Shortcomings in trial design can result in the “wrong” outcome: An example based on acupuncture

I have recently written about the problems with the decision by the National Institute for Health and Care Excellence (NICE) to include acupuncture in their draft guidelines on chronic pain. Here, I’m going to look at one of the studies they used as a basis for that decision in more detail. It includes a number of serious issues that means the results are unlikely to be accurate.

Study Overview

The study in question is “German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) – a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment”. The hypothesis for the study was “There is a significant difference for the responder rate in the verum group compared to that of sham and of COT. The patients with a pain reduction of at least 50% compared to baseline were classified as responders.” (Note that “verum” in this case refers to the acupuncture treatment group and COT is short for conservative orthopaedic treatment). Patient self-assessment of pain levels on a visual analogue scale (VAS) was used as the measurement. This primary endpoint was assessed 3 months after the completion of the 6 weeks of treatment.

The study claimed: “The trial indicates that Chinese acupuncture is an effective alternative to conventional orthopaedic treatment for CSP”. Due to the many flaws in this study, this trial doesn’t actually show this at all.

Main Flaws in the Study

Here are some of the main issues with this study:

• Use of traditional acupuncture points. The study states that the following points were used: “ventral – Lung 1, 2; ventrolateral – Large Intestine 4, 11, 14, 15; lateral – Sanjiao 5, 13, 14; dorsal – Small Intestine 3, 9”. Traditional Chinese acupuncture is based on Qi and meridians, which are ideas that conflict with modern science. These traditional acupuncture points don’t actually exist.
• Delay in publication. Patients were recruited between 1997 and 1999 but the paper was only submitted for publication in March 2009, a full ten years later. There may have been valid reasons for this but it is certainly unusual and raises concerns. Even if there were genuine reasons for such an extended delay, it seems reasonable to expect that the paper authors would struggle to remember full details of the trial after such an extended period.
• Drop-outs and how these were handled in the analysis. Drop-outs were high, particularly in the sham arm. Only 74 out of 135 (just 55%) in the sham arm reached the primary endpoint. In the treatment arm 128 out of 154 (83%) reached this point, along with 106 out of 135 (79%) in the conservative orthopaedic treatment (COT) arm. In all cases the drop-outs were “treated as non responders”. The problem with this is the very high drop-out rate in the sham arm. Treating the people who have dropped out from the sham arm as “non responders” is likely to underestimate the improvement in this arm. Because the drop-out rate in the treatment arm was much lower this will make the treatment appear more effective than the sham. It is a mistake from the authors to not consider this issue in their analysis. They don’t even mention it. One possible solution they could have used is to assume that drop-outs in the sham arm are “responders” (https://www.sciencedirect.com/science/article/pii/B9780128042175000084 ). This is the most cautious way of assessing the results but is a way of minimising the impact of the very high drop-out in the sham arm.
• Adverse events. Adverse event reporting is very important for any trial of a treatment. This is what the authors say: “Although we did not observe any serious adverse events (SAEs), it cannot be excluded that this is due to an underreporting by centres not being experienced in reporting SAEs.” Were the centres not given a clear protocol for how and when to report adverse events? Inadequate reporting of SAEs raises safety concerns about the trial.
• Contextual effects and blinding. The sham acupuncture points used in this trial were located on the leg. Yet, this was a treatment for shoulder pain. The authors provide this explanation “the further away sham points were located from verum points, the greater the observed difference between verum and sham treatment”. I would suggest that there is a very obvious explanation for this. When sham points are chosen that are nowhere near the area of the body needing treatment, this makes the sham less believable. It seems likely that many patients will realise that they are receiving the sham treatment when they need treatment for their shoulder and acupuncture needles are placed in their leg! This means the patients are effectively unblinded at this point, resulting in less contextual effects and invalidating the comparison between treatment and sham.

Professor Edzard Ernst also raised concerns about this paper after it was published, particularly focusing on the potential for the observed benefits to be down to contextual effects rather than the treatment itself.

Conclusion

There are many serious issues with this trial including with the treatment approach, inadequate blinding, analysis issues and safety concerns. The results from this study therefore shouldn’t really be used to inform treatment choices and it definitely isn’t evidence of the effectiveness of acupuncture. It’s disappointing that NICE have used such poor quality studies as a basis for their recommendations in their draft guideline on chronic pain.

