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AK: Nonsense on Full Automatic

I start these entries about a week before their due date, and when I saw Dr Hall’s Applied Kinesiology (AK) post from Tuesday, I thought the heck, there goes my post for Friday.  After reading Harriet’s post, I think mine will be both complementary and alternative, and perhaps even integrative, to her entry.  I do have one quibble with her post. She said

“we skeptics don’t dismiss AK just because it sounds silly.”

AK doesn’t just sound silly, it is silly.  I have found over the years writing for SBM that I have developed an increasing bias around the concept of prior probability.  As best I can tell there is a well described reality, and that reality constrains what is not only probable, but what is possible.  Within the limitations of our current understanding of reality, some processes are impossible, i.e. have zero prior probability. AK’s prior probability is exactly zero.   I sometimes think the blog should be called Reality Based Medicine.  Science gives us understanding of reality and AK, like many a SCAM (Supplements, Complementary and Alternative Medicine) discussed in this blog, parted company with reality from the beginning.

This blog has two often overlapping purposes.  Blogs offer timely commentary on contemporary issues, and this blog certainly fills that role.  More than other blogs, SBM also has the opportunity to be a reference source on various SCAM’s .  I have had the recent opportunity to reread the entire oeuvre of SBM, and it is impressive in the breadth and depth of topics covered in its three plus years.  It is not yet encyclopedic and there are many topics not yet reviewed in the blog, such as Applied Kinesiology.  So many many SCAM’s, so little time. (more…)

Posted in: Chiropractic, Diagnostic tests & procedures, Energy Medicine, Science and Medicine

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“Obama Promises $156 Million to Alzheimer’s…But where will the money come from?” That’s easy: the NCCAM!

The quoted language above is part of the headline of this story in today’s The Scientist:

Citing the rising tide of Americans with Alzheimer’s—projections suggest 10 million people will be afflicted by 2050—the Obama administration and top National Institutes of Health officials are taking action. On February 7, they announced that they will add an additional $80 million to the 2013 NIH budget for the Alzheimer’s research program.

The problem is that there ain’t no such thing as a free lunch:

However, Richard Hodes, director of the NIH’s National Institute on Aging, told Nature that the 2013 dollars still have to be approved by Congress in the next budget and, if not, existing programs may need to be cut. And this year’s $50 million is likely to bump other projects, perhaps at NIH’s National Human Genome Research Institute. “If there’s a finite budget anywhere, once there’s more of something, there is less of something else,” he said.

Often such budget compromises are difficult, because there is no ready way to choose between two or more competing recipients of taxpayers’ money, each of which might be comparably worthy. Thus it is with a great sense of relief that in this case, we in the biomedical community can assure President Obama that no such dilemma exists. This is one of those occasional decisions that requires no hair-pulling whatsoever. The obvious solution is to defund the National Center for Complementary and Alternative Medicine (NCCAM), which, at about $130 million/yr, would solve the problem of funding Alzheimer’s research and take the heat off other worthy programs such as those mentioned by Richard Hodes.

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Posted in: History, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine

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What is Science?

Consider these statements:

…there is an evidence base for biofield therapies. (citing the Cochrane Review of Touch Therapies)

The larger issue is what constitutes “pseudoscience” and what information is worthy of dissemination to the public. Should the data from our well conducted, rigorous, randomized controlled trial [of 'biofield healing'] be dismissed because the mechanisms are unknown or because some scientists do not believe in the specific therapy?…Premature rejection of findings from rigorous randomized controlled trials are as big a threat to science as the continuation of falsehoods based on belief. Thus, as clinicians and scientists, our highest duty to patients should be to investigate promising solutions with high benefit/risk ratios, not to act as gatekeepers of information based on personal opinion.

–Jain et al, quoted here

Touch therapies may have a modest effect in pain relief. More studies on HT and Reiki in relieving pain are needed. More studies including children are also required to evaluate the effect of touch on children.

Touch Therapies are so-called as it is believed that the practitioners have touched the clients’ energy field.

It is believed this effect occurs by exerting energy to restore, energize, and balance the energy field disturbances using hands-on or hands-off techniques (Eden 1993). The underlying concept is that sickness and disease arise from imbalances in the vital energy field. However, the existence of the energy field of the human body has not been proven scientifically and thus the effect of such therapies, which are believed to exert an effect on one’s energy field, is controversial and lies in doubt.

—Cochrane Review of Touch Therapies, quoted here

 …

Science is advanced by an open mind that seeks knowledge, while acknowledging its current limits. Science does not make assertions about what cannot be true, simply because evidence that it is true has not yet been generated. Science does not mistake absence of evidence for evidence of absence. Science itself is fluid.

—David Katz

When people became interested in alternative medicines, they asked me to help out at Harvard Medical School. I realized that in order to survive there, one had to become a scientist. So I became a scientist.

