October is National Chiropractic Health Month!

October is National Chiropractic Health Month (NCHM) and chiropractors can’t resist the opportunity to overstate, obfuscate, and prevaricate in celebration.

They do this in the face of some unfortunate (for them) statistics revealed by a recent Gallup Poll. The Poll was paid for by Palmer College of Chiropractic as part of an effort to increase the chiropractic share of the health care pie. (There is also a secondary analysis of the poll in the Journal of Manipulative and Physiological Therapeutics.) We’ll get to those stats in a few minutes.

But first, in celebration of NCHM, the American Chiropractic Association (ACA) has produced a set of six graphics chiropractors can download and display. Four of them fudge on the facts. Let’s take a look at these graphics, compare them to the evidence cited in support of their claims, and see where the ACA went astray. (The ACA also hosted a twitter chat yesterday with the hashtag #PainFreeNation.)


The study cited as evidence for this graphic actually compared both manual thrust manipulation (MTM) and mechanical-assisted manipulation (MAM) to each other as well as manipulation versus usual medical care (UMC). Although MAM, such as the Activator Method, is the second most common manipulation technique used by American chiropractors, is increasing in popularity among them, and is touted to be a safe and effective alternative to MTM, this study found that MTM is more effective (at 4 weeks) than MAM and that MAM had no advantage over UMC. But you don’t see that in this graphic.


Posted in: Chiropractic, Clinical Trials, Critical Thinking

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Open vs Blinded Peer-Review


The overall goal of science-based medicine is to maintain and improve the standard of science in the practice of medicine at every level. At the heart of the scientific basis of medical knowledge and practice is a process known as peer-review. We have occasionally written about peer-review on SBM, and once again the process is under the microscope over a specific question – should peer review be open or blinded?

What is peer review

The term peer-review refers to a pre-publication process in which a journal editor will send a submitted manuscript to 2-3 experts in a field relevant to the paper to carefully examine every aspect of the paper. They then provide a detailed analysis of the paper: is the research question relevant and appropriate, did the study design properly address the question, were the methods rigorous, was the statistical analysis appropriate, was the data presented fairly, are the conclusions supported by the data, did the authors account for other publications addressing the same issue, and did they address every possible question or objection?

The reviewers’ reports will make specific recommendations for changes that would be necessary to improve the paper, and also make their bottom-line recommendation: accept as is, accept with revisions, or deny. The journal editor(s) then rely upon those reviews, plus their own assessment, to make a final decision.


Posted in: Medical Academia, Science and Medicine

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“Female Viagra?” Misleading Headlines and Regulatory Dilemmas

addyiThe FDA recently approved flibanserin (brand name Addyi) for the treatment of hypoactive sexual desire disorder (HSDD) in pre-menopausal women. The story of flibanserin illustrates several of the issues we have confronted on this blog:

  • It was hyped in the media.
  • Misleading headlines called it the female Viagra.
  • It was initially rejected by the FDA and was approved only after extensive lobbying efforts.
  • The drug is only minimally effective and has a lot of drawbacks.
  • Two of the three supporting scientific studies claimed effectiveness based a surrogate measure but failed to show any measurable improvement in sexual desire.
  • A campaign to support “women’s sexual health equity” pushed for approval, framing it as a step towards correcting what they perceived as gender bias (they claimed the FDA was biased because it had provided Viagra to help men have sex but hadn’t done anything to help women have sex).
  • And the validity of the diagnosis of HSDD itself has been questioned.


Posted in: Pharmaceuticals, Politics and Regulation

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“Liquid biopsies” for cancer screening: Life-saving tests, or overdiagnosis and overtreatment taken to a new level?

Could a blood draw be all you need to diagnose cancer and identify the best treatment for it? Not so fast...

