Appeals to other ways of knowing for "integrative" medicine

So-called "complementary and alternative medicine" (CAM) or, as it's now as frequently called, "integrative medicine" (IM) represents a hodge-podge of remedies that are mostly based on prescientific concepts about how the human body works and how disease attacks it. Homeopathy, through its concept of "like cures like" and law of contagion. The former in essence is a manifestation of the magical concept that "like produces like." Similarly, homeopathy's law of infinitesimals, in which serial dilutions to the point that there is unlikely to be a single molecule left of the substance thought to be a remedy, is postulated to retain and increase the potency of the remedy is a manifestation of the magical law of contagion, which postulates that there is a lasting connection between things that were once in contact. What is the homeopath's prized "memory of water" but the claim that water that has been in contact with a remedy retains a connection with that remedy ("memory")? And don't even get me started on the various forms of "energy" healing, which postulate imbalances in a mystical life force that science can't detect and further claim that humans can somehow manipulate this life force to healing effect. Reiki, therapeutic touch, and even acupuncture are forms of "energy healing," and many of these "energy" modalities are, when stripped to their core, nothing more than faith healing that substitutes Eastern mysticism for Christian beliefs. One of the only forms of CAM/IM that has any scientific plausibility is the use of herbal remedies, which substitute impure active ingredients at variable concentrations and with variable contaminants for pure active ingredient.

Given all this, it is not surprising that, when tested in rigorous scientific settings in well-designed clinical trials, the vast majority of CAM modalities fail miserably to show any efficacy greater than that of a placebo. Yet, so strong is the belief in these modalities that physicians who should know better cling to them even after clinical trial after clinical trial fail to show any efficacy beyond that of a placebo. Even worse, all too frequently they argue that, if randomized clinical trials can't show efficacy for these modalities, then it's because controlled clinical trials are somehow not appropriate or inadequate to the challenge of testing these treatments, usually because they're so "personalized." Sadly, this nonsense keeps cropping up even today in mainstream medical journals whose editors should also know better than to think this sort of "appeal to other ways of knowing" belongs in scientific medicine. The most recent journal to succumb to this sort of "reasoning" is BMJ, which published earlier this week a depressing exercise in pseudoscientific prestidigitation in the form of an editorial entitled Closing the evidence gap in integrative medicine. Written by Hugh MacPherson, David Peters (professor of integrated healthcare), and Catherine Zollman from the University of York, the University of Westminster, and the Nightingale Valley Practice of Bristol, respectively, it's an exercise in how not to think about CAM right from the very start:

Integrative medicine was recently defined as "medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines (conventional and complementary) to achieve optimal health and healing" (www.imconsortium.org).

First off, this is a steaming, stinking, slimy pile of fetid dingo's kidneys. "Integrative" medicine is nothing more than a "rebranding" of "complementary and alternative medicine" that removes the word "alternative" and seeks to slap a patina of scientific respectability on modalities that have no science behind them. It's nothing more than "integrating" pseudoscience with effective medicine. There's no proven benefit, but IM promoters like to try to get you to think there is, and they're willing to do anything (other than acknowledging the science, of course) to accomplish this. Even worse, all this blather about "holistic" medicine, "reaffirming the importance of the relationship between the practitioner and the patient" and focusing on the "whole person" are a part of all good medical practice. This is nothing more than another example of the "bait and switch" of CAM/IM, in which woo-meisters appropriate perfectly valid parts of the practice of science-based medicine and act as though they and they alone have discovered their importance. They did it with diet and exercise, which are not in any way "alternative" or "integrative," and they do it here with "holistic" medicine.

So let's see what MacPherson et al think. After standard boilerplate about how chronic diseases are difficult to deal with, account for 78% of health care expenditures, and aren't always handled as well as we would like by scientific medicine, the authors whine about how the evidence base for IM is just not what advocates would like it to be. This is the key sentence of the entire paper:

Yet when it comes to deciding whether an intervention, and which type of intervention, might be helpful for a particular patient, a worrying gap exists between the perceived potential for using integrative approaches in areas of poorly met clinical need and the availability of supporting evidence derived from good research.

