Yesterday, The Hinckley Times published a report on Parliament’s foremost medical expert which I take the liberty of reproducing below in a slightly shortened version.
Alternative therapy proponent David Tredinnick has pitched in with the possibility of complementary practitioners being the solution to the current A&E crisis. The Tory MP for Bosworth raised the issue with the Department of Health saying: “To ask the Secretary of State for Health, what assessment he has made of the potential contribution of regulated complementary and alternative medical practitioners to reducing demands on the NHS.” The question came against the backdrop of the nation’s casualty departments being swamped with new cases since Christmas.
Despite Mr Tredinnick’s pleas his faith in less mainstream medical care was not supported by Government health chiefs. In a written answer to the former Grenadier Guardsman, the Parliamentary Undersecretary of State for Health, Daniel Poulter, said: “Practitioners of complementary and alternative medicines are not subject to statutory regulation. A working group has been established to consider a number of matters relating to the use of herbal and traditional medicines by practitioners. I know my hon. Friend is a member of this working group. “The findings of the working group will be published in due course, once it has finished its work. Until that working group has reported, no assessment can be made of the contribution of such practitioners to reducing demands on the National Health Service.”
Just days before in the House of Commons, Mr Tredinnick was apparently slapped down by a fellow Conservative MP and GP Sarah Wollaston when he called for a homeopathic flu vaccine to be given to people at risk this winter. Making the suggestion in his role as a member of the Health Select Committee he was rebuked by Mrs Wollaston, the chairman of the group, who distanced herself and said she would “personally be horrified” if his view was taken up.
Mr Tredinnick’s Liberal Democrat opponent councillor Michael Mullaney, said: “Dr Sarah Wollaston is a highly respected GP and Conservative MP whose background in the health service makes her someone who should be listened to on health issues. Unlike Mr Tredinnick, who has no formal medical training, yet constantly tries to tell doctors how to do their job. “If even Dr Wollaston, a fellow Conservative MP, is saying David Tredinnick is wrong and should be ignored, it is time he listened and stopped opening his mouth on things he knows nothing about. Mr Tredinnick has told doctors not to operate on a full moon and told GPs to use patients’ horoscopes when they come for consultations. With his way out views, Mr Tredinnick is increasingly becoming a joke even to his fellow Conservative MPs. How can he represent the people of Hinckley and Bosworth when even his own fellow Conservative MPs are condemning his views?”
Cllr Mullaney’s remarks relate to an episode in the Commons in October 2009 when Mr Tredinnick said blood didn’t clot when there was a full moon and more recently when the MP advocated the integration of astrology into the NHS.
I am deeply saddened by this unfair opposition to my friend Tredinnick. Finally, we have someone in Parliament who shows us a way out of the crisis and all we can do is to slap him down! Just think how much we could gain from his innovations:
- crystal healers and Reiki masters could take the pressure off A+E departments throughout the country;
- homeopathic vaccinations would protect us all from Ebola and other nasty infections;
- astrology could replace expensive screening programs which are of disputed value anyway.
I find it truly depressing to realise that we live in a time where great visionaries like Tredinnick are viciously belittled and their progressive messages ignored. We certainly do this at our very own peril! To me it is clear that none other than BIG PHARMA is behind this deplorable development.
I for one urge the good citizens of Bosworth to continue voting for this genius, and I vow to plead with the next prime minister to make Tredinnick secretary of health – this shrewd move would significantly strengthen the Tory’s effort to save out National Health Service for the benefit of us all.
Few subjects lead to such heated debate as the risk of stroke after chiropractic manipulations (if you think this is an exaggeration, look at the comment sections of previous posts on this subject). Almost invariably, one comes to the conclusion that more evidence would be helpful for arriving at firmer conclusions. Before this background, this new publication by researchers (mostly chiropractors) from the US ‘Dartmouth Institute for Health Policy & Clinical Practice’ is noteworthy.
The purpose of this study was to quantify the risk of stroke after chiropractic spinal manipulation, as compared to evaluation by a primary care physician, for Medicare beneficiaries aged 66 to 99 years with neck pain.
The researchers conducted a retrospective cohort analysis of a 100% sample of annualized Medicare claims data on 1 157 475 beneficiaries aged 66 to 99 years with an office visit to either a chiropractor or to a primary care physician for neck pain. They compared hazard of vertebrobasilar stroke and any stroke at 7 and 30 days after office visit using a Cox proportional hazards model. We used direct adjusted survival curves to estimate cumulative probability of stroke up to 30 days for the 2 cohorts.