Could a blood draw be all you need to diagnose cancer and identify the best treatment for it? Not so fast…

I’ve written many times about how the relationship between the early detection of cancer and decreased mortality from cancer is not nearly as straightforward as the average person—even the average doctor—thinks, the first time being in the very first year of this blog’s existence. Since then, the complexities and overpromising of various screening modalities designed to detect disease at an early, asymptomatic phase have become a relatively frequent topic on this blog. Before that, on my not-so-super-secret other blog, I noted that screening MRI for breast cancer and whole body CT scans intended to detect other cancers early were not scientifically supported and thus were far more likely to cause harm than good. That was well over ten years ago. Now we have a company offering what it refers to as a “liquid biopsy” for the early detection of cancer. I fear that this is the recipe for the ultimate in overdiagnosis. I will explain.

The problem, of course, is that disease progression, including cancer progression, is not always a linear process, in which the disease progresses relentlessly through its preclinical, asymptomatic phase to symptoms to complications to (depending on the disease) death. There is such a thing as disease that remains asymptomatic and never progresses (at which point it’s hard to justify actually calling it a disease). As I pointed out in my first SBM post on the topic, at least three-quarters of men over 80 have evidence of prostate cancer in autopsy series. Yet nowhere near three-quarters of men in their 80s die of prostate cancer—or ever manifest symptoms from it. This is what is meant by overdiagnosis, the diagnosis of disease that doesn’t need to be treated, that would never cause a patient problems.

When teaching medical students and residents, I frequently emphasize that overdiagnosis is different from a false positive because overdiagnosis does diagnose an actual abnormality or disease. For example, ductal carcinoma in situ (DCIS) diagnosed by mammography leading to a biopsy is a real pathological abnormality; it is not a false positive. We just do not know which cases of DCIS will progress to cancer and which will not, leading to a question of how DCIS should be treated or at the very least whether we should treat it as aggressively as we do now, particularly given that the apparent incidence of DCIS has increased 16-fold since the 1970s, all of it due to mammographic screening programs and the increased diagnosis of DCIS and early stage breast cancer has not resulted in nearly as much of a decrease in the diagnosis of advanced stage breast cancer as one would expect if early diagnosis were having an impact in reducing the diagnosis of late stage disease.

Overdiagnosis would not be such an issue if it didn’t inevitably lead to overtreatment. DCIS, for instance, is treated with surgery, radiation, and anti-estrogen drugs. Early stage prostate cancer used to be treated with radical prostatectomy, but now more frequently with radiation. Many of these men and women didn’t actually need treatment. We just don’t know which ones. This is why over the last six or seven years a significant rethinking of screening for breast and prostate cancer has occurred. There has been a backlash, of course, but the rethinking seems to have taken hold.

Not everywhere, of course. (more…)

Posted in: Basic Science, Cancer, Diagnostic tests & procedures, Public Health

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The Enigma of Chiropractic: A Brief Review with a Perspective on Chiropractic as a Specialty

 Subluxation-based chiropractic care is sustained more by faith than by facts.

Subluxation-based chiropractic care is sustained more by faith than by facts

Much of what is discussed in this article has been said before in previous articles I have written for Science-Based Medicine. But since the audience for SBM has greatly increased over the past few years, some subject matter should be repeated for the new readers and researchers coming to this site for reliable information on health care.

Many consumers now search SBM for articles dealing with controversial alternative treatment methods that have been shown to be ineffective or to be loaded with fraud and quackery. Chiropractic in particular continues to be problematic for its failure to renounce the scientifically indefensible, nonfalsifiable subluxation theory that defines the profession as a whole. A review of chiropractic web sites reveals that many chiropractors continue to base their treatment methods on subluxation theory, encompassing a broad scope of health problems. Some chiropractors are now including use of “functional medicine” which uses “natural tools” to treat diabetes, thyroid disease, neuropathy, and other diseases best treated by conventional medical care. Most alarming of all is the treatment of infants and children by “pediatric chiropractors.” Chiropractors are being certified in 10 different specialties, including a diplomate in Diagnosis and Internal Disorders.

As long as chiropractic is licensed as a health-care profession based on subluxation theory or some other unscientific approach, it will continue to be subjected to scrutiny and criticism by the science-based community. It is, in fact, the moral and ethical responsibility of science-based practitioners to oppose any form of unscientific health care, wherever it might exist, separating sense from nonsense without being influenced by politics, special interest, pseudoscience, or belief systems.