Note the phraseology: the perceived potential for using integrative medicine in areas of poorly met clinical need. That's what it is, perception, and what MacPherson et al are in essence admitting is that here is a gap between their perception of how awesome IM is for chronic diseases and the reality of the largely negative clinical trial data that is available. I can't help but pointing out that real scientists, when faced with a gap between their perception and the cold, hard evidence of science, generally close the gap by losing or adjusting their perception, ditching therapies that don't stand up to scientific scrutiny and moving on to others. True, it may be a messy process. It may take a lot longer than we would like it to. It may be very contentious. But in science, ultimately evidence wins out, and scientists and science-based physicians ultimately adjust their perceptions to align with the evidence. As you might imagine, hwoever, that's not what MacPherson et al do. Oh, no, not at all. For them, if there is a gap between perception and reality when it comes to CAM/IM, it's time to measure reality differently until reality appears to align itself with their perception:

Integrative interventions tend to involve potentially synergistic, multimodal, and complex interactions that are often dependent on the relationship between practitioner and patient, and on patients' preferences, expectations, and motivations. For example, the motivation, compliance, and response of a patient undertaking dietary or other lifestyle changes, or practising relaxation exercises, will depend greatly on how they feel about their practitioner. Consequently, a randomised placebo controlled trial aiming to study components of integrative interventions in isolation may actually distort the very thing it is investigating. Moreover, many patients who seek integrative medicine in routine care would often be excluded from entry into a trial because they have chronic diseases, multiple pathologies, strong preferences, or are using concurrent treatments. Therefore, the extent to which findings from randomised controlled trials can be generalised to these patients is far from clear.

The limitations of making systematic reviews and meta-analyses of randomised double blind placebo controlled trials the pinnacle of an evidence hierarchy were recently stressed by Sir Michael Rawlins, who expressed his concern that, "Hierarchies attempt to replace judgment with an over-simplistic, pseudo-quantitative, assessment of the quality of the available evidence" and that "hierarchies of evidence should be replaced by accepting--indeed embracing--a diversity of approaches." Similarly, the translational research movement suggests using a "multiplicity of tactics."

First, note the standard CAM-speak about "synergistic" and "complex" interactions that depend on the relationship between the practitioner and patient. If there were a more blatant admission that CAM relies on placebo effects, I haven't seen it. No doubt MacPherson didn't mean it that way, but perhaps it's a Freudian slip.

Now, in fairness, I'll point out that part of the reason I've come to embrace science-based medicine (SBM) over evidence-based medicine (EBM) is due to shortcomings in the EBM paradigm, but my reasons do not concern primarily what's at the top of the EBM hierarchy of evidence but rather what's at the bottom: Basic science studies and prior probability based on science. The problem with EBM is that it values clinical trials over every other form of evidence, even when testing remedies as patently ridiculous as homeopathy. However, I also have to point out that SBM already uses a "multiplicity of tactics." Its a frequent canard of the CAM crowd that, if the evidence isn't from a double-blinded, randomized controlled clinical trial, it's worthless. That's not true at all. There are lots of clinical questions that don't always lend themselves to an RCT (many surgical procedures come to mind). That doesn't mean there's no evidence. As I said, we do use a "multiplicity of methods" and often end up using a confluence of evidence from different sources that converge into an answer, and often those sources are not RCTs. However, RCTs are in general the strongest form of clinical evidence and to be preferred when it is possible to do them. And few are the CAM modalities that can't be subjected to RCTs. It's just that the woo-meisters don't like the results; so they label EBM hierarchies as "simplistic" devices that preclude independent thought, which, presumably they have in abundance, not being the pharma shill science drones who can't see the "whole patient," as CAMsters can.

