher standard of evidence.”

While getting high with acupuncture is safer and less expensive than using black market drugs, public health officials are already warning users that familiar communicable disease dangers exist if needles are shared.  “We are discussing setting up a free acupuncture needle exchange to reduce the risk of hepatitis and HIV transmission.”

AT FAP No 8 (by Edzard Ernst)

THE END OF EBM and the arrival of VBM

Inspired by a recent popular vote in Scotland on the need of having homeopathy free on the NHS, top-ranking health politicians from across the UK have met to discuss the implications of this intriguing and ground-breaking development. The politicians were taken by the idea of replacing evidence with a popular vote. They felt that they were much more familiar with the various ways to influence voters than with the often fiendishly complex issues of scientific evidence. “Everything becomes understandable and transparent with one single stroke”, one senior official commented, “what could be more logical than finally democratising health care? It was time anyway to break the dictatorship of science; as politicians, we cannot tolerate to be told by scientists what is right and wrong.”

The panel drew up plans to have all major health care decisions decided by popular vote. Pilot projects that followed this courageous move have already generated most encouraging results: diabetics voted to have free chocolate, claudicants opted for cheaper cigarettes, addicts wanted to legalise hard drugs and the entire population of Totness was in favour of replacing conventional by alternative medicine.

On the basis of these findings, the secretary for health issued a press release pointing out that innovations of this nature might look counter-intuitive to notoriously short-sighted medics but from a more realistic perspective, they do make a lot of sense: patients deserve to be given a choice; if many to the most desperately ill diabetics die early as a consequence, it might even be humane to let them end their suffering quickly and with dignity – and from a societal point of view, early fatalities mean significant cost-savings which will certainly free funds to improve the health of the rest of the nation. “I am sure that this innovation will win us votes”, one Tory health politician was quoted saying. A white paper was drawn up which suggests the nationwide implementation of these progressive concepts, and well-informed circles at Westminster indicate that David Cameron views the new ‘Vote-Based Medicine’ (VBM) as a possible solution to steer the NHS out of its current crisis.

AT FAP No 9 (by Edzard Ernst)

A bitter row has broken out in the US-based ‘Palmer Institute of Straight Chiropractic’ (PISC) over the interpretation of the results generated by the largest long-term study of chiropractic that has ever been initiated. The study in question, which had been funded by the NIH and several chiropractic bodies across the world, started recruiting in the 1970. Its was aimed at testing the effects of chiropractic maintenance treatment. Based on D D Palmer’s , the father of chiropractic, axiom that all diseases are caused by ‘subluxations of the spine’, chiropractic maintenance care is a method of regularly adjusting subluxations of healthy people before they can do any significant damage to health and well-being. Top officials of PICS had therefore concluded that regular adjustments would prevent illness and prolong life. The project was thus to administer maintenance care to 1000 volunteers for their entire life time and compare the mortality and morbidity of this cohort with the data from the US population at large.

So far, the findings of this study had been kept under tight wraps; the protocol foresaw that the first analysis should only be at the 40-year follow-up. Last months, however, the first preliminary analysis emerged at a closed meeting of the PISC in Devonport, US. A leaked note shows that, despite the large sample size and the sizable number of morbidity and mortality outcomes in the study cohort, the comparison with the general population did not demonstrate any significant differences; if anything, the incidence of neurological problems, e.g. stroke, in the experimental group seems unusually high.

As soon as the results were known to the PISC-officials, dramatically different interpretations of these findings emerged, our reporter was told:

  • One group of chiropractors claimed the results were obviously rigged; some were sure that BIG PHARMA had bribed the researchers/statisticians to produce false negative findings. “It stands to reason”, one chiropractor from this camp was quoted saying, “just imagine what would happen, if the effectiveness of chiropractic maintenance care would become general knowledge; nobody would need the pharma-industry any more. It is therefore clear that they did everything in their power to supress the truth”
  •  The other group of chiropractors claimed that the maintenance treatment implemented in the study was not intensive enough to be effective. On average, every study participant had 1.6 sessions of spinal manipulation per week (the costs of these treatments were estimated at US$ 60 million across the study period). But these chiropractors argued that “subluxations occur much more frequently and need to be treated more regularly; we advocate daily sessions to be on the safe side – besides, this would be ever so good for the profession as a whole.”

So far none of the chiropractors who have commented on the results of this study considered that their original hypothesis was false, i.e. that subluxations might not be the cause of all human disease. When our reporter put this possibility to the president of PISC, the answer was prompt and abrupt: ” You must be kidding! That would mean that D D Plamer was wrong. This is not a realistic possibility at all. Chiropractors are foremost manipulators; we will now manipulate the data until they confirm Palmer’s theory.”

