Selling falsehoods? A cross-sectional study of Canadian naturopathy, homeopathy, chiropractic and acupuncture clinic website claims relating to allergy and asthma

Working with patients' treatment expectations - what we can learn from homeopathy

The usual homeopathic remedy, "globules," does not contain any pharmacologically active ingredient. However, many patients and practitioners report beneficial effects of homeopathic treatment on various health outcomes. Experimental and clinical research of the last two decades analyzing the underlying mechanisms of the placebo effect could explain this phenomenon, with patients' treatment expectations as the predominant mechanism. Treatment expectations can be optimized through various factors, such as prior information, communication, and treatment context. This narrative review analyses how homeopathy successfully utilizes these factors. Subsequently, it is discussed what evidence-based medicine could learn from homeopathic practice to optimize treatment expectations (e.g., using an empathic, patient-centered communication style, deliberately selecting objects in practice rooms, or using clear treatment rituals and salient contextual stimuli) and thereby treatment effectiveness. Homeopathic remedy does not work beyond the placebo effect but is recommended or prescribed as an active treatment by those who believe in it. Thus, practitioners need to understand the manner in which homeopathy (as an example of inert treatment) works and are advised to reintegrate its underlying effective placebo mechanisms into evidence-based medicine. This promises to increase treatment efficacy, tolerability, satisfaction, and compliance with evidence-based treatments, and addresses the desires patients are trying to satisfy in homeopathy in an ethical, fully informed way that is grounded in evidence-based medicine.

Explaining Health Misinformation Belief through News, Social, and Alternative Health Media Use: The Moderating Roles of Need for Cognition and Faith in Intuition

Explaining the spread and impact of health misinformation has garnered considerable attention with the uptake of social media and group messaging applications. This study contributes to that line of work by investigating how reliance on multiple digital media may help support or suppress misinformation belief, and how individual differences in misinformation susceptibility condition this process. Alternative health outlets (AH media), advocating home/homeopathic remedies over conventional medicine can be important sources of misinformation, yet are largely ignored previously. In this study, we first test how reliance on different platforms predicts health misinformation belief. Drawing from the elaboration likelihood model, we further investigate how need for cognition (NFC) and faith in intuition (FI) moderate the relationship between news reliance and susceptibility to misinformation. We conducted a survey in Singapore, Turkey, and the U.S (N = 3,664) to measure how these proposed relationships explain misinformed beliefs about vaccines, genetically modified foods and alternative medicine. We found reliance on online legacy news was negatively associated with the likelihood of believing health misinformation, while the reverse was true for social media and AH media. Additionally, those with both greater NFC and FI were more susceptible to health misinformation when they relied on social media and AH media more. In contrast, neither NFC nor FI moderated the relationship between reliance on online legacy news and health misinformation belief. These findings, mostly consistent across countries, also show that extensive reliance on social media and AH media for news mostly overwhelms the individual differences in predicting misinformation belief.

A taxonomy of risk-associated alternative health practices: A Delphi study

Defining alternative health care and the recording of associated adverse events and harm remains problematic. This Canadian study aimed to establish and classify risk-associated alternative health practices in a Delphi study undertaken with an interdisciplinary panel of 17 health experts in 2020. It provides a new functional definition of alternative health care and an initial taxonomy of risk-associated alternative health care practices. A number of risk-associated practices were identified and categorized into general practices that conflict with biomedical care or largely untested therapies, alternative beliefs systems, physical manipulative alternative therapies, and herbal and nutritional supplements. Some risk significant harms including major physical injuries or even death. The lack of systematic methods for recording adverse events in alternative health care makes establishing the frequency of such events challenging. However, it is important that people engaging with alternative health care understand they are not necessarily risk-free endeavours, and what those risks are.

Digging deeper: exploring chiropractors online claims about non-musculoskeletal disorders

Background

Some chiropractors suggest that chiropractic treatment is appropriate for health issues other than musculoskeletal problems. The prevalence of such claims on individual clinic websites has previously been reported as approximately one-in-four in Denmark. The underlying rationales for such claims may reflect convictions about traditional chiropractic subluxations paradigms, but are not self-evident and has not previously been studied.

