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A constant theme of this blog is that the NHS should not pay for useless treatments. By and large, NICE does a good job of preventing that. But NICE has not been allowed by the Department of Health to look at quackery.

I have the impression that privatisation of many NHS services will lead to an increase in the provision of myth-based therapies. That is part of the "bait and switch" tactic that quacks use in the hope of gaining respectability. A prime example is the "College of Medicine", financed by Capita and replete with quacks, as one would expect since it is the reincarnation of the Prince’s Foundation for Integrated Health.

One such treatment is acupuncture. Having very recently reviewed the evidence, we concluded that "Acupuncture is a theatrical placebo: the end of a myth". Any effects it may have are too small to be useful to patients. That’s the background for an interesting case study.

A colleague got a very painful frozen shoulder. His GP referred him to the Camden & Islington NHS Trust physiotherapy service. That service is now provided by a private company, Connect Physical Health.

That proved to be a big mistake. The first two appointments were not too bad, though they resulted in little improvement. But at the third appointment he was offered acupuncture. He hesitated, but agreed, in desperation to try it. It did no good. At the next appointment the condition was worse. After some very painful manipulation, the physiotherapist offered acupuncture again. This time he refused on the grounds that "I hadn’t noticed any effect the first time, because there is no evidence that it works and that I was concerned by her standards of hygiene". The physiotherapist then became "quite rude" and said that she would put down that the patient had refused treatment.

The lack of response was hardly surprising. NHS Evidence says

"There is no clinical evidence to show that other treatments, such as transcutaneous electrical nerve stimulation (TENS), Shiatsu massage or acupuncture are effective in treating frozen shoulder."

In fact it now seems beyond reasonable doubt that acupuncture is no more than a theatrical placebo.

According to Connect’s own web site “Our services are evidence-based”. That is evidently untrue in this case, so I asked them for the evidence that acupuncture was effective.

I’d noticed that in other places, Connect Physical Health also offers the obviously fraudulent craniosacral therapy (for example, here) and discredited chiropractic quackery. So I asked them about the evidence for their effectiveness too.

This is what they said.

Many thanks for your comments via our web site. In response, we thought you might like to access the sources for some of the evidence which underpins our MSK services:

Integrating Evidence-Based Acupuncture into Physiotherapy for the Benefit of the Patient – you can obtain the information you require from www.aacp.org.uk

The General Chiropractic Council www.gcc-uk.org/page.cfm

We have also attached a copy of the NICE Guidelines.

So, no Cochrane reviews, no NHS Evidence. Instead I was referred to the very quack organisations that promote the treatments in question, the Acupuncture Association of Chartered Physiotherapists, and the totally discredited General Chiropractic Council.

The NICE guidelines that they sent were nothing to do with frozen shoulder. They were the guidelines for low back pain which caused such a furore when they were first issued (and which, in any case, don’t recommend chiropractic explicitly).

When I pointed out these deficiencies I got this.

Your email below has been forwarded to me.  I am sorry if you feel that that that information we pointed you towards to enable you to make your own investigations into the evidence base for the services provided by Connect Physical Health and your hospital did not meet with your expectations.

‘ ‘ ‘

Please understand that our NHS services in Camden were commissioned by the Primary Care Trust.  The fully integrated MSK service model included provision for acupuncture and other manual therapy provided by our experienced Chartered Physiotherapists.  If you have any problems with the evidence base for the use of acupuncture or manual therapy within the service, which has been commissioned on behalf of the GPs in Camden Borough, then I would politely recommend that you direct your observations to the clinical commissioning authorities and other professional bodies who do spend time evidencing best practice and representing the academic arguments.  I am sure they will be pleased to pick up discussions with you about the relative merits of the interventions being procured by the NHS.

Yours sincerely,

Mark

Mark Philpott BSc BSc MSc MMACP MCSP
Head of Operations, Community MSK Services
Connect Physical Health
35 Apex Business Village
Cramlington
Northumberland NE23 7BF

So, "don’t blame us, blame the PCT". A second letter asked why they were shirking the little matter of evidence.

In response to your last email, I would like to say that Connect does not wish to be drawn into a debate over two therapeutic options (acupuncture and craniosacral therapy) that are widely practiced [sic] within and outside the NHS by very respectable practitioners.