So what, according to MacPherson, is the answer? This:

What sort of diversity or multiplicity might better reflect the complex causality of the real world?9 To give some examples, pragmatic randomised controlled trials are increasingly used to collect evidence from typical populations receiving treatment in ways that reflect normal practice.10 Within pragmatic trials it is possible to optimise rather than constrain patient-practitioner interactions, and by incorporating patient preferences into trial design, the effects of synergies between treatment and choice can be captured.5 Observational studies might help target treatments and frame future research questions more effectively. More basic science research could help identify mechanisms of action, and meta-regression could better explain variability in response. Evidence from different sources can be combined using decision-analytical modelling and can be used for economic evaluations.11 Overall, research should aim to serve both practice and policy development.12

This is more errant nonsense. First off, "pragmatic" trials are usually performed after a treatment has been shown to be efficacious in order to see how a given treatment performs in the "real world," which is usually much messier in how medicine is practiced than the regimented paradigm of the RCT. The reason is not because effects are expected to be greater than in an RCT but because the less rigorous application of the treatment and broadening of its use to patients beyond the inclusion criteria for an RCT usually results in a decrease in the observed efficacy, not the increase in efficacy that MacPherson appears to expect to see if CAM is studied this way. As for "synergy" between "treatment and choice," I have no idea what the hell that means. It's woo-speak bordering on Lionel Milgrom's homeopathy articles.

Next, observational studies are nothing more than retrospective trials, which are prone to all sorts of confounders and biases that can be devilishly difficult to control for, which is why they produce all sorts of seemingly "positive" results (i.e., false positive results) that quite often don't hold up in later better-designed prospective randomized trials. Moreover, the implication that SBM doesn't deal with such studies is nonsense. The literature is chock full of observational studies, which are often the first step (and, on occasion, the only step) in finding evidence that influences practice. The Women's Health Intiative, for example, is the study following thousands of women and correlating health outcomes to lifestyle. It's the study that demonstrated, among many other things, that hormone replacement therapy does not prevent heart disease in postmenopausal women and is associated with an increased risk of breast cancer.

Finally, as for basic science research, I rather think that basic science doesn't mean what MacPherson thinks it does. The reason is that it is basic science considerations alone that dismiss the vast majority of CAM as being so scientifically implausible as to be not worth spending a lot of money studying. Examples include homeopathy and most, if not all "energy healing" modalities. MacPherson should be careful what he asks for on this score; he might actually get it someday, and when that day comes I rather suspects he won't like the results. Indeed, I'm working to see that he does get what he claims to want when it comes to basic science.

MacPherson concludes, after denigrating RCTs yet one more time as having "non-typical patients and artificially standardised interventions," that the only way to "close the evidence" gap is to "broaden" the range of evidence used to study CAM/IM. What he really means is to substitute lower quality trials and evidence for the highest quality RCTs because high quality RCTs almost inevitably fail to find efficacy for most CAM/IM. What MacPherson fails to acknowledge is that most IM therapies are perfectly amenable to RCT methodology and that whenever they are tested by this methodology they almost invariably fail to demonstrate any effects that are easily attributable to either placebo effect or random chance. Unfortunately, MacPherson tacitly assumes that, if only more research were done, an evidence base supporting efficacy of CAM/IM would somehow magically emerge from these "broadened" sources of data. It's an excellent example of what can only be called wishful thinking, and at some point science needs to say no to further special pleading. If CAM/IM advocates want to play by the rules of science, then they should play by the rules of science and quit trying to change the rules when they can't win under them.

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So-called "complementary and alternative medicine" (CAM) or, as it's now as frequently called, "integrative medicine" (IM)...

No, no, no!

It's Supplementary, Complementary, and Alternative Medicine.

