Image credit: Wellcome Images, Wellcome Library, London, via Wikimedia Commons.
Last week I gave a quick overview of standard treatment options for migraine, a severe form of recurrent headaches. As promised, this week I will address some common treatments for migraine that I don’t think are supported by the evidence.
Acupuncture is the CAM modality that, it seems to me, has infiltrated the furthest into mainstream medicine, including for the treatment of migraine. In fact the The American Headache Society includes acupuncture on its list of recommended treatments. The reason for this is that acupuncture proponents have been able to change the rules of clinical research so that essentially negative or worthless studies of acupuncture are presented as positive.
I reviewed the evidence for acupuncture and migraine previously, demonstrating the multiple problems with the acupuncture literature in general, and specifically acupuncture in migraines. Most studies suffer from at least one fatal flaw: they are not properly blinded, they do not include a control, they mix acupuncture with non-acupuncture variables (mostly including electrical stimulation in the treatment group), comparison groups are not adequately treated, they make multiple comparisons to maximize chance outcomes, or they are simply too small making them susceptible to all the usual problems of bias in research.
What we don’t see is a consistent and clinically-relevant effect in properly-controlled double-blind trials where the variables of acupuncture are isolated.
SBM frequently receives questions from readers asking for more information or even challenging our position on various topics. We make extensive efforts to answer such questions, since engaging with the public is one of the primary purposes of this blog. In fact, I specifically chose the blog format because of its interactive nature and the ability to rapidly respond to items in the news or being discussed publicly.
Sometimes it’s helpful to provide answers to questions in the form of its own post. I do this when the questions are common or explore some new or interesting angle of a topic. I am also more likely to engage when the questions are polite and genuine.
We recently received the following e-mail which meets all these criteria, so here is my response. I will reprint the e-mail in sections as I address each question.
I have the utmost respect for the scientific method, and we subscribe to the Skeptical Inquirer. I respect much of what your organization does, and I do not believe that Reiki or Therapeutic Touch is effective, unless the person receiving these therapies believe they work. However, your organization seems to go out of its way to disprove things like the benefit of organic produce which has less pesticides than conventional produce. You claim that natural pesticides could be just as harmful. Here are some examples of these natural pesticides: apply 1 tablespoon of canola oil and a few drops of ivory soap to the leaves of plants and vegetables to repel insects. Also, apply 2 TBSPS of hot pepper sauce with a few drops of ivory soap to leaves, use baking soda and water or pureed onions to repel insects. How can you claim that these innocuous substances are as harmful as conventional pesticides?
Several snarks were painfully maimed in the writing of this blog post
I read a lot of the pseudo-medical websites. The writing is at best pedestrian, often turgid, and, at its worst, incoherent. It is rarely either engaging or clever.
Wit, the clever bon mot, the amusing turn of phrase or retort, is rare at best. So rare I cannot think of an example. It is ironic that those who engage in fantastical treatments are so often lacking in cleverness with language and thought. The closest you get to humor are the painfully-lame cartoons at the Natural News. I am sure that the readers will flood the comments with examples of all the clever writing I have missed in the world of pseudo-medicine just to prove me wrong. Not that the reality-based world is much better. It is the rare author on the internet whose style keeps me coming back for more.
But for some reason I found “Dear Science Based Medicine, Just a Few Questions About Acupuncture” funny and engaging, at odds with most of the purple quasi-paranoid articles I normally read. Just the right amount of chatty snarkiness to be enjoyable, at least for me. So refreshing given the style of the usual pro-acupuncture comments. Your millage may vary. (more…)
I am happy to report some good news: chiropractors, naturopaths, acupuncturists and assorted other practitioners of pseudo-medicine didn’t fare too well in the 2013-2014 state legislative sessions.
We’ve been following their legislative efforts all year over at the Society for Science-Based Medicine. Some state legislatures meet in yearly sessions. At the end of the year, pending bills die with the session. Some meet only every other year. Others meet in two-year sessions and, in some of these, legislation introduced in one year carries over to the next year. All states with two-year sessions ended these sessions at the close of 2014, except New Jersey and Virginia. If you want to see how your state operates, several websites can help you: MultiState Associates, National Conference of State Legislatures and StateScape.
Chiropractors are already licensed in all 50 states and all of their practice acts permit the detection and correction of the non-existent subluxation. Having achieved that goal, the focus of chiropractic legislative efforts is to expand their scope of practice (the holy grail, for some, being primary care physician status), turf protection and mandates requiring insurance reimbursement or their inclusion in various activities, such as sports physicals, concussion treatment, and scoliosis detection programs.
The most interesting chiropractic bill, one from Oklahoma, didn’t fall into any of those categories:
Chiropractic physicians in this state shall obtain informed, written consent from a patient prior to performing any procedure that involves treatment of the patient’s cervical spine and such informed consent shall include the risks and possible side effects of such treatment including the risk of chiropractic stroke.
