It must be Tuesday...
Without looking at the calendar, healthcare professionals know it’s Tuesday by the Medscape journals in their inboxes.
Medscape’s online journals have recently become the topic of debate among medical professionals over appearances of bias in its editorial content, coverage of research and health policy, and continuing medical education courses. This controversy would likely never have been raised among doctors if the content hadn’t sparked concerns because, as we know, funding sources alone don’t necessarily mean the science itself and interpretations are flawed. However, unless medical professionals take the time to vigilantly compare content to the actual research findings and have the know-how to recognize fair tests, the lack of balance in any publication can be easily overlooked. It would be too easy to write a weekly “Medscape Tuesday” column — as it became a redundant exercise years ago to itemize its problematic content. But, given its recent assurances of a new rigorous editorial process and refined standards, a column is warranted today.
Tuesday’s issue removes any doubt of the need for medical professionals to be exceptionally diligent in examining its content with a critical eye. The main continuing education credits offering at Medscape Nurse, for example, were for a course on complementary therapies for migraines in adolescents, which reported the effectiveness of dietary supplements, acupuncture, therapeutic touch, reiki, hypnosis, chiropractics, osteopathy and healing touch; and described dangers of nitrates and monosodium glutamate. Other CME/CE opportunities in Medscape journals included such things as “Poor coordination and physical function in childhood linked to adult obesity” and “Bariatric surgery may improve obstructive sleep apnea.” [Overviews below.]
But it was the Subject line of the email and this issue’s feature article which inescapably first caught the attention of every nurse:
“Call to Arms: Time to Fight an Epidemic”
This article was written by Paula A. Lucey, MSN, RN, CNAA, which began by saying:
When you think about fighting an epidemic what comes to mind? Influenza? Diseases of underdeveloped countries? Possible acts of terror such as smallpox? At a recent meeting of the Robert Wood Johnson Executive Nurse Fellows, Margaret Grey, DrPH, RN, FAAN, dean of Yale College of Nursing, noted researcher and a RWJ Executive Nurse fellow, called on her colleague fellows to begin to fight the epidemic of obesity.
The Call to Arms went on to report that “obesity can be defined as a body mass index rating of greater than 25” — [thereby, creating a new definition of obesity that now also includes every “overweight” person in the country]. The familiar statistics and chartsmanships to declare an obesity epidemic came next, followed by a list of obesity-related health risk factors, which were said obesity could cause. And finally, the “staggering financial costs” of obesity were cited.
“At the most basic, an individual's weight is the energy balance between calories eaten and calories utilized,” Ms Lucey said. She blamed the obesity epidemic on social norms, with the constant exposure to “high-fat and high-sugar foods, the convenience of pre-packaged foods and fast food restaurants,” and “portion distortion,” which, she wrote, “come at a high cost of unneeded calories.”
The “toxic environment” was the “flip side of the [calories in – calories out] equation,” she said, which was turning us into a sedentary nation. She cited the Surgeon General’s Office’s Call to Action to Prevent and Decrease Overweight and Obesity and its assertion that less than one-third of Americans meet the requisite amounts of daily exercise. “Forty percent of Americans do not participate in any leisure time physical activity,” she wrote. “Children's rates of activities have also decreased dramatically and the amount of ‘screen time’ has increased,” she reported. Finally, she said that obesity is worse in women of lower socioeconomic status and that the core reasons included “the availability and cost of fruit and other healthy choices at neighborhood grocery stores, neighborhood safety issues [purportedly leading to sedentary lifestyles] and social/cultural traditions.”
This led to the comment:
Public health officials have been able to begin to shift the conversation about obesity from one of solely an individual health concern to an issue that needs to be considered as a public health priority.
What Can a Nurse Leader Do to Join the Fight? First, it is important for nurse leaders to recognize the issue...our silence is killing our patients and staff... there are some simple things that every nurse can do to help in the fight against obesity. The important thing is to do something!
The first and foremost suggestion made — in fact, it was repeated three times in the article — was:
Clinically, we must find ways to have conversations with clients about weight and healthy lifestyles in ways that do blame the victim. Failure to do so will alienate the very people we need to help the most...