Orac,
Great post. But I do have a question. I agree with everything you've said here, but I'm in the choir. You're preaching to the choir here. Granted, some CAM readers are out there lurking but wouldn't you agree that most of your readers are "in the choir"? My question is, do you/have you submitted your wonderful posts to the "other side"? This post for example... do you plan on sending it to BMJ or to any of the authors you've mentioned? You, as well as many other medical bloggers, are able to articulate the issues very well. I'm just wondering if yours and other similar posts are being forwarded to the places where they're most needed.
Thanks and keep up the great work.
Chet

It's interesting that they don't seem to have quoted Sir Michael Rawlins' sentence which immediately follows the one about "embracing a diversity of approaches":

This is not a plea to abandon RCTs and replace them with observational studies.

The whole text can be seen here: De Testimonio: On the evidence for decisions about the use of therapeutic interventions. The quoted passages can be found in the last two sections, headed "Hierarchies of evidence" and "Concluding thoughts".

Of course, we've seen people suggest that Rawlins was arguing for the abandonment of RCTs in favour of other sorts of tests before (as predicted by Badly Shaved Monkey).

The implication that if there is a "gap" between evidence and belief then there must be a problem with the evidence is frankly bizarre.

MacPherson: "What sort of diversity or multiplicity might better reflect the complex causality of the real world?"

Translation: "What sort of pseudoscientific approach would be best for giving our woo a patina of respectability?"

There is a strong voice for science-based "integrative" medicine in Britain - Professor Edzard Ernst (Chair of the Dept. of Complementary Medicine, Peninsula Medical School). He would find MacPherson's meanderings embarassing and distasteful.

By Dangerous Bacon (not verified) on 04 Sep 2009 #permalink

"For example, the motivation, compliance, and response of a patient undertaking dietary or other lifestyle changes, or practising relaxation exercises, will depend greatly on how they feel about their practitioner."

Well, concerning motivation and compliance, it's the same thing for real medicine, isn't it? As for response, I guess it's affected by the placebo effect that is part of the effect of any drug, even real ones. So all this is not specific to IM, or CAM, or SCAM...

"Evidence from different sources can be combined using decision-analytical modelling and can be used for economic evaluations."

It sure can. But beware the dreaded GIGO effect...

By Christophe Thill (not verified) on 04 Sep 2009 #permalink

I agree with posts above that "integrative" is a positive term that could be applied to the best of scientifically based medical care. It is a mistake to allow this term to be co-opted by practitioners of alternative medicine, unless they are willing to accept, and work with, conventional medicine and scientific evaluation of treatments. If not, they are not integrating.

Great post - thanks.

Just one clarification/elaboration. What CAM/IMsters do not like is placebo-controlled RCTs --- because these tend to find no specific effect.

What they seem to have recently discovered is that open pragmatic randomized trials have two great benefits: first, they are accepted by the EBM community as providing good evidence; and second, they often produce positive results for CAM/IM treatments because the results reflect placebo and bias effects.

The weakness in the methodology of such pragmatic trials is that they are open, unblinded. Their results reflect the specific effects of the treatment (which is likely to be zero), plus placebo effects, plus bias effects.

They justify this by (a) forgetting about the bias effects and the possibility of negative placebo effects in the "usual best care" group, and (b) saying that what is important is the effect of the whole package of care, so it doesn't matter if the specific effect is negligible.

CAM/IM-sters like to call pragmatic trials, "effectiveness trials", presumably the label has more effective associations with the effectiveness they would like to see proved.

B-but... but... Evil Allopaths only treat symptoms! I'm more than my disease! I am not a number -- I am a free man!

(The implications of "integrative" and "holistic" as they are used by the woo crowd should be subtly insulting to any decent M.D.)

By Jeff Read (not verified) on 04 Sep 2009 #permalink

The Multiplicity of causalities found in the diversity of synergistic yet complex modalities only begin to leverage the touchpoints of the armature that supports the scientifically proven benefits of the quantum healing paradigm . . . oh, and meta-regression. I was supposed to make sure I said meta-regression. That's super sciency sounding.

Great smackdown Orac, but I have to say that the meaning of "synergy between treatment and choice" seems pretty obvious to me: it's a cynical way of acknowledging that CAM almost entirely depends on the placebo effect.