Why have NICE included acupuncture in their guidelines for chronic pain?

Earlier this month the National Institute for Health and Care Excellence (NICE) released a draft of their new guideline on chronic pain and one of the treatment recommendations was acupuncture. Although acupuncture is commonly used to treat pain, recent research found that the evidence is conflicting and inconclusive. NICE usually takes a rigorous approach to developing guidelines, so how did they end up recommending a treatment that does not have good evidence of effectiveness? This is a complex issue that deserves further investigation.

Summary of conclusions:

1. The evidence in favour of acupuncture for chronic pain is weak and in many cases conflicting.

2. Traditional Chinese acupuncture is based on entirely false beliefs in qi, meridians and other pre-scientific concepts. It shouldn’t be included in any health guidelines.

3. NICE seem to have made a mistake in recommending acupuncture in their draft guidelines for chronic pain. Hopefully they will correct this mistake in the final guidelines.

What is acupuncture?

There are many different types of acupuncture, with all of them being based in some way on placing needles in various parts of the body. There are two main ideas that underpin acupuncture: (i) Traditional Chinese acupuncture based on qi (or chi) and meridians and (ii) Modern acupuncture based on a neurophysiological model (that acupuncture needles stimulate nerve endings and alter brain function). Qi and meridians are based on pre-scientific beliefs and should have no place in modern healthcare.

What do the NICE guidelines for chronic pain say about acupuncture?

The NICE guidelines state:

Consider a course of acupuncture or dry needling, within a traditional Chinese or Western acupuncture system, for people aged 16 years and over to manage chronic primary pain, but only if the course:

• is delivered in a community setting, and
• is delivered by a band 7 (or lower) healthcare professional, and
• is made up of no more than 5 hours of healthcare professional time (the number and length of sessions can be adapted within these boundaries).

Besides the recommendation for acupuncture itself, it’s concerning that NICE refer to “a traditional Chinese or Western acupuncture system” (emphasis mine). As previously stated, traditional Chinese acupuncture is based on Qi and meridians. These are concepts that conflict with modern science and have never been shown to actually exist.

Looking in the more detailed Evidence review for acupuncture, things get even worse. In that section, NICE refer directly to the concept of Qi and talk about this as if it’s a real thing. Here is what they say:

“Therapists trained in traditional Chinese medicine operate under the assumption of optimising the flow of the vital energy “Qi” in the body.”

Now there is no such thing as “vital energy” but, for some reason that I’m struggling to understand, NICE appears not to know this. They also go on to say:

“protagonists of traditional Chinese medicine (TCM) choose distant points in their attempts to harmonise the perceived misbalance of body functions and emotions.”

This is complete nonsense, yet here is the organisation that is responsible for producing evidence-based health and social care guidance in the UK taking about it in their guideline for chronic pain.

I have written previously on this blog about other guidelines produced by NICE such as this post about acupuncture for low back pain. Their approach to developing guidelines is usually extremely rigorous. I have also personally worked with them on other topics and seen the same thorough approach there too. I am staggered, and I don’t use this word lightly, that an organisation that is usually so careful and thorough is referring to traditional Chinese acupuncture, Qi and related concepts in the evidence used to develop their guideline on chronic pain.

What does the actual evidence say?

Within NICE’s Evidence review for acupuncture they include a series of “Clinical evidence statements”. For acupuncture versus sham acupuncture they have a large number of these statements. In almost all cases the evidence is labelled as low or very low quality. Is evidence of such low quality sufficient to make a recommendation in favour of a treatment? I would argue that it is not. When you take into account that several of the papers used to prepare these evidence statements are based on traditional Chinese acupuncture, I would suggest that the argument in favour of acupuncture looks even more dubious.

I have looked more closely at some of the papers that NICE refer to in their Evidence review for acupuncture. I have focused on those papers that a) compare acupuncture to sham and b) have a reasonably large sample size. A detailed explanation of why I have done this is beyond the scope of this article but in short: a) comparison with sham is important to control for non-specific treatment effects such as placebo and b) studies with larger sample sizes are more likely to provide accurate results than those with smaller sample sizes. Overall the quality of papers is poor with numerous methodological flaws in most of them, ranging from problems with blinding to issues with the statistical analysis. Even where these poor quality papers found a benefit the improvement was actually pretty small and unlikely to be clinically significant. Importantly, several of the studies are also based on the use of traditional Chinese acupuncture. Here is an example quote from one of the papers:

“The most frequently diagnosed TCM syndromes were Liver Qi stagnation (44.4%), followed by Spleen and Kidney Yang deficiency (21%) and Yin deficiency (13.6%).”