The findings indicate that the proportion of subjects with a stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with a stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33-0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01-1.19).
The authors conclude that, among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.
I do, of course, applaud any new evidence on this rather ‘hot’ topic – but is it just me, or are the above conclusions a bit odd? Five strokes per 1000 patients is definitely not “extremely low” in my book; and furthermore I do wonder whether all experts would agree that a doubling of risk at 30 days in the chiropractic cohort is “probably not clinically significant” – particularly, if we consider that chiropractic spinal manipulation has so very little proven benefit.
My message to (chiropractic) researchers is simple: PLEASE REMEMBER THAT SCIENCE IS NOT A TOOL FOR CONFIRMING BUT FOR TESTING HYPOTHESES.
During the next few weeks, I will post several short excerpts from my new book ‘A SCIENTIST IN WONDERLAND‘. Its subtitle already discloses much of what it is all about: ‘A MEMOIRE OF SEARCHING THE TRUTH AND FINDING TROUBLE’.
Some of my critics are likely to claim that I engage in this form of ‘promotion’ because I want to maximise my income by enticing my readers to buy the book. This is partly true, of course: after having worked very hard on this book for about 5 years, I want it to be read (but, at the same time, my critics would be mistaken: I do not expect to get rich on my new book – I am not that naïve; this ‘memoire’ will never be found in any best-seller list, I am sure). So, I suggest (if you do not want me to profit in any way) that you read my memoire after you got it from your library (which obviously would not affect my cash-flow all that much).
So here it is: with much trepidation and even more excitement I present to you the very first, short excerpt (as I said, there will be more).
There are some people, a fortunate few, who seem to know from an early age where they want to go in life, and have no trouble getting there.
I was not one of them. I was born in Germany in the years immediately following the end of World War II and, like many German children of that era, I was acutely aware of the awkwardness and unease that my elders displayed when it came to discussions that touched on the country’s recent history. Even as a young boy, I was conscious that there was a large and restive skeleton in the nation’s closet, and that it belonged to all of us – even to those of us who had not been alive during the Nazi era were somehow nevertheless its legatees, inextricably bound to it simply by the awareness of its existence.
With time, the growing realization that so many of our peers – teachers, uncles, aunts; perhaps even our own parents – had lent their assent, or worse, their enthusiastic assistance to the Nazi regime robbed their generation of its moral authority and left us, their children, unmoored and adrift.
In a profound sense I felt homeless. An accident of fate had landed me on the planet with a German passport, and with German as my mother tongue, but where did I really belong? Where would I go? What would I do with my life?
There had been physicians in my family for generations and there was always an expectation that I, too, would enter that profession. Yet I felt no strong pull towards medicine. As a young man my only real passion was music, particularly jazz, with its anarchic improvisations and disobedient rhythms; and the fact that it had been banned by the Nazis only made it all the more appealing to me. I would have been perfectly happy to linger indefinitely in the world of music, but eventually, like a debt come due, medicine summoned me, and I surrendered myself to the profession of my forebears.
In hindsight I am glad that my mother nudged me gently yet insistently in the direction of medical school. While music has delighted and comforted me throughout my life, it has been medicine that has truly defined me, stretching, challenging and nourishing me intellectually, even as it tested me on a personal level almost to the limits of my endurance.
Certainly, I had never anticipated that asking basic and necessary questions as a scientist might prove so fiercely controversial, and that as a result of my research I might become involved in ideological wrangling and political intrigue emanating from the highest level.
If I had known the difficulties I would face, the stark choices, the conflicts and machinations that awaited me, would I have chosen to spend my life in medicine? Yes, I would. Becoming a physician and pursuing the career of a scientist has afforded me not only the opportunity to speak out against the dangerous and growing influence of pseudoscience in medicine, but also, paradoxically, has given me both the reason and the courage to look back steadily at the unbearable past.
This is the story of how I finally found where I belong.
Guest post by Louise Lubetkin
(A SCIENTIST IN WONDERLAND: A MEMOIRE OF SEARCHING FOR TRUTH AND FINDING TROUBLE has now been published. An apt opportunity perhaps to post a letter and comment from the person who helped me GREATLY in finishing it.)
