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AARP and Alternative Medicine

I know I said the next entry would be about the efficacy of the influenza vaccine. The road to blogging in paved with good intentions. I will eventually write that entry, but the ADD has kicked in and my attention has wandered elsewhere.

I am 51 and one of the benefits of this advanced age is you get to join AARP, the American Association of Retired People. Yes, I know I am not retired, and given the current economic situation I am already practicing for my retirement.

“Do you what paper or plastic?”

“For here or to go?”

“Do you want fries with that?

Piece of cake. Who needs a 401K?

The day I received the AARP application, on my 50th birthday, despite some misgivings (8), I joined.

The purpose of AARP, besides discounts at Denny’s and the right to yell at kids when they are on your lawn, is, according to their mission statement, “AARP is dedicated to enhancing quality of life for all as we age. We lead positive social change and deliver value to members through information, advocacy and service. (1)” AARP is a lobby/special interest group for the elderly. In medicine the elderly are considered a vulnerable/at risk group. The elderly may have have fixed incomes, chronic medical problems, declining cognitive function and social situations that make them particularly susceptible to scams of all kinds. So it was nice to have an organization looking after our interests.

AARP has at least 40 million members. Accompanying the membership is their magazine, somewhat eponymously entitled AARP Magazine. The AARP Magazine has the largest circualtion of any magazine in the US with 24 million copies, each read issue by more than one person (7). It has 3 times the circulation of Readers digest. Only Parade magazine has a wider circulation. These are the publications where people receive casual information about about health care. I would assume that a magazine from my advocacy organization would contain information that I can trust. After all, AARP is looking out for my interests as a senior, and any article they would publish, especially relating to health and finances, I should be confident was reliable.

The January/February had an article “Drug Free Remedies for Chronic Pain” by Loolwa Khazzoom (2).

Ms. Khazzoom is a freelance writer who, to judge from googling her name, occasionally dabbles in articles about pain relief. She has suffered significant trauma with resulting chronic pain and a continuing series of bad interactions with the medical industrial complex. She finally overcame her pain through dance, and consequently started helping other chronic pain patients at Dancing with Pain (3).

Her blog is sponsored in part by Chopra Center and Weil ™, which I mention as I did not know until I wrote this that Dr. Weil ™ is trademarked. I am so jealous. Dr Weil ™ also sponsors a line of Cookware including the Fuzzy Logic Rice Cooker. These things just write themselves, don’t they? Ms. Khazzoom’s site is heavily slanted towards alternative/spiritual/mind-body medicine. I mention the financial support, since I am deep in the pockets of big pharma (4), as one needs to know the potential conflicts of interest and bias of writers of medical advice.

Her expertise in pain is derived from the fact that she is a chronic pain sufferer who has had bad interactions with the medical industrial complex and positive interactions and financial support from the alternative medicine industry. From the article you would not know much about the expertise of the author or potential conflicts of interest beyond:

“Loolwa Khazzoom, who created the Dancing with Pain method of pain management, blogs about natural pain relief at www.dancingwithpain.com.”

Her background, of course, does not necessarily invalidate her writing. The world is filled with talented amateurs who have mastery of topics and add understanding to the world. The article needs to be evaluated for its content.

The subheading of the article is typical of the alternative medicine genre:

“Scientists don’t always know why these alternative therapies make the hurting stop. But a growing body of evidence suggests they work.”

The article starts with two sentences, neither of which are true. Science knows, if an abstraction can know, these alternative therapies do not work. To the contrary, the growing body of evidence suggests they do not work. It also suggests that the author has not read the growing body of evidence.

Not an auspicious beginning. Perhaps the article will clarify what constitutes the growing body of evidence and change my mind.

The first 600 words, almost half the text, are a compelling anecdote about a dancer, a Ms. Toussaint,  who had an injury, had a horrible interaction with the medical industrial complex, and was eventually healed through Feldenkrais, a movement therapy, and guided imagery.

