As efforts to bring clarity to the “infodemic”1 surrounding COVID-19 continue, the scientific community is realizing two key things: they stand on the cusp of an unprecedented opportunity to educate the public and, to do so, they need to communicate more effectively. The distance between the scientific and the nonspecialist world view has never been thrown into such sharp focus—the scientific community and the general public speak different languages. Clinicians seem to stand between the two, conversant but not always fluent in both.2 It is not a simple matter to “translate” the context of the scientific method: ideas and ways of thinking that the public cannot be expected to automatically understand.

Part of the problem is that many people are semi-literate in scientific thought and terminology, and this often leads them to think they have understood when they have not, to plunge into interpretations based on misunderstanding, or alternatively, dismiss them as untrue or misleading, and buy into false claims. It is all too easy even for highly educated people to fall prey to “scientistic”—rather than scientific—arguments and ideas, and from there, to quickly become convinced by—and to spread—ideas that have no basis in science. Equally concerning is a rapid increase in antiscience perspectives (also known as science denialism)3 and activism emerging among allied health professionals as well as the wider public, frequently couched as “free” or even “critical” thinking. As a result, a growing number of educators and researchers in the sciences are calling for reforms and expansion in the training of young scientists in order to equip them for “science public engagement and outreach.”4

A widely shared opinion piece in Nature World View by Canadian research chair Timothy Caulfield at the University of Alberta issues a strongly worded call to scientists to address these issues as follows:

“First, we must stop tolerating and legitimizing health pseudoscience, especially at universities and health-care institutions . . . If a respected institution, such as the Cleveland Clinic in Ohio, offers reiki—a science-free practice that involves using your hands, without even touching the patient, to balance the ‘vital life force energy that flows through all living things’—is it any surprise that some people will think that the technique could boost their immune systems and make them less susceptible to the virus? . . .

[T]he idea that a spinal adjustment, intravenous vitamin therapy, or homeopathy could fend off an infectious disease was nonsense before the pandemic . . . There is some evidence that alternative treatments and placebo effects can relieve distress—a common justification for tolerating unproven alternative treatments. But it’s inappropriate to deceive people (even for their benefit) with magical thinking, and it is inappropriate for scientists to let such misinformation go unremarked. Second, more researchers should become active participants in the public fight against misinformation. Those pushing unproven ideas use the language of real science—a phenomenon I call ‘scienceploitation’—to legitimize their products. It is, alas, all too effective . . . We need . . . all scientists from relevant disciplines to provide simple and shareable content explaining why this hijacking of real research is inaccurate and scientifically dishonest.”5

Regardless of your initial response to this excerpt, I would strongly encourage all readers to read the full article—carefully, calmly, and critically—and then consider its implications. It is part of a larger, older debate that appears set to continue in coming months and probably years, and has the potential for repercussions across the health professions, particularly those whose evidence base is still in the early stages of development. It is evident that this author has thrown out the wheat with the chaff, but we can expect a lot more of it in the near future. This applies especially to many aspects of the bodywork professions and most of the integrative health professions.

Calls such as this are increasing rapidly in the current climate, and may have one of three outcomes. First, they may herald a new wave of scientific rigor and outreach, which may indeed improve scientific literacy in the public sphere, but may also increase intolerance and unjustified demonization of practices with a weak evidence base—a point I will elaborate on later. Caulfield’s byline makes his intentions clear: “The scientific community must take up cudgels in the battle against bunk.” Cudgels are blunt instruments, and in this scenario, the baby is likely to be thrown out with the bathwater.

Second, if scientists follow such calls to take to the airwaves in droves, with charismatic bright-eyed graduates trained in communication methodology and public speaking skills, more confusion—or indeed a pushback—may occur, leading to further divisions and confusion. “Science apologists” and “shills” are labels often applied by those suspicious of such initiatives, and those who advocate for this point of view may be just as persuasive and influential among the unaware. The distinct communication problems identified by those calling for reforms in science training to improve public outreach will take some years to remedy.