Acupressure is a treatment-variation of acupuncture; instead of sticking needles into the skin, pressure is applied over ‘acupuncture points’ which is supposed to provide a stimulus similar to needling. Therefore the effects of both treatments should theoretically be similar.

Acupressure could have several advantages over acupuncture:

  • it can be used for self-treatment
  • it is suitable for people with needle-phobia
  • it is painless
  • it is not invasive
  • it has less risks
  • it could be cheaper

But is acupressure really effective? What do the trial data tell us? Our own systematic review concluded that the effectiveness of acupressure is currently not well documented for any condition. But now there is a new study which might change this negative verdict.

The primary objective of this 3-armed RCT was to assess the effectiveness and cost-effectiveness of self-acupressure using wristbands compared with sham acupressure wristbands and standard care alone in the management of chemotherapy-induced nausea. 500 patients from outpatient chemotherapy clinics in three regions in the UK involving 14 different cancer units/centres were randomised to the wristband arm, the sham wristband arm and the standard care only arm. Participants were chemotherapy-naive cancer patients receiving chemotherapy of low, moderate and high emetogenic risk. The experimental group were given acupressure wristbands pressing the P6 point (anterior surface of the forearm). The Rhodes Index for Nausea/Vomiting, the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool and the Functional Assessment of Cancer Therapy General (FACT-G) served as outcome measures. At baseline, participants completed measures of anxiety/depression, nausea/vomiting expectation and expectations from using the wristbands.

Data were available for 361 participants for the primary outcome. The primary outcome analysis (nausea in cycle 1) revealed no statistically significant differences between the three arms. The median nausea experience in patients using wristbands (both real and sham ones) was somewhat lower than that in the anti-emetics only group (median nausea experience scores for the four cycles: standard care arm 1.43, 1.71, 1.14, 1.14; sham acupressure arm 0.57, 0.71, 0.71, 0.43; acupressure arm 1.00, 0.93, 0.43, 0). Women responded more favourably to the use of sham acupressure wristbands than men (odds ratio 0.35 for men and 2.02 for women in the sham acupressure group; 1.27 for men and 1.17 for women in the acupressure group). No significant differences were detected in relation to vomiting outcomes, anxiety and quality of life. Some transient adverse effects were reported, including tightness in the area of the wristbands, feeling uncomfortable when wearing them and minor swelling in the wristband area (n = 6). There were no statistically significant differences in the costs associated with the use of real acupressure band.

26 subjects took part in qualitative interviews. Participants perceived the wristbands (both real and sham) as effective and helpful in managing their nausea during chemotherapy.

The authors concluded that there were no statistically significant differences between the three arms in terms of nausea, vomiting and quality of life, although apparent resource use was less in both the real acupressure arm and the sham acupressure arm compared with standard care only; therefore; no clear conclusions can be drawn about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting. However, the study provided encouraging evidence in relation to an improved nausea experience and some indications of possible cost savings to warrant further consideration of acupressure both in practice and in further clinical trials.

I could argue about several of the methodological details of this study. But I resist the temptation in order to focus on just one single point which I find important and which has implications beyond the realm of acupressure.

Why on earth do the authors conclude that no clear conclusions can be drawn about the use of acupressure wristbands in the management of chemotherapy-related nausea and vomiting? The stated aim of this RCT was to assess the effectiveness and cost-effectiveness of self-acupressure using wristbands compared with sham acupressure wristbands and standard care. The results failed to show significant differences of the primary outcome measures, consequently the conclusion cannot be “unclear”, it has to be that ACUPRESSURE WRIST BANDS ARE NOT MORE EFFECTIVE THAN SHAM ACUPRESSURE WRIST BANDS AS AN ADJUNCT TO ANTI-EMETIC DRUG TREATMENT (or something to that extent).

As long as RCTs of alternative therapies are run by evangelic believers in the respective therapy, we are bound to regularly encounter this lamentable phenomenon of white-washing negative findings with an inadequate conclusion. In my view, this is not research or science, it is pseudo-research or pseudo-science. And it is much more than a nuisance or a trivial matter; it is a waste of research funds, a waste of patients’ good will that has reached a point where people will lose trust in alternative medicine research. Someone should really do a systematic study to identify those research teams that regularly commit such scientific misconduct and ensure that they are cut off public funding and support.

