The Good Thinking Society is challenging the Professional Standards Authority’s reaccreditation of the Society of Homeopaths. Why is this important?

The Professional Standards Authority (PSA) say that they are “here to protect the public and help ensure their health and wellbeing by raising standards in the regulation and registration of people working in health and social care”. Within their activities they provide a set of accredited registers so that as a member of the public you can “choose a practitioner to meet your needs with confidence”. It would therefore be reasonable to expect that the PSA have vetted the providers of their accredited registers to ensure that the treatments their members offer to the public are suitable, effective and, most importantly, safe. However, it would appear that this is not always the case.  Some members of the Society of Homeopaths (SoH) offer a treatment called CEASE therapy. This is a treatment for autism based on the false premise that vaccinations cause autism and that this can be “cured” through a combination of homeopathy, high dose vitamin C and dietary restriction. The link between vaccines and autism has been thoroughly disproved; see this for instance, and there is no evidence that CEASE therapy provides any benefit. The PSA has acknowledged that CEASE therapy is potentially harmful and they are aware that this treatment continues to be provided by some members of the SoH. In order to protect the public, it would therefore be reasonable to expect the PSA to no longer accredit the SoH. In actual fact they have done quite the opposite and on 1st April 2019 they approved accreditation of the SoH for a further year. This decision seems to be in direct conflict with the purpose of the PSA which is to protect the public. No child with autism should be subjected to CEASE therapy and it is very good that the Good Thinking Society is challenging this decision by the PSA via judicial review.

Wider implications

The particular issue here being addressed here is protecting people with autism from being exposed to the completely unsuitable CEASE therapy. This in itself is very important. However, this judicial review potentially has wider implications. It also brings into question whether regulation in the UK actually fulfils its key function of protecting the public or instead lends legitimacy to unproven, unsuitable and potentially harmful treatments. This is important as it would appear that the current approach of the PSA (and other regulators) is not effective in protecting the public from harm from unsuitable treatments.

How can you help?

Here are a few ideas of things that you could do to support the Good Thinking Society with their judicial review:

  • Make a donation
  • Share information about the campaign on social media, such as Twitter or Facebook.
  • Raise awareness with local groups that provide support to people with autism and / or parents of children with autism such as charities or local parent carer forums.
  • Get in touch with the Good Thinking Society to find out how else you could help.

Bournemouth University and AECC University College newborn feeding clinic: integrating unproven chiropractic “treatments” with midwifery

Rulings - ASA - CAP - www.asa.org.uk - AECC feeding clinic croppedThe AECC University College and Bournemouth University provide a joint newborn feeding clinic incorporating midwives and chiropractors. Bournemouth University provides the midwives and AECC University College provides the chiropractors. Midwives clearly have an important role in newborn feeding but what about chiropractors?

Summary of conclusions:

1. There is no good evidence that chiropractic provides any benefit for feeding or any other infant condition.

2. By participating in this joint clinic Bournemouth University is lending an inappropriate legitimacy to a treatment that hasn’t been shown to be effective or safe. Bournemouth University ought to be embarrassed by this association and the potential for deception of parents who are misled into taking their babies to the clinic.

3. There is no situation in which it is appropriate to take your baby to a chiropractor (or osteopath).

4. In order to adequately protect the public it would seem appropriate for the General Chiropractic Council to impose a minimum age limit for treatment by a chiropractor.

About the clinic

The AECC University College Newborn Feeding Clinic says that it is for those who are breastfeeding exclusively or mixed feeding their babies up to 8 weeks of age. This clinic is based on student midwives and chiropractic interns working together. The role of the chiropractic intern includes:

  • Sharing taking of history of pregnancy, birth and any feeding concerns with the student midwife.
  • Undertaking an examination of the baby.
  • Offering advice about positioning and comfort when breastfeeding, along with the student midwife.
  • A chiropractic treatment of the baby.

A chiropractor being involved in the care of a baby at all raises concerns but it is particularly problematic that the chiropractor is undertaking an examination and providing treatment. In spite of many claims from chiropractors (and osteopaths), the reality is that there is no evidence that chiropractic (or osteopathy) treatment provides any benefit for any infant condition. There is also no plausible mechanism by which a chiropractic treatment could provide any benefits for breastfeeding. There is no good reason why a newborn feeding clinic should involve chiropractors and Bournemouth University should be embarrassed to be involved in such nonsense.

