Posts Tagged ‘CAM’
Faster than a speeding case report. More powerful than a double-blind, placebo-controlled study. Able to leap peer review in a single bound. Look! Up on the internet! It’s a story. It’s an anecdote. It’s a testimonial!
Every implausible and unproven quack therapy, from acupuncture to quantum healing, comes bearing testimonials of its effectiveness. These stories are typically brief, to the point, extremely powerful and, across the board, absolutely worthless. To anyone with a decent skeptical filter in place, the reliance on testimonials is an obvious sign of a complete lack of credible support for one’s claims. Yet to far too many people there is no introductory phrase more meaningful than “In my experience”. And no amount of published contradictory data or number of explanations from critically minded experts can match the effect from just one of the seemingly neverending supply of these uncontrolled, unblinded, and often tall, tales.
Sadly, even outright harm and suffering, or the complete lack of achieving the claimed benefit, are often unable to shake the faith of one who has stepped over the line that seperates credulity from a more critical approach to one’s health. It is far too easy to rationalize away these failures, placing the blame on themselves or the medical community, when the stranger whose gout was cured by taking goat urine supplements is trusted more than the family doctor. Perhaps the believer doesn’t realize that the near totality of the testimonials seen on television or on the internet are fabricated. Maybe they don’t realize that a significant number of them, as is often the case with fraudulent cancer cures, even when provided by real people are found to be the former words of the now deceased, victims of their disease process, their lack of critical thinking skills, and the bastards profiting off of them. It is more likely, however, that the undue influence of testimonials is hard-wired in the human brain, a remnant of something which at one point bestowed a survival advantage on our primitive ancestors.
There is a reason why quacks rely on testimonials. And that is because they don’t have science in their corner. Sure they will jump on poorly designed studies, usually coming out of the National Center for Complementary and Alternative Medicine and published in biased pseudojournals, and tout them as proof of their legitimacy. But they will just as quickly denigrate methodological naturalism and the methods of so-called “western science” when better studies come along revealing their pet delusion to be a charade. The testimonial circumvents this problem, rendering science irrelevant. This is a recipe for disaster, or at the very least a lighter wallet.
Proven treatments don’t need stories. In my line of work I often am faced with parents who refuse recommended practices such as vaccines and the administration of intramuscular vitamin K for newborns. When I am discussing the care of a child with parents, and presenting them with treatment options or evidence-based prophylaxis regimens, I don’t tell them about the time I used a particular treatment and how it cured the patient, or how I had this one kid who suffered a poor outcome because they didn’t get something I recommended. There are too many uncontrolled variables in most clinical situations to trust such anecdotes. I have to rely on good data, which should not consist of anecdotes regardless of how many I might collect over my career. I would be no better than the quacks I often rant about were I to attempt to manipulate parents with emotional testimonials.
Making it as a chiropractor is hard. Some do very well, but because of low demand and marketplace oversaturation many practices fail. In fact, chiropractors are more likely to default on student loans than any other health related profession. It is easy to see why so many turn to the practice building techniques taught in chiropractic school classrooms and seminars run by companies promising to bring more patients in.
Virtually everything you see on a chiropractic website or read about a chiropractor in a local publication, is part of a prepackaged practice building scheme. The wording is carefully chosed to have the biggest impact. Every flyer or handout found in a chiropractor’s waiting room is designed to indoctrinate you so that you not only come back, but you go out and spread the word. Here is a nearly ubiquitous example from a chiropractic website’s FAQ section:
“How long will you need chiropractic care?You’ll need chiropractic care as long as you live in Hanover Park and encounter physical, chemical or emotional stress that you cannot adapt to or accommodate. Ready to get started? Call our office today.”
“Ultimately, the goal of the chiropractic treatment is to restore the body to its natural state of optimal health. In order to accomplish this, I use a variety of treatment methods, including manual adjustments, massage, trigger point therapy, nutrition, exercise rehabilitation, massage, as well as counseling on lifestyle issues that impact your health. Since the body has a remarkable ability to heal itself and to maintain its own health, the primary focus is simply to remove those things which interfere with the body’s normal healing ability.”
These seemingly personal stories always revolve around two things. The chiropractor always tells the story of how he or she, or a family member, was injured and could only find relief in the caring hands of a chiropractor, thus inspiring them to join the field. And they always involve the chiropractor making a confession about how they have been taking the credit for healing all those patients when really it was the chiropractic all along. Check out the links above and you’ll see, and trust me there are thousands more that are easily accessible online.
The reason why the general format is similar, and often exactly the same word for word, is because these chiropractors are using a standard template bought from practice building firms. The chiropractor simply puts in his or her name, practice location and hours, and some personal information such as a picture and a description of his or her beautiful family. I imagine that they choose from a list of personal tragedies that led them into the chiropractors office, and the testimonials typically placed in the ad are likely invented as well.
Many of these ads disparage the medical profession, and I have come across a number which blame vaccines for SIDS and other health problems. I am constantly amazed at the audacity of placing these cookie cutter ads when the internet provides such an easy way to compare them to others and see through the charade. But I don’t think that anyone using such techniques ultimately care. It probably doesn’t take many suckers to fall for this tactic, and to sign a longterm maintenance contract, to turn a profit.
