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Update on CCSVI and Multiple Sclerosis

Balloon dialatation of a stenosed jugular vein, the "liberation procedure" wrongly promoted as treating multiple sclerosis.

Balloon dilation of a stenosed jugular vein, the “liberation procedure” wrongly promoted as treating multiple sclerosis.

In 2009 CCSVI was proposed by Italian vascular surgeon, Dr. Paolo Zamboni – that multiple sclerosis (MS) is caused by chronic blockage of the veins that drain the brain. Since that time we have seen the evolution of a medical pseudoscience. It has been a fascinating case study in how science sorts out what works and what doesn’t, and how patients, believers, and the public react to this information. The story is ongoing and there are some interesting updates.

Background on CCSVI

CCSVI stands for chronic cerebrospinal venous insufficiency. Zamboni believes that blockages in the veins that drain blood from the brain cause back pressure in the brain, decreasing blood flow and leading to secondary inflammation, and further that this results in the clinical diseases we collectively known as MS. Zamboni’s interest in MS is not random. His wife has MS, and it is interesting that he is a vascular surgeon and found what he believes is a cause of MS that can be treated by vascular surgeons. This does not mean his ideas are wrong, it just means he has a clear bias and his data needs to be looked at carefully and independently replicated.

His initial study found that 100% of the patients he examined with MS had cranial venous blockage. That is also curious. We rarely find 100% correlations in medicine, even for solid theories. It is a huge red flag for systematic bias.

The MS community was appropriately skeptical. While the exact cause of MS remains unknown, we have been studying it for decades and there is a lot we do know. We know, for example, that MS is primarily an autoimmune disease, and the pathology is largely caused by inflammation. We now, in fact, have a long list of effective treatments for some types of MS that suppress the immune system and inflammation. There are still some types, such as chronic progressive MS, that do not respond to the best treatments.

The idea that MS was caused by vascular blockage was therefore a radical idea that flew in the face of existing research. Occasionally, however, radical ideas turn out to be true, and so some MS researchers set out to test Zamboni’s hypothesis.

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Posted in: Neuroscience/Mental Health

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Quackery: The 20 Million Dollar Duck

quackery
The publisher recently sent me a review copy of Quackery: The 20 Million Dollar Duck, by Tony Robertson. My first thought was “Do we really need another book on this subject? Don’t I know all this stuff already?” I was very pleasantly surprised. Robertson has ferreted out an impressive array of facts and details that I wasn’t aware of; and yes, we need as many good books on the subject as we can get. Each author has a somewhat different approach that may appeal to a different audience. Robertson’s book is a worthy addition to the canon. He is a retired gynecologist who practiced, taught, and still lives in Zimbabwe. He is a critical thinker who understands and promotes science-based medicine, and he brings a unique perspective, especially on subjects related to his specialty. The book is not just about charlatans, it’s about non-science-based practices wherever they are found, including in mainstream medicine and in Robertson’s own field of obstetrics and gynecology.

I expected to like the book after I read the Dedication “To those who appreciate the truth fairy rather than the toothed one” and the Acknowledgements: “To my teachers and mentors who encouraged me to think, always to question and only to accept where there is good evidence.” That could serve as a motto for all skeptics, scientists, and critical thinkers to live by: Think, question, and only accept where there is good evidence. (more…)

Posted in: Book & movie reviews, Critical Thinking, Obstetrics & gynecology

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Therapeutic Touch Pseudoscience: The Tooth Fairy Strikes Again

When tested, therapeutic touch (TT) practitioners failed to detect the human energy field they thought they could feel. Experimental setup from Rosa et al., from JAMA, 1998, 279 (13)

When tested, therapeutic touch (TT) practitioners failed to detect the human energy field they thought they could feel. Experimental setup from Rosa et al., from JAMA, 1998, 279 (13)

A study out of Iran titled “Therapeutic touch for nausea in breast cancer patients receiving chemotherapy: Composing a treatment” was recently published in the journal Complementary Therapies in Clinical Practice. It is a great example of the Tooth Fairy science that permeates much of the research in complementary and alternative medicine. In Tooth Fairy science, researchers attempt to study a phenomenon without first determining whether it exists.