People write memoirs for a variety of reasons but perhaps one of the strongest impelling forces is the need to make sense of one’s own experiences. It is not surprising that you, who spent your entire professional career searching for explanations, identifying associations and parsing correlations, found yourself looking at your own life with the same analytical curiosity. Memoir is in many respects a natural choice in this regard.
That you chose to undertake a profoundly personal inventory at this juncture is also understandable in human terms. Retirement, whether anticipated and planned for, or (as in your case) thrust rudely upon you, reorders one’s sense of identity in ways that cannot fail to prompt reflection. It would have been surprising had you not felt an urge to look back and take stock, to trace the narrative arc of your life from its beginnings in post-war Germany all the way to the quiet house in rural Suffolk where you now sit, surrounded by the comfort of books and the accumulated paraphernalia of a life spent digging and delving in search of the building blocks of truth.
Given the contentious circumstances surrounding your departure from academic life, it is quite likely that you will be asked whether your decision to write a memoir was driven, at least in part, by a desire to settle scores. I think you can dismiss such a question unhesitatingly. You have no scores to settle: you came to England after a steady and unbroken ascent to the apex of your professional career, voluntarily leaving behind a position that most people would regard with envy and deference. You were never a supplicant at Exeter’s door; far from it. The fact that things went inexorably downhill over the course of your 20 years’ tenure there, and ended so deplorably, is not a reflection on you, your department, or the quality or quantity of work you turned out. Rather, it is a reflection on the very nature of the work you went there to do – and if there is any message in your memoir, it is this:
Alternative medicine is not, at its heart, a logical enterprise, and its adherents are not committed to – nor even interested in – a rational evaluation of their methods. Rather, alternative medicine is primarily an ideological position, a political credo, a reaction against mainstream medicine. To many of its adherents and impassioned advocates, its appeal lies not in any demonstrable therapeutic efficacy but in its perceived outsider status as the countercultural medicine, the medicine for Everyman, the David to the bullying medical-pharmaceutical Goliath. That your research work would elicit howls of protest was perhaps inevitable, given the threat it posed to the profitable and powerful alternative medicine industry. But it didn’t stop there: astonishingly, your work drew the ire of none less than the meddlesome heir apparent to the British throne. Prince Charles’ attempts to stymie your work call to mind the twelfth century martyr Thomas à Becket, of whom Henry II reputedly cried: “Oh, who will rid me of this turbulent priest?” (Henry’s sycophantic henchmen were quick to oblige, dispatching the hapless cleric on the steps of Canterbury cathedral.)
It’s clear that you were acutely aware, as a young man growing up in Germany, that science was not immune to the corrupting influence of political ideology, and that the German medical profession had entered – enthusiastically – into a Faustian compact with the Nazi regime. You have exhibited a courageous insistence on confronting and examining a national past that has at times felt like an intensely personal burden to you. It is ironic that in going to sleepy Exeter in an earnest, conscious attempt to shake off the constricting, intrigue-ridden atmosphere of academic Vienna, you ultimately found yourself once again mired in a struggle against the influence of ideology and the manipulation of science for political ends.
You went to Exeter strictly as a scientist, a skilled inquirer, a methodical investigator, expecting to be able to bring the rigors of logic and the scientific method to bear on an area of medical practice that had until then not been subjected to any kind of systematic evaluation. Instead, you were caught in a maelstrom of intrigue far worse than that which you had gratefully left behind in Vienna, buffeted and bruised by forces against which a lesser man would surely not have had the fortitude to push back so long and so hard.
On 1/12/2014 I published a post in which I offered to give lectures to students of alternative medicine:
Getting good and experienced lecturers for courses is not easy. Having someone who has done more research than most working in the field and who is internationally known, might therefore be a thrill for students and an image-boosting experience of colleges. In the true Christmas spirit, I am today making the offer of being of assistance to the many struggling educational institutions of alternative medicine .
A few days ago, I tweeted about my willingness to give free lectures to homeopathic colleges (so far without response). Having thought about it a bit, I would now like to extend this offer. I would be happy to give a free lecture to the students of any educational institution of alternative medicine.
I did not think that this would create much interest – and I was right: only the ANGLO-EUROPEAN COLLEGE OF CHIROPRACTIC has so far hoisted me on my own petard and, after some discussion (see comment section of the original post) hosted me for a lecture. Several people seem keen on knowing how this went; so here is a brief report.