Making the rounds last week was another example of the poor quality medical and science reporting that has come to saturate the mainstream media. The article in question, on the benefits of acupuncture for animals, is fairly typical. The situation appears to be rapidly worsening as more dedicated science reporters are being replaced with generalists, although as a skeptic I must recognize that a certain degree of selection bias may be coming into play. I do tend to go out and look for this sort of fluff pseudojournalism. But as I continue to read report after credulous and poorly researched report on topics like vaccine safety, alternative medicine, and even ghost or UFO sightings my expectations continue to steadily decline. If not for blogs like Science-Based Medicine and Neurologica, I feel I would have very few places to turn. I do like to tell myself, in an attempt to feel just a little better about the current state of affairs, that the blame falls primarily on inexperienced journalists, but even seasoned reporters with significant exposure to scientific topics are dropping the ball, as was the case in E.J. Mundell’s March 3rd HealthDay News report.
According to his bio, Mundell, the Senior Assigning Editor for HealthDay News, has 10 years of experience writing (among other things*) on health related topics for a variety of outlets such as Reuters Health and The Scientist. At one point he was even the managing editor for the consumer health news division for Reuters. Yet despite this experience, he penned a sloppy piece of pseudojournalism entitled Animals Respond to Acupuncture’s Healing Touch.
In the article, it is clear that Mundell did not seek out the scientific or skeptical viewpoint on acupuncture or its use in animals. But instead of the more common error made by journalists who, because of some seemingly pathologic need to provide a sense of balance, write as if there were two legitimate sides to a scientifically one-sided issue, Mundell has written what reads more like a press release from The International Veterinary Acupuncture Society. A vet who teaches one of their certifying courses is quoted in the piece along with a pro-acupuncture private vet and a ”skeptical” pet owner who is amazed by her animal companion’s miraculous turnaround. There isn’t even the typical misquoted straw man one-liner from a skeptic included so that a believer might easily shoot it down. The two vets in the piece are allowed to spread blatant misinformation unchallenged. Why would Mundell write such thoroughly false information as if it were gospel truth and pass along such worthless anecdotes and testimonials?
There is so much wrong with this story that it is difficult to know where to begin. I think I’ll start, as so many reports on alternative medicine miracles do, with the standard anecdote about how a suprising therapy changed a patients life. In the article, Mundell cleverly describes the medical problems of a patient named Nelly in a way that is meant to fool readers into thinking she is human. Status post spine surgery, weak, lethargic and with poor appetite, Nelly’s friend takes her to a specialist for a seemingly last resort attempt at recovery. After just a few sessions, Nelly the dog is restored to her vibrant former self, all thanks to acupuncture. That’s right, animal acupuncture.
“Almost immediately after the first treatment, Nelly’s energy went from zero to 100,” recalled that friend, Annie Washburn, who works as a community organizer in New York City. Nelly became more mobile, ate more and resumed regular bowel movements. “She bounced back in a way that seemed miraculous,” Washburn said.
This anecdotal experience is unreliable and unable to effectively establish that Nelly truly experienced any improvement secondary to the acupuncture. In the many months that have passed since those initial treatments, Washburn’s memory could easily have been altered over time by multiple retellings of the anecdote. Also, humans tend to exaggerate positive outcomes over time. In reality, the actual events could have been very different than what we are being told without Washburn actually lying. All memories, even those that have evolved over time or were implanted by another person, feel real to us. And the more dramatic a so-called flashbulb memory is to us, the less likely it is going to be accurate weeks, months, and years down the road. This is why we are such poor medical historians and a big part of why properly designed studies are necessary to answer questions regarding efficacy of treatments.
What is more plausible is that the dog improved slowly over time and would have recovered eventually regardless of what therapy was being provided. Many proponents of inert therapies make a fuss over animals as patients because of their supposed inability to be effected by placebo. This notion is entirely false, however, as the placebo effect does have an impact on animals as well as on the owner’s perception of their pet’s recovery. The primary error is in thinking of the placebo as a single entity, that being some kind of mind-over-matter effect stemming from the expectation of the patient. If that were the case, then I would agree that animals are not susceptible to placebo. But that is a straw man manifestation of it. Instead of simply being mind-over-matter, the placebo effect consists of a number of different components, some of which are pure artifact, which can lead to the appearance of a true improvement. Among these components are the tendency for symptoms to regress to the mean, which is probably the largest component of any placebo effect, investment justification, a novel therapy or more complicated therapy effect, or the desire to please an authority figure to name just a few. None of these have anything to do with an actual physiologic effect from the intervention and they only require the pet owner’s biased and subjective personal experience.
It is easy to imagine how a dog lover might interpret their pet’s behavior differently secondary to a placebo effect. It usually takes Rosco a whole week to get over his flare ups but with acupuncture it only takes 7 days. In addition to pet owners and the potential for biased evaluations, it is equally easy to see how an animal might act differently because of how their owner interacts with them. Rosco might actually act more energetic and appear to be feeling better simply because his owner is paying more attention to him in anticipation of a postive therapeutic result. Perhaps other changes, like an improved diet or a new and more interesting location, may lead to positive changes in behavior that do not stem from any new therapy. It is foolish to think that the placebo effect can’t be applied to animals, particularly our doting animal friends.