I am delighted to report that my invitation to contribute AT FAPs was successful! Some readers did indeed cotton on and submitted their funny satire and bizarre absurdities – oddly enough, they are all homeopathic by nature. If you like to know more about the idea of AT FAPs, please see here. And do not forget: if you want me to continue with this feature, keep your alt med satire coming!

AT FAP No 4 (sent in by an anonymous reader)

You’ve heard or Gerson but now we can reveal Dyson therapy!

The well established and long-proven facts of homeopathy – that like cures like, ultra diluted solutions of nothing are incredibly potent medicines, Hahnemann can’t be wrong etc. have, of course revolutionised our world view.  Nothing substantial had changed in homeopathy for 200 years, until now!  Vacuous homeopaths have now discovered an amazing breakthrough- Dyson therapy. After extensive research one afternoon, they have made a breakthrough that will rock the world and clean your carpet.

Some homeopaths believe that ultra diluted water contains silica that is remarkably similar to that found in the glass vessels it is prepared in. Vacuous homeopaths have found a way to reduce the content of the water still further, indeed eliminate it completely!

Using the principle of like cures like, a material is chosen for its powerful homeopathic effects,  and ground up in a small amount of water and/or alcohol until it turns into a paste or solution. Now here’s the science bit- it is then smeared on the floor. After being allowed to dry for precisely 3.4 minutes (trust us) it is then vacuumed up! This amazing breakthrough allows the nano-bollock essence of the material to be firmly trapped within the vacuum cleaner, but here is the genius part-as air is drawn over it the nano-bollock material is infinitely diluted. No need for complicated machines you can do this yourself at home. Vacuous homeopaths have found that the vacuum cleaner has to be tapped on the floor during the process, or for a far more potent effect on the head of a sceptic (we call this concussion). It has to be tapped a precise number of times, the number is decided by the current cost in pence of a avocado pear, this in scientific terms is known as the avocado number  -trust us it works!

We now have a homeopathic remedy inside the cleaner. The patient takes a tube from the cleaner applies it to their mouth * and vacuums out all those nasty miasmas  whilst simultaneously increasing the potency of the homeopathic preparation by yet further dilution.  But that’s not all! Dyson therapy removes harmful mercury vapour from your fillings, this is truly miraculous.

Until now vacuous homeopaths have argued that homeopathy  has no side effects effects. Sceptics have argued this is because it contains nothing does nothing and is worth nothing. Vacuous homeopaths have now found side effects, after all when you prepare the ultimate vacuum potencies we are dealing with the strongest medicine in the universe. Side effects include blisters of the lips and mouth, ruptured lungs and feelings of intense stupidity.

* Some experiments with Dyson therapy have been abandoned due to penile injury, but an exciting new avenue of research – anal Dyson therapy is being intensively studied, this combined with coffee enemas is an exciting new wake up call for homepathy. So far results have shown that homeopaths are full of shit.

Disclaimer: I do not own shares in Dyson, and am in no way associated with the company – Big Pharma wouldn’t let me. Other brands of vacuum cleaner are available.

AT FAP No5 (sent in by Norbert Aust)

German scientist succeeded in creating the ultimate homeopathic remedy: Vinum Christi C200! This remedy combines strong beliefs and ancient wisdom from christianity with the more recent scientific achievements of current homeopathy.

Details on the procedure are not clear yet, but the scientist (name known to the edotor) succeeded in building an entanglement with the the molecules of Our Lord’s last goblet of wine that today can be found in any glass of water. By banging his head on the wall he could successfully succuss just these molecules and could build a very powerful mother tincture. Further potentization yielded a very strong remedy, much more powerful than any of the current homeopathic alcoholic dilutions. It took only one tiny drop of this solution to turn a bottle of Scotch whisky into a very efficacious tincture outperforming any of our Lord’s wines or what you would expect of todays wines. In fact, the proving got a little out of control, but the effects could be witnessed nevertheless. It seems a perfect medicine for headaches, vertigo, nausea, general pain and feeling of being sick, difficulties in eye focus and speech, turns of general love and hate of the world in total. Many more symptoms expected to be found in further provings.

The scientist – after he recovered fronm the proving – made it a point, that the preparation of the mother tincture requires much experience and personality. The beginner might well end up entangled with the wrong molecules in his glass of water (like the donkey’s first pee after he carried our Lord to Jerusalem), which may lead to unpredictable results when proving the final compound.

Adress any inquiries for marketing of this medicine to the editor who will forward it to the scientist.

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