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…)
CAM proponents view National Health Interview Surveys recording the supposed popularity of CAM, an amorphous conflation of anything from conventional medical advice to mythical methods, as an invitation to unleash even more unproven remedies on the public. My interpretation is quite different. I see the same figures as proof that we are doing too little to protect the public from pseudoscience.
In fact, state and federal governments are acting as handmaidens to the CAM industry by legalizing practices and products that have insufficient proof of safety and efficacy and, in some cases, are so scientifically implausible that they can never meet that standard. The federal government keeps “integrative” medicine centers at major academic institutions and private foundations afloat with taxpayer money by funding research that has failed to improve public health or the treatment of disease, despite seemingly endless trials, because “more research is needed”.
As we shall see, Australia has a more effective regulatory system for dealing with CAM. And the advocacy group Friends of Science in Medicine (FSM), an organization with goals similar to our own Society for Science-Based Medicine, is keeping the government on its toes, investigating violations of the law on its own and reporting them. We in the US could learn something from their two recent successful campaigns attacking misleading health claims. (more…)
I was looking over a recent class catalog from my alma mater, University of Oregon. I see the Astronomy Department is having a day devoted to astrology, inviting astrologers to talk about their profession. And the Chemistry department is having alchemists give an overview on how to change base metals into gold. And, to green our energy, the Physics Department, where I acquired my undergraduate degree, is having a symposium on perpetual motion machines. I am so proud.
But not when it comes to SCAM (Supplements, Complementary and Alternative Medicine). Medicine is strange in that has no issues embracing pseudo-science. My medical school, OHSU, had an afternoon devoted to Integrative Medicine for the third year medical students, with lectures by a chiropractor, a traditional Chinese pseudomedicine practitioner, a naturopath and an integrative medicine practitioner. They also had a small group discussion of a case of irritable bowel syndrome where one of the discussion leaders was a……Qi……….Gong………..master. Really. I would be so pissed if I was going $166,000 in medical school debt and I was being taught about the approach to ANYTHING by a Qi Gong Master. It was a day to ignore that whole ‘science’ thing in the name of the school. (more…)
My article “Pediatric Chiropractic Care: The Subluxation Question and Referral Risk” was published in the 2016 February issue of the journal Bioethics. The abstract summarizes the message of the article:
Chiropractors commonly treat children for a variety of ailments by manipulating the spine to correct a “vertebral subluxation” or a “vertebral subluxation complex” alleged to be a cause of disease. Such treatment might begin soon after a child is born. Both major American chiropractic associations─the International Chiropractic Association and the American Chiropractic Association─support chiropractic care for children, care that includes subluxation correction as a treatment or preventive measure. I do not know of any credible evidence to support chiropractic subluxation theory. Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Referral of a child to a chiropractor for such treatment should not be considered lest a bad outcome harms the child or leads to a charge of negligence or malpractice.1
The first objection to my article came in a January 30 Facebook posting by Milehighchiro, a subluxation-based group: (more…)
As good a source of stem cells as any chiropractor.
My local newspaper is a constant source of topics to blog about. It regularly features ads for untested dietary supplements and for chiropractors who offer non-chiropractic treatments and don’t identify themselves as chiropractors. Recently, a full-page ad for NW Pain Relief Centers trumpeted “Stem Cell Technology Takes Joint Treatment to the Next Level.” It said stem cell treatments could heal and regenerate tissue in conditions such as knee osteoarthritis, carpal tunnel, peripheral neuropathy, spinal stenosis, hip pain, and tendinitis. A table titled “Consider these facts” compared stem cell therapy to surgery, saying stem cell treatments involve no known side effects, little or no pain, and immediate recovery; whereas surgery involves complications, poor outcomes, addiction to pain medications, severe pain for months, and a prolonged recovery over months and years. It said, “Call now if you experience any degree of joint pain or discomfort…Space is limited to the first 30 callers!”
A few days later there was another full-page ad for NW Pain Relief Centers, this time for hyaluronic acid injections into the knee for osteoarthritic knee pain. It reprinted the same table of comparisons with surgery, with an additional line comparing costs (that didn’t actually compare costs, but only vaguely mentioned insurance coverage, deductibles, copays, and time off work. It featured the same “Call now, space limited” ploy.
These ads reminded me so much of chiropractic ads that I had to wonder what was going on. They mentioned an “allied team of health professionals.” I guessed there must be at least one MD on their team if they were injecting stem cells and hyaluronic acid into joints. I guessed chiropractors were a prominent part of the team. I guessed right. (more…)
If you want money to pay for pseudoscience, but your pesky health insurance company is getting in the way, a Health Savings Account might be just the solution. And if the Health Savings Act of 2016, sponsored by the Big Supplement’s own Senator Orrin Hatch, becomes law, your opportunities will be greatly expanded.
First, let’s take a look at Health Savings Accounts and explore how they can be used to pay for quackery. Then we’ll see how Hatch’s Senate Bill 2499 (and companion House Bill 4469) would essentially force taxpayers to fund consumer purchases of unproven and potentially unsafe dietary supplements and “The One Quackery To Rule Them All,” homeopathy. Finally, we’ll look at how all of this might affect the presidential race.