Clinically, nurses must find ways to have conversations with clients about weight and healthy lifestyles in ways that do blame the victim.
This suggestion epitomizes the beliefs and stigma of obesity lamented by one of the country’s foremost obesity researchers, Dr. Jeffrey M. Friedman, M.D., Ph.D., head of the Laboratory of Molecular Genetics at Rockefeller University in New York, who wrote that the “simplistic notion” obese individuals can ameliorate their condition by simply eating less and exercising more is “at odds with substantial scientific evidence illuminating a precise and powerful biological system that maintains body weight within a relatively narrow range.” Yet, obese people continue to be victimized by these prejudicial beliefs, he wrote, while the known science on the natural diversity of human sizes and shapes continues to not find its way into the minds of the public and even a significant proportion of the scientific community, who believe their personal experience of gaining and losing a few dozen pounds with diet and exercise translates to an obese person simply needing to apply that several more times to become a different body type. Our body shapes and sizes are, to the most significant extent, genetically determined with a surprisingly narrow range of weight under our long-term control. “The heritability of obesity is equivalent to that of height and greater than that of almost every other condition that has been studied — greater than for schizophrenia, greater than for breast cancer,” he wrote.
A healthy lifestyle and simply eating healthfully will not result in everyone losing weight and having a BMI between 19-25 because a “tremendous body of research employing a great variety of methodologies has failed to yield any meaningful or replicable differences in the caloric intake or eating patterns of the obese compared to the nonobese,” as professors and clinicians David Garner, Ph.D., and Susan Wooley, Ph.D., concluded in their classic review of 500 studies on the long-term efficacy of weight loss interventions and the biology of weight regulation. The renowned clinical research of doctors Michael Rosenbaum, Rudolph Leibel and Jules Hirsch at the Laboratory of Human Behavior and Metabolism at Rockefeller University, for example, found nondieting fat and lean people eat and expend the same amount of calories per unit of lean body mass and that the proportions of protein, carbohydrates and fat do not determine (cause) true obesity, either.
While the first half of Ms Lucey’s article left out any actual obesity research, just as little evidence was provided to support the solutions proposed in her Call to Arms.
She said all nurse leaders need to address the toxic environment at workplaces and think about changing the social norms of their organizations to bring the focus on healthy eating and lifestyles, from fruits at meetings to healthy vending machines. “I heard a great suggestion of having signs in the parking lot showing the calories burned by parking further away from the entrance,” she wrote.
Besides offering wellness programs for employees, she said nurse leaders are in the ideal position to help encourage their organizations to implement corporate wellness programs, to include assessments of individuals and devise “personalized action plans,” and programs that could “include classes and support groups for weight management, smoking cessation, and other healthy lifestyle coaching.”
Nurses were especially called upon to work on bringing about public health policies, with the first step to raise awareness of the obesity epidemic and unhealthy lifestyles among elected officials. She went on to tell nurses that as “corporate community citizens,” they should work towards implementing public community design and “encouraging healthy urban planning” to oblige physical activity. She concluded: “Obesity is the epidemic in this country...nurse leaders should participate in the public debate as health leaders to assist elected officials in finding ways to address this national crisis.”
Disappointingly, this was the feature article in a nursing journal, yet it bore little resemblance to a thoughtful review of evidence-based clinical care that would serve nursing professionals. Absent was fact-checking by its author or the Medscape editorial board — as evidenced by the reality that not one obesity-related claim or solution was supportable with sound, objective evidence. Nor was there any effort made to balance its emotional language over a national obesity crisis with a careful, reasoned examination of the evidence, weighing the effectiveness and potential harm and costs of proposed solutions. The U.S. Preventive Services Task Force, for example, found no evidence in more than forty years of research to support the effectiveness, or conclude a favorable benefit-risk ratio, of healthy diet and lifestyle interventions; and even RWJF has admitted there’s no evidence for its obesity initiatives. Yet, there was no mention of those balancing facts.
Whenever such problematic clinical information is encountered, disclosure statements and potential biases come into play as we try to gain a better understanding of an issue.