Methods

An exploratory qualitative case interview study of Danish chiropractors with websites which contain claims about chiropractic efficacy in the treatment of non-musculoskeletal disorders. Websites were identified from a nation wide random sample (57%) of all chiropractic clinic websites.

Results

Of the original 139 websites, 36 were identified as mentioning non-MSK conditions. When revisited, 19 of those clinic websites still mentioned non-MSK disorders and were contacted. Eleven (11) declined our invitation to participate. Interviews were conducted with the responsible chiropractor from each of the remaining 8 clinics.

Five distinct themes were identified in the rationales for treating non-musculoskeletal disorders: ‘Positive side-effects,’ ‘Experience,’ ‘Web page,’ ‘Communication’ and ‘Conviction.’

Conclusions

A minority of Danish chiropractic websites suggest that non-musculoskeletal disorders are within the chiropractic scope of practice. Those that do, do so for varying reasons—poor communication and website maintenance were commonly cited problems. An explicitly stated adherence to traditional chiropractic subluxations concepts was uncommon. By contrast, a more tempered rationale that suggested a potential beneficial side-effect of chiropractic on non-musculoskeletal health issues were more common and was typically presented in softer-language and/or with some reservations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00407-z.

Reframing a debate in chiropractic

The chiropractic profession is 125 years old and has evolved a culture beset with internal conflict. The internal ructions have been particularly noticeable during the last 20 years. The recent resignation of the entire World Federation of Chiropractic Research Committee has again focussed the conflicting views and goals of the “wellness” and “evidence” factions within the profession. These polarising viewpoints are worsening to the degree that there are calls for the profession to break into two separate entities. Key to the recognition of the differences within the profession is the recognition of title for particular sub populations of patients presenting to chiropractors. For many of the sub populations such as sport or paediatrics there has grown appropriate post professional specialist educational training sometimes leading to a protected title. However, this is not occurring in that group of practitioners that choose to focus on wellness care. A recommendation is made that wellness chiropractic be viewed as a post professional specialty program within chiropractic, as it is in medicine and elsewhere, and that recognition follow after appropriate post professional educational programs have been completed, as is customary in the other special interest groups. In order to do so, consensus will be required from all stakeholders within the profession on the level, scope and depth of such programs. Furthermore, it is possible that different jurisdictions around the world may require different post graduate educational levels based on local competitive, legal and professional circumstances. In such cases, transitioning to the higher level over a period of time may be undertaken. Recognition of the wellness specialty by the profession would allow for vertical integration with other healthcare providers as well as help bridge a gap between the entrepreneur and academic groups that would be responsible for creating these programs at tertiary education institutions. Finally, should these programs acquire evidence to underpin them, a process that would be taught within the programs, it is likely that recognition of an extended scope of practice would occur increasing the appeal of chiropractic to the public.

Chiropractic website claims related to non-musculoskeletal conditions: a cross-sectional study

BACKGROUND

Chiropractors frequently use spinal manipulation therapy as a treatment modality in the management of musculoskeletal (MSK) conditions such as spinal pain and sometimes in the treatment of non-MSK disorders. The latter is not supported by evidence. This study aimed to investigate the extent of non-MSK website claims from French chiropractors to assess if websites were aligned with current recommendations on evidence-based practice.

METHODS

This was a cross-sectional study of a representative sample of French chiropractors. Information on non-MSK conditions was collected from chiropractic professional websites by two independent observers in June 2020. For each non-MSK condition, it was noted whether a clarifying explanation justifying the mentioning of the condition was available. In addition, data on professional association affiliation status, country of education, years since graduation, and special clinical focus (e.g., seniors, children) were collected.