I am glad Ms. Toussaint is better, and I have no doubts that her experiences with the medical industrial complex were awful. Chronic pain patients are definitely not the forte of many doctors and most of us dread the chronic pain patient, especially if they have no measurable pathology and want a refill on their oxycontin.

But. It is the the standard anecdote. Illness followed by the medical and personal failure of MD’s followed by the success of the ND/DC/Etc who emowers the patient to get better. Always a compelling story that contrasts the ineffective, heartless MD with the effective, caring alternative practitioner.

Anecdotes, no matter how compelling, are not evidence. The plural of anecdote is anecdotes not data. The unstated premise in these anecdotes is MD’s are bad and ineffective therefore alternative modalities are good and effective.

It is the usual false dichotomy. OK. For the sake of argument I will concede that ALL of the medical industrial complex consists of heartless, greedy, ignorant, arrogant, old white men who cannot and will not listen to or care about their patients and are pawns and puppets of big pharma, all conspiring to make sure you do not learn the real way to cure or prevent your illness. Take the worst adjectives you can devise to describe me and mine. Fine. They are all true. It still neither adds nor subtracts to the validity of whatever woo you say is effective.

Here is a odd idea: the validity of any therapy has to stand or fall on its own merits, not the faults and problems of others.

The data to support the guided imagery for pain? Here she quotes

“How is it possible that simply by engaging her imagination, Toussaint began healing her pain? New advances in neuroscience shed light on the process, says Martin Rossman, M.D., author of Guided Imagery for Self-Healing (New World Library, 2000). “While acute pain appears in areas of the brain that are connected to tissue damage, chronic pain lives in other areas of the brain—the prefrontal cortex and limbic system, which the brain uses for memories, especially emotional ones,” Rossman says. In some cases “the pain lives on long past the time when the body tissues have healed.”

“Repeated thoughts and emotions create nerve pathways in the brain. Chronic pain impulses travel along well-worn pathways. By using techniques such as guided imagery to build new nerve pathways, “the pain pathways can become less active,” Rossman says.”

More of a book plug than a reference. I do not usually consider popular books as part of a growing body of evidence. Pubmed references are the preferred source of scientific medical information. Dr. Rossman has one Pubmed publication to this name on guided imagery. But the quote is by an MD and filled with neuroscience words. Is what he says true?

I can find zero data to support the assertion that guided imagery builds new nerve pathways that bypass the old pain pathways. Perhaps he is speaking metaphorically; if so I suppose it should be mentioned as such, as it sure reads like a neuronanatomic explanation for how guided imagery works.

As to guided imagery and pain control, the literature is a hodgepodge of not so good studies. Part of the problem with the literature is that guided imagery is poorly defined , but it would appear that guided imagery acts like cognitive behavioral therapy with pain, that if you think the pain is less, it is less. It would appear to be effective at the level of the placebo, which in my mind is the same as saying no effect at all.

The one structured review of guided therapy and chronic pain in the elderly, germane to the readers of AARP magazine, concluded

“The eight mind-body interventions reviewed are feasible in an older population. They are likely safe, but many of the therapies included modifications tailored for older adults. There is not yet sufficient evidence to conclude that these eight mind-body interventions reduce chronic nonmalignant pain in older adults.”

The lack of good (randomized clinical trials, hopefully double blind as well) data for chronic pain and guided imagery does not prevent Ms. Khazzoom from asserting that

“Guided imagery and Feldenkrais, the therapies that helped Toussaint, are only two out of more than a dozen alternative therapies that have been scientifically documented to ease chronic pain when drugs can’t.”

My definition of scientifically documented is a randomized double blind clinical trial where chronic pain, refreactory to medications, was treated with a modaltiy that was better than placebo. It would be even nicer if there were biologic mechanims to account for the clinical effect. To be complete, I searched “Feldenkrais and chronic pain” in Pubmed. Nothing. No published clinical trials. An anecdote is not scientific documentation, even if it is a scientist doing the documentation.