A rare moment of quasi-honesty from the CAM folks.

Orac writes:
First, note the standard CAM-speak about "synergistic" and "complex" interactions that depend on the relationship between the practitioner and patient. If there were a more blatant admission that CAM relies on placebo effects, I haven't seen it.

CAM isn't just placebo effects. It's also our natural tendency to heal. See? Synergy! Multi-modal! Complex interactions, like: this placebo will make you feel better until your body heals

What I still can't fathom is that the woo-woos have this notion that "big pharma" is a bunch of evil con-men and their alternative is, what? More evil con-men.

Ahh yes. "Other ways of knowing".
See also "I made it up" and "I want that to be the answer".
See also "I pulled it out of thin air"

@Marcus Ranum:

CAM isn't just placebo effects. It's also our natural tendency to heal. See? Synergy! Multi-modal! Complex interactions, like: this placebo will make you feel better until your body heals

Or as Voltaire put it:

The art of medicine consists in amusing the patient while nature cures the disease.

An almost perfect description of sCAM!

Chet: "But I do have a question. I agree with everything you've said here, but I'm in the choir. You're preaching to the choir here. Granted, some CAM readers are out there lurking but wouldn't you agree that most of your readers are 'in the choir'?"

I think the readers here go beyond being 'in the choir'. I found out about this site because a friend was attacked on it for being a 'woo practitioner' (actually her institution was attacked, some months back, for being woo-sympathetic). Since then her profile has been greatly boosted at this institution and they may help her with some research in her field. A full out backfire. (Mention the name? Nah, I'm against the witch hunts that go on here.)

I stayed with this site because my wife and I are struggling with the decision whether to continue vaccinating our eight month old son. I went on the net to gather information from all sides. I was pro-shot and my wife was anti, and I went to gather evidence. Long story short, because I'll just get called a moonbat here anyway, no matter what I claim my reasons are...I've been converted and we're not vaccinating. I read this site, Science Mom and Science-Based-Medicine as well as the anti sites.

So that's one voice in the choir. I'm sure you're hoping I'm atypical. I have no idea whether I am or not. I'm a schoolteacher from a family of mostly mathematicians and engineers.

By Innocent Bystander (not verified) on 04 Sep 2009 #permalink

I think the readers here go beyond being 'in the choir'. I found out about this site because a friend was attacked on it for being a 'woo practitioner' (actually her institution was attacked, some months back, for being woo-sympathetic). Since then her profile has been greatly boosted at this institution and they may help her with some research in her field. A full out backfire. (Mention the name? Nah, I'm against the witch hunts that go on here.)

Confusing correlation with causation, I see. I highly doubt that my "attack" on anyone boosted anyone's profile enough to make a difference one way or the other. I'd like to delude myself that it could, but the realist in me knows that it's highly unlikely that anything I've written could have such a direct effect.

Maybe someday, though.

ut I do have a question. I agree with everything you've said here, but I'm in the choir. You're preaching to the choir here. Granted, some CAM readers are out there lurking but wouldn't you agree that most of your readers are 'in the choir'?

Actually, I know for a fact that there's quite the contingent of anti-vaccinations who check by here on a fairly regular basis. I suspect even J.B. Handley himself comes by from time to time.

Innocent Bystander - What on earth could have persuaded you to stop vaccinating and what on earth at this site remotely resembles a "witch hunt"? What part of the risk that you are exposing your child (to say nothing of the rest of the "herd") to do you not understand? This blog is failing (and Orac's response to you is annoying) and we should all be trying harder to have a dialog with you.

I think we should stop using the word "woo" as shorthand--it is offensive to people who feel that they are honestly seeking information about things they may have heard about and don't have the science background (this is the real problem) to sort out. I am deeply troubled that this blog has so offended this guy. He's not a wing nut (I remember reading his earlier posts and they were very sincere) and we let him down and now his kid isn't getting vaccinated--this is serious.