I was received, on 14/1/2015, with the utmost kindness by my host David Newell. We has a coffee and a chat and then it was time to start the lecture. The hall was packed with ~150 students and the same number was listening in a second lecture hall to which my talk was being transmitted.
We had agreed on the title CHIROPRACTIC: FALLACIES AND FACTS. So, after telling the audience about my professional background, I elaborated on 7 fallacies:
- Appeal to tradition
- Appeal to authority
- Appeal to popularity
- Subluxation exists
- Spinal manipulation is effective
- Spinal manipulation is safe
- Ad hominem attack
Numbers 3, 5 and 6 were dealt with in more detail than the rest. The organisers had asked me to finish by elaborating on what I perceive as the future challenges of chiropractic; so I did:
- Stop happily promoting bogus treatments
- Denounce obsolete concepts like ‘subluxation’
- Clarify differences between chiros, osteos and physios
- Start a culture of critical thinking
- Take action against charlatans in your ranks
- Stop attacking everyone who voices criticism
I ended by pointing out that the biggest challenge, in my view, was to “demonstrate with rigorous science which chiropractic treatments demonstrably generate more good than harm for which condition”.
We had agreed that my lecture would be followed by half an hour of discussion; this period turned out to be lively and had to be extended to a full hour. Most questions initially came from the tutors rather than the students, and most were polite – I had expected much more aggression.
In his email thanking me for coming to Bournemouth, David Newell wrote about the event: The general feedback from staff and students was one of relief that you possessed only one head, :-). I hope you may have felt the same about us. You came over as someone who had strong views, a fair amount of which we disagreed with, but that presented them in a calm, informative and courteous manner as we did in listening and discussing issues after your talk. I think everyone enjoyed the questions and debate and felt that some of the points you made were indeed fair critique of what the profession may need to do, to secure a more inclusive role in the health care arena.
My own impression of the day is that some of my messages were not really understood, that some of the questions, including some from the tutors, seemed like coming from a different planet, and that people were more out to teach me than to learn from my talk. One overall impression that I took home from that day is that, even in this college which prides itself of being open to scientific evidence and unimpressed by chiropractic fundamentalism, students are strangely different from other health care professionals. The most tangible aspect of this is the openly hostile attitude against drug therapies voiced during the discussion by some students.
The question I always ask myself after having invested a lot of time in preparing and delivering a lecture is: WAS IT WORTH IT? In the case of this lecture, I think the answer is YES. With 300 students present, I am fairly confident that I did manage to stimulate a tiny bit of critical thinking in a tiny percentage of them. The chiropractic profession needs this badly!
According to the ‘General Osteopathic Council’ (GOC), osteopathy is a primary care profession, focusing on the diagnosis, treatment, prevention and rehabilitation of musculoskeletal disorders, and the effects of these conditions on patients’ general health.
Using many of the diagnostic procedures applied in conventional medical assessment, osteopaths seek to restore the optimal functioning of the body, where possible without the use of drugs or surgery. Osteopathy is based on the principle that the body has the ability to heal, and osteopathic care focuses on strengthening the musculoskeletal systems to treat existing conditions and to prevent illness.
Osteopaths’ patient-centred approach to health and well-being means they consider symptoms in the context of the patient’s full medical history, as well as their lifestyle and personal circumstances. This holistic approach ensures that all treatment is tailored to the individual patient.
On a good day, such definitions make me smile; on a bad day, they make me angry. I can think of quite a few professions which would fit this definition just as well or better than osteopathy. What are we supposed to think about a profession that is not even able to provide an adequate definition of itself?
Perhaps I try a different angle: what conditions do osteopaths treat? The GOC informs us that commonly treated conditions include back and neck pain, postural problems, sporting injuries, muscle and joint deterioration, restricted mobility and occupational ill-health.
This statement seems not much better than the previous one. What on earth is ‘muscle and joint deterioration’? It is not a condition that I find in any medical dictionary or textbook. Can anyone think of a broader term than ‘occupational ill health’? This could be anything from tennis elbow to allergies or depression. Do osteopaths treat all of those?
One gets the impression that osteopaths and their GOC are deliberately vague – perhaps because this would diminish the risk of being held to account on any specific issue?