Onward with the exploration of the “growing body of evidence suggests they work”

Next follows is a short discussion on the multifactorial nature of pain, and the lack of pain specialists in the US.

“The latest trend, says Steven Stanos, D.O., medical director of the Rehabilitation Institute of Chicago Center for Pain Management, is to take a more comprehensive approach to treating chronic pain, a “bio-psycho-social approach.” The “bio,” or biological, part means treating the physical or underlying pathology—and, where possible, its root cause. The “psycho,” or psychological, part addresses the depression, fear, and anxiety that can accompany and even exacerbate the experience of chronic pain. The “social” part pertains to a patient’s ability to function, work, sustain friendships, and maintain status in society.

If a clinician ignores any of the biological, psychological, or social impacts of chronic pain, Stanos says, “it may become a struggle to successfully treat patients.”

True enough. Chronic pain is complex and difficult to treat.

Then a paragraph on the importance of having friend or family support and the importance of having health care providers you can talk to. Good advice, followed by the unintentionally ironic.

“When choosing therapies to try, “it’s important to think critically,” says journalist Paula Kamen, who wrote All in My Head (Da Capo Press, 2006), about her quest for relief from chronic daily headache. “There is so much desperation that makes us vulnerable as chronic-pain patients.” Be wary of anyone who promises to cure any problem, she says. Also, understand any risks before you participate. And remember, you can quit at any time—even in the middle of a session—if something doesn’t feel right.”

The evidence? A journalist with chronic headaches. “It’s important to think critically” and “Be wary of anyone who promises to cure any problem.” I’ll put on some Alanis Morissette here, and progress to the end of the article. It continues

“Check out the chart below to learn about alternative therapies that have been shown to help relieve chronic pain. Informing yourself could be your first step on the path to a pain-free life.”

A table of alternative therapies with the heading “Alternative Treatments That Work on Pain

Research shows these therapies can ease discomfort.”

Odd change in terminology. From chronic pain to pain to discomfort. Discomfort. Maybe the author was using the thesaurus to prevent repetition, but discomfort is not the equivalent of chronic pain.

Lets think critically, as suggested, and go down the list and do a Pubmed search using “chronic pain” and the suggested alternative modality as search terms. Chronic pain was in the headline, after all. Lets look at the growing evidience. Lets look for randomized clinical trials, the gold standard therapeutic efficacy.

Movement-Based Therapies:

- Physical therapy: not what I would consider an alternative therapy, but it is on the list. Lots of studies to support physical therapy to treat chronic pain.

- Yoga: nothing. No studies to support its use in chronic pain.

- Pilates: nothing.

- Tai chi: nothing.

- Feldenkrais: nothing.

Nutritional and Herbal Remedies:

- Anti-inflammatory diet: “A Mediterranean eating pattern”: nothing.

- Omega-3 fatty acids: nothing.

- Ginger: one study, negative (6).

- Turmeric: nothing.

- MSM: Methylsulfonylmethane: nothing. (Addendum (1/2/9; 9:45)).   There is evidence that this is beneficial with degenerative joint pain. Search criteria make all the difference.)

Mind-Body Medicine:

- Meditation: hard to say, as studies of mind-body/mindfullness/meditation modalities have a lot over lap in technique. Data suggests over all not effective but the data is not high quality and they are all probably just variations of cognitive behavoiral therapy.

- Guided imagery: mostly negative as discussed above.

- Biofeedback: to my surprise, for chronic pain, there are a few studies with mixed results. It worked for fibromyalgia (one study) and negative and positive results for low back pain.

- Relaxation: a smattering of small studies that show efficacy.

Energy Healing:

- Acupuncture “Manipulating the electrical energy—called chi in Chinese medicine—emitted by the body’s nervous system.”

Please. If chi is anything, it is most certainly NOT electrical energy. And it does not come from the nervous system. And it is not emitted, but flows and is blocked in meridians. At least get the woo right.

