Placebo effects help you feel better, they don’t make you actually better.
It is almost inevitable that whenever we post an article critical of the claims being made for a particular treatment, alternative philosophy, or alternative profession, someone in the comments will counter a careful examination of published scientific evidence with an anecdote. Their arguments boils down to, “It worked for me, so all of your scientific evidence and plausibility is irrelevant.”
Both components of this argument are invalid. Even if we grant that a treatment worked for one individual, that does not counter the (carefully observed) experience of all the subjects in the clinical trials. They count too – I would argue they count more because we can verify all the important aspects of their story.
I want to focus, however, on the first part of that statement, the claim that a treatment “worked” for a particular individual. Most people operationally define “worked” as, they took a treatment and then they improved in some way. This, however, is a problematic definition on many levels.
Much of the disagreement about how to define “works” comes down to placebo effects. The generally-accepted scientific approach is to conclude that an intervention works when the desired effect is greater than a placebo. When all other variables are controlled for, the intervention as an isolated variable is associated with an improved outcome. That is the basic logic of a double-blind placebo controlled trial.
Six years ago I wrote about the evidence for breastfeeding. I questioned an article that claimed 900 babies’ lives could be saved every year in the US if 90% of mothers breastfed for at least 6 months. I didn’t think that was true, but I did think the evidence supported the claim that breastfeeding was clearly better for babies. Now I’m not so sure we can trust that evidence.
A new study reevaluated the evidence from previous studies and found that the studies hadn’t adequately ruled out significant confounders. There are social, cultural and economic factors that contribute to the choice to breastfeed, factors that may have skewed the results of those studies to favor breastfeeding. The new study tried to correct for these issues.
Results from standard multiple regression models suggest that children aged 4 to 14 who were breast- as opposed to bottle-fed did significantly better on 10 of the 11 outcomes studied. Once we restrict analyses to siblings and incorporate within-family fixed effects, estimates of the association between breastfeeding and all but one indicator of child health and wellbeing dramatically decrease and fail to maintain statistical significance. Our results suggest that much of the beneficial long-term effects typically attributed to breastfeeding, per se, may primarily be due to selection pressures into infant feeding practices along key demographic characteristics such as race and socioeconomic status.
Women looking for relief from hot flashes will be disappointed if they think acupuncture will help them.
Arguably, one of the most popular forms of so-called “complementary and alternative medicine” (CAM) being “integrated” with real medicine by those who label their specialty “integrative medicine” is acupuncture. It’s particularly popular in academic medical centers as a subject of what I like to refer to as “quackademic medicine“; that is, the study of pseudoscience and quackery as though it were real medicine. Consider this. It’s very difficult to find academic medical centers that will proclaim that they offer, for example, The One Quackery To Rule Them All (homeopathy). True, a lot of integrative medicine programs at academic medical centers do offer homeopathy. They just don’t do it directly or mention it on their websites. Instead, they offer naturopathy, and, as I’ve discussed several times, homeopathy is an integral—nay, required—part of naturopathy. (After graduation from naturopathy school, freshly minted naturopaths are even tested on homeopathy when they take the NPLEX, the naturopathic licensing examination.) Personally, I find this unwillingness of academic medical centers that offer naturopathy to admit to offering homeopathy somewhat promising, as it tells me that even at quackademic medical centers there are still CAM modalities too quacky for them to want to be openly associated with. That optimism rapidly fades when I contemplate what a hodge-podge of quackery naturopathy is and how many academic integrative medicine programs offer it.
If you believe acupuncturists, acupuncture can be used to treat almost anything. Anyone with a reasonable grasp of critical thinking should recognize that a claim that an intervention, whatever it is, can treat many unrelated disorders is a huge red flag that that intervention is almost certainly not science-based and is probably quackery. So it is with acupuncture; yet, that hasn’t stopped the doyens of integrative medicine at the most respected medical schools from being seduced by the mysticism of acupuncture and studying it. I can’t entirely blame them. I must admit, there was a time when even I thought that there might be something to acupuncture. After all, unlike so many other CAM interventions, acupuncture involved doing something physical, inserting actual needles into the body. However, as I critically examined more and more acupuncture studies, I eventually came to agree with David Colquhoun and Steve Novella that acupuncture is nothing more than a “theatrical placebo.”
My reaction to reading the paper discussed herein, were I a handsome Spaniard.