—Ted Kaptchuk, quoted here.

 …It seems that the decision concerning acceptance of evidence (either in medicine or religion) ultimately reflects the beliefs of the person that exist before all arguments and observation.

 —Ted Kaptchuk, quoted here.

Together they betray a misunderstanding of science that is common not only to “CAM” apologists, but to many academic medical researchers. Let me explain. (more…)

Posted in: Basic Science, Book & movie reviews, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Homeopathy, Medical Academia, Science and Medicine

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IgG Food Intolerance Tests: What does the science say?

I spend a lot of time as a pharmacist discussing side effects and allergies to drugs. For your own safety, I won’t recommend or dispense a drug until I know your allergy status. I don’t limit the history to drugs—I want to know anything you’re allergic to, be it environmental, food, insects, or anything else. Allergies can create true therapeutic challenges: We can’t dismiss any allergy claim, but as I’ve blogged before, there’s a big gap between what many perceive as an allergy and what is clinically considered a true allergy. My concern is not only avoiding the harm of an allergic reaction, but also avoiding the potential consequences from selecting a suboptimal therapy that may in fact be appropriate. You may need a specific drug someday, so  I encourage patients to discuss vague drug allergies with their physician, and request allergist testing as required.

Food allergies can be as real as drug allergies, and are arguably much harder to prevent. We can usually control when we get penicillin. But what about peanuts, eggs, or milk, all of which can also cause life-threatening anaphylaxis?  Food allergies seems to be growing: not only anaphylaxis, but more people believe they have some sort of allergy to food.  Allergy is sometimes confused with the term “intolerance”, which seems more common, possibly as the availability of “food intolerance testing” grows. Food intolerance testing and screening is particularly popular among alternative practitioners. Testing can take different forms, but generally the consumer is screened against hundreds of food products and food additives. They are then provided with a list of foods they are “intolerant” to. I’ve spoken with consumers who are struggling to overhaul their diet, having been advised that they are actually intolerant to many of their favourite foods. These reports are taken seriously by patients who believe that they’ll feel better if they eliminate these products. In the pharmacy, I’ve been asked to verify the absence of trace amounts of different fillers in medications because of a perceived intolerance.  Children may be tested, too, and parents may be given a long list of foods they are told their child is intolerant of. I’ve seen the effects in the community, too. Think going “peanut free” is tough? A public school in my area sent home a list of forbidden food products: dairy, eggs, bananas, tree nuts, peanuts, soy, sesame, flax seed, kiwi, chicken, and bacon. Were these all true allergies? It’s not disclosed. Anaphylactic or not, the parents had informed the school, and the school had banned the food product.

But can a simple blood test actually identify and eliminate food intolerance? That’s the question I wanted to answer.

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Posted in: Basic Science, Diagnostic tests & procedures, Health Fraud, Herbs & Supplements, Naturopathy, Science and Medicine

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Placebo Again.

Medicine is simultaneously both easy and hard. As an Infectious Disease doctor, my day can be summed up with the phrase “me find bug, me kill bug, me go home.” Sometimes it is just that simple. A lot of the time it isn’t. I may not be certain what the infection is, or even if the patient has an infection, or allergies and/or antibiotic resistance limit therapeutic options, the host has co-morbidities that limit effectiveness, and the patient has no financial resources for the needed treatment.

I am lucky, since most infections are acute, make people feel terrible, and require a relatively short course of therapy during which the patient feels better. I rarely have to worry about compliance with the treatment plan; it is the rare patient, usually a heroin user or a particularly irascible old man, who will not follow through with their antibiotic course. I do not have to worry about chronic or symptomless diseases like diabetes or hypertension or the complications of obesity where long term compliance often limit therapeutic success. Long term it is difficult for many people to stick with their therapeutic plan, much less their diet and exercise resolutions.
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Posted in: Acupuncture, Medical Ethics, Science and Medicine

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What Is Traditional Chinese Medicine?

One of the themes of science-based medicine is to be suspicious of any form of medicine that is not science-based. In other words, beware of dodgy qualifiers placed before “medicine,” such as: “alternative”, “integrative”, or “complementary” – those that imply that something other than science or evidence is being used to determine which treatments are safe and effective. I would also include “traditional Chinese” medicine in the dodgy category.  A recent article defending Traditional Chinese Medicine (TCM) provides, ironically, an excellent argument for the rejection of TCM as a valid form of medicine. The authors, Jingqing Hua and Baoyan Liub, engage in a number of logical fallacies that are worth exploring.

Their introduction sets the tone:

Traditional Chinese medicine (TCM) has a history of thousands of years. It is formed by summarizing the precious experience of understanding life, maintaining health, and fighting diseases accumulated in daily life, production and medical practice. It not only has systematic theories, but also has abundant preventative and therapeutic methods for disease.