The recent history of of acupuncture trials (well documented in this blog), is that of increasingly well done acupuncture studies showing decreasing efficacy relieving pain to the point where some studies show sham or fake (!) acupuncture is superior to real (!) acupuncture. My conclusion about acupuncture and pain relief is it doesn’t work.

- Massage: supported by clinical trials.

- Chiropractic: “Physically moving vertebrae or other joints into proper alignment, to relieve stress.” Huh? Oddest definition of chiropractic I have heard and not one I have ever read. Again, define the woo correctly. Clinical trials only support the use of chiropractic for low back pain, although it is not superior to physical therapy.

- Osteopathy: I did find the article “The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study” that had modest benefit in decreasing pain. I would prefer the coccydynia. Otherwise, of 4 studies treating various musculoskeletal pain that demonstarted benefit, two published in osteopathic jounals.

Lifestyle Changes:

- Sleep hygiene: while I would not disagree with getting a good nights sleep is important in decreasing pain, there a few studies to support sleep hygiene to treat chronic pain.

- Positive work environment: America is the land of power of positive thinking. But the clinical data does suggest that thinking good thoughts decreases pain.

- Healthy relationships: will not argue, but no data.

- Exercise: supported by the data.

Somehow I do not categorize sleeping well, having good relationships and exercising as alternative therapies. This is innocence by association. By branding normal or proven activities as alternative, it lends an aura of reputability to the unsupported nonsense.

So what is the “growing body of evidence suggests they work?” Not much that I can find, at least if you look for randomized clinical trials. The clinical trials that are avaiable are often small, poorly done, and in low impact journals. Most of the “growing body of evidence” for the few well studied modalities like acupuncture or chiropractic suggests they do not work or have very limited efficacy.

I do not, of course, fault Ms. Khazzoom for writing an essay on alternative therapies and chronic pain. She is a writer and is doing her job.

I do fault AARP for publishing an article that apparently was never fact checked and for offering faulty medical advice from a free lance author. I thought that editors were supposed to, well, edit. Fact check. Make sure the article is true. The medical literature fails to support virtually every assertion in the article.

The elderly are often vunnerable due to limited income, isolation, and declining mental capacities. They often have multiple chronic medical problems and limited resources to devote to them. Offering worthless medical advice by what should be their advocate to the elderly is irresponsible.

I thought part of the purpose of the AARP was to protect the elderly from scam’s not guide them towards scam’s.

I got my AARP card for the comic effect. I did not realize the humor extended to medical advice in their magazine.

——

(1) http://www.aarp.org/aarp/articles/aarpmission.html

(2) http://www.aarpmagazine.org/health/drug_free_remedies_chronic_pain.html

(3) http://dancingwithpain.com/

(4) As an aside I have accepted nothing from big pharma in over 20 years. No pens, no pizza, no trips, no nothing. http://www.sciencebasedmedicine.org/?p=60

(5) Pain Med. 2007 May-Jun;8(4):359-75. Mind-body interventions for chronic pain in older adults: a structured review.

(6) Osteoarthritis Cartilage. 2000 Jan;8(1):9-12.A randomized, placebo-controlled, cross-over study of ginger extracts and ibuprofen in osteoarthritis.

(7) http://en.wikipedia.org/wiki/Magazine_circulation#cite_note-0

(8) http://www.theonion.com/content/node/33057

Posted in: Energy Medicine, Science and the Media

Leave a Comment (17) ↓

17 thoughts on “AARP and Alternative Medicine

  1. colli037 says:

    There is nothing “wrong” with placebo response, as long as you 1) know that it is a factor and 2) have some idea how much of a part it plays in treatment.

    In headache, placebo response can reach 35% or more (1). So almost anything done for “headache” will work for 1 out of 3 patients. It is an excellent way to discuss many quack therapies with patients, and often helps them understand why “it worked for my aunt” even though it doesn’t work for anyone else

    tim
    (disclaimer-I’m a full time clinician in a chronic pain clinic)

    1) Headache. 1998 Jan;38(1):35-8 Monitoring of acute migraine attacks: placebo response and safety data. Jhee et al

  2. Ex-drone says:

    “I did not know until I wrote this that Dr. Weil ™ is trademarked.”

