Tag Archives: CAM

Please can we give up on complementary, alternative and ‘integrative therapies’ now?

The Conversation

Michael Vagg, Deakin University

A purportedly serious publication in a serious forum that was published this week has given rise to a bunch of breathless CAM-related headlines in my news feed. CAM being Complementary and Alternative Therapies.

I presume that this is what the authors and their employer wanted, as the supposed good news story is in fact one of the most blatant examples of quackacademic confabulation I have seen in ages. By this I mean that all is not what it appears with this review.

Firstly, the article in question was not prepared as an original research article. This is important, as some of the headlines seem to claim this is “new evidence”.

Look at the table of contents in the journal. It is part of a “CME Credit” symposium. This is an exercise where the editor invites summary articles on behalf of the journal from experts in a field to create what is supposed to be an uncontroversial and impartial review of the state of consensus opinion based on the literature in any given field.

Busy doctors read the review and complete some questions, then claim the learning time for their professional development. I am responsible for a lot of this sort of thing in my professional life, so I know that they are not always peer reviewed and can sometimes go off the rails if the expert panel is not carefully chosen. They are most definitely not considered a means of introducing new findings.

The article is apparently the first in a “Pain Medicine Symposium” to be offered over several editions of the journal. I would have expected to see a few names I recognised from the American Academy of Pain Medicine or the International Association for the Study of Pain, or maybe even the American Pain Society among the authors. But did I?

Nope.

They all came from the National Centre for Complementary and Integrative Health (NCCIH). The lead author is an epidemiologist, and the co-authors include a naturopath with publications about echinacea and colds, a chiropractor (who at least has published about yoga and pain), a cardiologist who works in the regulatory affairs part of NCCIH and a statistician. Not exactly representative of mainstream opinion within the specialty of pain medicine I would submit.

Not to worry, I thought. There might be something to learn so let’s dive in. They start out reasonably enough sketching out some basic facts about the huge societal impact of persistent pain in the United States, which is similar to most countries. They nominate a few selected treatments: acupuncture, spinal manipulation, massage, meditation, “natural product supplements” and yoga, Tai Chi and qigong which all get lumped together, though they are in fact wildly different in practice and contradictory in theoretical concept.

After then setting out a few plausible-sounding excuses for what follows, which constitute the barest academic fig leaf to cover their sectarian belief systems, they also go on to specifically exclude cancer pain from their review. Why? I can guess. Even sincerely deluded cranks have some vestiges of conscience and wouldn’t stoop to taking advantage of cancer patients. (Or would they?)

Having cherry-picked the topics and modalities that have thrown up the most randomly positive studies over the years, they then set out a steady stream of mostly negative studies which they somehow conclude support their argument that there is some useful clinical evidence for some of the therapies.

The Science Based Medicine blog has set out an excellent critique of the methods and results of the review. But the authors would not have gotten this paper published even in an invited slot without the mandatory disclaimers about the shortcomings of the studies. These are worth looking at in detail. First:

The trial samples tend to be white, female, and older, with very few, if any, minority group participants; as such, the generalizability of the findings to the breadth of patients seen by primary care physicians in the United States is still unresolved.

Ummm, I can resolve it. They aren’t at all generalizable, since the world does not consist entirely of elderly white female people. Next caveat:

Often, the trials reviewed were small, with fewer than 100 total participants. Small trials are prone to more variability and to false-negative results.

No kidding. This is a well-known problem. If you combine the results of lots of small, bad trials you don’t reliably get closer to the truth. So why, after hundreds of trials and tens of millions of research dollars are we still getting acupuncture studies with a couple of dozen participants?

A false-negative result is one in which a real treatment is inappropriately rejected by the results of the study. However, an underpowered study is also far less likely to be reliable if positive. Doing underpowered studies using variable study designs is the exact opposite of what savvy research funders require. You don’t want to waste buckets of cash doing studies which can’t be compared or assimilated down the track to get you closer to the truth.

Given that they admit their analysis is entirely of suspect positive results from poorly-designed underpowered studies, it hardly seems worth discussing any further. But we will look at the next caveat the authors put forward:

In many of the trials in which the statistical superiority of a given complementary health approach was reported, it was not clear if the differences vs the control group were clinically relevant.

In plain English, this means you would not notice the benefit of the treatment in real life. Maybe the treatment helps but it’s not worth bothering with even if it does help. In pain medicine this is all-important, as we are currently on a crusade to reduce the prescribing of drugs such as sustained-release opioids and benzodiazepenes in situations where they have poor efficacy and significant risk. We have a couple of decades of research showing that small, short-term reductions in pain intensity are not associated with improved quality of life or health status.