Sadly, the author described herself as a fat person who “fight[s] the bathroom scale on a routine basis,” and yet views obesity as the fault of one’s personal behavioral and dietary failings, and a health crisis. Obesity stakeholders have widely permeated fat advocacy communities and helped advance concerns that fat is deadly and caused by poor lifestyle choices, and rally support for their healthy fruits and vegetables, preventive wellness and healthy lifestyle management, and community Active Living by Design initiatives as being imperative for their health. There are no disclosure statements or accountability required on virtual communities, even true identities don’t need to be revealed, better enabling social media marketing.
Most medical journals, however, do require their authors to disclose potential interests.
There was no disclosure statement in this article. Ms. Lucey’s byline said only that she is “President, Lamplighter Consulting, LLC, Greenfield, WI, and a Nursing Economics Editorial Board Member.” Her full bio appears at the Medical College of Wisconsin website for the MCW Consortium, where she is co-directs the Healthier Wisconsin Partnership Program, funded by RWJF. Its most recent endowment of $6.4 million was announced this spring. Last April’s issue of Nursing Economics, in fact, was devoted to building partnerships to address “social determinants of health” and describing the RWJF Healthier Wisconsin Partnership Program model. More significantly, her bio explains she “is currently serving an Executive Nurse Fellowship through the Robert Wood Johnson Foundation.”
Many nurses may be unaware of the significance of this disclosure. RWJF describes its program as “a leadership development program designed to prepare a select cadre of registered nurses who are in senior executive positions for influential roles in shaping the U.S. health care system of the future. The ultimate goal was to help the nursing profession gain a more influential voice in setting and implementing health care policy.”
This national program was established in 1997 and RWJF provides up to $45,000 per 3-year fellowship and the nurse’s employing institution matches $30,000. It was an outgrowth of its programs launched during the 1980s to strengthen the nation’s nursing corps. The RWJF Executive Nurse Fellowship program is managed through the Center for the Health Professions at the University of California, San Francisco. The Fellowship includes mentoring and guidance under RWJF leadership to facilitate specific nurse’s core competencies:
Interpersonal and communication effectiveness — The ability to translate a strategic vision into compelling and motivating messages.
Risk-taking and creativity — The ability to transform both self and organization by moving beyond traditional patterned ways of success.
Self-knowledge — The ability to understand and develop the self in the context of organizational challenges, interpersonal demands and individual motivation.
Inspiring and leading change — The ability to inspire, structure, lead and effectively implement organizational change in an inclusive way.
Strategic vision — The ability to connect broad social, economic and political changes to the strategic direction of institutions and organizations.
According to the program’s FAQ, most RWJF Executive Nurse Fellows go on to occupy, or directly work in, top leadership positions in their organizations... and champion RWJF initiatives. One institution reported: “the ENF program is creating a cadre of nursing leaders who think differently, act differently, collaborate differently and negotiate differently. This will help to change the course of nursing and health care in this country.”
The recent controversy surrounding Medscape and questions if it is working to shape clinician’s practices and public policies, or provide neutral, evidence-based education would appear well-founded. Last month, Medscape Nurse featured an article lobbying for a National Nurse and press every nurse to enlist in nurse corps and national service, also to support the Surgeon General’s mission.
Briefly, here is a few of the other articles in this Tuesday’s issue of Medscape Nurse, as well as appeared in other Medscape journals, that challenged healthcare professionals to look at the information presented with a more critical eye:
“Obesity Prevention in Child Care: A Review of U.S. State Regulations.” This article claimed that even among preschool children, obesity rates were “alarmingly high” and associated with type 2 diabetes, hypertension, sleep apnea, asthma, hyperlipidemia, early maturation and low self-esteem. The authors blamed the childhood obesity epidemic on sugar and sweetened beverages, high fructose corn syrup, television and computer screen time, sedentary behavior and nonparental child care. [All fallacies previously covered.]
For this paper, the authors reviewed child care legislation across the country to see how many had adequate child obesity prevention**** regulations, which they defined (with no supportive evidence for safety or effectiveness) as: require childcare facilities to make only water available and frequently encouraged at regular intervals, limit sweetened drinks and fattening foods, promote breastfeeding or require breastfeeding agreements to be on file, regulate screen time, and require specific number of minutes of physical activity per day.