Chiropractic treatments haven’t been shown to provide any benefit for babies

Many chiropractors (and osteopaths) offer treatments for babies for a range of different health conditions. In reality, there is no evidence that these treatments provide any benefits for any infant condition. The same is true for older children and I’ve written more about that here. Some chiropractors (and osteopaths) claim that babies experience “birth trauma” that can be corrected with their treatments. In reality, this “birth trauma” only exists in the minds of the chiropractors and osteopaths and isn’t actually a real issue.

Some babies may go for a treatment with a chiropractor (or osteopath) and appear to benefit from the treatment. Why does that happen? It’s important to understand that many conditions in infants improve of their own accord as the baby gets older. Children with colic, for instance, usually outgrow this at around 4-6 months of age. If a baby is being “treated” for colic by a chiropractor at the time they outgrow the problem then it’s natural to assume that the treatment helped and not realise that the problem was simply outgrown. In order to unpick this it’s necessary to run clinical trials to test the effectiveness of treatments. When these trials have been conducted they have not shown any benefit for chiropractic treatments for any infant condition. There is also no plausible mechanism by which a chiropractic treatment could provide any benefit for any common infant condition. There is therefore no good reason to take a baby to a chiropractor (or osteopath) for help with feeding or any other issue.

Chiropractic treatment for babies hasn’t been shown to be safe

It is not clear whether chiropractic in babies (or adults for that matter) is safe or not because a) many trials of chiropractic treatments do not adequately report adverse events (see this, for instance) and b) there is no standard mechanism for reporting adverse events or safety concerns experienced during routine chiropractic practice. It’s therefore not possible to know whether chiropractic (or osteopathy) for babies is safe.

Published research from the clinic

There are a number of published papers from the clinic. Here are some examples:

  • Demographic profile of 266 mother-infant dyads presenting to a multidisciplinary breastfeeding clinic: a descriptive study – In the abstract for this study it is stated “Musculoskeletal problems were prevalent in the babies presented to the feeding clinic, most commonly of the thoracic spine, cervical spine and sternocleidomastoid”. How were these musculoskeletal “problems” diagnosed? By chiropractors. Chiropractors who treat babies do so based on the mistaken belief that babies suffer “birth trauma” and therefore often present with musculoskeletal “problems” that a chiropractor can fix. In reality, babies don’t suffer this sort of “birth trauma” and there is no evidence that they have musculoskeletal problems that benefit from chiropractic treatment.
  • Parent Reports of Exclusive Breastfeeding After Attending a Combined Midwifery and Chiropractic Feeding Clinic in the United Kingdom – Within this paper they reported that 80 out of 85 infants demonstrated a biomechanical fault that required chiropractic care. This is, of course, utterly ridiculous. The vast majority of infants do not have a “biomechanical fault” and those that do should be treated by a suitably qualified paediatric doctor not a chiropractor. This is a classic case of chiropractors finding a “problem” that requires their “treatment” when such a problem doesn’t actually exist. This further highlights that chiropractors lack the necessary specialist skills to be able to adequately assess babies.
  • Maternal Report of Outcomes of Chiropractic Care for Infants – This paper is thoroughly criticised by Edzard Ernst here. Suffice to say it is a truly woeful piece of “research” that tells us precisely nothing about the suitability of chiropractic care for infants.

Unfortunately, it looks as though the researchers at Bournemouth University who are involved in this work have fully bought into the nonsense that is the chiropractic treatment of babies. This is a serious concern as it involves some senior research staff, one of whom is a Professor of Midwifery Education. It’s disappointing that such experienced research staff are unable to apply some critical thinking and realise that they are promoting a treatment for babies that hasn’t been shown to be effective or safe.

What action can be taken to tackle these unsuitable treatments?

I complained to the Advertising Standards Authority (ASA) about the misleading advertising claims made by the AECC University College Newborn Feeding Clinic. The ASA concluded that the advertising is likely to break their rules. Their response was to contact AECC University College to ensure that “in future the ad will be amended to make clear that the chiropractic element relates to the positioning and comfort of the mother only”. (In other words, there shouldn’t be any treatment of the baby by the chiropractor). This action by the ASA is useful progress but there remains the open question of whether it is appropriate for chiropractors to see babies at all. That isn’t a matter for the ASA but would instead fall under the remit of the regulator, the General Chiropractic Council (GCC). The primary role of the GCC is the protection of the public. As there is no evidence that chiropractic treatments provide any benefit for babies and safety has not been established it would seem to be a reasonable step for the GCC to impose a minimum age limit for chiropractic treatment. This is something that is currently being considered in Australia.