What are Health Savings Accounts?
A Health Savings Account (HSA) is a personal account created exclusively to pay for current or future health care expenses. They have significant tax advantages:
- Contributions to HSAs are tax deductible;
- Withdrawals are tax-free as long as they are used to pay for qualified medical expenses;
- Interest earnings accumulate tax-free and the balance in the account at year’s end can be rolled over into the next year with no tax penalty.
Well, we’re back.
Yes, after having our WordPress database somehow borked to the point where no new posts could be added and no existing posts could be edited since Friday, Science-Based Medicine is back in business—finally! As a result, some of you might have seen this post elsewhere, as it was considered to be somewhat time-sensitive, and I didn’t want to delay, particularly given that I didn’t know how long SBM would be down. Fortunately, we’re back a bit sooner than I thought; so let’s look at something that was in the news over the weekend.
Katie May was a model, and by all accounts a very successful one, having appeared in Playboy, Sports Illustrated, and other magazines and websites. Self-proclaimed the “Queen of Snapchat,” she also had nearly two million Instagram followers and was a major social media force, having recently parlayed her modeling and social media career into entrepreneurship. She also died unexpectedly on Thursday night at the too-young age of 34, leaving behind a seven-year-old daughter. What makes May’s tragic death an appropriate topic for SBM is not so much her young age but rather the circumstances surrounding her death, particularly the cause. Basically, May died of complications due to stroke, as her family confirmed in a statement issued on Friday:
“It is with heavy hearts that we confirm the passing today of Katie May – mother, daughter, sister, friend, businesswoman, model and social media star – after suffering a catastrophic stroke caused by a blocked carotid artery on Monday,” the statement reads.
“Known as MsKatieMay on the Internet and the “Queen of Snapchat,” she leaves behind millions of fans and followers, and a heartbroken family. We respectfully ask for privacy in this this difficult time. Those wishing to contribute to the living trust being set up for the care of her young daughter may do so at her GoFundMe page.”
Ohio recently issued Acute Pain Prescribing Guidelines as part of an effort to reduce the epidemic of opioid abuse and death from overdose. They were drafted under the auspices of the Governor’s Cabinet Opiate Action Team (GCOAT), assisted by medical organizations and other groups.
The guidelines include recommendations for non-pharmacologic treatment, a typical feature of pain treatment guidelines and a worthy effort to avoid prescribing opioids for pain. Unfortunately, the guidelines include treatments that are not evidence based and potentially harmful. We’ll return to that issue shortly.
But first, a brief look at the extent of the opioid problem. According to the CDC, opioids are used to treat moderate-to-severe pain and are often prescribed following surgery, injury, or for painful health conditions, like cancer. In the past few years, there has been a dramatic increase in the acceptance and use of prescription opioids for the treatment of chronic, non-cancer pain, such as back pain or osteoarthritis. From 1999 to 2013, opioid prescription and sales in the U.S. have nearly quadrupled, and overdose deaths have quadrupled right along with them. (more…)
One of the main, but perhaps underappreciated, reasons quackery thrives in the United States is that the states legalize it by licensing practitioners of pseudoscience as health care providers. These practitioners are placed under the regulatory jurisdiction of, well, themselves. I call the whole deplorable process Legislative Alchemy, and you can see all posts on the topic here. It gives practitioners an underserved imprimatur of state authority and leaves public protection from harmful practices to the oversight of those who are themselves engaging in the very same conduct. Each year, dozens of bills are brought before the state legislatures to establish initial licensure or, once that goal is achieved, scope of practice expansion.
Most attempts fail, but CAM practitioners are a dogged bunch, and they will come back each year until they get what they want. It took chiropractors about 60 years to become licensed in all 50 states. Acupuncturists are almost there. Naturopaths lag far behind, but are slowly gaining ground each year, even if it is only via practice expansion in states where they are already licensed. 2015 was a losing season for all, but not without advancement toward larger goals.
Strong medicine…along with a little nonsense
Since passing my board exams in family practice in 1979 I have relied heavily on the American Academy of Family Physicians for continuing medical education via the American Family Physician and the AAFP home study programs. The AAFP prides itself on its evidence-based approach to medicine. In general, it delivers. But the recent FP Essentials Number 432 on “Chronic Pain Management” fell short. It recommended treating chronic pain with acupuncture, chiropractic, touch therapy, and S-adenosyl methionine (SAM-e), presenting them in a way that misled readers into thinking that the recommendations were based on good scientific evidence. They were not.
With 6,500 peer reviewed journals and over two million papers published every year, it is easy to find a study to support pretty much any point of view. John Ioannidis taught us that most published research findings are false, with preliminary studies frequently being overturned by larger, better follow-up studies. When evaluating the evidence for a treatment, it is not enough to find one or two positive studies. It is essential to also look for negative studies and for systematic analyses that weigh all the published evidence, and to put all the available evidence into perspective. The authors failed to do that. (more…)