It may be trivially true that TCM has a long history, but it is hard to ignore that the placement of this statement at the beginning of a scientific article implies an argument from antiquity – that TCM should be taken seriously because of this long history. I would argue that this is actually a reason to be suspicious of TCM, for it derives from a pre-scientific largely superstition-based culture, similar in this way to the pre-scientific Western culture that produced the humoral (Galenic) theory of biology.

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Posted in: Acupuncture, Energy Medicine, Science and Medicine

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An Owner’s Manual for the Heart

In writing about science-based medicine, we give a lot of attention to medicine that is not based on good science. We use bad examples to show why science is important and how it is frequently misapplied, misinterpreted, misreported, or even wholly rejected. It’s a pleasure, for a change, to write about a straightforward example of the best of science-based medicine in action. The book Heart 411 is such an example.

The medical literature is a jungle of conflicting and complicated studies. It’s difficult for novices and even for sophisticated non-specialists to navigate. It’s useful to have experts as guides who can apply their knowledge, experience, and judgment to analyze the data and put everything into perspective. I can’t imagine anyone more qualified as guides to “matters of the heart” than the authors of this book. Heart surgeon Marc Gillinov and cardiologist Steven Nissen practice at the Cleveland Clinic, which has been ranked as the number one heart hospital by U.S. News & World Report for the last 15 years and is currently ranked 4th best hospital overall. They have treated more than 10,000 heart patients over 30 years of clinical practice and have also done extensive research and published hundreds of articles in peer reviewed journals. Their book contains everything they would like their patients to know about the prevention, diagnosis, and treatment of  heart disease.  It amounts to an owner’s manual for the heart.  (more…)

Posted in: Book & movie reviews, Science and Medicine

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Visceral Manipulation Embraced by the APTA

Many years ago, when I was a naïve and gullible teenager, I read about a home treatment for constipation that involved rolling a bowling ball around on the abdomen. I was intrigued, thought it sounded reasonable, and might even have tried it myself if I had been constipated or had had a bowling ball to experiment with. Many decades later, with the advantages of a medical education and experience in science-based medicine and critical thinking, I encountered a treatment that reminded me of the bowling ball: visceral manipulation (VM), a practice developed by a French osteopath and physical therapist, Jean-Pierre Barral. This time I was far more skeptical. VM may be more sophisticated than a bowling ball, but its effectiveness and safety are equally dubious.

Visceral manipulation (VM) will probably be unfamiliar to most of my readers, but its promoters say it has been adopted by osteopathic physicians, “allopathic” physicians, doctors of chiropractic, doctors of Oriental medicine, naturopathic physicians, physical therapists, occupational therapists, massage therapists and other licensed body workers. Its origin follows the path of many other alternative health systems. Like chiropractic, ear acupuncture, iridology, EMDR, and others, it was developed by one individual based on his personal observations and experiences without any kind of proper testing. Like the others, it started with a single patient: in Ignaz von Peczely’s case an owl with a spot on its iris, in D.D. Palmer’s case a janitor whose hearing allegedly improved after something was done to his back, in Barral’s case a patient who said he had felt relief from his back pain after going to an “old man who pushed something in his abdomen.” From a single case they extrapolated to a general belief about disease causation and a whole diagnostic and/or treatment system.

How is VM Done?

A video shows Barral demonstrating his skills.  He “listens with his hands” to detect tension (elsewhere the perception is designated as a thermal phenomenon). His diagnostic process begins by “listening with the hands” on the top of the patient’s head to determine the lateralization or general area of the problem. Then his hands “listen” to the areas of concern to further localize the problem.  In this demonstration he detects something in the stomach which he says could be from decreased acidity or emotional tension. Then he listens to the skull repeatedly with both hands, does something simultaneously to the neck and abdomen, and finally he is satisfied that his hands are telling him that he has corrected the problem. (more…)

Posted in: Energy Medicine, Science and Medicine

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The New England Journal of Medicine Sinks a Bit Lower

I suppose it was bound to happen, but it still rankles. Here is the back cover of last week’s issue of the decreasingly prestigious New England Journal of Medicine:

 


Here’s the front cover:

It’s the 200th Anniversary issue, no less. Some might protest that ‘probiotics’—live bacteria of ‘good’ varieties, as far as the gut is concerned—aren’t all that implausible, and that there is some trial evidence that they help for some conditions. That’s true, but as is typically the case even for the somewhat plausible end of the “CAM” spectrum, the hype greatly surpasses the evidence. The abstract of the most recent systematic review that I could find for probiotic treatment of irritable bowel syndrome (IBS: symptoms and signs that best match the claims in the advertisement above) concluded:

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Posted in: Clinical Trials, Herbs & Supplements, History, Legal, Medical Ethics, Pharmaceuticals, Politics and Regulation, Science and Medicine, Science and the Media

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The rebranding of CAM as “harnessing the power of placebo”

If there’s one thing I’ve learned over the past seven years or so that I’ve been blogging, first at my other “super secret” (or, more accurately, super “not-so-secret”) blogging location, and then the four years I’ve been blogging here at Science-Based Medicine (SBM), it’s that the vast majority of “alternative medicine,” “complementary and alternative medicine” (CAM), and “integrative medicine” (IM) treatments (or whatever you want to call them) are nothing more than placebo medicine. True, there are exceptions, such as herbal treatments, mainly because they can contain chemicals in them that are active drugs, but any critical look at things like homeopathy (which is water), reiki (which is faith healing substituting Eastern mystical beliefs for Christianity), acupuncture (whose effects, when tested rigorously, are found to be nonspecific), or “energy healing” must conclude that any effects these modalities have are placebo effects or responses. Given writings on this topic by Steve Novella, Mark Crislip, Harriet Hall, Peter Lipson, myself, and others, this should be abundantly clear to readers of this blog, but, even so, it bears repeating. In fact, it probably can’t be repeated enough.

There was a time not so long ago when proponents of unscientific medicine tried very, very hard to argue that their nostrums have real effects on symptoms and disease above and beyond placebo effects. They would usually base such arguments on small, less rigorously designed clinical trials, mainly because, if there’s another thing I knew before from my medical education but that has been particularly reinforced in me since I started blogging, it’s that small clinical trials are very prone to false positives. Often they’d come up with some handwaving physiological or biological explanation, which, in the case of something like homeopathy, often violated the laws of chemistry and physics. Be that as it may, the larger and more rigorously designed the clinical trial, the less apparent effects become until, in the case of CAM therapies that do nothing (like homeopathy), they collapse into no effect detectable above that of placebo. Even so, there are often enough apparently “positive” clinical trials of water (homeopathy) that homeopaths can still cling to them as evidence that homeopathy works. Personally, I think that Kimball Atwood put it better when he cited a homeopath who said bluntly, “Either homeopathy works, or clinical trials don’t!” and concluded that, for highly implausible treatments like homeopathy, clinical trials as currently constituted under the paradigm of evidence-based, as opposed to science-based, medicine don’t work very well. Indeed, contrasting SBM with EBM has been a major theme of this blog over the last four years. In any case, for a long time, CAM enthusiasts argued that CAM really, really works, that it does better than placebo, just like real medicine.

Over the last few years, however, some CAM practitioners and quackademics have started to recognize that, no, when tested in rigorous clinical trials their nostrums really don’t have any detectable effects above and beyond that of placebo. A real scientist, when faced with such resoundingly negative results, would abandon such therapies as, by definition, a placebo therapy is a therapy that doesn’t do anything for the disease or condition being treated. CAM “scientists,” on the other hand, do not abandon therapies that have been demonstrated not to work. Instead, some of them have found a way to keep using such therapies. The way they justify that is to argue that placebo medicine is not just useful medicine but “powerful” medicine. Indeed, an article by Henry K. Beecher from 1955 referred to the “powerful placebo.” This construct allows them then to “rebrand” CAM unashamedly as “harnessing the power of placebo” as a way of defending its usefulness and relevance. In doing so, they like to ascribe magical powers to placebos, implying that placebos can do more than just decrease the perception of pain or other subjective symptoms but in fact can lead to objective improvements in a whole host of diseases and conditions. Some even go so far as to claim that there can be placebo effects without deception, citing a paper in which the investigators — you guessed it! — used deception to convince their patients that their placebos would relieve their symptoms. Increasingly, placebos are invoked as a means of “harnessing the power of the mind” over the body in order to relieve symptoms and cure disease in what at times seems like a magical mystery tour of the brain.

Part of what allows CAM practitioners to get away with this is that placebo effects are poorly understood even by most physicians and, not surprisingly, even more poorly understood by the public. Moreover, we all like to think that we have more control than we do over our bodies and, in particular, illnesses and symptoms, which is why the selling of placebo effects as a means of harnessing some innate hidden power we have to control our own bodies through the power of mind is so attractive to so many, including some scientists and physicians. Exhibit A is Ted Kaptchuk, the researcher from Harvard University responsible for spinning an interesting study of placebo effects in asthma into the invocation of the power of placebo. Kimball Atwood has written extensively about Kaptchuk recently, revealing his rather dubious background and arguments. More recently, however, Kaptchuk seems to be everywhere, appearing in articles and interviews, promoting just the argument I’m talking about, that CAM is a way of harnessing placebo effects, so much so that I felt it was time to take a look at this argument.

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Posted in: Basic Science, Clinical Trials, Medical Ethics, Science and Medicine

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