None of these things is recognised or accepted as a medical diagnosis and they are based on an outdated and incorrect approach to carrying out such a diagnosis. Taking all of this into account, it is hard to understand why NICE think acupuncture is a viable treatment for chronic pain.

Why did NICE include acupuncture as a recommendation for chronic pain?

The evidence for acupuncture as a treatment for chronic pain is pretty thin on the ground and in a recent review has been described as conflicting and inconclusive. The traditional Chinese medicine approach to acupuncture is based on things that do not exist and makes no logical sense. Why then did NICE include it as a recommendation in their guidelines for chronic pain? I had given this significant thought and not come up with a good answer. I did wonder if they were just short of interventions to include as a treatment for chronic pain and had concluded that acupuncture is the best of a bad bunch. However, I think that on balance there are two better explanations:

• As described in the post from Steve Novella on Science Based Medicine, NICE have failed to consider Science Based Medicine altogether. This is a serious failing for an organisation that has such an important role in creating guidelines for health and social care.
• One of the members of the NICE committee is Jens Foell, a GP who makes use of acupuncture in his practice and has even authored papers supporting acupuncture. In the Declaration of Interests register for the committee members he declares “I have been a member of the council of BMAS, the British Medical Acupuncture Society and member of the editorial board of “Acupuncture in Medicine” in the 12 months preceding joining the advisory I stood down from these posts in the last weeks”. This is someone who is clearly a strong supporter of acupuncture and provides a potential explanation for the inclusion of acupuncture within the guideline. The DoI was handled by having him “Declare and withdraw from drafting recommendations on acupuncture.” However, it also states that “The committee member will remain in the room for presentation of the evidence and may be asked to respond to specific questions from the committee regarding this topic.” Is having a fellow member of the committee who could speak confidently and strongly in favour of acupuncture likely to influence the committee’s decision? Absolutely! My thanks to David Colquhoun for highlighting this issue.

The other important point raised in the Science Based Medicine post is the risk of legitimising acupuncture and the potential for acupuncturists to use this NICE recommendation to market acupuncture for other conditions. Quoting from the SBM article “By recommending acupuncture for pain, based upon very weak evidence of a clinically tiny effect in the face of a lack of a plausible mechanism, you are throwing patients to the wolves.”

To conclude, it is a serious concern that NICE has failed to apply any sort of science-based approach when selecting treatments to include in their guideline. This has resulted in them recommending a treatment based on Qi, meridians and other nonsensical concepts. Even putting the lack of plausible scientific basis to one side, the evidence supporting acupuncture as a treatment for chronic pain is very weak. I am not the only one to have these concerns. Besides the article by Steve Novella on SBM, Edzard Ernst has also written about this and reaches similar conclusions. I think that NICE have made a serious mistake here and hope that they correct this error when they produce the final version of the guideline.

Further reading – other reviews of the guidelines

• New NICE guidelines on chronic pain fall woefully short – and not just because of the acupuncture. An excellent article by Alice Howarth that highlights a number of problems with the guidelines.
• Doctors raise concerns about NICE guidelines on chronic primary pain. An article in the BMJ where doctors in pain management say that the guidelines do not reflect clinical practice or current evidence.
• FPM concerns regarding new NICE Chronic Pain Guidelines. The Faculty of Pain Medicine raises a number of concerns including: (i) risk of decommissioning of Pain Management Programmes (PMP), (ii) risk of secondary pain services being decommissioned, (iii) potential withdrawal of useful medications from patients by GPs and (iv) recommendation of treatment modalities such as acupuncture.
• Stakeholder feedback from the Cochrane Pain, Palliative and Supportive Care (PaPaS) Review Group on the National Institute of Health and Care Excellence (NICE) draft clinical guideline GID-NG10069 Chronic pain: assessment and management. A detailed review that raises some serious concerns such as the way that research was excluded for areas for which there is already NICE guidance (e.g. low back pain) even though the evidence is likely to be highly relevant for this guideline.