The more one looks into the subject of osteopathy, the more confused one gets. The profession goes back to Andrew Still ((August 6, 1828 – December 12, 1917) Palmer, the founder of chiropractic is said to have been one of Still’s pupils and seems to have ‘borrowed’ most of his concepts from him – even though he always denied this) who defined osteopathy as a science which consists of such exact exhaustive and verifiable knowledge of the structure and functions of the human mechanism, anatomy and physiology & psychology including the chemistry and physics of its known elements as is made discernable certain organic laws and resources within the body itself by which nature under scientific treatment peculiar to osteopathic practice apart from all ordinary methods of extraneous, artificial & medicinal stimulation and in harmonious accord with its own mechanical principles, molecular activities and metabolic processes may recover from displacements, derangements, disorganizations and consequent diseases and regain its normal equilibrium of form and function in health and strength.
This and many other of his statements seem to indicate that the art of using language for obfuscation has a long tradition in osteopathy and goes back directly to its founding father.
What makes the subject of osteopathy particularly confusing is not just the oddity that, in conventional medicine, the term means ‘disease of the bone’ (which renders any literature searches in this area a nightmare) but also the fact that, in different countries, osteopaths are entirely different professionals. In the US, osteopathy has long been fully absorbed by mainstream medicine and there is hardly any difference between MDs and ODs. In the UK, osteopaths are alternative practitioners regulated by statute but are, compared to chiropractors, of minor importance. In Germany, osteopaths are not regulated and fairly ‘low key’, while in France, they are numerous and like to see themselves as primary care physicians.
And what about the evidence base of osteopathy? Well, that’s even more confusing, in my view. Evidence for which treatment? As US osteopaths might use any therapy from drugs to surgery, it could get rather complicated. So let’s just focus on the manual treatment as used by osteopaths outside the US.
Anyone who attempts to critically evaluate the published trial evidence in this area will be struck by at least two phenomena:
- the wide range of conditions treated with osteopathic manual therapy (OMT)
- the fact that there are several groups of researchers that produce one positive result after the next.
The best example is probably the exceedingly productive research team of J. C. Licciardone from the Osteopathic Research Center, University of North Texas. Here are a few conclusions from their clinical studies:
- The large effect size for OMT in providing substantial pain reduction in patients with chronic LBP of high severity was associated with clinically important improvement in back-specific functioning. Thus, OMT may be an attractive option in such patients before proceeding to more invasive and costly treatments.
- The large effect size for short-term efficacy of OMT was driven by stable responders who did not relapse.
- Osteopathic manual treatment has medium to large treatment effects in preventing progressive back-specific dysfunction during the third trimester of pregnancy. The findings are potentially important with respect to direct health care expenditures and indirect costs of work disability during pregnancy.
- Severe somatic dysfunction was present significantly more often in patients with diabetes mellitus than in patients without diabetes mellitus. Patients with diabetes mellitus who received OMT had significant reductions in LBP severity during the 12-week period. Decreased circulating levels of TNF-α may represent a possible mechanism for OMT effects in patients with diabetes mellitus. A larger clinical trial of patients with diabetes mellitus and comorbid chronic LBP is warranted to more definitively assess the efficacy and mechanisms of action of OMT in this population.
- The OMT regimen met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain. It was safe, parsimonious, and well accepted by patients.
- Osteopathic manipulative treatment slows or halts the deterioration of back-specific functioning during the third trimester of pregnancy.
- The only consistent finding in this study was an association between type 2 diabetes mellitus and tissue changes at T11-L2 on the right side. Potential explanations for this finding include reflex viscerosomatic changes directly related to the progression of type 2 diabetes mellitus, a spurious association attributable to confounding visceral diseases, or a chance observation unrelated to type 2 diabetes mellitus. Larger prospective studies are needed to better study osteopathic palpatory findings in type 2 diabetes mellitus.
- OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.
Based on this brief review of the evidence origination from one of the most active research team, one could be forgiven to think that osteopathy is a panacea. But such an assumption is, of course, nonsensical; a more reasonable conclusion might be the following: osteopathy is one of the most confusing and confused subject under the already confused umbrella of alternative medicine.