RESULTS

A total of 287 randomly selected websites were included in the study corresponding to 22% of all chiropractors registered in France. One or more of 42 different non-MSK conditions were identified on 231 websites, of which 5 (2.2%) provided a clarifying explanation. 226 (79%) websites mentioned a non-MSK condition without a clarifying explanation. The non-MSK conditions most often mentioned were sleep problems, constipation/digestive problems, unease/discontent in children and menstrual cramps/pains. A larger proportion of the websites advertising treatment for non-MSK disorders was found among those claiming a special clinical focus on infants/children, seniors, pregnant women or athletes compared to those that did not. Also, a larger proportion of chiropractors who were affiliated with a professional association were advertising treatment for non-MSK disorders compared to those who were not affiliated.

CONCLUSIONS

Eight out of ten chiropractic websites mentioned one or more non-MSK diagnoses or symptoms. It is unclear if this reflects inaccurate communication or if treatments for non-MSK conditions are provided by the chiropractors.

Evaluating the effect on asthma quality of life of added reflexology or homeopathy to conventional asthma management - an investigator-blinded, randomised, controlled parallel group study

BACKGROUND

Asthma is a common chronic disease worldwide without any known cure. Despite remarkable improvement in asthma treatment, better education and guideline implementation strategies, there is growing interest in using complementary and alternative medicine, like reflexology and homeopathy. However, evidence supporting the effectiveness of homeopathy and reflexology in asthma treatment is not available.

OBJECTIVE

The aim of this study was to evaluate the effect of reflexology and homeopathy as adjunctive therapies in asthma.

METHODS

In a single centre, randomised, investigator blinded, controlled study 86 asthma patients were enrolled. They were assigned to one of three study groups (conventional treatment alone or conventional treatment with addition of either homeopathy or reflexology). All patients received their asthma treatment during the study and were followed as usual by their general practitioner. The study assignment group of individual patients were blinded to the investigators, who made the clinical evaluation of asthma control. The primary outcome was the change in the asthma quality of life questionnaire (AQLQ) scores after 26 weeks. Secondary outcomes included asthma control questionnaire, EuroQol, forced expiratory volume in 1 sec, morning and evening peak expiratory flow, asthma symptoms, rescue medication use, and total medication score.

RESULTS

Minor improvements in the AQLQ score were observed in all three groups. However, no statistically significant changes in AQLQ scores were seen within or between groups. Likewise, secondary outcomes did not differ between groups.

CONCLUSIONS

In this study, the addition of homeopathy or reflexology to conventional treatment did not result in improved quality of life in asthma.

Googling Allergy in Ireland: Content Analysis

Background

Internet search engines are increasingly being utilized as the first port of call for medical information by the public. The prevalence of allergies in developed countries has risen steadily over time. There exists significant variability in the quality of health-related information available on the web. Inaccurately diagnosed and mismanaged allergic disease has major downstream effects on patients, general practitioners, and regional allergy services.

Objective

This study aimed to verify whether Ireland has a relatively high rate of web-based allergy-related searches, to establish the proportion of medically accurate web pages encountered by the public, and to compare current search results localized to Dublin, Ireland with urban centers elsewhere.

Methods

Google Trends was used to evaluate regional interest of allergy-related search terms over a 10-year period using terms “allergy,” “allergy test,” “food allergy,” and “food intolerance.” These terms were then inputted into Google search, localizing them to cities in Ireland, the United Kingdom, and the United States. Output for each search was reviewed by two independent clinicians and deemed rational or nonevidence based, as per current best practice guidelines. Searches localized to Dublin were initially completed in 2015 and repeated in 2019 to assess for changes in the quality of search results over time.

Results

Ireland has a persistently high demand for web-based information relating to allergy and ranks first worldwide for “allergy test,” second for “food allergy” and “food intolerance,” and seventh for “allergy” over the specified 10-year timeframe. Results for each of the four subsearches in Dublin (2015) showed that over 60% of websites promoted nonevidence-based diagnostics. A marginal improvement in scientifically robust information was seen in 2019, but results for “allergy test” and “food intolerance” continued to promote alternative testing 57% (8/14) of the time. This strongly contrasted with results localized to Southampton and Rochester, where academic and hospital-affiliated web pages predominantly featured. Government-funded Department of Health websites did not feature in the top five results for Dublin searches “allergy testing,” “food allergy,” or “food intolerance” in either 2015 or 2019.