Last updated 12/04/21

The use of complementary medicine by cancer patients raises serious concerns

I came across an article that looked at complementary medicine use in people receiving palliative cancer treatment in Lyon, France. It found that the vast majority (90%) of this patient group used complementary medicine. This raises a number of serious concerns that I’d like to explore further.

Effectiveness

To start with, let’s make something really clear: There are no alternative or complementary approaches that are effective for the treatment of cancer itself. None. What about when these alternative approaches are used as complementary to (along with) conventional treatments? Even in this situation, there is still very little evidence that they provide any benefit whether that be for the symptoms of cancer or to help manage side effects of conventional treatments. For instance, acupuncture is sometimes used to help with cancer-related pain but a recent review concluded that “there are insufficient high-quality RCTs to judge the efficacy of acupuncture for cancer-related pain”. Put more simply, acupuncture hasn’t been shown to be effective for cancer pain. There is a reason why these alternative or complementary treatments haven’t been accepted by mainstream medicine even though they have been tried for a long time: they don’t work.

Safety

Use of complementary treatments by people undergoing palliative cancer care raises a number of risks. Firstly, there is the risk from the treatments themselves. No treatment is without risk, in spite of what some practitioners may claim. Probably more importantly, there are also a number of indirect risks. For instance, the complementary treatment may interact with mainstream treatments reducing their effectiveness or increasing side effects. What’s particularly concerning is the number of people who use complementary treatments without telling their doctor. In this study half of respondents had not disclosed their use of complementary medicine to their oncologist. This is concerning as it doesn’t allow the doctor to have a complete picture all of the treatments being used. When someone is experiencing particular symptoms is this due to the cancer itself, the conventional treatment or side effects from the complementary treatment that the doctor doesn’t know about? It’s very important that if you use complementary treatments you tell your doctor, regardless of how “safe” or innocuous these treatments may appear.

Cost

Within this study, about a third of patients said that it was difficult to manage financially some of the time, all of the time or that it was impossible. Yet, 90% of the people studied are spending money on complementary treatments. Some people are therefore spending money on completely ineffective complementary treatments when they are facing financial hardship. If they realised how ineffective these treatments are, would they still spend the money or would they put the money towards the costs of daily living instead?

Deception

Cancer patients use complementary treatments for a variety of reasons. However, according to the paper, some people say that they are using these treatments for “assisting in stimulating the body’s ability to fight the cancer” and “trying to do everything that can help their treatment or recovery”. None of the complementary treatments being used can help with these things and this raises the question of why members of the public end up believing that they could. Whilst there will be a range of reasons it seems probable that the original source of this misinformation is the complementary medicine practitioners themselves. Indeed this particular paper, as well as several of those that it references, paints the benefits of complementary treatments in an unjustifiably positive light. For instance, it suggests that aromatherapy “is considered a popular form of alternative medicine to treat various conditions, both internally and externally”. Popular it may well be, effective it certainly isn’t. Unfortunately, the paper authors forgot to mention the latter. They further make the unsubstantiated claim that osteopathy is beneficial for a range of cancer-related complaints. The “evidence” they provide to support this? A study of just 16 patients where the patients were asked what they thought osteopathy had helped with. No actual objective evidence at all. Members of the public are therefore being deceived into using complementary treatments based on unsubstantiated claims.

Potential for rejection of conventional treatments

There are a number of issues with a cancer patient using alternative approaches as complementary to their mainstream treatment but what happens if they are persuaded to use an alternative approach instead of their mainstream treatment? That’s when things get really bad. A study from 2017 found that the death rate from cancer was significantly higher when cancer patients chose to use only alternative treatments.

Conclusions

Many people who are diagnosed with cancer use some form of alternative or complementary treatments. There are a number of serious issues with using these treatments including lack of effectiveness, safety concerns, cost and the potential for rejection of conventional treatments. If somebody with cancer wants to go for a complementary therapy because they find it relaxing and enjoyable then provided they are fully informed of any risks this doesn’t present any particular concerns. What does need to stop is the promotion of these therapies as any form of “treatment” with any specific health benefit. They don’t provide that and it is high time that measures were put in place to protect members of the public from being deceived into believing that they do.