The authors stated that family home-centered childcare regulations tend to be less stringent than centers and opined that “states should provide the same regulations for both family child care homes and centers.” The article concluded that the “mere existence of a regulation, however, does not necessarily ensure compliance or enforcement” and called for the need to explore policy approaches on a federal level to address the obesity epidemic in children.
[While the authors declared no competing interests, they were each with childhood obesity programs, with the lead author from the Obesity Prevention Program at Harvard Medical School and Harvard Pilgrim Health Care in Boston.]
“Poor Coordination, Physical Function in Childhood Linked to Adult Obesity.” This CME/CE course covered the recent study published in the British Medical Journal. A close examination had revealed the authors found no tenable correlation at all between clinical measures of physical function during childhood and adult obesity.
The Medscape article, however, gave clinicians a very different take-away message. Its Pearls for Practice said: Teacher reports showed poor hand control, poor coordination and clumsiness in children at age 7 were associated with obesity, and that the children’s “deviant behavior” wasn’t likely due to the teacher’s perceptions of the children. And, clinician-administered evaluations at age 11 years “showed that poorer motor function was associated with later obesity, even after adjustment for BMI and markers of pubertal stage.”
The Medscape authors then hypothesized, with no clinical evidence or credible biological plausibility, that fat people have impaired brain function: “Obese adults may have a history of lower levels of cognitive function in childhood, suggesting that neurocognitive development and obesity may share common pathways reflecting early biological processes relevant to neurologic function. Alternatively, adult obesity and tests of cognitive function are both directly affected by social and cultural factors, and these may overlap, contributing to both conditions."
“Bariatric Surgery May Improve Obstructive Sleep Apnea.” This article and post-test was another CME offering. It examined the obstructive sleep apnea study just reviewed here, which had concluded bariatric surgery was not an effective treatment for obstructive sleep apnea. While the information was all there in the Medscape review for doctors who took the time to read the text carefully and critically analyze it for themselves, busy practitioners who might be tempted to skim the highlights, catch the headline and Medscape’s Pearls for Practice, were likely left with a slightly different impression of the study’s findings. It’s Pearls for Practice said: Weight loss after bariatric surgery is associated with reductions in AHI in severely obese patients. And weight loss after surgery is associated with a high incidence of persistent OSA, snoring, and discontinuation of CPAP.
“Headache in Adolescents: Prevention and Complementary Therapies”
Finally, we come to the largest continuing education course in this issue. For the next year, doctors and nurses can get CME/CE credits for taking this course on migraines in teens. It was authored by Dr. Kathi Kemper, M.D., MPH, the Caryl J Guth Chair for Complementary and Integrative Medicine at the Wake Forest University School of Medicine and the Director of the Program for Complementary and Integrative Medicine at Wake Forest University Baptist Medical Center.
This article was impossible for any medical professional to grasp what the actual research evidence shows on alternative modalities’ effectiveness for migraine headaches. Select studies were mentioned, but described in such a cursory manner so as to provide so little information on methodology, the statistical significance of the findings, or a perspective of the body of evidence, for any professional to determine the information’s reliability. Attaching a lengthy, impressive-looking bibliography also does not mean those 98 references actually credibly supported the paper’s assertions, are representative of the medical literature on the issue, or that those studies had been carefully evaluated.
Findings of ineffectiveness were rarely noted in this article’s text but, even when a study admittedly found nothing statistically significant, a very different account was given in the conclusion. The conclusion stated:
[S]cientific studies suggest that a number of complementary therapies can help reduce the frequency and severity of migraine headaches. These include: stress management practices such as biofeedback, autogenic training, guided imagery and relaxation; regular exercise; correcting deficiencies of essential nutrients such as magnesium; certain dietary supplements such as vitamin B2 (riboflavin), coenzyme Q10, fish oil, butterbur, feverfew, and ginger; and therapies such as massage and acupuncture. Additional research is needed to evaluate the cost-effectiveness of widely used therapies such as chiropractic therapy.