I’m cheating. No, I’m recycling. ‘Tis the season to have to no time to get anything done. Since I know none of you pay attention to the blog of at the Society for Science-Based Medicine and I have no time with work and the holidays to come up with new material, I am going to collect and expand on the entries on acupuncture I wrote from SfSBM. Anything I write really is worth reading twice. I really need to make my multiple personality disorder work for me, but the Goth cowgirl persona is a luddite at best, so you are stuck with the over -extended ID doctor. Here goes.
A recent study in the Journal of General Internal Medicine evaluated a treatment for constipation. It tested whether training patients to massage the perineum (the area between the vagina or scrotum and the anus) would improve their reported bowel function and quality of life at 4 weeks after training. They found that it did. It’s a simple, innocuous treatment that may be worth trying, but why, oh why, did they have to call it “acupressure”? That irritated me. Should it have? Why should it matter? Isn’t a rose by any other name still a rose? Is this a meaningless semantic quibble and hypersensitivity on my part, or am I right to see it as yet another example of quackademia’s attempts to infiltrate science-based medicine? I’ll explain my thinking and let you decide for yourself. (more…)
Oh, loneliness and cheeseburgers are a dangerous mix.
– Comic Book Guy
Same can be said of viral syndromes and Thanksgiving. My brain has been in an interferon-induced haze for the last week that is not lifting anytime soon. Tell me about the rabbits, George. But no excuses. I have been reading the works of Chuck Wendig over at Terrible Minds. (Really, really like the Miriam Black books). Writers write and finish what they start and only posers use excuses for not completing their work.
Recently I attended an excellent Grand Rounds on some of the reasons doctors do what they do. Partly it is habit. We learn to a certain way of practice early in our training and it carries on into practice and it is not always best practice. Patients also learn from us and have expectations on what diagnostics or treatments they should receive, and that too it is not always the best practice.
So to educate physicians and patients, the American Board of Internal Medicine (ABIM) started the Choosing Wisely initiative. (more…)
Age cannot wither her, nor custom stale. Her infinite variety.
– William Shakespeare
This is not a typical post for me, but something I have been meaning to do to satisfy my own curiosity. I have wondered, how many variations of acupuncture are there? I suspected a lot, but I thought I would go looking and make a list. Since acupuncture is not based in reality but is instead a collection of pseudo-knowledge, there is no reason for acupuncture to have fidelity to fundamental concepts. I suspect in the US that in the future acupuncture will become less heterogenous as schools start teaching to the test that allows for acupuncture licensure. For now variation rules.
So this will be a list, with description and commentary. If a missed form of acupuncture is noted by others, and I am sure I have, I will expand the list in an addendum. (more…)
Who would you guess authored a 250-page report which begins with this Preface?
This report marks the culmination of an intensive four-year review of quackery and its impact on the elderly. . . As this report details, quackery has traveled far from the day of the pitchman and covered wagon to emerge as big business. Those who orchestrate and profit from the sale and promotion of these useless and often harmful “health” products are no longer quaint and comical figures. They are well organized, sophisticated and persistent. [We estimate] the cost of quackery – the promotion and sale of useless remedies promising relief from chronic and critical health conditions – exceeds $10 billion a year. The costs of quackery in human terms, measured in disillusion, pain, relief forsaken or postponed because of reliance on unproven methods, is more difficult to measure, but nonetheless real. All too frequently, the purchaser has paid with his life. While the impact of quackery on our lives has been increasing and growing in sophistication, public and private efforts designed to address and control this problem have diminished, been redirected or disbanded.
I have a new term to add to the English language, ebolasmacked, a derivative of the British term gobsmacked. Ebolasmacked defines my life the last few weeks since Ebola, or at last preparations for Ebola, have taken a huge bite out of my time with many interesting twists and turns. I think this is maybe the 9th outbreak (HIV, MERS, SARS, Legionella, H1N1, Avian flu, West Nile, MRSA) of my career and it has certainly generated more hysteria relative to the risk than any to date. Many of my usual pastimes, like SBM (as this essay will no doubt demonstrate), have had to take a back seat to preparing for what should be a very unlikely, but very disruptive, event. We do not want to get caught with our hazmats down should a case of Ebola come through the door.
What makes life interesting, among other things, is the constant realization that the more you know the more there is to know. I like Richard Dawkins’ metaphor in Climbing Mount Improbable where he pictures scientific progress as a series of false summits extending into infinity. It sure seems that way. Every time I think I understand a topic, I find there is still more to learn.
My Dad told me when I graduated from medical school that half of everything I had just learned was probably not true, the only problem is that you didn’t know which half. It was partially true. There have been ideas that have been abandoned since I was an intern, the most famous being that ulcers were due to stress and diet. But a new paradigm has been the exception, not the rule.
The last thirty years have been more about refining knowledge about the complexity of disease and its treatment and, perhaps equally importantly, having a better understanding of the all slings and arrows of outrageous fortune that can make the results of a clinical trial suspect. (more…)