Integrative Health Convention 2019: A collection of unsuitable, unproven and potentially harmful treatments

On 5^th and 6^th October 2019 it’s the annual Integrative Health Convention. From QiGong to Homeopathy to Reflexology to Acupuncture and many more this really is quite the collection of unsuitable, unproven and potentially harmful treatments.

The convention aims to “show you how complementary therapy, self-care, and medicine are already working together successfully to improve health outcomes, reduce workload, limit overprescribing, and manage stress and workload, as well as resulting in a possible reduction in national health spending.” On the face of it this is a worthy aim. Improving health outcomes whilst reducing workload and costs to the NHS would be great if it could be achieved. Self-care is also clearly an important part of managing many health conditions. However, it’s already used alongside medicine in conventional healthcare. All that this convention therefore offers is the addition of complementary therapy. Most complementary therapies are not effective, carry risks and are carried out by practitioners who lack adequate skills in diagnosis and treatment. It is therefore hard to see how this convention can have a positive impact on public health.

Let’s look at just a small sample of the therapies being discussed at the convention:

• “Transforming responses to Stress with Integrative QiGong”. QiGong is a branch of Traditional Chinese Medicine (TCM). Like many aspects of TCM it is focused on the “life force” Qi (or Chi). Qi has never been shown to actually exist and therefore QiGong is highly implausible. There is no good evidence that QiGong has any health benefit.
• “Integrating Acupuncture – Western Medical Acupuncture, Traditional Chinese Acupuncture and Future Avenues in Acupuncture”. Like QiGong, acupuncture is a branch of Traditional Chinese Medicine. It is also based on the concepts of Qi and meridians, neither of which actually exists. Acupuncture has little or no evidence of effectiveness for any health condition. The perceived benefits of acupuncture are probably due to non-specific treatment effects, e.g. the relaxing environment and attention provided by the acupuncturist rather than the actual acupuncture treatment. This has led to acupuncture being called a “theatrical placebo”.
• “Reflexology: What is it and what is the evidence?” Reflexology is based on the

  

  An actual map of the feet

  mistaken belief that different parts of the feet correspond to different parts of the body. Reflexologists believe that by pressing on different parts of the feet they can bring about changes in other parts of the body. This is nonsense. Reflexology is a foot massage, nothing more, nothing less. As to the evidence, that’s very clear: It has not been shown to provide any benefit for any health condition.

• “Homeopathy explained – How does homeopathy work & How to use it at Home?” Homeopathy is made up of many strange beliefs such as the “memory” of water and “like cures like”. It conflicts directly with many aspects of science. Homeopathy has been extensively tested and not found to be effective for any health condition. For instance, see the NHMRC report on homeopathy. Put simply, homeopathy doesn’t work and there is no plausible mechanism by which it could. Recommending people to use homeopathy at home carries a number of risks, most importantly the potential to delay more effective treatments. In some situations this could have serious consequences.

  

  Does this look like a valid medical treatment?

• “The Successful Integration of Reiki into NHS Hospitals.” Reiki is a form of energy healing in which a “universal energy” is believed to be transferred through the palms of the practitioner to the patient in order to encourage healing. It’s based on the assumptions of Traditional Chinese Medicine including the existence of Qi. Qi has never been shown to actually exist and there is no plausible mechanism by which Reiki could work. When tested in clinical trials it has not been shown to provide any health benefits. Far from being a success, any use of Reiki in the NHS would therefore be a disaster and an appalling waste of scarce NHS resources.
• “An introduction to aromatherapy and essential oils.” Aromatherapy and essential oils are not medical treatments and have not been shown to provide any benefit for any health condition. Yes, they may be relaxing, particularly when combined with a pleasant environment, but they don’t have any medicinal properties and shouldn’t have any place in a conference about health. They also carry side effects, as does any treatment.

Conclusions

Most of the treatments being discussed at this convention are based on pre-scientific beliefs, are biologically implausible, lack evidence of effectiveness and carry risks. None of them should have any place in the treatment of any health condition.

Alternative Medicine – A Critical Assessment of 150 Modalities: book review

Alternative Medicine – A Critical Assessment of 150 Modalities, written by Edzard Ernst, is a book focused on alternative medicine and sets out to provide a “comprehensive, critical yet fair summary of the evidence that is easily accessible to a lay-person”. It is split into two main parts. Part 1 looks at general issues relating to alternative medicine and part 2 goes into 150 alternative therapies and diagnostic methods. Overall, this is a very good book and anyone reading it is going to be much better informed about the (un)suitability of most types of alternative medicine than they were before starting.