The article is overflowing with misinformation and contains the expected pseudohistorical mention of how acupuncture is an “ancient healing technique.” Perhaps I employ too narrow a definition of the word, but I would not consider a therapy that has in reality only been practiced for at most a few hundred years as ancient. It is a commonly accepted myth that acupuncture as we know it has existed for thousands of years. I’ve even read one source which claimed that acupuncture dated back to the dawn of man. I have to wonder where our primitive primate ancestors would have acquired not only the steel used to fashion such thin needles but also the paper upon which to bill insurance companies for their use. According to Mundell,
“Experts point out that animals have been treated with acupuncture therapy from the very beginning. In fact, Chinese records that go back thousands of years describe the use of healing needles on horses and other livestock.”
This is simply false. Needle like instruments considerably larger than what are used today were used to drain pockets of infection in animals but there is no historical record from that time period of the placing of thin needles in special areas of the body in order to remove obstructions to a mystical healing energy force. This concept, as mentioned above, is probably only a few hundred years old and did not even become popular in China until the 1960′s when it was forced on the public by their government. And it has become steadily less popular as scientific medicine has come to play a larger role in Chinese society.
Mundell further reveals his ignorance of the subject, or perhaps his purposeful covering up of the rather silly underlying mechanism claimed by acupuncture believers, in the following explanation.
“The points, referred to as loci, represent important locations for nerves and blood vessels that, when manipulated, somehow aid healing, experts say.”
Acupuncture, as it is promoted by the near totality of practitioners and patients, involves the shoving of thin needles into specific points on the body in order to relieve the obstruction of a vital, yet undetectable by any modern scientific techniques, energy force. There is no legitimate evidence, anatomic or otherwise, that these loci have any special relationship to nerves or blood vessels. They are, in fact, completely arbitrary. There isn’t even agreement over the number or location of these loci, or over which should be focused on. Some proponents claim that only the ear requires needling while others only care about the bottom of the feet.
One of the experts in the article reveals that “veterinary acupuncture has proven effective in healing or easing the symptoms of arthritis, acute injuries, hip dysplasia, respiratory disorders, immune system ailments and a host of other problems” This is also entirely false. There have been, over the years, a number of small and poorly designed studies, typically unblinded and uncontrolled, that have shown a weakly positive effect. But, as is the case with inert therapies, as larger and better designed studies are performed, particularly studies that are appropriately blinded and have a placebo control group, it becomes increasingly evident that there is no effect. This is certainly the case with acupuncture.
Animal acupuncture is only one very small step above pet psychics on the list of the most absurd jobs in the pseudosciences or the paranormal.
* E. J. Mundell was the production secretary for 1990′s Prom Night III: The Last Kiss
One of the more common approaches that attending physicians take when teaching medical students and residents is the use of clinical pearls. Rather than cold, hard facts, such as the most common form of congenital adrenal hyperplasia being 21-hydroxylase deficiency, these pearls of clinical wisdom are more akin to generally accepted rules of thumb. My personal favorite example is the admonition to avoid poking the skunk. Poking the skunk occurs when labs are ordered which aren’t necessary in the care of the patient. Checking a basic metabolic profile when all you really need is the serum sodium is risky. In fact, it seems that the less vital a particular lab value is to management decisions, the more likely it is going to come back as falsely abnormal, which often leads to further unnecessary tests. I don’t like to stick needles in babies, although you might not think that if you spent a day with me at work, so this particular clinical pearl comes up pretty often on my rounds.
I also make a point, on an almost daily basis, to incorporate pearls of critical thinking into my teaching of medical professionals in training. Naturally, these tend to focus on my particular area of interest, the myriad and often contradictory therapies falling under the umbrella term alternative medicine. As I’ve said many times before, I prefer terms like unscientific medicine, or quackery to be quite honest, over alternative medicine, integrative medicine, or complementary medicine. These are manipulative marketing terms used to lull the general public into acceptance with a false air of legitimacy, and the academic community into the application of a double standard to the evaluation of safety and efficacy of these therapies. There is only one legitimate means of determining whether a treatment works, and that is with science.
One example of a very helpful critical thinking pearl that should be applied to the claims of a large number of so-called alternative approaches to health, is that there is often an inverse relationship between the number of symptoms or conditions supposedly treated by a therapy and the number that is actually treated. This is better expressed with the adage that if something is claimed to cure everything, it almost certainly cures nothing. The number of alternative medical modalities that fall into this category are numerous and experiencing seemingly exponential growth, however the most important example because of its acceptance by the general public as a legitimate and science-based practice is that of chiropractic.
Though nobody, even chiropractors themselves, have been able to define themselves in a way that allows a consistent and practical understanding of just what it is that they do, there are some safe generalizations which can be made. For instance, they tend to be spine-centered rather than the oft advertised ”holistic”, and a significant percentage of them categorize themselves as “straight”. This distinction shares a dichotomous relationship with self-described “mixers”, which as the name implies are prone to incorporating a wide variety of decidedly non-spine centered therapies into their practice such as acupuncture, applied kinesiology, or nutritional supplementation, as well as some science-based modalities like standard physical therapy. Mixers outnumber straights by a large margin, and though they do make use of other therapies, they still primarily focus on the correction of a non-existant entity known as the subluxation.