By Janet Camp (not verified) on 04 Sep 2009 #permalink

BEEP! BEEP! BEEP!

By H*ppehDetector (not verified) on 04 Sep 2009 #permalink

He really is obvious, isn't he?

He's gone again. This time, I'm going to take steps to make sure he stays gone.

SCAM/IM/"holistic" medicine/ whatever they're calling it this week offers some treatments that feel good, e.g. massage, but nothing I would even consider curative, preventative, or possessing any beneficial medical properties.

It seems to me that many SCAM/IM practitioners spend more time talking to/interacting with those who choose that route. Perhaps interaction is what the SCAM/IM user perceives as 'curative effect' in addition to the placebo effect provided by whatever was done to/prescribed for them.

Compared to the various payment, education, and specialization/certification/licensure burdens medical doctors bear, many SCAM/IM providers get off easy.

Many SCAM/IM services are cash only, many of these services do not require their providers to acquire crushing educational debt in order to become practitioners, and many of these services have low barriers to entry with respect to specialization, qualification, and licensing. (There are other factors, I'm sure, but these were the first that sprung to mind.)

A SCAM/IM user might paraphrase SNL's Stuart Smalley's affirmation thusly: "I am ill, I have someone that listens to and believes me, and doggone it, this is going to help!"

Though we haven't given it the full Orac treatment, we have been discussing the BMJ editorial over on David Colquhoun's Improbable Science blog. As I posted there, the three authors of the editorial are all longtime CAM boosters and "Foundation Fellows" of the Prince's Foundation for Integrated Health (FIH) - yes, that Prince, the English heir to the throne (or as we often refer to him in Britain, the "Quacktitioner Royal").

As the Bravewell Collaborative folk are to the Royalty-free US, so the Prince's FIH are to the UK. The post on David Colquhoun's blog also discusses a recent report on CAM from a "Health Think-tank" in the UK, which also turns out to be largely written by a gaggle of Fellows / Alumni of the FIH and takes a similar line to the BMJ editorial.

* sorry, have left out most of the links to avoid Orac's spam filter *

And just like that -

"The Bravewell Collaborative has recently signed an historic agreement with The Princeâs Foundation for Integrated Health, a charitable trust founded in the United Kingdom by HRH The Prince of Wales, establishing a partnership focused on improving the health of the public in both countries by advancing the use of integrative medicine."

Bravewell Partners with The Prince's Foundation for Integrated Health

What a cosy CAM world it is.

Must go and lie down now - I feel a conspiracy theory coming on.

Oh, but CAM/IM is great with chronic illness. Often can "treat" people with chronic illnesses for the rest of their lives in return for giving them the notion they're making themselves better, even curing what cannot be cured. It's really great... for the CAM practitioners. The people with chronic illnesses, it's generally doing nothing but taking their money. Sometimes it even makes things worse, such as someone with an auto-immune disease taking something that increases, say, t-cell count.. or by changing the way drugs they take work.

I have MS and it pisses me off. Everybody seems to know exactly what it causes (because a friend of theirs knows someone.. or they knew some celebrity) as well as exactly what to do: Take this supplement or that, eat this non-standard diet, inject or drink peroxide, bee-sting therapy (can you imagine paying to be stung by bees?), chiropractic, acupuncture, just pray and believe God will heal you.. these are the things you need to do to be cured. Ugh. Patient groups can be even worse. Some advocate and argue those as well as encouraging prescription drugs that have no evidence here.. and they can argue causes besides. Doctors joining in on this so much, clinging to discredited stuff -- I shudder at the idea.

BEEP! BEEP! BEEP!

Posted by: H*ppehDetector | September 4, 2009 2:27 PM
24
He really is obvious, isn't he?

He's gone again. This time, I'm going to take steps to make sure he stays gone.