Conclusions

The Irish public demonstrates a keen interest in seeking allergy-related information on the web. The proportion of evidence-based websites encountered by the Irish public is considerably lower than that encountered by patients in other urban centers. Factors contributing to this are the lack of a specialist register for allergy in Ireland, inadequate funding for allergy centers currently in operation, and insufficient promotion by the health service of their web-based health database, which contains useful patient-oriented information on allergy. Increased funding of clinical allergology services will more meaningfully impact the health of patients if there is a parallel investment by the health service in information and communication technology consultancy to amplify their presence on the web.

A cross-sectional study of website claims related to diagnoses and treatment of non-musculoskeletal conditions

BACKGROUND

The Danish Authorisation Act sets out the chiropractic scope of practice. Under this legislation the scope of practice is diagnostics, prevention and treatment of biomechanical disorders of the spine, pelvis and extremities. Despite this and an international movement toward a scientifically active, evidence-based profession with a focus on treatment of musculoskeletal disorders, a large proportion of chiropractors still offer treatment of non-musculoskeletal disorders. This study aimed to investigate the content and characteristics of website claims by chiropractors in Denmark on non-musculoskeletal conditions and to assess whether these were aligned with the Danish Authorisation Act of the chiropractic scope of practice.

METHODS

In this cross-sectional study data on a representative sample were collected from chiropractic clinic websites in Denmark. Information on non-musculoskeletal conditions from the websites was categorised. For each non-musculoskeletal condition, it was noted whether a clarifying explanation justifying the presence of the diagnosis was available and what it said. These explanations were assessed and categorised according to agreement or disagreement with the chiropractic scope of practice as defined by the Danish Authorisation Act. In addition, data on geographic location, clinic size, reimbursement coverage, country of education and special clinical focus (children, athletes, etc) were collected. Differences in characteristics of the clinics and the frequency of reporting non-musculoskeletal conditions were tested using Pearson's chi-squared or Fisher's exact test.

RESULTS

A geographically stratified, random sample of 139 (57%) websites was included from chiropractic clinics in Denmark. In total, 36 (26%) of the sampled websites mentioned conditions of non-musculoskeletal origin that was not accompanied by a clarifying explanation in agreement with the chiropractic scope of practice. A positive association between advertising infant or children's care and advertising treatment for non-musculoskeletal disorders (without adequate explanation) was observed.

CONCLUSIONS

A total of 36 (26%) of the sampled chiropractic websites in Denmark mentioned diagnoses or symptoms of non-musculoskeletal origin on their websites without presenting an adequate clarifying explanation in agreement with the chiropractic scope of practice as defined by the Danish Authorisation Act. This could be misleading for patients seeking care for non-musculoskeletal conditions and consequently lead to inappropriate treatment.

The "subluxation" issue: an analysis of chiropractic clinic websites

Background

Vertebral subluxation theories are controversial in chiropractic. Divisions are evident in the chiropractic community among those who align their practices to subluxation theories and those who do not. This study investigated how many clinics offering chiropractic in the Canadian province of Alberta promote a theory of subluxation, which health ailments or improvements were linked to subluxation, and whether the subluxation discourse was used to promote chiropractic for particular demographics.

Methods

Using the search engine on the Canadian Chiropractic Associations’ website, we made a list of all clinics in Alberta. We then used Google searches to obtain a URL for each clinic with a website, totalling 324 URLs for 369 clinics. We then searched on each website for “subluxation” and performed content analysis on the related content.

Results

One hundred twenty-one clinics’ websites (33%) presented a theory of vertebral subluxation. The health ailments and improvements discussed in relation to subluxation were wide-ranging. An observed trend was the marketing of chiropractic for children, which was observed on 29 clinic websites (8%).

Conclusions

Based on the controversy surrounding vertebral subluxation, the substantial number of clinic websites aligning their practice with vertebral subluxation should cause concern for regulatory bodies.