Subluxations in the chiropractic sense, as opposed to the legitimate medical diagnosis, are as polymorphous as one would expect of something invented out of whole cloth* by a former magnet healer and spiritualist over a hundred years ago. Since 1895, the term has evolved into many different forms with all stages still believed in by varying numbers of chiropractors today. The manifestation which likely is accepted by the largest number of currently practicing chiropractors involves a proposed “complex of functional and/or structural and or pathological articular changes that compromise neural integrity and may influence organ system and general health”. This definition is so slippery as to be rendered utterly meaningless, and is a prime example of the inability of chiropractors to be able to establish a standard definition of who they are and what they do. This fact actually benefits chiropractors however, as it allows for a near limitless scope of practice and the ability to bill many insurance companies for the treatment of a phantom condition.
Regardless of whether a chiropractor is a straight or a mixer, they are likely to claim that they have special insight into your particular complaint regardless of what it is. With rare exception, chiropractors assert their ability to treat not just common musculoskeletal complaints, a category of conditions falsely considered by many to be their area of particular expertise, but the entirety of known medical maladies. Many will even treat one or more of a growing number of fictitious conditions such as adrenal fatigue or Wilson’s Thyroid Syndrome. This is often done overtly with outright claims of personal success in curing conditions ranging from asthma to zoster, with some even touting their ability to treat serious life-threatening illnesses like cancer and HIV.
Straight chiropractors take a different approach, boldly claiming only to treat subluxations, which then allows for the innate healing power of the human body to heal any disease state under the sun via an unimpeded spinal conduit. A critical evaluation of the medical literature reveals a far different reality however. After a little over a century of existence, there is essentially no good evidence that chiropractic care is effective in the treatment of any medical condition, or any made up one either. The one sliver of an exception is the treatment of acute lower back pain, which does appear to resolve under the care of a chiropractor. What they may not want you to know is that it has not been shown to work any better than more standard treatments such as physical therapy and the use of ibuprofen.
*The top link on google when inserting the phrase “invented out of whole cloth” takes one to an article on the history of chiropractic
As a young mother comforts her feverish and uncomfortable infant, a handsome doctor enters the dimly lit exam room. The child’s mother and the bedside nurse look at him expectantly.
“I’ve got the results. There is an infection in your son’s spinal fluid, which was one of the things we discussed as a possible cause of his high fever and irritablity,” the physician explains to the now crying mother. ”We need to start treatment right away and admit him to the hospital.”
After answering the distraught mother’s questions and discussing his treatment plan with her, the doctor leaves the room and begins to write orders in the patient’s chart. The nurse, eager to begin appropriate therapy looks over his shoulder with a confused look on his face.
“Excuse me doc, but you’ve got to be a little more clear on that order don’t you think?”
Written in barely legible doctor scribble, next to the date and time of the encounter and above his signature and hospital number, is the lone word antibiotics.
“What do you mean? This child is sick and he needs antibiotics stat!”
“Sure doc, but which one, how much and how often? Where did you go to med school again?”
“Clearly you aren’t current on the literature. Antibiotics have been around for decades and have been proven time and time again to treat infections. Millions of people take them every year. Now you are wasting precious time that could be spent caring for this sick child!”
The nurse, unhappy with the response, storms off to find assistance from his supervisor. The doctor, confident that he is providing competent medical are for his patient, expresses dismay at how closed-minded some of his colleagues are.
Naturally, the above situation is absurd, and the nurse is completely correct in questioning the physician on his order for “antibiotics”. What antibiotic, or antibiotics, are appropriate and at what dose? Through what route, oral or parenteral, should the antibiotic be administered? How often should it be given and for what duration? Five days? Two weeks? To condense the large number of antibiotics available in a hospital pharmacy into one all-encompassing term makes no sense.
Antibiotics are drugs, often consisting of completely different chemical structures and with significantly different side effect profiles. There are varying degrees of effectiveness of each individual antibiotic depending on the bacteria/virus/fungus being treated, the location of the infection, the age of the patient, and the presence of comorbid conditions such as renal or liver failure. Calling for “antibiotics” in this fashion would never happen outside of a poorly written (is there any other kind?) medical drama on Lifetime.
As new antibiotics have been developed over the years, they are studied scientifically on an individual basis. Sure there are classes of antibiotics that work via similar mechanisms, such as breaking down a bacterial cell wall, or that might be effective in killing or delaying the growth of the same types of bacteria, but nobody would make a blanket statement, let alone write an order, like the one stated and written by our fictional physician. Unfortunately, this kind of thinking is rampant in the world of so-called complementary and alternative medicine. It is employed by invidual practitioners and by large government agencies as a means of deceptively gaining a foothold for unproven therapies with little or no plausibility. Their targets are the hearts and minds of consumers as well as a growing number of academic medical institutions. In a number of instances, proponents of these therapies, buoyed by the media-fueled pseudopopularity of a variety of bogus therapies, funding from the National Center for Complementary and Alternative Medicine (NCCAM), and clever marketing, have managed to set up shop in our most hallowed halls of learning.
A common saying amongst advocates of science-based medicine, and skeptics taking on the suprisingly successful incursion of unproven therapies into academic medicine, is that there is really no such thing as alternative medicine. I agree with this completely and would add that there is no such thing as complementary or integrative medicine either, regardless of what NCCAM puts on its website. These are marketing terms meant to distract healthcare consumers and providers from the reality that these therapies have either not been subjected to proper scientific study or that they have failed that study and are held aloft only by a foundation of tenacious, anecdote fueled belief.