Posted in: Chiropractic, Science and Medicine

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A “Natural Cure” for Eczema Leaves a Young Child in Agony…..


“I swear I had nothing to do with this!”

A short post today, for me at least, but an important one to file away for the next time somebody asks “What’s the harm?” during a discussion on the use of irregular medicine in the care of pediatric (or any) patients.

The case

The September 2015 issue of Pediatrics in Review, the official American Academy of Pediatrics source for continuing medical education, contains a case report that should be of particular interest to readers of Science-Based Medicine. The authors, pediatricians at Children’s Hospital at Albany Medical Center, describe the ordeal of a six-year-old boy, previously healthy except for eczema, suffering with lower extremity pain to the point of crying with attempts to walk or to even bear weight. For those of you who don’t have experience with children of this age, it takes a considerable amount of discomfort or disability to interfere with their determination to remain in a near constant state of motion. Refusal to bear weight is a red flag that we take very seriously as the cause in a young child is often serious, ranging from traumatic injuries and severe infections of the bones or joints to diagnostic dilemmas such as leukemia and juvenile rheumatoid arthritis. (more…)

Posted in: Science and Medicine

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An aspirin a day to prevent heart attacks, strokes, and cancer?

Low dose aspirin is now recommended to prevent heart disease and cancer.

Low dose aspirin is now recommended to prevent heart disease and cancer.

Despite the remarkable advances in medicine over the past 20 years, cardiovascular disease and cancer will still kill half of us. Beyond the deaths, millions survive heart attacks, strokes and cancer, but many are left with disability and a reduced quality of life. While lifestyle changes can improve our odds of avoiding these diseases, they do not eliminate our risk. Finding ways to medically prevent these diseases before they occur, a term called “primary prevention”, is a holy grail in medicine. Primary prevention can be a tough sell, personally and medically. It means taking medicine (which may cause side effects) when you’re well, with the hope of preventing a disease before it occurs.

The US Preventative Services Task Force (USPSTF) released draft guidelines on the primary prevention of cardiovascular disease and colorectal cancer last week. The USPSTF is now recommending daily aspirin in some age groups who have at least a 10% risk of cardiovascular disease in the next 10 years. This isn’t the first guideline that’s recommended aspirin for primary prevention of cardiovascular disease, but it is the first major guideline to endorse aspirin to prevent colorectal cancer. Given these recommendations will apply to millions of people, they have attracted considerable controversy. Is this strategy going to reduce deaths and disability? Or are we about to start “medicalizing” healthy people inappropriately? (more…)

Posted in: Public Health, Science and Medicine

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NPR and the False Choice of Alternative Medicine

NPR National Public Radio logo

A recent segment on NPR is an excellent representation of some of the mischief that promotion of unscientific medical treatments can create. The title is a good summary of the problem: “To Curb Pain Without Opioids, Oregon Looks To Alternative Treatments.

The entire segment is premised around a false dichotomy, between excess use of opioids and unproven alternative treatments. It is clear that the reporters didn’t even speak to a pain specialist who relies upon science-based treatments, or if they did the specialist was completely ignored because a SBM approach did not fit into the narrative of the report.

Non-opioid options for pain control

The problem addressed by the segment is real – the current technology of pain control is limited. I don’t want to sell pain management short, we have an array of powerful and effective treatments. There are limitations, however, and many patients are inadequately treated.


Posted in: Acupuncture, Science and the Media

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Keep Naturopathy Out of the VA!