If we go on the internet, we find no end of positive claims for TM. The official TM website, for instance, claims that more than 350 peer-reviewed research studies on the TM technique have been published in over 160 scientific journals. These studies were conducted at many US and international universities and research centers, including Harvard Medical School, Stanford Medical School, Yale Medical School, and UCLA Medical School.
This may well be true – but do those studies amount to more than a heap of beans? Let’s find out.
The objective of our Cochrane review was to determine the effectiveness of TM for the primary prevention of cardiovascular disease (CVD). We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10); MEDLINE (Ovid) (1946 to week three November 2013); EMBASE Classic and EMBASE (Ovid) (1947 to week 48 2013); ISI Web of Science (1970 to 28 November 2013); and Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database and Health Economics Evaluations Database (November 2013). We also searched the Allied and complementary Medicine Database (AMED) (inception to January 2014) and IndMed (inception to January 2014). We hand searched trial registers and reference lists of reviews and articles and contacted experts in the field. We applied no language restrictions.
We included randomised controlled trials (RCTs) of at least three months’ duration involving healthy adults or adults at high risk of CVD. Trials examined TM only and the comparison group was no intervention or minimal intervention. We excluded trials that involved multi-factorial interventions. Outcomes of interest were clinical CVD events (cardiovascular mortality, all-cause mortality and non-fatal events) and major CVD risk factors (e.g. blood pressure and blood lipids, occurrence of type 2 diabetes, quality of life, adverse events and costs). Two authors independently selected trials for inclusion, extracted data and assessed the risk of bias.
We identified 4 RCTs with a total of 430 participants for inclusion in this review. The included trials were small, short term (three months) and at risk of bias. In all studies, TM was practised for 15 to 20 minutes twice a day. None of the included studies reported all-cause mortality, cardiovascular mortality or non-fatal endpoints as trials were short term, but one study reported survival rate three years after the trial was completed. In view of the considerable statistical heterogeneity between the results of the studies for the only outcomes reported, systolic blood pressure (I2 = 72%) and diastolic blood pressure (I2 = 66%), we decided not to undertake a meta-analysis. None of the four trials reported blood lipids, occurrence of type 2 diabetes, adverse events, costs or quality of life.
We concluded that there are few trials with limited outcomes examining the effectiveness of TM for the primary prevention of CVD. Due to the limited evidence to date, we could draw no conclusions as to the effectiveness of TM for the primary prevention of CVD. There was considerable heterogeneity between trials and the included studies were small, short term and at overall serious risk of bias. More and larger long-term, high-quality trials are needed.
Even though I am a co-author of this review, I am not entirely sure that the last sentence of our conclusion is totally correct. The TM movement has, in my view, all the characteristics of a cult with all its the dangers that cults entail. This means, I think, we ought to be cautious about TM and sceptical about their research and results. At the risk of provoking harsh criticism, I would even say we should be distrustful of their aims and methods.
Hard to believe but, in the last 35 years, I have written or edited a total of 49 books; about half of them on alternative medicine and the rest on various subjects related to clinical medicine and research. Each time a new one comes out, I am excited, of course, but this one is special:
- I have not written a book for several years.
- I have worked on it much longer than on any book before.
- Never before have I written a book with is so much about myself.
- None of my previous book covered material that is as ‘sensitive’ as this one.
I started on this book shortly after TRICK OR TREATMENT had been published. Its initial working title was ALTERNATIVE MEDICINE: THE INSIDE STORY. My aim was to focus on the extraordinary things which had happened during my time in Exeter, to shed some light on the often not so quaint life in academia, and to show how bizarre the world of alternative medicine truly is. But several people who know about these things and who had glanced at the first draft chapters strongly advised me to radically change this concept. They told me that such a book could only work as a personal memoire.
Yet I was most reluctant to write about myself; I wanted to write about science, research as well as the obstacles which some people manage to put in their way. So, after much discussion and contemplation, I compromised and added the initial chapters which told the reader about my background and my work prior to the Exeter appointment. This brought in subjects like my research on ‘Nazi-medicine’ (which, I believe, is more important than that on alternative medicine) that seemed almost entirely unrelated to alternative medicine, and the whole thing began to look a bit disjointed, in my view. However, my advisers felt this was a step in the right direction and argued that my compromise was not enough; they wanted more about me as a person, my motivations, my background etc. Eventually I (partly) gave in and provided a bit more of what they seemed to want.