In contrast to the conclusion of a benefit of fish oil and ginger, for instance, no supportive evidence was found in the article’s text. Substantiation for fish oil was loosely said to come only from anecdotes and one open-label (unblinded) study that suggested the oils could offer benefits. “However, a small controlled trial of adolescents, 2 months of supplementation with fish oil was associated with significant reductions in headache frequency and severity, but these improvements were not significantly better than improvements noted among control patients who took olive oil. Similar studies also found effects no better than olive oil placebo.” And ginger was said only to be “an herbal medicine that is traditionally used in Ayurvedic and Tibetan systems...and may be useful for patients who are troubled by nausea and vomiting.”
There were so many mixed messages throughout this article that it was confusing, but mostly troubling because of the consistency with which readers were led to believe alternative modalities were considerably more beneficial than the evidence supported. And no matter what the findings, additional research was repeatedly said to be warranted.
“Randomized controlled trials suggest that acupuncture has significant benefits for both adult and pediatric patients with chronic headaches — both migraines and tension-type headaches,” Dr. Kemper stated. But she went on to admit that the effects were no different than those produced by a placebo — hence, they weren’t actually “significant”: “According to a recent study, benefits persisted for 6 months of follow-up, although sham treatment produced similar effects.” Yet, she still concluded acupuncture to be among the alternative modalities than can help migraines.
“Chiropractic therapy is used by over 10% of migraine sufferers to help prevent symptoms.,” she wrote, suggesting in readers’ minds, perhaps, that the popularity of a modality is evidence of effectiveness. Dr. Kemper went on to write: “Anecdotal experience and pilot studies suggest that spinal manipulation, particularly of the cervical spine, can be effective for some patients however, dramatic adverse effects of cervical manipulation in a few case reports (eg, fatal cerebral artery dissections) have limited the number of referrals of migraine patients from allopathic healthcare providers to chiropractors.”
Medical professionals reading this article, however, were left completely in the dark as to the balance of benefits to risks, especially for growing, young people. In fact, none of the studies presented for any of the physical modalities had actually tested them on kids (except for one acupuncture study mentioned finding null results, with no safety analysis), yet young people was the patient population in this paper.
Pilot study. And how many readers caught the mistaken leap from a pilot study to evidence of the effectiveness of a medical intervention? Remember, not all studies are created equal. As NC3Rs [National Centre for the Replacement, Refinement and Reduction of Animals in Research, based in London] explained in Why do a Pilot Study: “A pilot, or feasibility study, is a small experiment designed to test logistics and gather information prior to a larger study, in order to improve the latter’s quality and efficiency. A pilot study can reveal deficiencies in the design of a proposed experiment or procedure and these can then be addressed before time and resources are expended on large scale studies.”
Biostatistician Paul. W. Stewart, Ph.D., at the University of North Carolina in Chapel Hill, said the term ‘pilot study’ is widely misused and some think it’s a term for a small study. But it refers to “a preparatory investigation that is in no way intended to test the research hypotheses of interest,” he said. For instance, it can assess costs and financial feasibility of a later full-scale study, test the research hypothesis and validate the scientific approach, or gather information about variances and correlations needed for statistical analysis of the power and sample size need in a later full scale study. Most pilot studies are not normally publishable, he said, and often camouflage a small, poorly-conducted study. Most importantly, they don’t excuse the researcher from the need to perform a full study to credibly test an intervention in a randomized, controlled clinical trial. The misconceptions of pilot and small-scale studies are described in more detail here.
“Several case series and small studies have demonstrated the effectiveness of osteopathic therapy in preventing tension-type headaches,” Dr. Kemper wrote. While she went on to say that additional controlled studies are needed to evaluate the long-term effectiveness, professional nurses and doctors were left merely to trust her claims that effectiveness had been adequately demonstrated to support continued research.
While Dr. Kemper said in her summary that armed with the information in this Medscape article, “clinicians can provide appropriate, evidence-based advice,” this article neglected to even mention the major evidence-based critical reviews recently issued from reputable expert panels — all of which could provide professional nurses and doctors with a much sounder overall picture of the evidence. While such expert systematic reviews [as opposed to meta-analyses] aren’t infallible, they can help us see the strengths and weaknesses in the research, what the body of evidence to date shows, and help us to weigh the benefits and risks associated with various clinical interventions.