Conclusions

Chiropractic (and osteopathy) treatments have not been shown to be effective for feeding problems or any other infant condition. The safety of these treatments for babies has not been established. There is therefore no good reason to take a baby to a chiropractor (or osteopath) and it is completely inappropriate for there to be a joint feeding clinic with chiropractors and midwives. A reputable UK university should not be seen to be promoting such unsuitable treatments and Bournemouth University should be embarrassed by their involvement in this. In order to adequately protect the public it would seem appropriate for the General Chiropractic Council to impose a minimum age limit for treatment by a chiropractor.

Acupuncture is not an effective treatment for autism

Earlier this year a report was published on the HealthCMi website claiming that acupuncture is an effective treatment for autism. A number of acupuncturists have linked to that article and used it to promote their treatments on twitter and other social media. The NHS estimates that about 1 in every 100 people in the UK is autistic. If acupuncture were to be found effective for autism, it could therefore provide benefits to a large number of people. Let’s look more closely at these claims.

Summary of conclusions:

1. The principles of acupuncture conflict directly with a modern understanding of science and the human body.

2. Acupuncture has not been shown to be beneficial for autism.

3. Acupuncture treatments cause distress and other side effects for some children.

4. There is no good reason to recommend acupuncture as a treatment for autism.

What is Autism?

The National Autistic Society says:

Autism is a lifelong developmental disability that affects how people perceive the world and interact with others.

Autistic people see, hear and feel the world differently to other people. If you are autistic, you are autistic for life; autism is not an illness or disease and cannot be ‘cured‘. Often people feel being autistic is a fundamental aspect of their identity.

Autism is a spectrum condition. All autistic people share certain difficulties, but being autistic will affect them in different ways.”

What is Acupuncture?

According to Wikipedia, Acupuncture “is a form of alternative medicine in which thin needles are inserted into the body. It is a key component of traditional Chinese medicine (TCM). Acupuncture is a pseudoscience because the theories and practices of TCM are not based on scientific knowledge.”

In the study investigated here it says “In traditional Chinese acupuncture, nearly 400 acupoints on the body surface are interrelated to various functions linked through 14 meridians to various organs or viscera of the human body. By stimulating various meridian points, acupuncture may be able to correct the disharmony and dys-regulation of organ systems, which might be involved in various dimensions of ASD, to relieve symptoms and restore the mind and body.” If this sounds a bit strange, that’s because it’s complete nonsense. The concept of meridians conflicts directly with a modern understanding of the human body. There is no plausible mechanism by which inserting needles could have any effect on “organ systems”.

The article goes on to provide a TCM theory of ASD (Autism Spectrum Disorder): “According to TCM, the pathogenesis of ASD is the derangement and insufficiency of the brain and mind. The pathological involvement is in the brain, relating to the Heart, Pericardium, Liver, Spleen, and Kidney. The etiology results from an innate lesion or insufficiency of the brain/mind and dysregulation of the Heart, Liver, Spleen, and Kidney after birth.” This is also complete nonsense. The National Autistic Society says “Autism is a developmental condition affecting the way the brain processes information.” This is a much clearer and accurate explanation than the one from the paper. In reality, Autism has precisely nothing to do with “dysregulation of the Heart, Liver, Spleen, and Kidney”.

What did the study show?

The main focus of the article was this study, which was published back in 2010. The study has the following conclusion: “A short, 12-session course of electro-acupunc-ture at selected acupoints was found to improve some functions in children with ASD, especially language comprehension and self-care ability. Thus, acupuncture might be a useful adjunctive therapy in early interventional programs for children with autism”. However, there are MANY issues with study and the conclusions drawn are simply not valid. Let’s review some of the biggest issues:

  • Primary and secondary outcomes were switched in the final paper from those specified in the original protocol. The original protocol is specified here: https://clinicaltrials.gov/ct2/show/NCT00346736?term=NCT00346736&rank=1. A number of changes were made in the final paper such as the Aberrant Behavioral Checklist (ABC) switching from a primary outcome measure to secondary and the Leiter International Performance Scale-Revised changing from secondary to primary. The purpose of publishing a protocol in advance is so that it is publicly known and can’t be changed later. Changing it after publication is a really bad practice that means the rest of the research can probably not be trusted.
  • A total of 7 measurement scales were used plus a parental report. Within those 7 measurement scales only 3 of the individual values were found to have a statistically significant improvement in the treatment arm. That’s 3 out of 33 scores that showed improvement. It’s likely that if you assess this many scores, a small number of them will show improvement by pure chance. This result is therefore consistent with a treatment that is NOT effective.
  • The parental report also shows some improvements but this isn’t appropriate to use as solid evidence because a) this is not a standardised measure and b) parental (or self) report is a potentially unreliable way of measuring outcomes.
  • This was a double-blind trial with parents and assessor supposed to be blinded but no assessment of the success of blinding was carried out. It’s therefore impossible to know whether either parents or assessor were truly blind or they discovered / guessed whether they were receiving the treatment or not. If they did discover which treatment they were receiving that is likely to have influenced the results.