But I am clearly not a novelist, most of what I have ever written is medical stuff; my style is too much that of a scientist – dry and boring. In other words, my book seemed to be going nowhere. Just when, after years of hard work, I was about to throw it all in the bin, help came from a totally unexpected corner.
Louise Lubetkin (even today, I have never met her in person) had contributed several posts as ‘guest editor’ to this blog, and I very much liked her way with words. When she offered to have a look at my book, I was thrilled. It is largely thanks to her that my ‘memoire’ ever saw the light of day. She helped enormously with making it readable and with joining up the seemingly separate episodes describes in my book.
Finding a fitting title was far from easy. Nothing seemed to encapsulate its contents, and ‘A SCIENTIST IN WONDERLAND’, the title I eventually chose, is a bit of a compromise; the subtitle does describe it much better, I think: A MEMOIR OF SEARCHING FOR TRUTH AND FINDING TROUBLE.
Now that the book is about to be published, I am anxious as never before on similar occasions. I do, of course, not think for a minute that it will be anything near to a best-seller, but I want people with an interest in alternative medicine, academia or science to read it (get it from a library to save money) and foremost I want them to understand why I wrote it. For me, this is neither about settling scores nor about self-promotion, it is about telling a story which is important in more than one way.
– Chronic low back pain (CLBP) is a condition which affects so many people that it represents a huge burden to individual patients’ suffering as well as to society in terms of loss of work time and increased economic cost. The number of therapies that have been claimed to be effective for CLBP can hardly be counted. Two of the most common treatments are spinal manipulation and exercise.
The purpose of this systematic review was to determine the effectiveness of spinal manipulation vs prescribed exercise for patients diagnosed with CLBP. Only RCTs that compared head-to-head spinal manipulation to an exercise group were included in this review.
A search of the current literature was conducted using a keyword process in CINAHL, Cochrane Register of Controlled Trials Database, Medline, and Embase. The searches included studies available up to August 2014. Studies were included based on PICOS criteria 1) individuals with CLBP defined as lasting 12 weeks or longer; 2) spinal manipulation performed by a health care practitioner; 3) prescribed exercise for the treatment of CLBP and monitored by a health care practitioner; 4) measurable clinical outcomes for reducing pain, disability or improving function; 5) randomized controlled trials. The methodological quality of all included articles was determined using the criteria developed and used by the Physiotherapy Evidence Database (PEDro).
Only three RCTs met the inclusion criteria of this systematic review. The outcomes used in these studies included Disability Indexes, Pain Scales and function improvement scales. One RCT found spinal manipulation to be more effective than exercise, and the results of another RCT indicated the reverse. The third RCT found both interventions offering equal effects in the long term.
The author concluded that there is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP. More studies are needed to further explore which intervention is more effective.
Whenever there are uncounted treatments for a given condition, one has to ask oneself whether they are all similarly effective or equally ineffective. The present review does unfortunately not answer this question, but I fear the latter might be more true than the former.
Considering how much money we spend on treating CLBP, it is truly surprising to see that just three RCTs are available comparing two of the most commonly used treatments for this condition. Equally surprising is the fact that we simply cannot tell, on the basis of these data, which of the two therapies is more effective.
What consequences should we draw from this information. Obviously we need more high quality trials. But what should we do in the meantime?
Whenever two treatments are equally effective (or, in this case, perhaps equally ineffective?), we must consider other important criteria such as safety and cost. Regular chiropractic care (chiropractors use spinal manipulation on almost every patient, while osteopaths and physiotherapists employ it less frequently) is neither cheap nor free of serious adverse effects such as strokes; regular exercise has none of these disadvantages. In view of these undeniable facts, it is hard not to come up with anything other than the following recommendation: until new and compelling evidence becomes available, exercise ought to be preferred over spinal manipulation as a treatment of CLBP – and consequently consulting a chiropractor should not be the first choice for CLBP patients.
Guest post by Nick Ross
If you’re a fan of Edzard Ernst – and who with a rational mind would not be – then you will be a fan of HealthWatch.
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HealthWatch was inspired 25 years ago by Professor Michael Baum, the breast cancer surgeon who was incandescent that so many women presented to his clinic late, doomed and with suppurating sores, because they had been persuaded to try ‘alternative treatment’ rather than the real thing.
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As Edmund Burke might well have said, all it takes for quackery to flourish is that good men and women do nothing.