Bleh. I turned from a short trip to the city of angles with a bad man cold that just isn’t going away. Those who do primary care all tell me that whatever is going around lasts 2-3 weeks. Great. I am not sick enough to get out of work but I am not well enough to have any enthusiasm to do anything. I look at the key board and sigh. I just want to binge watch something mindless.
I know Harriet covered “Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation” last week. But it is one thing to read the evaluation of a paper and quite another to evaluate a paper on your own. It is the latter process where you, and by you I mean me, actually learn something. I write mostly for my edification, not yours. Sorry. It is all about me. I will likely read Harriet’s post this weekend.
The issue at hand is whether chiropractic manipulation can cause a stroke. (more…)
The Integrative Medicine Wheel
“Integrative medicine” (IM) is an ideological movement within medicine driven in large part by those whose livelihoods depend on its continued existence. This includes both those with positions in academic medicine and individual practitioners who use the IM brand to attract patients.
Despite IM and its antecedents (alternative, complementary, alternative and complementary, complementary and integrative) having been around for about a quarter century, we still do not have a working definition of integrative medicine or have any idea whether it positively affects patient outcomes. And, despite the lip service given to IM being evidence-based, or “evidence-informed” or incorporating “appropriate” services into conventional medicine, there does not seem to be any standard for determining which modalities are appropriate for inclusion. We can infer, however, that evidence of effectiveness is not a criterion, as reiki, cranial sacral “therapy”, and homeopathy are standard fare.
In fact, the prospect for actually improving patient outcomes by importing CAM treatments (such as acupuncture) into medical practice would seem to be decreasing over time, as more and more fail to hold up under the scrutiny of well-designed and conducted clinical trials. Perhaps the dearth of evidence for “alternative” treatments is the impetus behind the importation of conventional modalities, such as nutrition and exercise, into the IM fold, treatments that were never viewed as CAM when the whole enterprise started. It has also led to special pleading demanding that research standards be loosened, most recently by the NCCIH, its director’s promise to ensure “rigorous science” notwithstanding.
There is no standard delivery model for integrative medicine or, importantly, an agreed-upon role for the various practitioners who bring the “integrative” to integrative medicine, such as chiropractors, naturopaths and acupuncturists. For example, should they be allowed to practice independently or should the medical doctor have final say on patient care? And, if they differ in their proposed diagnoses and treatments, how are those issues to be resolved? (more…)
Alternative medicine, like all good marketing, is largely about creating a narrative. Once you have sold people on the narrative, products essentially market themselves. That narrative has been evolving for literally centuries, although it seems to have accelerated with the advent of mass media and now the internet. It is optimized to push emotional buttons in order to sell products.
There are countless examples available on the internet, with many peaking above the crowd for their 15 minutes of fame. In my feed this morning came this typical example: “Cancer Cells Die In 42 Days: This Famous Austrian’s Juice Cured Over 45,000 People From Cancer And Other Incurable Diseases!“
The story has many of the typical alternative medicine narrative talking points: natural is good, a healthful diet can cure anything, anti-inflammatory, anti-oxidants, and detoxification are all good.
NOTE: Today we offer a double feature on the treatment of cervicogenic headache: this post and Dr. Harriet Hall’s post, “When Headaches Are a Pain in the Neck: Spinal Manipulation vs. Mobilization for Cervicogenic Headache.” They complement each other, as well as Dr. Hall’s post from last week on the possible risk of stroke with neck manipulation.
A cervicogenic headache has been defined as a secondary headache (beginning in the suboccipital area) caused by nerve pain referred from a source in the upper cervical spine. According to the American Migraine Foundation, “To confirm the diagnosis of cervicogenic headache, the headache must be relieved by nerve blocks….Treatment includes nerve blocks, physical therapy, exercise, Botox injections, and medication. Physical therapy and an ongoing exercise regime often produce the best outcomes.”1
There are a number of published studies advocating use of upper cervical manipulation as a treatment for cervicogenic headache,2 often without adequate consideration of the danger of such treatment. While upper neck manipulation might sometimes be an effective treatment for a cervicogenic headache, care must be taken to avoid upper cervical manipulative techniques that may pose risk of stroke by damaging vertebral and internal carotid arteries.