Lastly, it is possible that scientific outreach may in fact slow and die out as the pandemic is brought under control. The insightful educators across the spectrum of the sciences, but especially within the health-care professions, who do decide to incorporate such approaches into their training may be few and far between. Yet, rather than being a positive result, this would also represent the loss of an immense opportunity for professions who are misunderstood by the scientific establishment to clear out some cobwebs; isolate and detach from unscientific language and practices; build a healthy ecosystem of fruitful, constructive dialogue; and encourage higher quality research and research literacy where it is desperately needed.

Whichever outcome—or combination of outcomes—prevails, if the scientific community responds to Caulfield’s appeal (echoed by many), there is a clear and present danger that well-established therapies and modalities whose research base is young but not pseudoscientific will be tarred with the same brush as true pseudoscience. It has never been more crucial to demonstrate the difference and to find constructive ways to ensure that young fields are ring-fenced from flaky antiscientific claims that can only do them damage. The onus of proof weighs on those within the field, and to produce that proof, the scientific method needs to be understood and respected. This cannot be done through bickering on social media, through personal attacks on people who may be well-meaning but ignorant, or by insisting on the truth of something based solely on anecdotes or shoddy research.

Critical Thinking

Integral to this discussion is the establishment of what the terms critical thinking and rational reasoning do and do not mean. Critical thinking is not the same as reactive skepticism that automatically approaches a scientific claim with suspicion, because critical thinking does not incorporate emotion. Critical thinking is cool, logical, and, above all, objective. The first step toward developing that logic is to recognize, separate, and compartmentalize our own cognitive bias (shortcuts in thinking that we develop through experiences that make us lose objectivity) and emotional reactions, which often occur because we feel our world view is threatened. The second step is to admit when something is outside our area of expertise and acknowledge what we do not know. Alongside this, understanding and avoiding the host of logical fallacies that are destructive to true critical thinking is vital.6
This is not to say that the scientific method is perfect. It is far from it, as I will explore in my next column focusing on another current debate regarding the flaws in the current form of scientific research. It is also important to acknowledge that the same points on critical thinking and cognitive bias apply to those on both sides of the debate: scientism (an excessive, often dogmatic belief in the superiority of science) is every bit as misguided as pseudoscience. Nevertheless, scientific reasoning is the predominant way of understanding and discussing the science of health and healing, and its authority comes from 300 years of development based on the principles of impartiality, objectivity, and rationalism (basing opinions on logic and knowledge as opposed to subjective experience).

If we do not like the way a system works, then we need to bring viable, logical, and applicable solutions to the table. If we do not like rationalism, then we can join the long-standing philosophical debate on the theory of knowledge, also known as the rationalism versus empiricism debate. That does, however, require advanced training in the history of philosophy and epistemology (the science of thinking about knowledge and the difference between justified belief and opinion). Key to that training is the use of logic.

The essence is that we cannot join the discussion and hope to be heard by shrieking on social media, burying one’s head in the sand, attacking individuals instead of using reasoned debate to dismantle their ideas. Using catchphrases and arguments like “It’s funded by big pharma, so it’s corrupt” is a logical fallacy known as a red herring: appealing to prejudices surrounding something’s origin to discredit it not due to its content, but due to its source to shut down an argument. A solid argument does not need to do this; it can effectively stand up to scrutiny and overturn wrong claims by using rational argumentation and solid evidence. Using fallacies to avoid taking this route suggests cognitive bias, intellectual dishonesty, and an inability to form an argument. In turn, this discredits whoever commits these fallacies and makes it far less likely that their views will be heard. All too often, this tarnishes the whole field they represent.

If those in the fields of bodywork and integrative health want—as I presume most do—to earn the respect and validation of the wider establishment, then they have to play by the rules. Put simply: if you want to play baseball, you need to follow the rules of the game. In this case, those are the rules of the scientific method and reasoned argument. To win the game, we need to play. To play the game, we need to know the rules so well that we cannot be disqualified or disregarded for overstepping them.