In part 1 there are some real “nuggets” of information about what makes alternative medicine attractive, the problems with alternative medicine and the approaches that alternative medicine practitioners use to promote their treatments. I’ll go through each of the 6 chapters in a little more detail shortly but I’d like to whet your appetite with something I think is critically important: the indirect risks of alternative medicine. This is highlighted in section 3.2 “Alternative Medicine Is Risk-Free”. The book says “Indirect risks are not caused by the treatment per se but arise in the context in which therapy is given. If, for instance, a completely harmless but ineffective alternative treatment replaces a vital conventional one, the harmless therapy becomes life-threatening.” Personally, I think this is really important and I believe that if the general public fully understand the level of indirect risk that seeing a homeopath, chiropractor, osteopath, naturopath, acupuncturist or other alternative practitioner presents most people would never go to see one again.

The second part of the book (chapters 7-11) goes through 150 alternative therapies and diagnostic methods assessing each in turn for plausibility, efficacy, safety, cost, risk / benefit balance. It provides nice succinct summaries of many alternative therapies that you have probably heard of as well as a good number that you probably haven’t. Are you thinking about trying acupuncture, gua sha or chiropractic? Check out this section of the book first for a summary of each of these treatments and many more.

Chapter 1 Introduction

The first chapter highlights the large number of books on alternative medicine and how so many of them promote “bogus, potentially harmful treatments”. This book sets out to provide a “comprehensive, critical yet fair summary of the evidence that is easily accessible to a lay-person”. As the book itself says this is a large and challenging task. Is Edzard the right person to take this on? The book claims that he is, and I agree. He arguably has more knowledge and experience in this area than anyone else including having published more peer-reviewed articles on the subject.

This chapter also explains the way that each of the 150 modalities are evaluated and the rating system used to assess each of them in the five areas of plausibility, efficacy, safety, cost, risk / benefit balance. The rating system is deliberately simple which doesn’t allow for much subtlety:

Personally, I think this simple approach is appropriate for the intended aims of the book – to provide information that is easily accessible for the lay-person. This is a good introductory chapter.

Chapter 2 Why Evidence?

This chapter aims to answer the questions “What is evidence?” and “Why is it important?”. To start with, this chapter tackles the notion that a patient getting better isn’t necessarily a result of the treatment they are receiving. Put another way, correlation does not equal causation. The book offers a few alternative explanations for a patient improving after treatment:

• the natural history of the condition (most conditions get better, even if they are not treated at all)
• regression towards the mean (outliers tend to return to the mean when we re-check them)
• the placebo-effect (expectation and conditioning affect how we feel)
• concomitant treatments (people often take more than one treatment when ill)
• social desirability (patients tend to claim they are better simply to please their therapist)

I agree with all of these points. However, I think the book has lost track of its intended audience a bit here: the lay-person. Would a member of the public who has no particular experience with science be expected to understand all of the above? Take for instance “regression towards the mean (outliers tend to return to the mean when we re-check them)”. I don’t think that most people outside the science / medical community would understand the term “regression towards the mean” and even the explanation in brackets is still rather “sciencey”. Perhaps a better lay explanation would be something like: “People often go for a treatment when they are feeling at their worst. Because many conditions have fluctuating symptoms, it is likely that with time they will return to something more like their average symptoms even without treatment. ”

The book then looks at what is suitable as evidence and why it’s important. The book, correctly, suggests that controlled clinical trials are the best way of determining if a treatment caused the improvement and the treatment is therefore effective. The book acknowledges that clinical trials are not perfect (they aren’t) but they are the best way that we have of assessing treatment effectiveness.

I think that overall this chapter is more science-focused than any other. That’s understandable as explaining what evidence is and why it’s important does require some science. However, I do wonder if members of the general public without any science background might find some of what’s in here a bit difficult to follow. Overall it’s still a decent chapter but perhaps some re-wording / additional explanation would have been beneficial in some parts?