When proponents of alternative medicine, far too many of which being influential lawmakers, call for financial support in the form of taxpayer money, they tend to use a similar tactic. They hold up a small group of therapies that have been shown to be effective, typcially entities involving stress reduction, positive lifestyle changes like increased exercise and smoking cessation, improved nutrition, or various herbal remedies, as symbols of how wonderful alternative medicine is. This ignores two important realities. Not suprisingly, these proposed symbols of the success of alternative medicine have been co-opted from the science-based medicine which discovered them and established their benefit. More importantly, these alt med proponents are ignoring the fact that the overwhelming majority of what is considered CAM, whether legitimately or not, is absolute quackery. In other words, just because a good massage helps your migraines or decreases your fatigue it doesn’t mean that non-existant molecules of poison ivy will cure your itchy rash. The use by proponents of terminology like alternative medicine is just as preposterous as our handsome young doctor writing an order for antibiotics. Which alternative therapy? Acupuncture? Homeopathy? Quantum Reiki? And for what indication? Each individual treatment must be investigated for efficacy and safety with the tools of science, not the machinations of politicians and idealogues.
In the not too distant past, treatments supported only by sloppy anecdotal evidence or poorly designed studies that were still being offered to consumers and patients as effective had a name. Rational minded folk were unapologetic when describing a bogus cancer cure or an implausible and disproven treatment for depression as quackery. But over the past couple of decades the quack has become the alternative medicine provider and the bogus treatment has morphed into alternative medicine, CAM, or integrative medicine. This was no accident. The change in terminology has served proponents of quackery quite well by successfully leading the public to think that these therapies or just another way of achieving health. Some may be, most will not. Only science can provide the answers. In the meantime, no therapy should be allowed to circumvent science because of semantics.
During a press conference held today at their headquarters in Bethesda, Maryland, officials from the National Center for Complementary and Alternative Medicine (NCCAM) announced that preliminary data from a landmark 2008 study shows that obstructed meridians may have taken the place of heart disease as the most common cause of death in America.
“To many in the scientific community this will likely come as a complete shock and it is going to be met with skepticism,” NCCAM assistant to the travelling secretary Embeth Guzman explained. “But to other, less close-minded medical mavericks, particularly those fighting on the front lines of integarive healthcare, this is a validation of the years spent working to unclog vital human energy pathways.”
The NCCAM, which is the federal goverment’s lead agency in investigating alternative healing modalities, has issued a nationwide call for medical professionals to be on the lookout for a number of less familiar but potentially deadly conditions. Guzman further states that “It is now time for all of us in the medical field, regardless of our personal beliefs, to come together and fight this scourge of humanity. I don’t want to come off as an alarmist here, but the lives of countless millions hang in the balance.”
The updates to the list of leading causes of death in America are as follows:
1. Obstructed meridians - 219 million deaths per year
2. Chiropractic subluxations - 138 million deaths per year
3. Brain fog – 87 million deaths per year
4. Adrenal fatique – 62 million deaths per year
5. Wilson’s Thyroid Syndrome – 49 million deaths per year
6. Medical errors by allopathic physicians – 48 million deaths per year
7. Morgellons Syndrome – 18 million deaths per year
8. Engram infestation complex -9 million deaths per year
9. Chi stagnation – 3 million deaths per year
10. High-fructose corn syrup – 913,000 deaths per year
This NCCAM study, which ran from January through December of 2008, involved a randomized, double-blinded, placebo-controlled questionairre which was filled out by nearly 100 Bethesda area 5th and 6th grade students according to lead author and clinical mathologist Harken Marrow. After using a number of complex statistical analyses to arrive at the number of yearly deaths, the final results were voted on at a meeting of the top minds in complentary and alternative medicine. ”The science and the math really speak for themselves on this one,” Marrow reveals. “But really it’s all about the science. Science!!!”
Several news sources and blogs have recently reported on a study looking into the benefit of transcendental meditation (TM) in children diagnosed with ADHD. A January 5th report from Reuters Health, a news service which claims to be “internationally recognized as unbiased, authoritative, timely and dependable, with the reputation for quality that one expects from a Reuters company“, actually serves as a perfect example of how not to cover science or health news. With a skeptical mindset, a few minutes of spare time and an internet connection, I was easily able to discover the dubious reality behind this “landmark” research.
The study, led by “cognitive learning specialist” Sarina J. Grosswald, involved the instruction in TM techniques of 10 students previously diagnosed with ADHD and enrolled in a private school for children with learning disabilities. These students were followed over three months, at the end of which they were evaluated for improvement in a number of areas. According to the Reuters’ piece,
“After three months, Grosswald and her colleagues found, the students reported lower stress and anxiety levels, while their also improved, based on questionnaires given to teachers and parents.”
Impressive. For those who are confused, TM is a form of meditation developed by Maharishi Mahesh Yogi in the 1950′s which involves the repetition of a meaningless sound, or mantra, while sitting quietly with eyes shut. This allows the practitioner to quiet the mind and discover the “source of thought”. The mind and body are then able to achieve a state of calm and, according to proponents, reap myriad medical benefits far beyond that of simply increased peace of mind. Believers in TM have also been known to claim that an extension of the technique can lead to fighting crime with their minds and flying. I’m not kidding.