In short, the “improvements” observed in this study could very easily (and probably did) occur by pure chance. The results observed in this study are consistent with a treatment that is NOT effective. It is therefore completely inappropriate to recommend acupuncture as a treatment for autism based on this study.

Compliance and safety

In the paper they report that 70 percent of participants achieved “good compliance” with acupuncture treatment. Their definition of compliance is that “subjects were able to sit or lie on a couch to accept acupuncture, even if they cried or needed gentle hand or head holding”. How is a child who is crying during a procedure considered to be “compliant”? There are ethical issues here with exposing children to a treatment which lacks a plausible mechanism of action when the treatment is causing distress.

With regards to side effects they say “the mild side effects of minor superficial bleeding or crying and irritability during acupuncture were experienced by some”. They don’t, however, quantify the number of participants who experienced side effects which is a serious shortcoming in the reporting of this study. Although no serious side effects were reported in this study, a sample size of only 55 is not anywhere near enough to know whether serious side effects may occur. As serious side effects usually occur infrequently, a much larger sample size is needed to assess them.

Is Acupuncture a suitable treatment for autism?

In short, no. The principles behind acupuncture conflict directly with a modern understanding of science and the human body. Acupuncture has not been shown to be effective for autism. The report from HealthCMi is highly misleading and distorts the true picture in an attempt to provide marketing material for acupuncturists. The study on which this is based is full of flaws and in reality the results are more consistent with a treatment that is ineffective. There are serious concerns about the safety of acupuncture as a treatment for autism and the potential to cause distress in this vulnerable patient group during treatment. To conclude, there is no good reason to recommend acupuncture as a treatment for autism.

Should you see a chiropractor or an osteopath for your migraines?

migraineI’ve previously written about the problems with chiropractors and osteopaths claiming to be able to treat all types of headaches. The Advertising Standards Authority (ASA) permits chiropractors and osteopaths to advertise their treatments for only two specific types of headache:

  • Headache arising from the neck (cervicogenic)
  • Migraine prevention

In this post I’m going to look more closely at chiropractic and osteopathy treatment for the prevention and treatment of migraines. How strong is the evidence behind these treatments?

Summary of conclusions:

1. Based on the currently available evidence there doesn’t seem to be any good reason to recommend osteopathy or chiropractic for the prevention or treatment of migraines.

2. The treatments recommended in the NICE guidelines for prevention and treatment of migraines are all available from a GP rather than a chiropractor or osteopath.

3. Further research in this area may be worthwhile as there is currently relatively little good research.

Evidence for chiropractic and osteopathy for migraine prevention

I don’t know the source of the ASA guideline permitting chiropractors and osteopaths to advertise their treatments for migraine prevention. However, it’s probable that at least part of the source is the Effectiveness of manual therapies: the UK evidence report (Bronfort report). Within this publication it states: “The impetus for this report stems from the media debate in the United Kingdom (UK) surrounding the scope of chiropractic care and claims regarding its effectiveness particularly for non-musculoskeletal conditions.” That’s not a very good reason for carrying out research. Regardless, let’s look at what it says about migraine prevention.

The Bronfort report states that there is “Moderate quality evidence that spinal manipulation has an effectiveness similar to a first-line prophylactic prescription medication (amitriptyline) for the prophylactic treatment of migraine”. This is based on 2 systematic reviews of manual therapy for migraine headache. The Bronfort report chooses to discard the results of 1 of the systematic reviews because it “evaluated study quality using a scale that is no longer recommended by the Cochrane Collaboration and did not apply evidence rules for their conclusions”. They chose instead to follow only the conclusions from the other systematic review. Who was the lead author for that systematic review? Gert Bronfort, the same person who is lead author for the Bronfort report. There is clearly a potential conflict of interest here so let’s have a look at the actual papers that formed the basis of both systematic reviews (there are only 3 of them and the same papers are in both reviews):

