Jan 02 2009
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.
- 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.)
- 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.
- 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.
- 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.
(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.
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