It is sad that Caulfield is correct on many points. It is true that mistaken, misguided, or downright false scientific claims are being made and shared within the bodywork and integrative health communities, often with the best of intentions due to a simple leap of logic or a lack of specialized skills. It is also true that unless this is addressed, it is likely to have a damaging effect on the perception of these professions, undoing years of hard work by leaders who have fought to shake off the “underdog” image and bring maturity and respectability to these fields.

Example 1: Elderberries

A real-life example I recently encountered on social media includes the claim that elderberry syrup is a powerful antiviral that can protect us from COVID-19, based on a belief in age-old traditional medicine. There is indeed some evidence to support the conclusion that at certain dosages, in certain usages (note these caveats), with appropriate timing, preparations using Sambucus nigra or related elder species can—under some circumstances—reduce viral load for some viral diseases and inhibit influenza virus types A and B and herpes simplex-1 virus, while also improving some flu-like symptoms. However, these studies were small, in some cases poorly designed, and noted numerous contraindications and warnings regarding potential side effects if mixed with other medication or used in certain types of patients.

In this example, there appear to be clear indications that an old natural folk remedy indeed has the potential for further study and may well be highly beneficial.7 The evidence thus far has been gathered in a systematic review (considered the highest form of evidence that gathers all available studies on a topic according to certain parameters, and evaluates and aggregates their results). Unfortunately, the studies covered in the review were all graded as moderate evidence due to design flaws or study size. A more recent review on the same topic concluded that “a deficit of studies comparing these S. nigra products and standard antiviral medications makes informed and detailed recommendations for use of S. nigra extracts in medical applications currently impractical.”8 In short, because there has not been enough research to compare whether elderberry extracts can do a better job than existing medications—and because not enough is known about its safety profile in higher doses or other conditions—currently, scientists cannot conclude one way or another as to whether it can be widely prescribed for influenza, even though we know it appears to be beneficial.

Does the meager evidence we do possess mean that qualified practitioners can safely recommend S. nigra products to alleviate the symptoms of influenza? If the actual formulations have been deemed safe, then yes, it seems that they can. But does this same evidence support the conclusion that “influenza is a virus, COVID-19 is a virus, elderberry is good for influenza, therefore elderberry can cure COVID-19?” No, it does not. There are three fallacies built into that assumption: the bandwagon fallacy (where tradition validates the theory), the appeal to nature fallacy (if something is natural, it must be ideal), and the composition fallacy (because elderberry is good for one virus, it must be good for all viruses). The current lack of evidence does not mean that elderberry may not eventually be proven to be beneficial for COVID-19 cases, but we do not yet have that evidence—and we need to admit that.
Elderberry may certainly be worth trying, as Chinese physicians indeed desperately reached for various traditional remedies in the early days of the COVID-19 outbreak. Anecdotal evidence suggests that the traditional Chinese remedies may have shown some benefit too. Clinical experience may bear this out even further, but we simply do not have enough information yet. There are no human studies at all to support the idea that elderberry can prevent viral infection, and there is no current evidence for or against its benefits regarding the symptoms of COVID-19.

Unfortunately, because laboratory testing takes time and resources that are currently dedicated to facing the immediate fallout from the pandemic, this is not something we can discover quickly. Therefore, although we could safely say it is worth exploring, that is where we must, regretfully, stop if we want to be taken seriously. For health practitioners to claim that elderberry must be effective based only on meager research on a different virus, or to take the early positive results as “proof” that “all” herbal remedies are effective, or to make sweeping statements that attack the scientific search for evidence instead of supporting its use, perpetuates the already problematic reputation of what may indeed be effective treatments, if only more evidence were available.

Example 2: Myofascial Research

A second striking example is illustrated in two key articles on myofascial research. A 2019 systematic review of studies exploring the efficacy of dry cupping and dry needling in the reduction of myofascial pain and trigger points concluded that though moderate evidence was present for the beneficial effects of manual therapy, “The evidence for dry needling and cupping is not greater than placebo.” The authors go on to note, “Future studies should address the limitations of small sample sizes, unclear methodologies, poor blinding, and lack of control groups.”9

As noted above, systematic reviews are a form of research that evaluates the available evidence according to certain parameters. How those parameters are set is important, because if they are too narrow or too broad, they can result in inaccurate conclusions. This particular review followed most of the standard procedures for conducting this kind of research and ended up with a total of eight studies on manual therapy, 23 on dry needling, and only two on cupping. A key reason for the small number of studies examined was that the authors excluded studies without control groups.