You will be as aware, as Connect is, that there are lots of treatments that don’t have a huge evidence base that are practiced in mainstream medicine. Connect has seen many carefully selected patients helped by acupuncture and manual therapy (craniosacral therapy / chiropractic) over many years. Lack of evidence doesn’t mean they don’t work, just that benefit is not proven. Furthermore, nowhere on our website do we state that ALL treatments / services / modalities that Connect offer are ‘Evidence Based’. We do however offer many services that are evidence based, where the evidence exists. We aim to offer ‘choice’ to patients, from a range of services that are safe and delivered by suitably trained professionals and practitioners in line with Codes of Practice and Guidelines from the relevant governing bodies.

Connect’s service provision in Camden is meticulously assessed and of a high standard and we are proud of the services provided.

This response is so wrong, on so many levels, that I gave up on Mr Philpott at this point. At least he admitted implicitly that all of their treatments are not evidence-based. In that case their web site needs to change that claim.

If, by "governing bodies" he means jokes like the GCC or the CNHC then I suppose the behaviour of their employees is not surprising. Mr Philpott is evidently not aware that "craniosacral therapy" has been censured by the Advertising Standards Authority. Well he is now, but evidently doesn’t seem to give a damn.

Next I wrote to the PCT and it took several mails to find out who was responsible for the service. Three mails produced no response so I sent a Freedom of Information Act request. In the end I got some

"Connect PHC provide the Community musculoskeletal service for Camden. The specification for the service specifically asks for the provision of evidence based management and treatments see paragraph on Governance page 14 of attached.. Patients are treated with acupuncture as per the NICE Guidelines (May 2009) for  the management of low back pain … . .. Chiropractors are not employed in the service and craniosacral therapy is not provided as part of the service either."

Another letter, pointing out that they were using acupuncture for things other than low back pain got no more information. They did send a copy of the contract with Connect. It makes no mention whatsoever of alternative treatments. It should have done, so part of the responsibility for the failure must lie with the PCT.

The contract does, however, say (page 18)

The service to be led by a lead clinician/manager who can effectively demonstrate ongoing and evidence-based development of clinical guidelines, policies and protocols for effective working practices within the service

In my opinion, Connect Physical Health are in breach of contract

Another example of Connect ignoring evidence

The Connect Physical Health web site has an article about osteoarthritis of the knee

Physiotherapy can be extremely beneficial to help to reduce the symptoms of OA. Treatments such as mobilizations, rehab exercises, acupuncture and taping can help to reduce pain, increase range of movement, increase muscle strength and aid return to functional activities and sports.

There is little enough evidence that physiotherapy does any of these things, but at least it is free of mystical mumbo-jumbo. Although at one time the claim for acupuncture was thought to have some truth, the 2010 Cochrane review concludes otherwise

Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding.

This conclusion is much the same as has been reached for acupuncture treatments of almost everything. Two major meta-analyses come to similar conclusions. Madsen Gøtzsche & Hróbjartsson (2009) and Vickers et al (2012) both conclude that if there is an effect at all (dubious) then it is too small to be noticeable to the patient. (Be warned that in the case of Vickers et al. you need to read the paper itself because of the spin placed on the results in the abstract.). These papers are discussed in detail in our recent paper.

Why is Connect Physical Health not aware of this?

Their head of operations told me (see above) that

"Connect does not wish to be drawn into a debate [about acupuncture and craniosacral therapy]".

That outlook was confirmed when I left a comment on their osteoarthritis post. This is what it looked like almost a month later.

connect

Guess what? The comment has never appeared..

The attitude of Connect Physical Health to evidence is simply to ignore it if it gets in the way of making money, and to censor any criticism.

What have Camden NHS done about it?

The patient and I both complained to Camden NHS in August 2012. At first, they simply forwarded the complaints to Connect Physical Health with the unsatisfactory results shown above. It took until May 2013 to get any sort of reasonable response. That seems a very long time. In fact by the time the response arrived the PCT had been renamed a Clinical Commissioning Group (CCG) because of the vast top-down reorganisation inposed by Lansley’s Health and Social Care Act.

On 8 May 2013, this response was sent to the patient, Here is part of it.

I have received your email of complaint from the NHSNCL complaints department regarding your care.
I am sorry to read of your experience as we take the quality of care seriously in NHS Camden CCG.

You raise some very clear concerns and I will attempt to address these in order.

1)      The fact that you felt pressurised into having acupuncture is a concern as everybody should be given a choice. As part of the informed consent relating to acupuncture you should have been told about the treatment, it’s [sic] benefits and risks and then you sign to confirm you are happy to proceed. I understand that this was the case in your situation but I have reinforced that the consent is important and must be adhered to by the provider Connect Physical Health. There are clear standards of clinical practice that all Chartered Physiotherapists must follow which I will discuss further with the Connect Camden team Manager Nick Downing.