Twenty years of randomized, controlled clinical trials and other prospective clinical trials of behavioral-cognitive and physical treatments for migraines were reviewed in a Agency for Health Care Policy and Research Technical Review, for example. Its findings were published by the American Academy of Neurology and the U.S. Headache Consortium*. As they concluded:
Evidenced-based treatment recommendations are not yet possible regarding the use of hypnosis, acupuncture, TENS, cervical manipulation, occlusal adjustment, and hyperbaric oxygen as preventive or acute therapy for migraine.
The body of evidence is limited and problematic. The AAN noted that the “seven small trials of acupuncture yielded mixed results,” citing methodological problems, such as unreported statistical significant or studies unable to show any statistical differences at all between acupuncture and a sham (fake placebo) intervention. “A single trial of cervical mobilization (oscillation of a joint within its normal range of movement) and cervical manipulation (movement of a joint beyond its normal range of movement) provided little support for the use of these interventions for patients with chronic headache,” they concluded.
Bandolier, an online project out of Oxford University which does regular examinations of medical evidence, reviewed the randomized controlled clinical trials on complementary therapies for tension and cervicogenic headaches in 1998 and concluded that “there is a paucity of evidence from randomized trials that any of these interventions is truly effective.” This review had included trials on acupuncture, spinal manipulation, physiotherapy, electrostimulation, homeopathy, massage and therapeutic touch. They found “a lack of high quality trials. The existing trials tended to be of poor methodological quality, and are therefore subject to bias.”
A 2001 Bandolier systematic review of clinical trials on spinal manipulation for headaches concluded “there is no evidence of specific benefit with chiropractic for headache,” with studies showing no consistency over control groups using sham therapies or other interventions. The reviewers were unable to determine if effects observed were due to chiropractic or other nonspecific factors. They also concurred with a recent Cochrane Collaborative review on acupuncture for idiopathic headaches, stating that the “clinical bottom line” is: “There is no evidence that it works, and not a single trial was of sufficient quality or validity and size, and was positive.” They cautioned medical professionals about the dangers of drawing incorrect conclusions from systematic reviews that don’t take into consideration the “quality, validity and appropriateness of the application and method of acupuncture used” in studies when evaluating the effectiveness of acupuncture. It’s easy to be led astray by simple tallies on one side or another.
Bandolier’s special Migraine issue**, published in January 2002, reviewed the causes and various treatments of migraines. It issued its strongest statement yet about alternative modalities:
There have been several systematic reviews of complementary therapies for migraine or migraine-type headaches, mainly but not exclusively for prophylaxis to prevent headaches. The stark message is that these do not work, or there is no evidence that they do work. What we know from both homeopathy and acupuncture is that the better the trials, and the more the trial designs minimise bias, the more negative are the results. These interventions are a waste of money and time.
The one exception may be feverfew for migraine prophylaxis. In common with a number of other herbal remedies, there is some evidence that it works, but even here that is not entirely convincing. Feverfew is a chemical, or mix of chemicals, and may not be without adverse effects.
Going back to the Medscape article and the alternative modalities most popularly promoted by contemporary nursing theory — therapeutic touch, reiki and healing touch — Dr. Kemper stated:
Biofield therapies such as therapeutic touch, healing touch, and Reiki are widely used to treat tension and migraine headaches. Numerous anecdotes attest to the benefits of these therapies for headaches, and no side effects have been reported. One study, published in 1986, showed that therapeutic touch was linked to reduced pain in tension headaches.
This is especially disappointing in its service to nursing professionals. It exemplifies the findings of medical chemistry and bioethics professor Dr. Donal P. O’Mathuna, Ph.D., currently in the department of healthcare ethics at the School of Nursing at Dublin City University in Dublin, Ireland. He had examined how accurately nursing journals adhere to evidence-based practice and health care policies, and published his findings in a 2000 issue of the Journal of Nursing Scholarship. Admirably, he worked from the construct of “critical thinking and scientific integrity.”