This is quite common in bodywork research, for methodological reasons that belong in another—important—discussion.10 The authors evaluated the quality of the included studies according to the standard PEDro scale11 (developed by the Physiotherapy Evidence Database to determine the quality of clinical trials), and established that there was limited evidence and a lack of consistency in the manual therapy studies; very low to moderate evidence in favor of dry needling for short-term outcomes, though information beyond the short term remains unexplored; and, extremely limited, low-quality evidence in favor of dry cupping. A lack of standardized methods and study design was found to be a key limitation in appraising all the studies.

These findings may come as a surprise to readers familiar with, perhaps even practitioners of, some of these techniques—especially if they have had good results with their patients. Yet, it is the hallmark of a “young” field of evidence. Researchers often lack the training, skills, or resources to successfully plan a high-quality trial and can also run into problems with recruitment, funding, or appropriate facilities that result in small sample sizes that cannot be generalized and methodological flaws that will leave open the question of whether no treatment or placebo would have been just as effective. Frustrated clinicians may be certain of the effectiveness of these treatments, but that conviction cannot be brought to a scientific debate.

A very important critical appraisal of this type of systematic review has highlighted further problems with building an evidence base: even systematic reviews are not immune to flaws, and the way they are designed, conducted, and their findings communicated back to those conducting primary research is crucial to correcting these problems along the research chain. In his analysis on this topic, presented at the 2018 Fascia Research Congress and published in 2019 in the Journal of Bodywork and Movement Therapies, researcher M. S. Ajimsha listed and scrutinized the areas in which systematic reviews can fall short, highlighting important, useful tools that researchers can use to improve the quality of their work.12

The point of having these different types of study, from the randomized controlled trial (RCT) to the systematic review and the meta-analysis, is so that the scientific community can continuously assess and revise its views if necessary. If a systematic review finds a healthy number of well-designed RCTs with evidence of one finding or another, and if it follows careful internal checks to avoid internal bias and interpretation errors, then in turn, if an organization performs a meta-analysis at the instruction of a policy-making entity, that evidence will be convincing. This then has the potential to lead to policy change. But as long as the primary research—RCTs or even case series and studies—are lacking, then the result of higher level research will always be “we don’t have enough evidence and we need better studies.”

Lack of evidence is the challenge that every “young field” must overcome. Successfully building a robust evidence base is the making of that field; not doing so can turn into a vicious circle if better research practices are not encouraged. Therefore, even though the bodywork and integrative health professions may use age-old, traditional methods, in terms of building an evidence base acceptable to the scientific community and thus achieving the credibility to join the discussion as equals, they will remain in their infancy until this is remedied. A lack of scientific studies does not mean that there is evidence against their efficacy; it means that we cannot sit across a panel from a research scientist or a biomedical practitioner and claim that we have proof that something works.

Making claims that draw on anecdotes or tradition alone leaves professions wide open to accusations of pseudoscience and undermines their credibility. One potential solution is to conduct small, well-designed studies; ensure they are utterly watertight, even the humble but significant case report; and use them to convince those in positions of influence to explore them further with larger-scale trials. There are many stakeholders when it comes to research, and rational persuasion that works with (rather than against) the established methods is more effective than simply abandoning the effort or attacking the system because it seems insurmountable.

Tradition, Scientization, and Pseudoscience

There are many who do not see a reason to go through such a laborious process as the scientific method, either because they are professionally and ideologically invested in a given therapeutic direction, or for more nefarious, commercial purposes. It is much easier (and intellectually lazier) to take the anti-science position and simply cherry-pick scientific language when it suits the argument. It is also intellectually dishonest, and though it may do little harm when speculating about theoretical physics, it does immense harm when applied to health-care practices, and damages those responsible professionals who have worked hard to build their reputation.