I do disagree with you around acupuncture; there is no conclusive  evidence for acupuncture in frozen shoulder but I have referenced a systematic review which concludes the studies were too small to draw any conclusions although shoulder function was significantly  improved at 4 weeks  (Green S et al. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005; 18: CD005319). There is a growing body of evidence supporting the use of acupuncture and until such time as there is specific evidence against it I don’t think we would be absolutely against the practice of this modality alongside other treatments.

.Best wishes

Strategy and Planning Directorate
NHS Camden CCG
75 Hampstead Road
London
NW1

This response raises more questions than it answers.

For example, what is "informed consent" worth if the therapist is his/herself misinformed about the treatment? It is the eternal dilemma of alternative medicine that it is no use referring to well-trained practitioners, when their training has inculcated myths and untruths.

There is not a "growing body of evidence supporting the use of acupuncture". Precisely the opposite is true.

And the statement "until such time as there is specific evidence against it I don’t think we would be absolutely against the practice of this modality alongside" betrays a basic misunderstanding of the scientific process.

So I sent the writer of this letter a reprint of our paper, "Acupuncture is a theatrical placebo: the end of a myth" (the blog version alone has had over 12,000 page views). A few days later we had an amiable lunch together and we had a constructive discussion about the problems of deciding what should be commissioned and what shouldn’t.

It seems to me to be clear that CCGs should take better advice before boasting that they commission evidence-based treatments.

Postscript

Stories like this are worrying to the majority of physiotherapists who don’t go in for mystical mumbo-jumbo of acupuncture. One of the best is Neil O’Connell who blogs at BodyInMind. He tweeted

It isn’t clear how many physiotherapists embrace nonsense, but the Acupuncture Association of Chartered Physiotherapists has around 6000 members, compared with 47,000 chartered physiotherapists (AACP), so it’s a smallish minority. The AACP claims that it is “Integrating Evidence-Based Acupuncture into Physiotherapy”. Like most politicians, the term “evidence-based” is thrown around with gay abandon. Clearly they don’t understand evidence.

Follow-up

12 June 2013

The Advertising Standards Authority has, one again, upheld complaints against the UCLH Trust, for making false claims in its advertising. This time, appropriately, it’s about acupuncture. Just about everything in their advertising leaflets was held to be unjustifiable. They’ve been in trouble before about false claims for homeopathy, hypnosis and craniosacral "therapy".

Of course all of these embarrassments come from one very small corner of the UCLH Trust, the Royal London Hospital for Integrated Medicine (previously known as the Royal London Homeopathic Hospital).

Why is it tolerated in an otherwise excellent NHS Trust? Well, the patron is the Queen herself (not Charles, aka the Quacktitioner Royal), She seems to exert more power behind the scenes than is desirable in In a constitutional monarchy

asa uclh

29 June 2013

I wrote to Dr Gill Gaskin about the latest ASA judgement against RLHIM. She is the person at the UCLH Trust who has responsibility for the quack hospital. She previously refused to do anything about the craniosacral nonsense that is promoted there. This time the ASA seems to have stung them into action at long last. I was told

In response to your question about proposed action:

All written information for patients relating to the services offered by the Royal London Hospital for Integrated Medicine are being withdrawn for review in the light of the ASA’s rulings (and the patient leaflets have already been withdrawn). It will be reviewed and modified where necessary item by item, and only reintroduced after sign-off through the Queen Square divisional clinical governance processes and the Trust’s patient information leaflet team.

With best wishes

Gill Gaskin

Dr Gill Gaskin
Medical Director
Specialist Hospitals Board
UCLH NHS Foundation Trust

It remains to be seen whether the re-written information is accurate or not.

The rules for advertising

The Advertising Standards Authority gives advice for advertisers about what’s permitted and what isn’t.

Acupuncture The CAP advice

Craniosacral therapy The CAP advice

Homeopathy The CAP advice and 2013 update

Chiropractic The CAP advice.

Jump to follow-up

Last year the Royal London Homeopathic Hospital was rebranded as the Royal London Hospital for Integrated Medicine (RLHIM). The exercise seems to have been entirely cosmetic. Sadly, they still practise the same nonsense, as described in Royal London Homeopathic Hospital rebranded. But how different will things be at the Royal London Hospital for Integrated Medicine?.

Recently I came across a totally disgraceful pamphlet issued by the RLHIM [download pamphlet].

If you haven’t come across craniosacral therapy (and who could blame you, a new form of nonsense is invented daily), try these sources.

uclh-cranio-vs

In short, it is yet another weird invention of an eccentric American osteopath, dating from the 1930s. Like Osteopathy and Chiropractic, there is no ancient wisdom involved, just an individual with an eye for what makes money.