At-risk advertising by Australian chiropractors and physiotherapists

Background

Society expects professionals to promote their businesses in an ethical manner, refraining from misleading or deceptive marketing due to the potential to harm members of the community. In Australia this expectation resides in the Australian registration board advertising guidelines or the Health Practitioner Regulation National Law. Registration board data indicate there are many health care professionals failing to meet these expectations. The aims of this research were to determine the frequency, type and nature of at-risk advertising by Australian chiropractors and physiotherapists and whether there is a correlation between professional association membership and advertising guideline compliance.

Method

A cross sectional audit examining practitioner advertising was performed on representative samples of Australian chiropractors and physiotherapists. Two auditors examined advertising by 380 physiotherapists and 359 chiropractors for material potentially in breach of the regulatory authorities' advertising guidelines. The advertising appeared on practitioner websites and linked Facebook pages.

Results

Two-hundred and fifty-eight (72%) audited chiropractors and 231 (61%) audited physiotherapists had breaches of the Advertising Guidelines on their websites and linked Facebook pages. The frequency of breaches by chiropractors was higher. The type and nature of the breaches by chiropractors was potentially more harmful. Membership in a professional association influenced neither the frequency nor the severity of breaches with chiropractors.

Discussion

Advertising breaches were common in both samples even though regulators and professional associations provide practitioners with explicit information on how to comply with advertising guidelines. Breaches by chiropractors were more numerous and more serious due to their greater potential to lead consumers to make inappropriate and potentially harmful healthcare decisions.Stronger enforcement strategies may have a positive effect on compliance.

Promotion of Testing for Celiac Disease and the Gluten-Free Diet Among Complementary and Alternative Medicine Practitioners

INTRODUCTION

We identified the frequency and assessed the validity of marketing claims made by American chiropractors, naturopaths, homeopaths, acupuncturists, and integrative medicine practitioners relating to the diagnosis and treatment of celiac disease and nonceliac gluten sensitivity (NCGS), both of which have increased in prevalence in recent years.

METHODS

We performed a cross-sectional study analyzing websites of practitioners from 10 cities in the United States and analyzed the websites for any mention of celiac or NCGS as well as specific claims of ability to diagnose, ability to treat, and treatment efficacy. We classified treatments promoted as true, false, or unproven, as assessed independently by 2 authors.

RESULTS

Of 500 clinics identified, 178 (35.6%) made a claim regarding celiac disease, NCGS, or a gluten-free diet. Naturopath clinic websites have the highest rates of advertising at least one of diagnosis, treatment, or efficacy for celiac disease (40%), followed by integrative medicine clinics (36%), homeopaths (20%), acupuncturists (14%), and chiropractors (12%). Integrative medicine clinics have the highest rates of advertising at least one of diagnosis, treatment, or efficacy for NCGS (45%), followed by naturopaths (37%), homeopaths (14%), chiropractors (14%), and acupuncturists (10%). A geographic analysis yielded no significant variation in marketing rates among clinics from different cities. Of 232 marketing claims made by these complementary and alternative medicine (CAM) clinic websites, 138 (59.5%) were either false or unproven.

DISCUSSION

A significant number of CAM clinics advertise diagnostic techniques or treatments for celiac disease or NCGS. Many claims are either false or unproven, thus warranting a need for increased regulation of CAM advertising to protect the public.

Chiropractic, one big unhappy family: better together or apart?

Background

The chiropractic profession has a long history of internal conflict. Today, the division is between the ‘evidence-friendly’ faction that focuses on musculoskeletal problems based on a contemporary and evidence-based paradigm, and the ‘traditional’ group that subscribes to concepts such as ‘subluxation’ and the spine as the centre of good health. This difference is becoming increasingly obvious and problematic from both within and outside of the profession in light of the general acceptance of evidence-based practice as the basis for health care.

Because this is an issue with many factors to consider, we decided to illustrate it with an analogy. We aimed to examine the chiropractic profession from the perspective of an unhappy marriage by defining key elements in happy and unhappy marriages and by identifying factors that may determine why couples stay together or spilt up.