The first thing that surprises me here is that both systematic reviews found only 3 trials related to manual therapy and migraines. This suggests that it’s an area that is under-researched and makes drawing strong conclusions difficult. Furthermore, the conclusion drawn by the Bronfort report that “Moderate quality evidence that spinal manipulation has an effectiveness similar to a first-line prophylactic prescription medication (amitriptyline) for the prophylactic treatment of migraine” is rather strange. It is based on just a single trial. Drawing conclusions from a single trial is always problematic and we would usually like to see similar results independently replicated in another trial before making any significant recommendations. In fact, given the apparent success of SMT found in this trial, which was conducted over 20 years ago, it’s surprising that there isn’t further published research looking at the same thing in the 12 year period to 2010 (when the Bronfort report was published).

NICE Guidelines

For a more definitive and recent view it makes sense to look at the NICE guidelines. There are two key publications from NICE on this topic: NICE guidelines on Headaches in over 12s: diagnosis and management and the Clinical Knowledge Summary for Migraine. Neither of those publications makes any recommendation in favour of the use of the main treatments provided by chiropractors or osteopaths (manual therapy). If you look into the evidence behind the guidelines in more detail it’s easy to see why. This is what the NICE GDG (Guideline Development Group) had to say: “For migraine, there was one study showing some benefit. The GDG were concerned that the evidence reviewed was of low to very low quality with a lot of uncertainty in the effect estimates, and that rare adverse events may be severe when they do occur. It was agreed that better evidence was required to make a recommendation.”

The NICE guidelines recommend the use of medication-based treatments for the prevention and treatment of migraines. This should be in addition to use of a headache diary as well as providing appropriate information and support. All of these treatments and approaches are available from a GP.

Conclusion

Overall, the lack of research in this area makes it difficult to draw any significant conclusions about the effectiveness of osteopathy or chiropractic for migraines. There is certainly not enough evidence in order to make a recommendation in favour of using these treatments. It makes sense to use the NICE guidelines as the most reliable source of evidence and they recommend treatments that are available from a GP rather than those from a chiropractor or osteopath.  I would summarise the current position as follows:

Based on the currently available evidence there doesn’t seem to be any good reason to recommend osteopathy or chiropractic for the treatment or prevention of migraines.

It would, however, make sense to conduct further research to see whether osteopathy or chiropractic could be of benefit. (The NICE guidelines make a similar recommendation for further research.)

In view of the lack of evidence, it’s surprising that the ASA guidelines allow chiropractors and osteopaths to advertise their treatments for migraines. The ASA guidelines would probably benefit from a review and update based on the evidence that’s available, in particular the NICE guidelines. In the meantime, if you have migraines it is best that you receive evidence-based treatments and these are all available from your GP.

A recent paper suggests Spinal Manipulation Therapy (SMT) is as effective as recommended treatments for low back pain. Chiropractors celebrate. Should they?

Introduction

Spinal Manipulation Therapy (SMT) is the primary treatment used by most chiropractors and osteopaths as well as being used by some physiotherapists. This study set out to compare Spinal Manipulation Therapy (SMT) with recommended therapies, non-recommended therapies, sham SMT and SMT as adjuvant therapy. It concluded that SMT showed similar benefits to “recommended interventions”. When it was published it was met with trumpet fanfares by a number of chiropractic organisations, as well as others, and claimed as providing strong justification for their treatments. In actual fact it does not do this so let’s explore further.

Summary of conclusions:

1. There are currently no really effective treatments for low back pain.

2. At best, SMT results in a modest average clinical effect. It has also not been shown to be more effective than sham SMT.

3. It’s not currently possible to know whether SMT is safe.

4. It is not currently clear whether SMT is cost effective or not.

5. Taking into account the limited clinical effectiveness and unclear position on safety and cost effectiveness it doesn’t seem to make sense to recommend SMT as a first-line treatment.

Background

Back pain is a widespread problem and SMT is currently listed as a second-line or adjunctive treatment in a number of national guidelines, such as the UK NICE Guidelines as well as the Lancet low back pain guidelines from last year. It’s not recommended as a first-line treatment because current evidence shows it is not sufficiently effective when used alone.

The study and its conclusions

The study was a systematic review and meta-analysis that compared SMT with recommended therapies, non-recommended therapies, sham SMT and SMT as adjuvant therapy. It identified recommended and non-recommended interventions based on guidelines from US, UK and The Netherlands. It’s not clear why these particular guidelines were picked. The Lancet series used a similar set but with Denmark in place of The Netherlands. Perhaps the inclusion of the guideline from The Netherlands is due to the lead author being based there? Whilst it’s understandable that someone will be more familiar and comfortable with guidelines from the country in which they live and work this does introduce a degree of bias into the results and it would be good to see that acknowledged in the paper.