    I was going to ask if other people named Weil become doctors, whether they would have to change their names, but if they were determined to be known as credible medical doctors, then that might not be a bad idea in any case.

  3. phiend says:

    One thing, there is a trial on MSM and osteoarthritis pain of the knee which I assume would qualify is chronic pain.
    Efficacy of methylsulfonylmethane (MSM) in osteoarthritis pain of the knee: a pilot clinical trial by Kim et all. I can’t figure out how to link a pub med search but the PMID is 16309928. I point this out only because I recently became aware of this supplement when my mothers doctor recommended it to her for her chronic arthritis pain, (on top of some very serious prescribed drugs including oxycotin) and was wondering if there was any validity to its usage.

  4. force5 says:

    Thanks for reviewing the article. I saw the article featured on the cover and was immediately skeptical. I went directly to the chart and saw that there was nothing new… same old woo.

  5. Militant Agnostic says:

    Re (4) – not even any Eneman paraphenalia?

    I once succesfully used mental imaging to block pain from a bladder infection. I visualized a fog spreading down from my brain to my abdomen. This “technique” was improvised without any training in woo whatsoever. Perhaps I should invoke dark energy (quantum mechanics is so 20th century) and build my own brand of woo around this.

  6. Harriet Hall says:

    The abstract of the Kim trial concludes “The benefits and safety of MSM in managing OA and long-term use cannot be confirmed from this pilot trial, but its potential clinical application is examined. Underlying mechanisms of action and need for further investigation of MSM are discussed.”

  7. tarran says:

    To be frank, the AARP does not have your best interests at heart.

    Many of the programs they advocate are expensive wealth transfers from workers to the elderly/retired. They are either paid for by taxes or by inflation. Taxes, of course, make it harder for people to make ends meet and tend to result in less savings and economic investment (taken to an extreme, taxation can even cause economic contraction as the lack of savings prevents the renewal of capital that is being consumed in production).

    Inflation, on the other hand is even more destructive than taxation – they cause boom/bust cycles that impact the entire economy. It is interesting to note that most violent social revolutions are presaged by periods of high inflation, the most famous of which is the hyperinflation that smoothed the path to Hitler’s rise to power.

    Under both regimes, people have difficulty saving for the future, which makes them more vulnerable to periods when theyhave trouble working whether due to injury, illness or old age.

    Since taxation is politically painful now, while the problems caused by inflation are in the future, groups like AARP lobby against tax hikes while lbying for massively increased government spending.

    Honestly, I think you would get more benefit from donating your membership dues to the Discovery Institute than to the far more socially destructive AARP.

  8. maus says:

    “To be frank, the AARP does not have your best interests at heart.

    Many of the programs they advocate are expensive wealth transfers from workers to the elderly/retired.”

    Ah, the classic “Social Security and Socialized medicine are for AARP commies” Randroid spiel.

    Unless I’m mistaken here and there’s something past the usual Objectivist hyper-Libertarian hatred of the AARP.

  9. durvit says:

    filled with neuroscience words. Is what he says true?

    I can find zero data to support the assertion that guided imagery builds new nerve pathways that bypass the old pain pathways. Perhaps he is speaking metaphorically; if so I suppose it should be mentioned as such, as it sure reads like a neuronanatomic explanation for how guided imagery works.

    Dr Ben Goldacre reported on some interesting and relevant studies that may provide some insight into why we find neuroscience-y explanations so persuasive:

    a set of experiments from the March 2008 edition of the Journal of Cognitive Neuroscience, which elegantly show that people will buy into bogus explanations much more readily when they are dressed up with a few technical words from the world of neuroscience. Subjects were given descriptions of various psychology phenomena, and then randomly offered one of four explanations for them: the explanations either contained neuroscience, or didn’t; and they were either good explanations or bad ones (bad ones being, for example, simply circular restatements of the phenomenon itself).