This is a pilot study published in a online education journal edited by graduate students, something which does no inspire confidence in me. I do not think that a reputable peer-reviewed medical journal would have accpeted it. At least the authors do admit in the discussion section that it would be inappropriate to make claims regarding a cause and effect relationship between TM and any improvement in ADHD symptoms based on these results. That doesn’t stop them from making bold statements regarding the benefit of TM, however, as I will soon get to.
The flaws in this study are numerous. The number of subjects is too small, there is no control group and it isn’t blinded. The study reveals that some of the children are on medication but it does not take into account the possibility of recent changes in medical therapy, or improved compliance while on the study. It is based purely on self-report and subjective questionairres and there is very high liklihood that a placebo effect could have been the sole responsible factor in the subjects’ apparent improvements. The authors then call for larger and better designed studies, something which I don’t think is justified for these reasons, but my problem with this study, and concerns regarding the credulous take by the media, go much deeper than what I’ve already explained.
What led me to dig deeper after reading the Reuters’ report was the following quote:
“The effect was much greater than we expected,” lead researcher Sarina J. Grosswald, a cognitive learning specialist in Arlington, Virginia, said in a written statement.”
I wondered why the researcher had expected an effect and hypothesized that there may be a connection between the researchers and TM more significant than academic curiosity. I was quickly able to discover that Grosswald is a hardcore believer in TM. Just read this quote by Grosswald from a website called Ask The Doctors, which provides a forum for specialists to answer questions related to TM and health:
“The TM technique is the exact opposite of harmful. It reduces your risk of getting serious chronic health problems like hypertension, diabetes, and heart disease. In fact, research on the Transcendental Meditation program shows that people who practice it go to the doctor about 50% less than the general population. And if they are in the hospital for some reason, their hospital stay is 50% shorter, on average. For some conditions, the need for medical care is as much as 87% less for TM meditators. Practicing the Transcendental Meditation technique is one of the best things you can do for your health.”
She clearly does not come across as an unbiased investigator. In reading her other responses on the “Ask The Doctors” website, and especially after listening to a 16-minute talk she gave in 2005, when this research actually took place, which is posted on a Maharishi Vedic Education Development Corporation sponsored website that focuses on “ADHD, the Mind and the Transcendental Meditation technique” called Insights in Health, it is obvious that she is a true believer. That doesn’t prove the research is bogus by itself, but it is a red flag.
A more concerning red flag, and one which was also discovered in the talk given by Grosswald, is the fact that the 10 children involved in the study may have been coached. In the last few minutes of the presentation, Grosswald presents clips of the children meeting with the TM proponents prior to the initiation of the study, where it appears that they are told what the expected outcome of the trial is, that their symptoms will improve with TM.
Not only are these kids aged 11 to 14 being told what the expected outcome of the study is by study investigators, the headmaster of the school, Linda Handy, can be seen at the very end of the video discussing how amazing the technique is and how it will change the students’ futures for the better. I am forced to question whether the teachers, whose evaluations of the study subjects’ behavior and performance are an integral component of the study conclusions of positive effect, might have been hesitant to give a negative evaluation when their boss is clearly also a true believer.
In the acknowledgments section, The authors thank the Abramson Family Foundation for funding and the Institute for Community Enrichment for support. The Abramson Family Foundation is an organization which believes that TM can help students achieve the full potential of their brain.
“The Abramson Family Foundation has been funding research on Transcendental Meditation and providing scholarships for students to learn the technique for the past 20 years. This has been a rewarding investment in the youth of our nation. Here is a common sense approach—a sound and scientific way—of fulfilling the purpose of education, which is to create intelligent, dynamic, happy, healthy and successful human beings.”
Of note, Grosswald sits on the Board of Advisors for the foundation. Joining her on the Board is none other than the school headmaster Linda Handy. Whatever doubt I had in my lack of enthusiasm for this study fell by the wayside upon that discovery. While it may not have been intentional on the part of the study authors, the school headmaster, or the pro-TM funding organizations, this study was designed in a way that coulnd’t possibly yield anything other than a positive result. And calls for further study, especially with public funds in addition to the over twenty million already spent by the NIH on TM, are unwarranted.
It wasn’t difficult to look at this study and see that the claims being made by TM supporters aren’t valid. It wasn’t even that hard to uncover the connections between the investigators, the school where the study was conducted and pro-TM organizations. Yet I was unable to find one news report that displayed even the slightest amount of critical thinking, instead reading like press releases from TM believers. The current state of science and health reporting is rather depressing, and I don’t see things improving any time soon as more and more dedicated science writers are falling prey to the poor economy.
In my last post, I harshly critiqued the recent Parade Magazine article on alternative medicine by Dr. Mark Liponis. I was delighted to find that I was not the only skeptic to tackle the poorly researched claim by Dr. Liponis that acupuncture, biofeedback and meditation “have scientific backing and have passed the litmus test of rigorous medical inquiry.” I enjoyed reading Dr. Steven Salzberg’s post on the subject, which I’ve linked to above.
Both Dr. Salzberg and I received nearly identical responses from Dr. Liponis attempting to rebut the concerns raised in our respective posts. Dr. Salzberg did an excellent job responding, taking each of Dr. Liponis’ points to task seperately. I recommend you read his response as he goes into more detail regarding the specific studies. I want to focus a little more on the errors in logic committed. Here is the comment on my post by Dr. Liponis, with my comments interspersed:
“I suppose everyone is entitled to their opinions…
But just because we don’t understand something doesn’t mean it’s not true.