Posted by: Orac | September 4, 2009 2:31 PM
25
These two comments were posted directly following mine which is posted under my real name so I definitely don't understand. I have made numerous comments on this blog (which I read regularly) about "preaching to the choir" and asked for input on how we can enlarge our umbrella as it seems limiting to just continually congratulate each other on our common understanding while this large group of "other" quit vaccinating their kids because they were better convinced by the other side.

If these comments are directed at me, I am saddened and deeply offended. I guess I'll just stay with JREF, Quackwatch and Richard Dawkins. So sorry I don't measure up as a skeptic and it is truly insulting to be mistaken for Heppeh!

By Janet Camp (not verified) on 04 Sep 2009 #permalink

Janet,

Happ*h's comment was there. I deleted it as soon as it was recognized. That's what I meant when I said "he's gone again." I meant that I had deleted his comment and banned him.

Chill.

Orac - Well thank you for that, but how was I supposed to know? I'm an old lady doing my best to keep up with technology. And don't tell me to "chill" young man; it's a simple misunderstanding and I appreciate you clearing it up, but I don't think I was wrong to feel badly treated under the circumstances. Wouldn't you be upset if you thought you were being taken for Hepp*h (is the asterisk to keep it from being deleted?)?

Mike Stanton - Thank you for responding as well. I love this blog and am glad I was mistaken.

By Janet Camp (not verified) on 04 Sep 2009 #permalink

Even worse, all this blather about "holistic" medicine, "reaffirming the importance of the relationship between the practitioner and the patient" and focusing on the "whole person" are a part of all good medical practice.

No it's not. You have to know the code.

When they say "whole person," they mean body, mind, and spirit. That's why they think "conventional," science-based medicine is going to miss important factors. Although they exist, science can't find God, or the soul, or the hope-filled faith inside which can do miracles, if you just believe it can. That is, ordinary science can't find it. Special science, however, can.

And this approach resonates with patients, because they already accept the premise.

I have to say, if I were a true "innocent bystander" (hee hee) and didn't know anything about the sCAM business, if I saw this article, it would be pretty obvious to me that this is a group scrambling. This "we need to investigate using other ways" is an out-and-out admission that they are completely failing using the standard scientific approaches. Why else would they need to look for other ways to validate themselves?

Moreover, even if, as that innocent bystander, I accept their assertion that there are "other ways of knowing," I am still left wondering, why does that only apply to their stuff? Can drug companies play the same gambit?

Actually, I am really curious about that. Do McPherson et all think drug companies should be allowed to use the same methods that they think are needed to justify sCAM treatments?

Open the flood gates, folks, because here would come a ton of worthless drugs...

I knew neither one of you could be Happ*h; there's no way he could suppress the crazy for two whole paragraphs. Although I do suspect Innocent Bystander of being a concern troll.

I did one of those scam IM applications -ozone therapy which not only cured a condition but cured by brother's lifelong asthma. Long live the scammers!

@Dr Aust:

...the three authors of the editorial are all longtime CAM boosters and "Foundation Fellows" of the Prince's Foundation for Integrated Health (FIH)...

The post on David Colquhoun's blog also discusses a recent report on CAM from a "Health Think-tank" in the UK, which also turns out to be largely written by a gaggle of Fellows / Alumni of the FIH and takes a similar line to the BMJ editorial."

A little ironic that the BMJ editorial has attracted a rapid response complaining about "the licensed drug lobby", isn't it?

Orac- Thank you for leaving chiropractors off the target list. We do not belong on the same list as homepaths and energy healers. As you know the research that shows we are effective is mounting and the number of hospitals and medical practices that are integrating our services is multiplying daily. If we are not not yet mainstream then we are on the bridge and leaving the island or misfits.

By DrWonderful (not verified) on 05 Sep 2009 #permalink

I have little problem with chiropractors, as long as they stick to musculoskeletal complaints, particularly back complaints, and do not engage in neck manipulation, which bears the risk of stroke. As I've said before, chiropractors tend to be physical therapists with delusions of grandeur in that they claim to be able to heal all sorts of diseases unrelated to the spine.

