The National Institute for Health and Clinical Excellence (NICE) describes its job thus
“NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health.”
Its Guidance document on Low Back Pain will be published on Wednesday 27 May 2009, but the newspapers have already started to comment, presumably on the assumption that it will have changed little from the Draft Guidance of September 2008. These comments may have to be changed as soon as the final version becomes available.
The draft guidance, though mostly sensible, has two recommendations that I believe to be wrong and dangerous. The recommendations include (page 7) these three.
- Consider offering a course of manual therapy including spinal manipulation of up to 9 sessions over up to 12 weeks.
- Consider offering a course of acupuncture needling comprising up to 10 sessions over a period of up to 12 weeks.
- Consider offering a structured exercise programme tailored to the individual.
All three of this options are accompanied by a footnote that reads thus.
“A choice of any of these therapies may be offered, taking into account patient preference.”
On the face if it, this might seem quite reasonable. All three choices seem to be about as effective (or ineffective) as each other, so why not let patients choose between them?
Actually there are very good reasons, but NICE does not seem to have thought about them. In the past I have had a high opinion of NICE but it seems that even they are now getting bogged down in the morass of political correctness and officialdom that is the curse of the Department of Health. It is yet another example of DC’s rule number one.
Never trust anyone who uses the word ‘stakeholder’.
They do use it, often.
So what is so wrong?
For a start, I take it that the reference to “spinal manipulation” in the first recommendation is a rather cowardly allusion to chiropractic. Why not say so, if that’s whar you mean? Chiropractic is mentioned in the rest of the report but the word doesn’t seem to occur in the recommendations. Is NICE perhaps nervous that it would reduce the credibility of the report if the word chiropractic were said out loud?
Well, they have a point, I suppose. It would.
That aside, here’s what’s wrong.
I take as my premise that the evidence says that no manipulative therapy has any great advantage over the others. They are all more or less equally effective. Perhaps I should say, more or less equally ineffective, because anyone who claims to have the answer to low back pain is clearly deluded (and I should know: nobody has fixed mine yet). So for effectiveness there are no good grounds to choose between exercise, physiotherapy, acupuncture or chiropractic. There is, though, an enormous cultural difference. Acupuncture and chiropractic are firmly in the realm of alternative medicine. They both invoke all sorts of new-age nonsense for which there isn’t the slightest good evidence. That may not poison your body, but it certainly poisons your mind.
Acupuncturists talk about about “Qi”, “meridians”, “energy flows”. The fact that “sham” and “real” acupuncture consistently come out indistinguishable is surely all the evidence one needs to dismiss such nonsense. Indeed there is a small group of medical acupuncturists who do dismiss it. Most don’t. As always in irrational subjects, acupuncture is riven by internecine strife between groups who differ in the extent of their mystical tendencies,
Chiropractors talk of “subluxations”, an entirely imaginary phenomenon (but a cause of much unnecessary exposure to X-rays). Many talk of quasi-religious things like “innate energy”. And Chiropractic is even more riven by competing factions than acupuncture. See, for example, Chiropractic wars Part 3: internecine conflict.
The bait and switch trick
This is the basic trick used by ‘alternative therapists’ to gain respectability.
There is a superb essay on it by the excellent Yale neurologist Steven Novella: The Bait and Switch of Unscientific Medicine. The trick is to offer some limited and reasonable treatment (like back manipulation for low back pain). This, it seems, is sufficient to satisfy NICE. But then, once you are in the showroom, you can be exposed to all sorts of other nonsense about “subluxations” or “Qi”. Still worse, you will also be exposed to the claims of many chiropractors and acupuncturists to be able to cure all manner of conditions other than back pain. But don’t even dare to suggest that manipulation of the spine is not a cure for colic or asthma or you may find yourself sued for defamation. The shameful legal action of the British Chiropractic Association against Simon Singh (follow it here) led to an addition to DC’s Patients’ Guide to Magic Medicine.
(In the face of such tragic behaviour, one has to be able to laugh).
Libel: A very expensive remedy, to be used only when you have no evidence. Appeals to alternative practitioners because truth is irrelevant.
NICE seems to have fallen for the bait and switch trick, hook line and sinker.
The neglected consequences
Once again, we see the consequences of paying insufficient attention to the Dilemmas of Alternative Medicine.