Dr. Liponis claimed that three alternative therapies worked as if it were fact. In no way did he come off as if merely stating an opinion. My statements is based on the medical literature, an understanding of which would not lead any reasonable person to believe that acupuncture has, to beat a dead horse, “passed the litmus test of rigorous medical inquiry.”
There is little doubt that a lack of full understanding of a phenomenon does not equate to that something not being true. It would be equally valid for me to state, however, that just because we don’t understand something doesn’t mean that it is true. These are true statements but in the context of attempting to support a claim are nothing but arguments from ignorance.
Here’s some more research to support the “patently ridiculous” concepts:
In the 2005 study mentioned by you (Cardini et al., BJOG 112(6): 743-747) the authors state: “The study was interrupted when 123 participants had been recruited (46% of the planned sample). Intermediate data monitoring revealed a high number of treatment interruptions. “… “They do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.” http://tinyurl.com/6hcdmp
I’m not clear what Dr. Liponis’ point is exactly. This reaks of a biased author attempting to save face but perhaps it is merely a researcher stating the obvious. No negative study can completely prove that a treatment does not work in all circumstances. But taking into account the extreme implausibility of using toe acupuncture to reposition a malpositioned fetus, a negative study that is better designed and controlled comes pretty close in my opinion. And it raises the question of whether or not precious research dollars should go towards further studies looking into this.
In a systematic meta-review of 65 citations including six RCTs (randomized controlled trials) authors of this April 2008 review conclude: Our results suggest that acupuncture-type interventions on BL 67 are effective in correcting breech presentation compared to expectant management. Here’s the source from pubmed: http://tinyurl.com/6pvhks
Meta-analyses are notorious for their ability to thoroughly misrepresent reality. There is an old saying regarding these unwieldy monstrosities of “Garbage In, Garbage Out”. Taking a large number of small, poorly designed studies and using statistical analysis to attempt to amplify them results in what amounts to one large, poorly designed study. In this case, you have a biased journal of poor quality and a group of studies with bad methodology. But no meta-analysis is more meaningful than one large and well designed RCT. And a comprehensive review of the literature, as are reported in the Cochrane database, tend to be much more accurate as well.
A review by Cochrane database in April 2005 (3 RCTs involving 597 women) concluded: “Moxibustion may be beneficial in reducing the need for ECV (external cephalic version), and decreasing the use of ocytocin” although numbers of participants precluded statistical analysis. http://tinyurl.com/56kbky
And speaking of Cochrane reviews, when I read the conclusion of this one I once again began to doubt whether or not Dr. Liponis actually did any research into these topics that wasn’t effected by confirmation bias. If I weren’t such an damn optimist, I’d swear he was being purposefully deceitful. The conclusion of the review comes across as decidely more reasonable when read as a whole rather than carved up: “There is insufficient evidence to support the use of moxibustion to correct a breech presentation. Moxibustion may be beneficial in reducing the need for ECV, and decreasing the use of ocytocin, however there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.”
An April 2004 study of 240 women published in the Journal of Maternal Fetal and Neonatal Medicine concluded; “Acupuncture plus moxibustion is more effective than observation in revolving fetuses in breech presentation. Such a method appears to be a valid option for women willing to experience a natural birth.” Here’s the pubmed reference: http://tinyurl.com/6fq7w9
Was it published on April 1st? This is yet another study done with poor methodology, no placebo and questionable blinding.
I have no idea how it really works, it just seems to work, somehow. Also, as a physician (MD) who sees patients and works with acupuncturists I have also seen many patients helped by acupuncture. I don’t presume to understand how it works.
These statements make it abundantly clear where Dr. Liponis is coming from. He is a believer in acupuncture and doesn’t care about what the science shows. When all is said and done, science is irrelevant unless it supports, or at least appears to as in this case, his stance. I wonder, would Dr. Liponis stop recommending acupuncture at any point based on scientific evidence that it was ineffective. I doubt it. It is extremely easy for even the brightest of people to be fooled by our inate weakness in interpreting the world around us. Anecdotal evidence is the weakest form of evidence, and notice I didn’t say it was devoid of all value, simply because our brains are so prone to bias. We are at the mercy of entities such as the placebo effect, the desire to please, the thrill of a novel therapy, regression to the mean, errors in logic and sometimes outright fraud. Taking these concerns, and countless others, into account is why scientific medicine has been so successful.
Do you believe it’s unreasonable for a woman to try acupuncture/moxibustion when faced with the alternative of a C-section or manual manipulation of the baby at the time of delivery?”
I do not think it unreasonable for an adult to try acupuncture/moxibustion if they are doing so based on what they perceive to be accurate information. Unfortunately, the public is generally woefully naive when it comes to science and medicine and often depends on sources of information such as the article written by Dr. Liponis. I would think it unreasonable were a patient to seek out any therapy knowing that it has zero prior-plausibility and is not supported by the medical literature.