What is therapeutic touch?

Therapeutic touch (TT) is a type of energy medicine; practitioners claim to be able to:

  1. sense a patient’s “human energy field” with their hands,
  2. manipulate the energy field by moving their hands near (but not touching) a patient’s skin surface, and
  3. thereby improve the patient’s health.

TT was the delusional invention of a nurse and a theosophist, and it has no scientific basis. Scientists can detect and measure minute energies down to the subatomic level, but they have never detected a “human energy field.” And when TT practitioners were tested on their ability to detect such a field, they failed miserably.

Therapeutic touch is pure vitalism, the belief in a soul or animating force,” writes Paul Ingraham, “exactly like the Force in Star Wars, and just as fanciful. Auras and life energy do not exist and cannot be felt, let alone manipulated therapeutically.”

Despite the combination of extreme implausibility and a total lack of evidence, TT is taught to nurses in many otherwise reputable institutions, and there are more than 90,000 practitioners worldwide. There is even a Therapeutic Touch International Association that claims TT is evidence-based. It is not.

TT practitioners believe they are helping patients. That belief is reinforced by seeing patients improve due to the natural course of illness, suggestion, and the “placebo” or nonspecific contextual effects of the provider/patient encounter. They allow confirmation bias to overcome scientific reality, and they do poorly-conceived research seeking further confirmation. Since the studies are designed to show that TT works rather than to ask if it works, they find evidence that is convincing to believers but not to the scientific community as a whole. (more…)

Posted in: Energy Medicine

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Acupuncture does not work for menopause: A tale of two acupuncture studies

Women looking for relief from hot flashes will be disappointed if they think acupuncture will help them.

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.”
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Posted in: Acupuncture, Cancer, Clinical Trials, Traditional Chinese Medicine

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Cranial Manipulation and Tooth Fairy Science

Tooth Fairy Science is science that studies a phenomenon that doesn’t exist. You can do studies on the Tooth Fairy; for instance, comparing how much money she leaves to kids in different socioeconomic groups. You can do studies on the memory of homeopathic water. You can do studies on the therapeutic effects of smoothing out wrinkles in the imaginary human energy field with therapeutic touch. Or you can do studies of craniosacral therapy. “Therapeutic Effects of Cranial Osteopathic Manipulative Medicine: A Systematic Review,” by Jakel and Hauenschild, was published 2011 in the Journal of the American Osteopathic Medical Association. It is a perfect example of Tooth Fairy Science.

In the 1930s, William G. Sutherland, DO looked at a disarticulated skull and noticed that the sutures were beveled, like the gills of a fish. He concluded that this indicated articular mobility for a respiratory mechanism. He invented cranial osteopathic manipulation to allegedly move the bones of the skull relative to each other for therapeutic benefit.

In the 1970s, John E. Upledger developed this idea further, inventing craniosacral therapy (CST). It postulates rhythmic fluctuations of the cerebrospinal fluid (CSF), mobility of the cranial bones and dural membranes, and involuntary motion of the sacrum. The CST practitioner palpates the skull, senses pulsations transmitted to the skull by the CSF, gently moves the skull bones relative to each other, and thereby releases restrictions to the flow of CSF, which somehow restores health in an astounding variety of human illnesses. (more…)

Posted in: Energy Medicine

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Frightening Breast Cancer Patients with Bad Science

No Time to Waste: Avoidant Coping Style Scrambles Circadian Rhythms in Breast Cancer Patients, warned the headline of an article in Clinical Psychiatry News. The article went on to claim

Even in the earliest days following a diagnosis of breast cancer, maladaptive coping styles are associated with a disruption in circadian rhythms –which are proven in metastatic disease to be a prognostic indicator of mortality. The surprising finding… holds potentially profound implications for the timing and tailoring of psychosocial interventions in newly diagnosed patients.

And it invoked psychoneuroimmunology for an authoritative sounding warning to breast cancer patients:

The fact that circadian disruption was significant in a subset of patients a mean 19 [sic] days after diagnosis suggests that there may be no time to waste in identifying and treating potentially maladaptive coping responses that could impact not only their adjustment, but also their prognosis.