What Caulfield calls “scienceploitation” is a very old, very effective spin technique, more commonly known as “scientization,” which dates from the late 18th century and the aftermath of the Scientific Revolution. It was used primarily by philosophers and occultists to express mystical and philosophical beliefs using scientific terminology, so as to validate them in a newly secular society in which science had largely replaced religion.13

Throughout the 20th century, scientization has been used to develop theories about mind-body interaction and does not always result in junk science. In fact, the discipline of psychology grew out of the early glimmerings of these schools of thought. There are times when it is justified, when highly theoretical scientific ideas are being explored. However, scientizing theories remains a tool of choice to gloss over the lack of an evidence base, or for promoting actual pseudoscience.

It can be difficult to tell the difference between true scientific research and scientized theory; in truth, it can fool the most intelligent of readers by playing to the emotions or known biases of the audience precisely due to the lack of hard facts. This is not always done with malicious intent and can often be due to strong convictions of the individual or group promoting a given theory.

As I wrote this piece, I stumbled across the work of a respected colleague who used a scientized—but not scientific—interpretation of the COVID-19 case and death rates to conclude that one of the wilder conspiracy theories currently spreading on the blogosphere must be true. I am certain that this line of argumentation—into which this person had obviously put a lot of work—was made in good faith and in the name of critical, free thinking.

Nevertheless, their argument and supposed “evidence” was littered with logical fallacies, the most obvious of which was the Texas Sharpshooter fallacy: cherry-picking information to suit an argument and finding a pattern in it to confirm one’s assumption. The name of this fallacy is based on the idea of a marksman shooting at a barn, and then painting a target around the place where most of the bullet holes appeared.

This analysis began with a lack of understanding of how epidemiological data is calculated and interpreted, much like the discredited “Bakersfield doctors” viral interview.14 This is something taught in advanced public health and epidemiology courses, which this particular individual has not studied. However, their good track record as an author and practitioner has won over their unquestioning audience, who in turn see themselves as “free thinkers.” Nevertheless, a couple of hours of basic epidemiology methods training, along with some basic sociological observations, would dissolve the arguments made—and the conspiracy theory along with them. Such training is freely available on the Centers for Disease Control and Prevention (CDC) website (with continuing education credits attached.)15

Why Belief Trumps Facts

Audience bias can take the form of belief based on anecdotal experience or that of strong disciplinary boundaries built through overspecialization that can all too frequently result in dogmatic thinking. Overspecialization is an occupational hazard in nearly all fields of modern scientific and medical education. It affects everyone who has been through a standard modern education (perhaps with the exception of the liberal arts). The focus on specialization in education is largely a result of managerial decisions within educational institutions and attempts to balance curricula and staff within a tight academic framework. The modern educational system grooms us for this from an early age, so as we delve deeper into our area of study and practice, we can easily become locked into that world and forget that there are other ways of thinking and seeing. Holistic practitioners are not immune to this, for despite their holistic outlook, not all have the skills training and knowledge base to appraise “hard science.” This carries the same risk of ideological bias as does conventional scientific training. Awareness of the Dunning-Kruger effect (whereby we become aware of the limits of our understanding) is a significant tool to avoid blind spots in either direction.

The compartmentalization of knowledge serves practical purposes in the modern world but is also a liability because it gives us isolated tools with which to deal with life. If all our training and experience has taught us to use only hammers, then everything looks like a nail. If somewhere along the way, we learn to use a screwdriver, then we see both screws and nails, and we may think the person holding the wrench is a fool. If shown a full toolbox, we may turn away in disgust, thinking that someone is out to trick us.