December has seen a big spike in reports on alternative medicine, in particular the practice of acupuncture. Last week, a number of outlets ineptly covered the release of the most current numbers on CAM usage, choosing to simply regurgitate press releases from the National Center for Complementary and Alternative Medicine rather than practice actual journalism. Prior to that, the official journal of the American Academy of Pediatrics had published a blatantly pro-CAM article on pediatric use of alternative medicine in which the authors boldly provided the following gem:
“Formal evaluation has suggested that the quality of RCTs of CAM is as good as that of RCTs of conventional medicine, and the quality of systematic reviews of CAM exceeds that of systematic reviews of conventional medicine.”
This notable diversion from reality was followed up by a healthy, and not at all unexpected, dose of praising anecdotal n-of-1 studies and then blaming difficulty obtaining IRB approval of CAM studies on ignorance of just how wonderful the stuff is. On Saturday, I was made aware of the habitually woo-friendly U.S. military’s foray into “battlefield acupuncture“. And yesterday, as I sat down to peruse the Sunday paper I happened upon the following article on “Alternative Therapies That Really Work” in Parade Magazine.
Now I am painfully aware of the reality that Parade Magazine is not a medical journal. It isn’t even a popular science magazine like Discover or Scientific American. Its articles barely even qualify as reporting at all. Occassionally entertaining fluff, from cover to cover, just about sums it up. But it is a source of information that millions of people read each and every week, many of whom very likely consider what they read within to be reliable. And it may be reliable when it comes to the latest news on which actresses still wear fur or who readers think is the hottest celebrity in 2008 (still Jennifer Connelly, always Jennifer Connelly), but it is horrendous when it comes to coverage of medical topics.
It was 2.5 years ago, in June of 2006, when Dr. Isadore Rosenfeld wrote a typical article on acupuncture for Parade. In it, after cherry picking a few positive and negative studies to mention, he cautioned readers that more studies are needed before a conclusion on efficacy could be made. Sound reasonable right? He then included an absurd anecdote, one which he has used before in prior articles and one which was effectively handled by Gary Posner and Wally Sampson 10 years ago:
”My personal experience with acupuncture helps me keep an open mind. In 1978, I was invited to China to witness an open-heart procedure on a young woman. She remained wide awake and smiling throughout the operation even though the only anesthesia administered was an acupuncture needle placed in her ear.”
Naturally this significantly hampered any chance of most readers taking home the only reasonable conclusion which could be made from the article, that acupuncture had not been proven by appropriate investigation to be effective. It still hasn’t. In fact, the position that acupuncture has no real effect, and not that it hasn’t been proven either way, is well supported by the trend in the literature of increasingly negative results in studies of increasingly improved design and control.
With the help of a number of “experts”, like the aforementioned Dr. Isadore Rosenfeld and Dr. Mark Liponis, Parade has mishandled the subject of alternative medicine for years. The current example is yesterday’s one page article by Dr. Liponis, who according to his profile,
“…..has always had an interest in holistic health and wellness, and continues to expand his expertise in integrative medicine as Corporate Medical Director of Canyon Ranch.”
I suspect that he is more interested in expanding his bank account by taking advantage of the public credulity more so than his expertise. There certainly is not a hint of any any regarding acupuncture, one of the three alternative modalities claimed to work in the article. Here is what Liponis has to say about it:
“What it is: Acupuncture is a traditional Chinese practice involving the placement of very skinny, sterile needles into the skin at specific points located along “energy meridians.”
How it works: Eastern philosophy says that acupuncture affects the flow of qi (pronounced “chee”), or energy, through the energy meridians. Western science reasons that the needles interact with our nervous system, triggering the release of hormonelike chemicals that affect our mood, perception of pain, and immune response.
What it’s good for: In a 2004 study, acupuncture was shown to be helpful in reducing pain due to knee arthritis. It also could be beneficial for sufferers of post-traumatic stress disorder. And when used along with in vitro fertilization, it may be effective in increasing the odds of success in female conception. Stimulating an acupuncture point in the toe even may help correct the breech position of babies in the last trimester and allow more women to avoid C-sections, according to a study in the Journal of the American Medical Association.“
First off, invoking the terminology ”western science” is a huge red flag that you will soon be venturing off the well-trodden path of critical thinking on a subject. The scientific method is the same regardless of where you live and this kind of terminology serves the underhanded purpose of attempting to establish a double-standard when it comes to evaluating therapies. Usually when it is mentioned it isn’t long before someone is claiming that it isn’t the right way to study [insert unproven therapy]. Furthermore, some scientists may express the opinion that apparant effects of acupuncture are due to the release of a chemicals within the body, but many would argue that this is putting the cart before the horse. If there is no proven effect, what is the point of attempting to establish a mechanism.
As far as the cherry picked studies chosen by Liponis go, well I think calling them cherry picked pretty much makes my point. Looking at three studies, at least two of which are of very poor quality, is insufficient to make a claim that acupuncture works. Enjoy Steven Novella’s dismantling of the claims of acupuncture’s effectiveness in improving IVF success rates back in November. The study on acupuncture and the repositioning of breech fetuses is equally dubious. It is an unblinded and uncontrolled study. All three of those aspects make studies on acupuncture very suspect. Virtually all studies on acupuncture coming out of China are positive and should be approached with appropriate skepticism. When replication in a non-Chinese population was attempted by the same study author in 2005, no effect was found. This isn’t suprising as it is a patently ridiculous concept with zero prior-plausibility. Dr. Liponis very likely did not do any research when preparing his article as this information was extremely easy to find.