Examining how the original research findings on therapeutic touch were presented in nursing literature, he found that authors often cited only the studies with favorable findings. In many reviews, he said research was claimed to have indicated efficacy when the actual findings had shown it to be ineffective. When citing studies with contradictory findings, he found only the favorable findings were usually mentioned in reviews of the literature and every single review had made at least one significant error in representing the research.
He concluded that accurate presentations of the research are imperative for clinicians to make evidence-based decisions and to ensure that limited healthcare resources are used safely and effectively. These principles apply equally to following popular beliefs in alternative therapies to obesity.
Regrettably, such calls for scientific grounding continue to go unheeded by many in nursing leadership. A recent review of the research on healing touch exemplified Dr. O’Mathuna’s findings. Nurses at the University of Texas Houston Health Science Center reviewed more than 30 studies on therapeutic touch and while they found no “generalizable results,” they still claimed there was a foundation to justify continuing to test “its benefits.” This was followed two years later by a pilot study on healing touch for pain in 12 people with spinal cord injury, led by the same author, published in the Journal of Holistic Nursing.
These energy-based modalities have been covered extensively, so there’s little need to review the science again. But JFS isn’t alone among nursing professionals voicing concerns about nonscientific, noncritical evaluations of research, including therapeutic touch, healing touch and other mind-body modalities, guiding clinical practice. Katherine Bowman, RN, Ph.D., at the University of Texas at Austin, for example, wrote a stunning commentary on that published pilot study that was surprisingly straight-forward about its misrepresentation of the data and fallacies of logic:
The report by Wardell et al. is another example of results showing the ineffectiveness of healing touch, but the discussion indicated more favorable results. This was a well-written article in which scientific terminology was used to mask pseudoscience. Several features of the report lead to this conclusion. First, the authors acknowledged that they found almost nothing statistically significant but wrote as if their findings were significant. At best, this was confusing and, at worst, it was deceptive. For example, in the first and final paragraphs of the discussion, the authors indicated that most of their findings were not statistically significant, but they called for more studies with more complex designs. The authors provided no rationale to justify further research...
[T]he authors described the appearance, size, shape, and purpose of energy fields. They reported that the energy fields of many of the participants were damaged, absent, or detached but improved with treatment. The authors did not explain how the [healing touch practitioners] were able to see the energy fields, how the energy fields were measured, or how the improvements were measured.
The lack of concrete measures leaves in question the motives and psychological health of individuals who can see things that only other individuals with similar belief systems can see.
Finally, the authors suggested using complimentary pain-relief methods in a future study. They suggested that multiple methods might provide more pain relief, decrease participant disappointment, and prevent participants from focusing on healing touch as the “failed” method of pain relief. The authors indicated that they did not want the participants to focus singularly on their pain experience. This was confusing. If the goal of this research was to find pain-relief methods, then a focus on the pain experience seemed appropriate. In addition, why examine healing touch as a pain-relief method in a future study if other methods must be used to provide the pain relief? Perhaps the multiple pain relievers were to camouflage the lack of pain relief effectiveness from healing touch.
While the Journal of Holistic Nursing is among the list of nonrecommended medical journals at Quackwatch, Medscape isn’t, but could be a contender.
Most nurses are smart, caring, hard-working professionals. Rather than follow a Call to Arms for nurses to get behind beliefs, policies and clinical interventions that have no credible scientific evidence to support their safety or effectiveness, how about a Call to Action for nursing professionals to devote themselves to the highest standards of scientific evidence-based care for all of our patients and members of our communities? Imagine what advocates for people nurses could really be then.
© 2008 Sandy Szwarc
* U.S. Headache Consortium:
American Academy of Family Physicians
American Academy of Neurology
American Headache Society
American College of Emergency Physicians*
American College of Physicians-American Society of Internal Medicine
American Osteopathic Association
National Headache Foundation
** Per the disclosure statement for this Migraine special: “The Bandolier migraine resource was sponsored by the Gwen Bush Foundation, and by MSD. For the avoidance of doubt, neither sponsoring organisation had or has any form of control over content, and sponsorship is accepted only when this condition is accepted.”