Most headaches are of the tension-type variety, often originating in the myofascial structures of the head and neck. There are many other types of headache, some of which can be life-threatening or unbearably painful, none of which are neck related. Headache caused by a leaking brain aneurysm may portend possible rupture of a swollen blood vessel. A migraine or a cluster headache is less serious but can cause agonizing pain. Sudden appearance of neck pain with headache can be a symptom of spontaneous vertebral artery dissection, which can result in a full-blown stroke if aggravated by neck manipulation. When a headache is sudden, severe, or persistent, it is important to have a medical evaluation before concluding that you have a neck-related headache or before submitting to neck manipulation, especially upper cervical manipulation that involves rotation of the atlas on the axis. (more…)
NOTE: Today we offer a double feature on the treatment of cervicogenic headache. My article is about a study that compared manipulation to mobilization; it is followed by retired chiropractor Sam Homola’s guest article on manipulation for cervicogenic headache. The two posts complement each other and also complement my post from last week on the possible risk of stroke with neck manipulation.
If a headache originates in the neck, does manipulation provide more relief than mobilization?
Cervicogenic headache (CGH) refers to headaches that are caused by problems in the neck, as opposed to headaches of non-neck etiology that may be accompanied by neck pain. There is controversy over whether CGH is even a valid diagnosis. Diagnostic criteria usually include unilateral headache triggered by head/neck movement or by pressure on the neck, headache that spreads to the neck, shoulder or arm; and often limited range of motion in the neck. If a nerve block in the neck relieves the headache, that would confirm that the pain originates in the neck, but nerve blocks are not routinely done and are not required for diagnosis.
Is manipulation effective for CGH?
There is controversy over whether spinal manipulation is an effective treatment for CGH. A 2005 systematic review concluded that “A greater number of well-designed, randomized, controlled trials are required to confirm or refute the effectiveness of spinal manipulation.” (more…)
Functional Medicine practitioners like to make patients think that this diagram actually means something.
We at Science-Based Medicine often describe “integrative medicine” as integrating quackery with medicine (at least, I often do), because that’s what it in essence does. The reason, as I’ve described time and time again, is to put that quackery on equal footing (or at least apparently equal footing) with science- and evidence-based medicine, a goal that is close to being achieved. Originally known as quackery, the modalities now being “integrated” with medicine then became “complementary and alternative medicine” (CAM), a term that is still often used. But that wasn’t enough. The word “complementary” implies a subordinate position, in which the CAM is not the “real” medicine, the necessary medicine, but is just there as “icing on the cake.” The term “integrative medicine” eliminates that problem and facilitates a narrative in which integrative medicine is the “best of both worlds” (from the perspective of CAM practitioners and advocates). Integrative medicine has become a brand, a marketing term, disguised as a bogus specialty.
Of course, it’s fairly easy to identify much of the quackery that CAM practitioners and woo-friendly physicians have “integrated” itself into integrative medicine. A lot of it is based on prescientific ideas of how the human body and disease work (e.g., traditional Chinese medicine, especially acupuncture, for instance, which is based on a belief system that very much resembles the four humors in ancient “Western” or European medicine); on nonexistent body structures or functions (e.g., chiropractic and subluxations, reflexology and a link between areas on the palms of the hands and soles of the feet that “map” to organs; craniosacral therapy and “craniosacral rhythms”); or vitalism (e.g., homeopathy, “energy medicine,” such as reiki, therapeutic touch, and the like). Often there are completely pseudoscientific ideas whose quackiness is easy to explain to an educated layperson, like homeopathy.
An inverted quantum matrix proving the myriad benefits of using of a dental doula
Suzy Flanders had always dreamed of having a natural tooth extraction without pain medications, sedation, or local anesthesia, just like in the Bible or on an episode of Keeping Up With Kardashians. “When the day finally came on April 1st 2011, and my dentist recommended the removal of an impacted third molar, I almost couldn’t believe it,” Flanders explained. “After reading everything I could find online and talking to a few trusted friends and family members, the right choice became clear. I had to do what was best for me and for my precious tooth.”
What she found in her research was the consistent recommendation to have someone present during the procedure that had been through the experience themselves. Many proponents of natural dental care endorse this practice because there is evidence that it helps to reduce the need for harmful medications that might prevent a quick return to normal activity. They also argue that a dental procedure is about more than just the removal of an abscessed tooth or the correction of malocclusion, it’s about experiencing what the procedure feels like and discovering what you are capable of achieving. Natural dental care patients learn to manage their pain and remain open to the excitement and exhilaration of the process, and often report feeling higher levels of satisfaction. After all, modern humans have been experiencing the beauty of natural dental pain for 250,000 years.