    I have to say that I recognise a lot of those recommendations from the writings of self-styled nutritionists in the UK – the anti-inflammatory diet, the supplements etc.

    I see that some nutritionists are now offering a labelling system with their own, evidence-free, assertion-heavy anti-inflammation index.

  10. clgood says:

    Thanks for yet another reason, as if I needed one, never to join the AARP. What an insulting bunch of whining redistributionists they are. And now they’re woo pitchers also.

    Talk about a chronic pain: They’re also pestering my daughter to sign up.

    She’s 10.

  11. Dr Benway says:

    Holy crap, 50? You get the AARP stuff at 50?

    I wuz thinkin’ 50 might not be as old as I used to think…

    Life goes by too effin’ fast.

  12. Jayhox says:

    I think the article should have credibility because the name “Loolwa Khazzoom” is one of the coolest names I’ve heard in a long time, and with a cool name like “Loolwa Khazzoom,” she must know of what she speaketh.

    On a serious note, did you write the AARP expressing your disgust with their crappy article Mark? I think one step we can all take is to call editors out for allowing pseudo-science into their publications, be it AARP or Reader’s Digest, all the way down to the Mayberry Chronicle. Until people are held accountablel, alt med will continue to grow.

  13. wertys says:

    What really yanks my chain is when woo rubbish is combined with effective techniques and the whole thing is presented to people with chronic pain as if all they had to do was turn up and get treated. A mountain of evidence suggests that engaging the sufferer as an active participant in the rehabilitation process is more important than whatever modality you want to actually treat them with. If you read an article like that you would be tempted to think of all this as alt med, and when a real pain specialist recommended it to you the reaction would be ‘Tried it, didn’t work’. Which then torpedoes the engagement with rehabilitation from their disabling pain.

    Half the truth is worse than complete untruth in this situation.

  14. DLC says:

    Regardless of what you think of the AARP and any political agenda it may have, their magazine reaches a huge audience.
    As such, they should be made aware of when they do their readership a disservice. In my opinion, publishing articles like the one Dr Crislip very correctly demolishes do the readers of AARP Magazine a disservice.

  15. overshoot says:

    Holy crap, 50? You get the AARP stuff at 50?

    I’ve been getting it since my early 30s, actually.

    The AARP really wants to carry all of us on their rolls, since one of their biggest lobbying bludgeons is their PZ-Myers-grade horde of voters who (supposedly) support their agenda.

  16. MedsVsTherapy says:

    There have been yoga interventions for chronic pain. you may need different searh terms, such as “back pain” and “yoga.” I know there was one a few years ago abt yoga and wrist pain – can’t remember if it included or excluded carpal tunnel. a fair amount of chronic pain cases are where a muscle or a few muscles have been overly stressed or overly used. The muscle gets inflamed – to recruit the healing processes of inflammation, and to mechanically/physically isolate the joint so that the chance of further injury is decreased. Unless stretching/strengthening is done once the acute healing is done, the healed muscle will be a lot less strong in the extended position. The pain can continue from this situation of short muscle. Stretching / strengthening works to counter this. Yoga will make a person perform this type of rehab. Exercise, likewise, is effective for some skeletal chronic pain that is really due to muscle problems versus some bone problem such as arthritis. One positive of yoga is the emphasis on breathing deeply. This keeps the abdomen muscles from being used for trunk / “core” support, and forces the muscle strength to the back muscles. Otherwise, the exercises are the equivalent of “sloppy form” in weightlifting. You won’t get bulging biceps if you sway your back to swing that handweight during an armcurl. Medline has a bunch of articles on phys rehab for back pain.

  17. Dr Benway says:

    “The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study” that had modest benefit in decreasing pain. I would prefer the coccydynia.

    OMG I just laughed so hard I frightened the cat.

    The first time I read this article, somehow I missed the bit about sticking fingers up the patient’s butt. To help butt pain.

    HA!

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