What the UCLH pamphlet claims

UCLH-cs2

The claims made in this pamphlet are utterly baseless. In fact there isn’t the slightest evidence that craniosacral therapy is good for anything. And its ‘principles’ are pure nonsense.

No doubt that is why the Advertising Standards Authority has already delivered a damning indictment of rather similar claims made in a leaflet issued by the Craniosacral Therapy Association (CSTA)

The Advertising Standards judgement concluded

" . . the ad breached CAP Code clauses 3.1 (Substantiation), 7.1 (Truthfulness) and 50.1 (Health and beauty products and therapies)."

"We noted that the CSTA believed that the leaflet was merely inviting readers to try CST to see if it could alleviate some of their symptoms and did not discourage them from seeing a doctor. However, we considered that the list of serious medical conditions in the ad, and the references to the benefit and help provided by CST, could encourage readers to use CST to relieve their symptoms rather than seek advice from a medical professional. We therefore concluded that the ad could discourage readers from seeking essential treatment for serious medical conditions from a qualified medical practitioner.

Complaint through the official channels. It took 3 months to extract “No comment” from Dr Gill Gaskin

Given that I have every reason to be grateful to UCL Hospitals for superb care, i was hesitant to leap into print to condemn the irresponsible pamphlet issued by one of their hospitals. It seemed better to go through the proper channels and make a complaint in private to the UCL Hospitals Trust.

On 21st December 2010 I wrote to the directors of UCLH Trust

I have just come across the attached pamphlet.

“Craniosacral” therapy is a preposterous made-up invention.

More to the point, there is no worthwhile evidence for the claims made in the pamphlet.

The leaflet is, I contend, illegal under the Consumer protection regulations 2008. It is also deeply embarrassing that UCLH should be lending its name to this sort of thing.

If you can think of any reason why I should not refer the pamphlet to the Advertising Standards Association, and to the office of Trading Standards, please let me know quickly.

Best regards

David Colquhoun

On 7th January 2011 I got an acknowledgment, which told me that my letter had been forwarded to the Medical Director for Specialist Hospitals for a response.

The Specialist Hospitals of the Trust include the Eastman Dental Hospital, The Heart Hospital, The National Hospital for Neurology & Neurosurgery (the famous Queen’s Square hospital) and, yes, The Royal London Hospital for Integrated Medicine. I’ve been a patient at three of them and have nothing but praise, Queen’s Square and the UCLH baby unit saved the life of my wife and my son in 1984 (see Why I love the National Health Service).

The Medical Director for Specialist Hospitals is Dr Gill Gaskin, and it is to her that my letter was forwarded. Of course it is not her fault that, in 2002, the Royal London Homeopathic Hospital (as it then was) was acquired by the UCLH Trust in 2002, The excuse given at the time was that the space was needed and the nonsense espoused by the RLHH would be squeezed out. That hasn’t yet happened.

After that nothing happened so I wrote directly to Dr Gaskin on 14th February 2011

Dear Dr Gaskin
The letter below was sent to the Trust on 20 December last year. I am told it was forwarded to you. I’m disappointed that I have still had no reply, after almost two months.  It was a serious enquiry and it has legal implications for the Trust. Would it help to talk about it in person?
David Colquhoun

I got a quick reply, but sadly, as so often, the complaint had simply been forwarded to the object of the complaint. This sort of buck-passing is standard procedure for heading off complaints in any big organisation, in my experience.

From: <Gill.Gaskin@uclh.nhs.uk>

To: <d.colquhoun@ucl.ac.uk>

Cc: <jocelyn.laws@uclh.nhs.uk>, <Rachel.Maybank@uclh.nhs.uk>

Dear Professor Colquhoun
 
I received your email in January.
I have now received the response from the Associate Clinical Director of the Royal London Hospital for Integrated Medicine, which is as set out below.
 

The brochure makes no claims of efficacy for Craniosacral Therapy (CST).  In terms of safety, only two randomised trials have reported adverse effects, neither found an excess of adverse effects of CST over control interventions (disconnected magnetotherapy equipment and static magnets respectively):
 
(Castro-Sanchez A et al.  A randomized controlled trial investigating the effects of craniosacral therapy on pain and heart rate variability in fibromyalgia patients. Clin Rehabil 2011 25: 25–35.  published online 11 August 2010 DOI: 10.1177/0269215510375909
Mann JD et al. Craniosacral therapy for migraine: Protocol development for an exploratory controlled clinical trial.   BMC Complementary and Alternative Medicine 2008, 8:28 published 9 June 2008 doi:10.1186/1472-6882-8-28)

The only reports of adverse effects of CST relate to its use in traumatic brain injury.  (Greenman PE, McPartland JM. Cranial findings and iatrogenesis from craniosacral manipulation in patients with traumatic brain syndrome. J Am Osteopath Assoc 1995;95:182-88).