The study concluded that SMT showed similar benefits to “recommended interventions”. It also concluded that SMT vs “non-recommended interventions” shows a statistically but not clinically significant benefit for pain but a statistically and clinically significant benefit for “back specific functional status”. There have been some criticisms, but more on that shortly.

The reaction

A number of chiropractic organisations, as well as others, latched onto this study and claimed it is strong justification for their treatments. Take for instance, this tweet from the British Chiropractic Association:

BCA on Twitter_ _As part of the package of care, chiropractors often _ - twitter.com

It suggests that SMT, the treatment most favoured by most chiropractors, should be considered a first-line treatment for chronic low back pain.

There is also this from the Chiropractic Research Council which includes the comment “supersedes other reviews and publications e.g The Lancet Series which only recommended SMT as a second line treatment option. Groundbreaking stuff!”

As I’ll explain shortly, this review is not particularly “groundbreaking” and the justification for SMT being a first-line treatment is nowhere near as strong as these comments would suggest.

Criticisms of the paper

A thorough and clear critique of the paper was submitted by Mary O’Keeffe and Neil O’Connell. This highlighted a number of issues, including:

  1. SMT was not shown to be better than sham SMT. As this is the only reliable way of assessing efficacy of SMT, it suggests that SMT is not effective as a treatment.
  2. The choice of “recommended” and “non-recommended” therapies was strange and does not align with guidelines. For instance, treatment with paracetamol (which is not recommended by clinical guidelines) was included as “recommended” therapy.
  3. The authors do not seem to interpret their results in line with their own thresholds for determining clinical effectiveness.

The authors submitted a response in which they stand by their original conclusions. They say that SMT cannot be adequately blinded and that therefore trials that compare with other treatments are more valuable than those comparing SMT to sham. In response to point 2 above about choice of “recommended” and “non-recommended” therapies, they say they have undertaken additional analysis taking account of this point and have still arrived at similar results. As far as I can tell, they haven’t responded to the point about thresholds for clinical effectiveness.

Neil O’Connell has sent some further replies on twitter about comparison with sham and the fact that we might see the same minimal benefit for an ineffective treatment:

Neil O'Connell on Twitter_ _Thanks for a considered and thoughtful re_ - twitter.com

It seems likely that this discussion will continue. Hopefully the authors will continue to engage as it’s good to have a healthy debate on complex issues like this. What’s clear is that SMT has not been shown to be particularly effective for low back pain and this new study doesn’t change that.

Safety of SMT

The paper says “About half of the studies examined adverse events (table 2). In most of these studies it was unclear how and whether adverse events were registered systematically; therefore, these data might be unreliable and not accurate for incidence.” In other words: due to a lack of systematic reporting of adverse events, it’s impossible to adequately assess the safety of SMT. The paper does go on to say “clinicians should ensure that patients are fully informed of potential risks before treatment”. This is good advice but I wonder how much this actually happens in practice? Do the main people who carry out SMT (osteopaths, chiropractors and some physiotherapists) ensure that their patients are fully informed of potential risks before they start treatment? Or do they just go ahead and start treatment without doing this?

Cost effectiveness

The paper states “it remains to be determined whether SMT is a cost effective option for the treatment of chronic low back pain.” As more research is needed to assess the cost effectiveness of SMT it would make sense to conduct this research before deciding whether to recommend it as a first-line treatment. If it turns out to be significantly more expensive than other similarly effective treatments then it would not make sense to recommend it as a first-line treatment.

Placing these results in the context of other research

In the section of the paper “Comparison with other studies” it is stated that our results are consistent with other recently published high quality systematic reviews and guidelines that recommend SMT”. I disagree that it is consistent with guidelines, e.g. from NICE, because they have SMT as a second-line treatment option whereas this paper suggests it is as good as currently recommended first-line treatments.

Future research

The paper says “Given the considerable data available, we can now calculate within reasonable certainty the effect of SMT in this setting as well as the impact of a future, methodologically well conducted trial (as determined by the prediction intervals).” In other words, don’t keep doing more similar research in this area because it isn’t going to add anything. This is good advice and is something that researchers should conclude much more often than currently happens. Far too often a study that doesn’t show effectiveness suggests that “more research is needed”. This is a waste of time and money as there is no point in continuing to carry out research when it isn’t going to add anything new.