For most complementary approaches, there are no standard treatment protocols or algorithms, and in the case of dietary supplements, no rigorously established dosages and products; as such, trials of a given complementary approach rarely compare the exact same intervention.

This is the bald truth. There is no standardisation of therapies, no quality control of products, nothing at all but spin and fervent belief. The situation with acupuncture for example is nicely summed up by Paul Ingraham of the Pain Science blog:

the most favourable evidence available is also the oldest, weakest and the most biased, and even that evidence is underwhelming, benefits that barely register as clinically significant — much ado about not much, even if it’s actually real, which no better study has ever confirmed.

So to recap, NCCIH released a statement for the press as if this represented new research, when their employees actually published a CME activity rehashing mostly old data, that by their own admission drew from highly unreliable studies and even if accurate was not generalizable to the population as a whole.

Never even mind that some of the therapies are conceptually exclusive of each other and biologically implausible. The press release of this through-the-looking-glass piece of “research” was then widely distributed to inform the public of the exact opposite of what the data presented actually showed. This apparently represents the pinnacle of quality in CAM research. It’s certainly the most expensively-funded.

I will be closely watching with interest the next part of the Pain Medicine Symposium from Mayo Clinic Proceedings. I hope the editors were mortified to see the opportunism with which the solid reputation of their publication was exploited by the media beat-up that followed. They have let their readership and their academic integrity down badly with this review. I can hardly believe they will embarrass themselves so badly again.

The ConversationMichael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine & Pain Specialist, Deakin University

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

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Alternative medicine can be scientific, say besieged academics

The Conversation

Matthew Thompson, The Conversation

RMIT University’s School of Health Sciences has rejected the suggestion that it peddles pseudo-scientific quackery via its courses in complementary and alternative medicine (CAM).

Acting head of the school Dr Ray Myers has defended RMIT’s health science programs as “evidence-based education and practice”, citing collaboration in clinical research of CAM treatments funded by the National Health and Medical Research Council (NHMRC).

Dr Myers was speaking in the face of a campaign by a coalition of prominent medical researchers to expunge higher education of the “undisciplined nonsense” taught in CAM courses at Australia’s “somewhat lesser universities”.

The campaigning group, Friends of Science in Medicine (FSM), has about 400 signatories, including immunologist Sir Gustav Nossal and Professor Jock Findlay, chairman of the NHMRC’s Embryo Research Licensing Committee. It has written to every vice-chancellor in Australia asking for a review of their health science courses to “ensure that primacy is given to scientific principles based on experimental evidence”. The letter laments the spread of chiropractic studies to 19 Australian universities, and complains that ‘energy medicine’, ‘tactile healing’, homeopathy, iridology, kinesiology, acupuncture, and reflexology are taught “as if they were science”.

Group co-founder Emeritus Professor John Dwyer from the University of NSW said that FSM wants “vice-chancellors to ask their deans of science what’s the heck’s going on … It’s just extraordinary that such undisciplined nonsense is being taught in universities around Australia.”

“One of the complaints that we have about so-called alternative medicine is that it doesn’t strive to be tested. … modern medicine is totally devoted to doing everything we can to take this evidence-based approach and do good science and do good research into the things we do to people,” he said. “Alternative medicine doesn’t do that – it’s more than happy to rely on tradition and anecdote and it doesn’t really want to be tested.”

However, Dr Myers said that CAM research at RMIT was conducted in a thoroughly scientific manner, with the NHMRC funding clinical trials of alternative medicines. In a clinical study granted A$560,000 by the NHMRC and A$30,000 by the National Institute of Complementary Medicine, the university was collaborating with two Melbourne hospitals on a clinical study investigating the use of ginseng, a herb used in traditional Chinese medicine, for improving lung function in patients with Chronic Obstructive Pulmonary Disease (COPD), he said.

The NHMRC had also granted A$400,000 for a project in which the university was collaborating with three Melbourne hospitals on a three-year clinical trial of acupuncture for pain management in emergency departments, Dr Myers said. “The project follows the promising results of pilot studies by RMIT researchers, in which more than 1,000 patients received acupuncture treatment for acute pain relief at the emergency department of the Northern Hospital.”

The professions of Chinese medicine, chiropractic and osteopathy are government regulated, Dr Myers said, with RMIT programs in these fields meeting current professional standards and subject to external accreditation. Chiropractic and osteopathy were areas in which clinical research was limited, but RMIT’s education program incorporated the “best available evidence, while promoting further clinical research into these treatments,” Dr Myers said. “RMIT stands by its long record of evidence-based research and the high quality of its health sciences programs.”