The RLHIM does not treat this condition and it is not mentioned in the brochure. 

The Craniosacral Therapy Association is planning a safety audit, to be launched later this year.  The RLHIM intends to participate in this.

With best wishes
 
Gill Gaskin



Dr Gill Gaskin

Medical Director

Specialist Hospitals Board

UCLH NHS Foundation Trust



I don’t know who wrote this self-serving nonsense because there is no sign on the web of a job called "Associate Clinical Director of the Royal London Hospital for Integrated Medicine".

It is absurd to say that the leaflet makes “makes no claims of efficacy”. It says "Craniosacral therapy can be offered to children and adults for a variety of conditions:" and then goes on to list a whole lot of conditions, some of which are potentially serious, like "Recurrent ear infections and sinus infections, glue ear " and "Asthma". Surely anyone would suppose that if a UCLH Hopsital were offering a treatment for conditions like these, there would be at least some evidence that they worked. And there is no such evidence. This reply seemed to me to verge on the dishonest.

Remember too that this response was written on 16th February 2011, long after the Advertising Standards Association had said that there is no worthwhile evidence for claims of this sort, on 8th September 2010.

I replied at once

Thanks for the reply, but I thought that this was your responsibility. Naturally the RLHIM will stick up for itself, so asking them gets us nowhere at all.  The buck stops with the Trust (in particular with you, I understand) and it is for you to judge whether pamphlets such as that I sent bring the Trust into disrepute

. . ..

I’d be very pleased to hear your reaction (rather than that of the RLHIM) to these comments.  It seems a reasonable thing to ask for, since responsibility for the RLHIM rests with you

David Colquhoun

On the 13th March, after a couple of reminders, Dr Gaskin said "I will respond to you tomorrow or Tuesday,". No such luck though. On 25th March, more than three months after I first wrote, I eventually got a reply (my emphasis).

I do not wish to comment further on the matter of the leaflets as a complaint to the advertising standards authority would be dealt with formally.

I am aware of your views on complementary medicine, and of course am entirely open to you pointing out areas where you believe there is misleading information, and I ask colleagues to review such areas when highlighted.

I would make several additional comments:

– patients are referred into NHS services by their GPs (or occasionally by consultants in other services) and cannot self-refer

– patients attending the Royal London Hospital for Integrated Medicine report positively on NHS Choices

– GPs continue to make referrals to the Royal London Hospital for Integrated Medicine and many request that patients stay under follow-up, when UCLH seeks to reconfirm this

– UCLH is engaging with North Central London NHS commissioners on work on their priorities, and that includes work on complementary medicine (and combinations of conventional and complementary approaches)

I think you will understand that I will not wish to engage in lengthy correspondence, and have many other competing priorities at present.

With best wishes

Gill Gaskin

So, after three months’ effort, all I could get was ‘no comment‘, plus some anecdotes about satisfied customers -the stock in trade of all quacks.

I guess it is well known that complaints against any NHS organisation normally meet with a stonewall. That happens with any big organisation (universities too). Nevertheless it strikes me as dereliction of duty to respond so slowly, and in the end to say nothing anyway.

The Advertising Standards Authority have already given their judgement, and it appears to be based on sounder medicine than Dr Gaskin’s ‘reply’..

There are plans afoot to refer the UCLH pamphlet to the the Office of Trading Standards.IIt is for them to decide whether to prosecute the UCLH Trust for making false health claims. It is sad to have to say that they deserve to be prosecuted.

Follow-up

28 March 2011. Two days after this post went up, a Google search for “Dr Gill Gaskin” brought up this post as #5 on the first page. Amazing.

On 25 May, the same search alluded to this post in positions 2, 3, 4 and 5 on the first page of Google.

29 June 2013

Despite several judgements by the Advertising Standards Authority (ASA) against claims made for craniosacral therapy, nothing was done.
But after UCLH Trust was comprehensively condemned by the ASA for the claims made for acupuncture by the RLHIM, at last we got action. All patient pamphlets have been withdrawn, and patient information is being revised.

. It isn’t obvious why this has taken more that two years (and one can only hope that the revised information will be more accurate)

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