Conclusions

Overall, this is a decent piece of research and shows fairly similar results to other previous research. It concludes “The evidence suggests that SMT results in a modest, average clinical effect at best”. What’s most strange is not the paper itself but the hype that has surrounded it. There were many “trumpet fanfares” from chiropractic organisations suggesting that this vindicates their treatments and should be used to promote them. It doesn’t actually do this. It shows that SMT isn’t a particularly effective treatment, that it’s not possible to adequately assess its safety and it is not known whether it’s cost effective or not. This is hardly a justification for shouting from the rooftops about how good it is.

What this study does do is add to the body of evidence that indicates that, unfortunately, there remains no good treatment for low back pain. This presents an issue for the many people who suffer with low back pain as there are no really effective treatments. When presented with a number of treatments that are not particularly effective, what is someone with back pain supposed to do? There is no easy answer. However, exercise is known to provide general health benefits and the NHS provides activity guidelines. The importance of these general health benefits should not be understated and is something that SMT cannot provide. In addition, the NICE guidelines recommend exercise as the first-line treatment as well as highlighting the importance of continuing with normal activities as far as possible (self-management). These approaches have the advantage of empowering the patient whereas SMT is a purely passive treatment that does not encourage self-management. I can understand the temptation for someone with back pain to want to go and “get fixed” by seeing a chiropractor, osteopath or physiotherapist who uses SMT. Unfortunately, the evidence indicates that it is not particularly effective and it’s not clear how safe it is. Bearing in mind that it doesn’t provide other general health benefits or empower the patient and is not currently considered a first-line treatment by national guidelines it should probably remain a second-line or adjunctive treatment.

It’s Chiropractic Awareness Week. Or should that be Chiropractic Marketing Week?

marketingChiropractic Awareness Week 2019 runs from 8th to 14th April and is being led by the British Chiropractic Association (BCA). In preparation for this week they have conducted a survey about how people manage their back health. They conducted a similar survey last year which looked at the incidence of back pain in different regions. Unfortunately, they don’t publish the raw details of their survey results but the highlights they have published do raise a number of issues with this “research”.

They conclude that “11% wouldn’t seek help from a health professional for back pain” and “31% would wait a month or longer”. They present this as if it’s a bad thing. However, the advice from the NHS is that back pain often improves within a few weeks or months and that “you may not need to see a doctor or other healthcare professional”. The treatments available for low back pain are currently not particularly effective, and that includes any treatments that a chiropractor may offer. Self-management is also seen as a key step in managing low back pain. It therefore seems entirely reasonable to wait for a little while before seeking professional advice. These statistics presented by the BCA seem to be more focused on marketing the services of chiropractors rather than giving rationale evidence-based advice. (Note: It’s important to be aware that there are situations where getting immediate medical advice is essential and the NHS website provides advice on this. This sort of immediate medical advice should come from a doctor rather than a chiropractor.)

They also say that “42% of people don’t take any steps to look after their back health” and “Only 58% have taken preventative steps to protect themselves from developing back or neck pain”. The more observant amongst you might have noticed that these numbers appear to add up to exactly 100%. That’s because they are exactly the same statistic, one simply being the reverse of the other. By reporting both separately, it looks like there is more “research” that can be reported on.

They report that “19% choose their mattresses bases on price, rather than comfort”. This is hardly surprising. If everyone had plenty of spare cash then they would ideally choose the mattress that is the most comfortable. However, in reality some people simply do not have enough money to be able to choose a mattress purely based on its comfort level and need to take into account the cost.

During Chiropractic Awareness Week, a number of other chiropractic organisations have reported on this research conducted by the BCA. They each seem to be reporting statistics based on their own region such as this and this. The research from the BCA seems to be suggesting that people from certain regions are better at taking steps to protect themselves from back pain than those from other regions. This is, quite frankly, ludicrous. Whenever you conduct a survey like this you will inevitably get a spread of results across the different groups (in this case, regions). This is what statisticians refer to as the normal distribution. This is a normal variation that is entirely to be expected and does not indicate that some regions manage back pain better than others! It should also not be used to derive specific advice such as tailoring recommended treatment approaches to particular regions.