But FSM is not buying it. “Those universities involved in teaching pseudoscience give such ideologies undeserved credibility, damage their academic standing and put the public at risk,” the group’s letter states.

The great danger, said Professor Dwyer, was that people who have chronic health problems or who have been persuaded that doctors do not have the answers are delaying the “proper investigation and treatment” of their illness by instead seeking help from therapists offering alternative medicine.

“These are dangerous delusions, and our campaign at the moment is aimed at those somewhat lesser universities, but nonetheless universities, that are offering and teaching pseudoscience as if there was an evidence base to support it, because obviously that gives credibility in the eye of the public,” Professor Dwyer said.

Citing the late CEO of Apple, Professor Dwyer said that “Steve Jobs spent a year with his cancer of the pancreas trusting homeopathic remedies, and by the time he got to the surgeons it was all over.” It is worth noting the veracity of this claim by Professor Edzard Ernst about Mr Jobs treating his cancer with homeopathy has left some struggling to find evidence for it, while others have claimed that for nine months after his diagnosis, Mr Jobs spurned what could have been life-saving surgery in favour of not homeopathy but a vegan diet and herbal remedies.

The “lesser universities” that have aroused the ire of FSM include the Australian Catholic University, Charles Sturt University, Central Queensland University, Edith Cowan University, Macquarie University, Monash University, Murdoch University, RMIT University, Southern Cross University, Swinburne University, the University of Ballarat, the University of New England, the University of Newcastle, the University of Queensland, the University of Technology Sydney, the University of Western Sydney, and the University of Wollongong. To buttress its case, FSM has gathered a list of offending courses, which includes Chinese Medicine, Wellness studies, Applied Eastern Anatomy, Clinical Science with options to study osteopathy and naturopathy, Mind/Body Medicine, and many others.

“It should be a policy that all universities, higher education institutions, should not be involved in in this woolly teaching,” Professor Dwyer said, adding that “I suspect that these are well attended, popular, money-earning courses for cash-strapped universities.”

The claims of FSM, however, ignore the evidence about CAM in higher education, said Dr Wardle, a NHMRC Research Fellow at the University of Queensland’s School of Population Health and co-director of the Network of Researchers in Public Health and Complementary and Alternative Medicine (NORPHCAM), an international group promoting clinical research in CAM.

“They’re actually not that interested in evidence, because the overwhelming evidence is that putting CAM into universities has increased the standards, decreased the fringe element, and improved public safety, so it definitely smacks of dogmatism,” said Dr Wardle, who is a naturopath.

“They love to say that there’s no such thing as complementary medicine and conventional medicine, there’s just evidence-based and non-evidence-based, but, for example, St John’s Wort for over a decade now has been shown to be equally as effective as any pharmaceutical indication for mild to moderate depression, yet there’s still a large group of doctors who refuse to integrate it simply because it’s a herbal medicine,” Dr Wardle said.

The world of CAM is not a “homogenous entity”, said Dr Wardle. “There is a lot of crap, but there’s good stuff, and treating it like it’s all the same thing is very, very fraught. Taking it out of universities runs a real risk of the fringe element getting a stronger voice in the profession.”

“There are studies from Canada, Australia, and Britain that show that CAM practitioners are less anti-vaccination when they’re university trained, and they refer more to conventional [medical] providers when things get serious if they’re university trained.”

“If you look at chiropractic courses [in universities], most of it is human physiology. Chiropractic is certainly not the dominant part of the course. If you look at naturopathy, they do learn herbal medicine and nutrition but they also learn basic health science: they learn the common language of health practice – they learn what a physio or a medical doctor or a nurse would learn. Putting it into the universities diminishes the fringe element,” Dr Wardle said. “If they [FSM] are really worried about public safety they should be not trying to exclude and ostracise them from the university sector.”

He questioned how representative FSM’s roll call of doctors really is, saying that he has just completed a survey of every rural GP in NSW and qualitative interviews with about 30. “About a third wouldn’t have anything to do with complementary medicine providers, another third were very open to it – maybe too open – and the other third if they knew a practitioner who got results they’d send people on.”

About 70 per cent of Australians use CAM and it thus makes sense for research and training to be carried out within the regulation and scientific rigour of the universities, Dr Wardle said.

Comments welcome below.

The ConversationThis article was originally published on The Conversation. (Reblogged by permission). Read the original article.


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