It is only when we consciously realize that our expertise with the hammer has an equal value to someone holding the wrench, and understand the limitations of our own tools, that we might perceive the value of the toolbox. This understanding is the beginning of humility and the first step toward learning, and only then can we break out of the narrow view formed by our education or experiences. It may be difficult to perceive or admit that our view has become narrowed through these formative experiences, especially for people who have pursued a variety of career changes, who eagerly seek out learning opportunities, and whose identity is defined by their profession.
In view of the debate underway regarding science and pseudoscience, it has never been more crucial that we reexamine those limitations and reconsider the value of the tools we do not yet understand. In this analogy, the hammer is the given set of skills and professional approaches we have learned to work with, through effort, sweat, and, no doubt, pride. However, this does not mean that wrenches, screwdrivers, and other tools are useless, nor that we know how to use them without being taught. And a structure cannot be built without the whole toolbox working in harmony.

A Unique Opportunity

It might be easy to think that I am taking the position of a science apologist with this line of thought. Even if I were, that would still be a red herring; whatever my convictions, it is the quality of an argument, not someone’s world view, that makes or breaks it. In fact, I see my role as that of translator—someone who speaks two languages (as I do in real life) and who is uniquely placed to see both sides of an issue and translate between them.

When we have treatments and modalities that are effective and safe, and that clinical experience—or indeed tradition—has shown to be worthwhile but crucially lack sufficient evidence (or evidence of high enough quality for the reasons explained earlier), then unfortunately (if we do not take great care to use the right language and to stay away from “flaky” claims) we will end up having some aspects unfairly labeled as pseudoscience or worse. If we do not develop the skills to sit at that debating table, then such labels will go unchallenged, and this has a cumulative effect on the whole field. Leaders in these professions have spent long years and made great efforts to drive this point home, to produce textbooks, upgrade educational practices, and encourage high-quality research, precisely so as to ensure a robust scientific underpinning.16

This pandemic was always going to bring a sea change. A fresh look at those elements that unite, rather than divide, may go a long way toward furthering, rather than damaging, professions that have suffered from fragmentation and misperception for decades. It would be a great shame, and a lost opportunity, to leave them open to the kind of criticism they have the potential to attract. There is a unique chance to join a dialogue and contribute to the strengthening (rather than the weakening) of the professions and overlapping bodywork and integrative health fields in the face of what is likely to be a new public understanding of science.