The lying dilemma
If acupuncture is recommended we will have acupuncturists telling patients about utterly imaginary things like “Qi” and “meridians”. And we will have chiropractors telling them about subluxations and innate energy. It is my opinion that these things are simply make-believe (and that is also the view of a minority of acupuncturist and chiropractors). That means that you have to decide whether the supposed benefits of the manipulation are sufficient to counterbalance the deception of patients.
Some people might think that it was worth it (though not me). What is unforgivable is not to consider even the question. The NICE guidance says not a word about this dilemma. Why not?
The training dilemma
The training dilemma is even more serious. Once some form of alternative medicine has successfully worked the Bait and Switch trick and gained a toehold in the NHS, there will be an army of box-ticking HR zombies employed to ensure that they have been properly trained in “subluxations” or “Qi”. There will be quangos set up to issue National Occupational Standards in “subluxations” or “Qi”. Skills for Health will issue “competences” in “subluxations” or “Qi” (actually they already do). There will be courses set up to teach about “subluxations” or “Qi”, some even in ‘universities’ (there already are).
The respectability problem
But worst of all, it will become possible for aupuncturists and chiropractors to claim that they now have official government endorsement from a prestigious evidence-based organisation like NICE for “subluxations” or “Qi”. Of course this isn’t true. In fact the words “subluxations” or “Qi” are not even mentioned in the draft report. That is the root of the problem. They should have been. But omitting stuff like that is how the Bait and Switch trick works.
Alternative medicine advocates crave, above all, respectability and acceptance. It is sad that NICE seems to have given them more credibility and acceptance without having considered properly the secondary consequences of doing so,
How did this failure of NICE happen?
It seems to have been a combination of political correctness, failure to consider secondary consequences, and excessive influence of the people who stand to make money from the acceptance of alternative medicine.
Take, for example, the opinion of the British Pain Society. This organisation encompasses not just doctors. It
includes “doctors, nurses, physiotherapists, scientists, psychologists, occupational therapists and other healthcare professionals actively engaged in the diagnosis and treatment of pain and in pain research for the benefit of patients”. Nevertheless, their response to the draft guidelines pointed out that the manipulative therapies as a whole were over-represented.
The guidelines assess 9 large groups of interventions of which manual therapies are only one part. The full GDG members panel of 13 individuals included two proponents of spinal manipulation/mobilisation (P Dixon and S Vogel). In addition, the chair of the panel (M Underwood) is the lead author of the UKBEAM trial on which the positive recommendation for
It seems that the Pain Society were quite right.
LBC 97.3 Breakfast Show (25 May 2009) had a quick discussion on acupuncture (play mp3 file). After I had my say, the other side was put by Rosey Grandage. She has (among other jobs) a private acupuncture practice so she is not quite as unbiassed as me). As usual, she misrepresents the evidence by failing to distinguish between blind and non-blind studies. She also misrepresented what I said by implying that I was advocating drugs. That was not my point and I did not mention drugs (they, like all treatments, have pretty limited effectiveness, and they have side effects too). She said “there is very good evidence to show they (‘Qi’ and ‘meridians’] exist”. That is simply untrue.
There can’t be a better demonstration of the consequences of falling for bait and switch than the defence mounted by Rosey Grandage. NICE may not mention “Qi” and “meridians”; but the people they want to allow into the NHS have no such compunctions.
I first came across Rosey Grandage when I discovered her contribution to the Open University/BBC course K221. That has been dealt with elsewhere. A lot more information about acupuncture has appeared since then. She doesn’t seem to have noticed it. Has she not seen the Nordic Cochrane Centre report? Nor read Barker Bausell, or Singh & Ernst? Has she any interest in evidence that might reduce her income? Probably not.
Where to find out more
An excellent review of chiropractic can be found at the Layscience site. It was written by the indefatigable ‘Blue Wode’ who has provided enormous amounts of information at the admirable ebm-first site (I am authorised to reveal that ‘Blue Wode’ is the author of that site). There you will also find much fascinating information about both acupuncture and about chiropractic.
I’m grateful to ‘Blue Wode’ for some of the references used here.
This is a follow-up of the poat on BBC2 and the Open University on Alternative Medicine.
Following the article by Simon Singh in the Guardian (25 March 2006), two letters appeared on April 1, 2006. The first, from Prof. Edzard Ernst, confirmed that he felt the BBC had ignored and misrepresented his advice.