Let's not change the eagle into a duck

Let’s not change the eagle into a duck

AMVETS has joined with The American Association of Naturopathic Physicians in seeking to “promote natural, non-pharmacological approaches to treating patients suffering from chronic pain.” They are petitioning Congress and the VA to authorize bringing licensed NDs into the VA system. As a veteran myself, a retired Air Force Colonel and an MD, I find this appalling. During my twenty years service in the U.S. Air Force as a family physician and flight surgeon, I took pride in the high-quality science-based medical care my colleagues and I were able to provide. This proposal would jeopardize the welfare of our veterans by exposing them to substandard care with irrational, untested, and potentially harmful treatments. Letting naturopaths into the VA would be a grave mistake. (more…)

Posted in: Naturopathy, Politics and Regulation

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Donald Trump and the dangerous vaccine politics of the 2016 Presidential race

Republican candidates Ben Carson and Donald Trump during the CNN Republican presidential debate at the Ronald Reagan Presidential Library and Museum on Wednesday, Sept. 16, 2015,

Republican candidates Ben Carson and Donald Trump during the CNN Republican presidential debate at the Ronald Reagan Presidential Library and Museum on Wednesday, Sept. 16, 2015

I’ve been writing about vaccines and the antivaccine movement since the turn of the millennium, first in discussion forums on Usenet, then, beginning in 2004, on my first blog (a.k.a. the still existing not-so-super-secret other blog), and finally right here on Science-Based Medicine (SBM) since 2008. Vaccines are one of the most important, if not the most important, topics on a blog like this because (1) arguably no medical intervention has prevented more deaths and suffering throughout history than vaccines; (2) few medical interventions are as safe and effective as vaccines; and (3) there is a vocal and sometimes effective contingent of people who don’t believe (1) and (2), blaming vaccines for all sorts of diseases and conditions to which science, despite many years of study, has failed to link them. The most prominent condition falsely linked to vaccines is, of course, autism, but over the years I’ve written about a host of others, including sudden infant death syndrome, shaken baby syndrome, autoimmune diseases, and even cancer. In a similar vein, antivaccine activists will try to claim that vaccines are loaded with “toxins” or even tainted with fetal “parts” or cells because some vaccines’ manufacturing process involves growing virus in two cell lines that were derived from aborted fetuses many decades ago. Even the Catholic Church doesn’t say that Catholics shouldn’t use these vaccines, but that doesn’t prevent some antivaccine groups from portraying vaccines as virtually being made by scientists cackling evilly as they grind up aborted fetuses to make vaccines. (I exaggerate, but not by much.)

On a strictly scientific, medical level, antivaccine claims such as the ones described above are fringe, crank viewpoints. There is no serious scientific support for any of them and lots of scientific evidence against them, particularly the most persistent myth, namely that vaccines cause autism. It also used to be the case that, politically, antivaccine views tended to be those of the fringe. Unfortunately, in the current election cycle, those fringe views seem to be coming to the fore among prominent candidates for the Republican Presidential nomination. This was most evident at the second Republican Presidential debate last week, where Donald Trump spewed antivaccine tropes and neither of the two physicians also running for the Republican nomination mounted a vigorous defense of vaccines. Even candidates who have previously issued strong statements defending vaccines (Senator Marco Rubio and Louisiana Governor Bobby Jindal) remained silent.

(Video of the exchange can be found here.)

How did we get to this point? And why is it that antivaccine views, which in the past were stereotypically associated with crunchy lefties in the mind of the public, seem now to have found another comfortable home among small government conservatives, including the man who currently appears to be the frontrunner for the Republican nomination? In the days that followed the debate, there have been many discussions of Donald Trump’s antivaccine views, but none that take the long view. All seem to flow from the idea that it’s mainly just Donald Trump and his wacky views, rather than Trump being part of a more widespread phenomenon. I’ve frequently said that antivaccine beliefs tend to be the pseudoscience that knows no political boundaries, occurring with roughly equal frequency on the left and the right. However, it’s virtually inarguable that right now, in 2015, the loudest political voices expressing antivaccine views (or at least antivaccine-sympathetic views) are in the Republican Party. Yes, Robert F. Kennedy, Jr. is back in a big way, partying like it’s 1999 with Bill Maher over thimerosal-containing vaccines and autism, but neither he nor Bill Maher holds public office or is currently running for office. The über-liberal website The Huffington Post might have been promoting antivaccine propaganda since its inception, but its writers are not running for office, either, and of late it seems to be much less antivaccine than before. (more…)

Posted in: Neuroscience/Mental Health, Politics and Regulation, Vaccines

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