Main body

We argue here that the situation within the chiropractic profession corresponds very much to that of an unhappy couple that stays together for reasons that are unconnected with love or even mutual respect. We also contend that the profession could be conceptualised as existing on a spectrum with the ‘evidence-friendly’ and the ‘traditional’ groups inhabiting the end points, with the majority of chiropractors in the middle. This middle group does not appear to be greatly concerned with either faction and seems comfortable taking an approach of ‘you never know who and what will respond to spinal manipulation’. We believe that this ‘silent majority’ makes it possible for groups of chiropractors to practice outside the logical framework of today’s scientific concepts.

Conclusion

There is a need to pause and consider if the many reasons for disharmony within the chiropractic profession are, in fact, irreconcilable. It is time to openly debate the issue of a professional split by engaging in formal and courageous discussions. This item should be prioritised on the agendas of national associations, conferences, teaching institutions, and licensing/registration as well as accreditation bodies. However, for this to happen, the middle group of chiropractors will have to become engaged and consider the benefits and risks of respectively staying together or breaking up.

The law of food allergy and accommodation in Canadian schools

BACKGROUND

There is ongoing controversy surrounding the appropriate standards and limits of accommodation of children with food allergies in schools. We identify and explain how relevant Canadian common law, legislation, constitutional law and human rights policy can inform future school policy around allergy, disability and food bans.

MAIN BODY

The Canadian Charter of Rights and Freedoms applies to governmental laws or policies, including the policies of schools, and grants every individual the right to freedom from discrimination based on, among other things, disability. Canadian constitutional and human rights law define disability broadly including perceived disabilities. Provincial human rights tribunals in both Ontario and BC have explicitly found allergy to be a disability requiring accommodation, even in cases not involving anaphylaxis risk. However, the cases most pertinent to the scenarios faced by schools have found that food bans may not be required, due to recent scientific evidence that they do not render allergy sufferers safer.

CONCLUSION

Anaphylaxis-level allergy constitutes a disability under both the Charter and human rights legislation, despite the fact that higher courts have not definitively ruled on the matter. Accordingly, schools must make careful decisions about how to deal with life-threatening allergies among their students. Food bans are generally not legally necessary, and, in the absence of new legislation, are only likely to become so if sufficient scientific evidence demonstrates that they increase safety for students. School policies should be substantially informed by evidence-based research in order to ensure ongoing congruence with human rights law.

Challenges in the implementation of the EAACI AIT guidelines: A situational analysis of current provision of allergen immunotherapy

PURPOSE

The European Academy of Allergy and Clinical Immunology (EAACI) has produced Guidelines on Allergen Immunotherapy (AIT). We sought to gauge the preparedness of primary care to participate in the delivery of AIT in Europe.

METHODS

We undertook a mixed-methods, situational analysis. This involved a purposeful literature search and two surveys: one to primary care clinicians and the other to a wider group of stakeholders across Europe.

RESULTS

The 10 papers identified all pointed out gaps or deficiencies in allergy care provision in primary care. The surveys also highlighted similar concerns, particularly in relation to concerns about lack of knowledge, skills, infrastructural weaknesses, reimbursement policies and communication with specialists as barriers to evidence-based care. Almost all countries (92%) reported the availability of AIT. In spite of that, only 28% and 44% of the countries reported the availability of guidelines for primary care physicians and specialists, respectively. Agreed pathways between specialists and primary care physicians were reported as existing in 32%-48% of countries. Reimbursement appeared to be an important barrier as AIT was only fully reimbursed in 32% of countries. Additionally, 44% of respondents considered accessibility to AIT and 36% stating patient costs were barriers.

CONCLUSIONS

Successful working with primary care providers is essential to scaling-up AIT provision in Europe, but to achieve this, the identified barriers must be overcome. Development of primary care interpretation of guidelines to aid patient selection, establishment of disease management pathways and collaboration with specialist groups are required as a matter of urgency.