Unfortunately, the British Chiropractic Association, as well as others who have promoted their research, don’t seem to have a good understanding of the basics of research and statistics. They seem to be more interested in producing marketing material that can be used to encourage people to seek out the care of a chiropractor rather than on conducting some actual useful research and providing evidence-based advice. Chiropractic Awareness Week seems to be used by chiropractors primarily as a means of marketing their services. I therefore think it could be more appropriately named Chiropractic Marketing Week.

Can a nutritionist help you treat autism or cancer with diet?

Diana Wright - Rulings - ASA - CAP - www.asa.org.ukI recently became aware of a nutritionist, Diana Wright Food Science and Nutrition, who was advertising treatment for autism with diet and supplementation. On closer investigation it became apparent that she also claimed to be able to treat a range of other health conditions including cancer, IBS, women’s hormonal health, arthritis, fibromyalgia, chronic fatigue and children with learning difficulties and genetic disorders. This is concerning because nutritionists are not permitted to provide diets for health conditions and it therefore warranted closer investigation.

Summary of conclusions:

1. Nutritionists are not qualified to provide specific diets for people with health conditions. Only dietitians are permitted to do that.

2. Beware of nutritionists who claim that they can treat serious health conditions such as autism or cancer with diet. These claims are not substantiated by evidence.

What is a nutritionist?

A nutritionist is a professional who advises on diet and nutrition. However, unlike dietitian, nutritionist is not a protected term. Therefore, anyone can call themselves a nutritionist regardless of whether they hold relevant qualifications and skills or not. In addition, only dietitians are actually qualified to provide advice on specific diets for health conditions. Nutritionists may provide information about food and healthy eating but not special diets for health conditions.

All of this does not mean that all nutritionists are bad. Nutritionists that are registered with a trustworthy professional body and don’t claim to be able to treat medical conditions don’t raise any particular cause for concern. This situation is different, however. Here we had a nutritionist who claimed to be able to treat a whole range of health conditions. She was clearly going beyond her professional expertise and scope of practice, which puts unsuspecting members of the public at potential risk of harm.

Nutritional and biomedical protocols for autism

Diana Wright claimed that there are nutritional and biomedical protocols that are effective for treating autism. She listed a range of different protocols including “Eliminating heavy metals”, “Improving detoxification pathways” and “Supporting the immune system”. Is there any science or evidence behind these treatment approaches? Short answer: no. Longer answer:

  • “Eliminating heavy metals” is covered in some detail on Science Based Medicine (a site that I thoroughly recommend if you aren’t aware of it already).
  • As to “improving detoxification pathways”, your body is perfectly capable of detoxing on its own and you cannot improve this through diet and supplementation.
  • With regards to “supporting the immune system”, this is covered in detail in this excellent article by Dr Dave Stukus (spoiler: there is no basis to this claim of supporting the immune system).

Cancer

Diana Wright also made unsubstantiated claims related to the treatment of cancer. She said that you can keep “your liver clean with dandelion tea and fresh juices of beetroot and kale with carrot and apple” to “fight cancer”. She also suggests that green tea can “inhibit tumour growth as well as help them self destruct”. These claims are nonsensical and there is no evidence to back them up. Although a healthy diet is important for people with cancer, you cannot treat cancer with diet. More information is available on the Cancer Research UK website.

What action can be taken to stop these misleading treatments?

I reported Diana Wright Food Science and Nutrition to the Advertising Standards Authority (ASA) for their misleading claims. My complaint focused on two main issues:

  1. The lack of evidence to back up these claims.
  2. The fact that these conditions are those for which appropriate medical supervision should be sought. Diana Wright is not a doctor or a registered dietitian.

The ASA investigated my complaint and contacted Diana Wright. She said that the site is out of date and would soon be taken down and on this basis the ASA closed my complaint. Given the seriousness of the misleading claims on this site, I would have preferred the ASA to insist on this happening before closing the complaint. Fortunately, the site has since been taken down and there is now a message to say that a new version is being worked on. Let’s hope that the new site doesn’t include such misleading and nonsensical claims.

In response to my complaint, the ASA picked up on the misleading claims related to cancer and suggested that I should contact Trading Standards about this because it is a legal issue. If the claims relating to cancer appear on the new site I will follow up with Trading Standards directly.

Conclusions

When looking for dietary advice, it’s important to be aware of the credentials of the professional that you are going to see. This is particularly important if you want to use diet as treatment for a medical condition. Only registered dietitians are qualified to provide advice on specific diets for health conditions. Nutritionists are not permitted to do this and may only provide more general information about food and healthy eating. If you are thinking of using diet as a treatment for a medical condition, it would make sense to take the advice of your own doctor first.