Notes

1. World Health Organization, “Novel Coronavirus (2019-nCoV): Situation Report–13,” last modified February 2, 2020, accessed May 2020, www.who.int/docs/default-source/coronaviruse/situation-reports/20200202-sitrep-13-ncov-v3.pdf.
2. Sasha Chaitow, “Whose Research is it Anyway?” Journal of Bodywork and Movement Therapies 23, no. 3 (July 2019): 435–38 (2019), https://doi.org/10.1016/j.jbmt.2019.08.002.
3. Sven Ove Hansson, “Science Denial as a Form of Pseudoscience,” Studies in History and Philosophy of Science Part A 63 (July 2017): 39–47, https://doi.org/10.1016/j.shpsa.2017.05.002.
4. Peter J. Hotez, “Combating Antiscience: Are We Preparing for the 2020s?” PLOS Biology 18, no. 3 (March 27, 2020): e3000683, https://doi.org/10.1371/journal.pbio.3000683.
5. Timothy Caulfield, “Pseudoscience and COVID-19—We’ve Had Enough Already,” Nature (April 27, 2020), accessed May 2020, www.nature.com/articles/d41586-020-01266-z.
6. “Critical Thinking—Writing Lab Tips and Strategies: Logical Fallacies,” Morgan Library Research Guides, last modified July 25, 2016, accessed May 2020, https://libguides.grace.edu/CriticalThinking/logicalfallacies; Jesse Richardson et al., School of Thought, “Thou Shalt Not Commit Logical Fallacies,” last modified 2020, accessed May 2020, https://yourlogicalfallacyis.com; Richard Paul and Linda Elder, The Miniature Guide to Critical Thinking Concepts and Tools, 8th ed. (Lanham: Rowman & Littlefield, 2019); Lewis Vaughn, The Power of Critical Thinking, 4th ed. (Oxford University Press, 2016).
7. Catherine Ulbricht et al., “An Evidence-Based Systematic Review of Elderberry and Elderflower (Sambucus nigra) by the Natural Standard Research Collaboration,” Journal of Dietary Supplements 11, no. 1 (January 2014): 80–120, https://doi.org/10.3109/19390211.2013.859852.
8. Randall S. Porter and Robert F. Bode, “A Review of the Antiviral Properties of Black Elder (Sambucus nigra L.) Products,” Phytotherapy Research 31, no. 4 (April 2017): 533–54, https://doi.org/10.1002/ptr.5782; J. E. Vlachojannis, M. Cameron, and S. Chrubasik, “A Systematic Review on the Sambuci Fructus Effect and Efficacy Profiles,” Phytotherapy Research 24, no. 1 (January 2010): 1–8, https://doi.org/10.1002/ptr.2729.
9. Derek Charles et al., “A Systematic Review of Manual Therapy Techniques, Dry Cupping and Dry Needling in the Reduction of Myofascial Pain and Myofascial Trigger Points,” Journal of Bodywork and Movement Therapies 23, no. 3 (July 2019): 539–46, https://doi.org/10.1016/j.jbmt.2019.04.001.
10. Cheryl Ritenbaugh et al., “Whole Systems Research Becomes Real: New Results and Next Steps,” The Journal of Alternative and Complementary Medicine 16, no. 1 (January 2010): 131–37, https://doi.org/10.1089%2Facm.2009.0650; Nadine Ijaz et al., “Whole System Research Methods in Health Care: A Scoping Review,” The Journal of Alternative and Complementary Medicine 25, Suppl. 1(March 2019): S21–S51, https://doi.org/10.1089%2Facm.2018.0499.
11. Physiotherapy Evidence Database, “PEDro Scale,” last modified June 21, 1999, accessed May 2020, www.pedro.org.au/english/downloads/pedro-scale; C. G. Mahler et al., “Reliability of the PEDro Scale for Rating Quality of Randomized Controlled Trials,” Physical Therapy 83, no. 8 (August 2003): 713–21.
12. Derek Charles et al., “A Systematic Review of Manual Therapy Techniques, Dry Cupping and Dry Needling in the Reduction of Myofascial Pain and Myofascial Trigger Points”; M. S. Ajimsha and Pramod D. Shenoy, “Improving the Quality of Myofascial Release Research—A Critical Appraisal of Systematic Reviews,” Journal of Bodywork and Movement Therapies 23, no. 3 (June 2019): 561–67. https://doi.org/10.1016/j.jbmt.2019.03.011.
13. Sasha Chaitow, “Redemption Through The Arts: Joséphin Péladan’s Platonic Legendarium,” PhD Thesis, University of Essex, June 2014; Nicholas Goodrick-Clarke, Western Esoteric Traditions: A Historical Introduction (Oxford University Press, 2008), 234–45; Lukas Szrot, “The Idols of Modernity: The Humanity of Science and the Science of Humanity,” MA Thesis, University of Texas, May 2015, http://hdl.handle.net/10106/25014.
14. Anna-Maja Rappard, “Dubious Coronavirus Claims by California Doctors Condemned By Health Experts,” CNN Health, last modified April 30, 2020, accessed May 2020, https://edition.cnn.com/2020/04/29/health/california-doctors-coronavirus-claims/index.html; “ACEP-AAEM Joint Statement on Physician Misinformation,” American College of Emergency Physicians,” American Academy of Emergency Medicine, April 27, 2020, accessed May 2020, www.acep.org/corona/COVID-19/covid-19-articles/acep-aaem-joint-statement-on-physician-misinformation/?.
15. Franz Wiesbauer, “Epidemiology Essentials,” accessed May 8, 2020, www.medmastery.com/course/epidemiology-essentials?; Cheryl Ritenbaugh, “Whole Systems Research Becomes Real: New Results and Next Steps,” The Journal of Alternative and Complementary Medicine 16, no. 1 (January 2010): 131–37.
16. Leon Chaitow, “Evolution from Quakery to Integration to Functional,” January 26, 2008. www.leonchaitow.com/2008/01/26/evolution-from-quackery-to-integration-to-functional.