Chapter 3 The Attractiveness of Alternative Medicine

Alternative medicine is undoubtedly popular and this chapter tackles a number of the unsubstantiated claims alternative medicine practitioners make in order to sell their services:

• Alternative medicine is effective
• Alternative medicine is risk free
• Alternative medicine is natural
• Alternative medicine is holistic
• Alternative medicine has stood the test of time
• Alternative medicine tackles the root causes of an illness
• Alternative medicine is inexpensive
• Alternative medicine is a small, innocent cottage industry
• Alternative practitioners are more human
• Conventional medicine does not live up to its promises

I often see alternative medicine practitioners making these sorts of claims. Edzard tackles each one in turn in his book. One point that he makes is of particular importance I think. He highlights that one important reason for the popularity of alternative medicine is the failings of conventional medicine (sections 3.10 & 3.11 in the book). That makes a lot of sense. How often do we see someone who has been told that their cancer is terminal going to a “cancer clinic” that offers fake “cures”. It’s unfortunate that sometimes there just aren’t solutions available through conventional medicine. When someone is told by a doctor that there is nothing that can be done to help them it’s entirely natural that they look elsewhere as they need someone to give them hope. That’s when alternative medicine practitioners step in and offer people false hope by claiming that they can help (even though they usually can’t).

Chapter 4 The Unattractiveness of Alternative Medicine

This chapter goes through the reasons why alternative medicine is unsuitable:

• It is not plausible
• There is no evidence
• The “Promised Land” for charlatans
• Pseudo-science

The book highlights the large number of papers that have been published about alternative medicine. In most cases, those trials that are of high quality fail to demonstrate that alternative medicine is effective.

This chapter and the previous one should help members of the public to know how to spot misleading claims.

Chapter 5 Ethical Problems in Alternative Medicine

Ethics is a complex and important topic in the context of any medical treatment, including alternative medicine. This chapter highlights the numerous ethical problems with alternative medicine including informed consent, neglect, competence, truth and risk / benefit analysis. Informed consent is a particular challenge for all types of alternative medicine. For a practitioner of alternative medicine to take true informed consent they would normally have to admit that their treatments are not particularly effective and that there are other better treatments available. As the book explains this would be bad for business and means that alternative medicine practitioners have a powerful conflict of interest that keeps them from adhering to the rules of informed consent and medical ethics. The book gives a very good example of potential encounters with a chiropractor to help explain this.

Chapter 6 Other Issues

This chapter picks up on other issues relating to alternative medicine that don’t fit in the earlier chapters including patient choice, science cannot explain and integrative medicine. I think the last part of the chapter is particularly interesting as it covers what conventional healthcare professionals could say when asked about alternative medicine by a patient. The book suggest four different approaches, some better than others. One of the challenges for conventional healthcare professionals is that they often lack sufficient knowledge about alternative medicine to be able to talk about the evidence (or lack of evidence) behind them. Whilst the book is aimed primarily at the lay person it may also be helpful for conventional healthcare professionals to inform themselves about the evidence and risks of alternative medicine.

Part 2

The second part of the book (chapters 7-11) goes through 150 alternative therapies and diagnostic methods assessing each in turn for plausibility, efficacy, safety, cost, risk / benefit balance. The breadth of modalities covered here is seriously impressive. I’ve been tackling misleading claims in alternative medicine for a number of years and there were a reasonable number of therapies and diagnostic methods that I’d never heard of such as Jin Shin Jyutsu, Kirlian Photography and Eurythmy. As far as I can tell, the assessment of each of the approaches is fair and objective. In fact, I would say that on occasions the assessment is quite generous in favour of some of the alternative therapies. It is certainly not the case that every alternative therapy is criticised. Some are given a positive assessment such as St John’s Wort, Alexander Technique (for chronic low back pain) and Feldenkrais Method.

This section of the book is great for the reader to “dip into” when they want to find out about a particular therapy. It doesn’t go into any of them in great detail, and further reading would be needed here, but it serves as a great reference for a really wide range of alternative therapies and diagnostic methods.

Conclusion

Overall, I think this is an excellent book. It fills an important gap in the market to provide members of the public with objective information about a wide range of alternative medicine approaches. It should help to tackle the widespread misleading (promotional) information that exists around alternative medicine. Readers of this book will undoubtedly be much better informed about the reality of alternative medicine. I just hope the book receives the wide readership it deserves.