In its response to our criticism of the Alternative Medicine series, the BBC says “it is extremely unusual that Professor Ernst should make these comments so long after the series was aired” (Report, March 25). I made my criticism in writing two months before the programme was broadcast. The reason why I reiterated them when I did was simply because Simon Singh interviewed me in my capacity as adviser to the BBC. Extremely unusual? Long after? I don’t think so.
Prof Edzard Ernst
Peninsula Medical School, Exeter
The second letter defended the BBC. It was unequivocal in its support of the entire series of programmes, and its appearence surprised me. In the light of all that has been written, one might have hoped that the BBC would listen and learn from its mistakes. The letter has ten signatories.
We are all scientists involved as consultants or contributors to the BBC2 series, Alternative Medicine. We do not in any way recognise the experience of working on the series as described in your article (Was this proof of acupuncture’s power … or a sensationalised TV stunt?, Science, March 25), nor do we share the views of those scientists you have quoted in it. In all its dealings with us, the BBC asked for advice and input where needed, took on board our feedback and incorporated our comments into the final edit of the programme as transmitted, where appropriate. Far from feeling dissatisfied with the final outcome, we feel the series seemed well balanced and informative, doing full justice to the subject matter it addressed.
Dr Jack Tinker
Prof Brian Berman
Prof Liz Williamson
Dr Andrew Vickers
Dr James Warner
Dr Mike Cummings
Prof Gary Green
Dr Carl Albrecht
Dr Jen Cleland
Professor Irving Kirsch
But all is not what it seems. Contrary to appearances, this letter was actually written by the BBC who also compiled the signatories (it seems to have been the responsibility of Kim Creed, of BBC Factual Publicity).
- One of the signatories. Dr James Warner, had never seen the letter until after it was published, and tells me that “[I] substantially do not agree with the sentiments expressed therein. Indeed, we had to resist attempts by the programme makers to sensationalise our work”.
The Guardian has published a correction.
- Six other signatories tell me that their approval was limited to the way their own contribution was treated, and was not intended as approval of the whole series. One commented ” I’ve obviously been naïve, and I am very fed up with this whole thing”. Another says ” I suppose I (foolishly by the sounds of things) extrapolated from my own programme and experience, without considering the wider implications of the concluding sentence”.
- Only one of the eight signatories whom I’ve asked has actually seen all three programmes, as they were transmitted. This makes it rather odd that they should appear to endorse so unequivocally the whole series.
- One of the signatories, Carl Albrecht, gives his address as “University of Johannesburg”, but oddly the BBC forgot to mention that Dr Albrecht is co-owner (at least until very recently) of the South African Company, Phyto Nova, that makes, promotes and sells the untested herb, Sutherlandia, for treatment of AIDS (see, for example, here).
He is, therefore, highly biassed. He is also exceedingly controversial. One of his strongest critics has been Stuart Thomson, Director of the Gaia Research Institute,
hardly an organisation that is biassed against “natural medicines”. Albrecht is indeed a very curious choice of advisor for a programme about science.
- Three of the signatories (Berman, Cummings and Albrecht) are heavily committed to CAM, and so unlikely to be critical of anything that favours it, even apart from financial interests in the outcome. Brian Berman even has is own an entry in Quackwatch. So several of the signatories are pretty much committed in advance. Asking them if they endorse the programmes is about as informative as asking a group of priests if the endorse god.
- It gets worse. This morning, 6th April, I heard from Andrew Vickers, of the Memorial Sloan-Kettering Cancer Center, New York. This is what he says.
“I didn’t sign this letter ”
“I was shown the text of the letter but didn’t fully agree with it and told them so. I said something along the lines that the series didn’t do ‘full justice to the subject matter’ (how could it possibly?) but that what they did was fair and reasonable within the constraints set by the medium. You are also right to point out that my comments only go so far as the acupuncture episodes (which I saw) rather than the other two shows (which I did not). No doubt had I been shown a final version for signature I would have also pointed this out.”
The BBC brought us superb programmes like Life on Earth and Planet Earth. They bring us superb news (I’m listening to the incomparable John Humphrys on the Today Programme right now). They have suffered unjustly at the hands of spin-meisters like Alastair Campbell and the execrable Hutton Report (If the Hutton Report had been an undergraduate essay, it would have scored alpha-plus for collection of evidence and gamma-minus for ability to connect evidence to conclusions).
How ironic it is, then, to see the BBC behaving in this case like spin artists. Deny everything, and, if necessary, falsify the evidence.