Women who are diagnosed with breast cancer, enroll yourself immediately in a stress reduction program or support group, if you want to stem the progression of your disease and prolong your life! If you have metastatic disease, maybe you can blame your “maladaptive coping,” your inept handling of the days and weeks immediately after your diagnosis. Such frightening messages to women who are vulnerable because they have just received their diagnosis should require high standards before being released. This article reeks of hype and distortion, starting with its emotional title, No Time to Waste and “Scrambles Circadian Rhythms,” continuing with claims of “profound implications for the timing of psychosocial interventions,” and ending with an exhortation to breast cancer patients that “early breast cancer patients certainly warrant paying closer attention to coping from Day 1.”

The issue is not just skewered science, because  the article contains information that is easily misunderstood without a proper context. Breast cancer patients are urged to take get psychosocial intervention under the threat that if they do not, they are missing an opportunity to control the progression of their disease. This is an example of the irresponsible nonsense that I have been complaining in the past two blogs. There is simply no evidence that psychological interventions can slow progression of cancer or extend life. Claims to the contrary serve to burden cancer patients with an unrealistic responsibility for the outcome of their medical condition. Patients who experience progression to a terminal condition are provided with an irrational sense that they are to blame because they did not take the right steps, namely avail themselves of effective psychological interventions. This article implies that breast cancer patients with an unfavorable course have brought it on themselves by getting too stressed out.

It’s not clear whether journalist Betsy Bates Freed, PsyD. actually interviewed the authors of the study on which the story is based. Media coverage often offers direct quotes that appear to have been obtained directly from authors when they actually come from the scientific article.  In this particular case, Freed provides a highly speculative direct quote that “circadian cycles regulate tumor growth” as if it came directly from the mouth of the lead author of the study. For the record, there is some evidence of an association between circadian rhythms and progression of metastatic breast cancer, but it is not clear that it is causal or  affects”regulation” or in what direction any causal arrows run. Importantly, such findings have not been replicated with early breast cancer patients.

Clinical Psychiatry News is not some dubious CAM website, but an Elsevier published monthly newspaper with an advisory editorial board with recognizable scientist and clinician psychiatrists. It has largely free web access because of pharmaceutical company support. One has to question what editorial control over content is exerted before releasing articles like No Time to Waste.
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Posted in: Cancer, Neuroscience/Mental Health

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The Mind in Cancer: Low Quality Evidence from a High-Impact Journal

My science writing covers diverse topics but increasingly concerns two intertwined themes in cancer and psychology. First, I bring evidence to bear against an exaggerated role for psychological factors in cancer, as well as against claims that the cancer experience is a mental health issue for which many patients require specialty mental health interventions. Second, I explore unnoticed social and organizational influences and publishing practices, which limit evaluation of the best evidence for theories and practices claiming to be evidence based, especially those recommended (and even mandated) by professional organizations and accrediting bodies.

I benefit from a great set of international collaborators, and my colleagues and I have repeatedly  debunked claims that psychological interventions increase the survival time of cancer patients by improving their immune systems. Wally Sampson and Bernie Fox provided important inspiration for these efforts. A key source of such claims is the classic Lancet study by David Spiegel, which I will dissect in a later post for ScienceBasedMedicine.org (for now, see our published critique of Spiegel).
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Posted in: Cancer, Neuroscience/Mental Health, Science and the Media

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Chiropractic and Deafness: Back to 1895

Daniel David Palmer, creator of the nebulous subluxation and father of chiropractic.

Daniel David Palmer, creator of the nebulous subluxation and father of chiropractic.

Chiropractic originated in 1895 when D.D. Palmer claimed to have restored deaf janitor Harvey Lillard’s hearing by manipulating his spine. This makes no anatomical sense, and few if any chiropractors claim to be able to reverse deafness today. But now a chiropractic website is attempting to vindicate D. D. Palmer. They list deafness among a long (wrong) list of “Conditions That Respond Well to Chiropractic”

They list 6 supporting studies. Three are case reports, two are case series, and one is a review of the literature that is labeled in its title as “A Search to Validate” D.D. Palmer. (more…)

Posted in: Chiropractic

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