Start claiming chiropractic is good for asthma, diarrhea, and non-musculoskeletal conditions, and chiropractic gets the ol' not-so-Respectfully Insolent treatment.

Your fears about the risk of stroke are founded on the false premise that manipulation can tear a healthy artery. It has already been shown to be impossible. Those that suffer a CAD after manip either have a stroke in progress that the provider missed or the manip aggravated pre-existing damage that was about to go anyway.

This is why many more people suffer form CAD's while reaching overhead, sleeping on their stomach, backing out of a parking spot, getting their hair done, etc than have ever suffered in a chiropractic office. Actually the rate of incidence is nearly 3 times lower in the chiropractic population than it is in the general population. The incidence rate is equal in our offices than in GP offices that do not even touch the patient. More CAD's in progress are actually detected by chiropractors (ask the ER docs) than any other provider group because of our high level of training in pickign them out. Does not make it any less serious, just much less sinster.

In order to damage healthy arterial tissue during manipulation there would have to be at least some collateral damage to the surrounding bone and support tissue which is never found to be the case. Numerous neurosurgeons have testified to that fact and in every instance pre-existing tissue damage has been documented.

Also, the frequency of any injury with manipulation, let alone serious injury, is far below the threshold of "low risk" as established by medicine which says a procedure is considered low risk if the adverse effect rate is less than 1:100,000. Serious compications from cervical manipulation are reported to be anywhere from 1:1,000,000 to 1:6,000,000. Regardless, this puts it as hundreds of times lwoer than low risk.

Also, you seem to ignore the fact that chiropractic manipulation really is classified as a Grade 5 joint mobilization that utilizes a high velocity/low amplitude thrust into the paraphsyciological space. This perfomeed by a multitude of providers including chiropractors, physical therapists, osteopaths, orthoedic surgeons, and naturopaths. yet, the rate of injury is far lwoer for chirorpactors than it is for all other providers combined.

We do agree on the claims, yet to be supported, that manipulation can have an overarching effect on visceral disease.

By DrWonderful (not verified) on 05 Sep 2009 #permalink

"Excuse me, the fact is that most FDA approved drugs do not work for most of the people taking them most of the time!"

Beyond the fact that Dr. Rogers was not talking about "FDA-approved" drugs, there are several points that can be made in response to this:

Rogers seems to have been making his estimate in regard to any one given pharmaceutical drug, not the interventions as a whole that science-based medicine has available for a particular condition like asthma or cardiac arrhythmias. He would like to see improved testing to maximize the benefits of drug treatment for individual patients so they can go on the most effective therapy immediately without having to try less efficacious remedies first.

Pointing fingers at science-based medicine is a common tu quoque strategy employed by backers of woo when pressed on their dismal record of failure. And it is also typical for woo supporters to claim that "everybody is different" and to vastly exaggerate the importance of individual responses to treatment, to explain away the fact that there's such a multiplicity of ineffective woo therapies for any given condition and little but testimonials in favor of any of them.

I would love to see chiropractic as a whole leaving the "island of misfits", but the bridge off the island keeps getting blocked by the profession's boosters of adjustments for infant colic and other internal medical problems, use of expensive and ineffective gadgets, quacky "nutritional" therapies and destructive anti-vaccination positions taken by many chiropractors.

By Dangerous Bacon (not verified) on 05 Sep 2009 #permalink

Orac wrote: "if CAM/IM wants to play by the rules of science, it should play by the rules of science and quit trying to change the rules when they can't win under them."

This reminds me of a claim in the Textbook of Natural Medicine, that naturopathy tome of absurdity by Murray and Pizzorno:

"[with Bradley, 2nd edition] the criteria of the scientific method can be met by vitalistic medicine, but only when the researchers recognize that it cannot be studied as though it is reductionistic or based on a simplistic model of linear causality. When the experimental model acknowledges the complexity of a living system in a social context (i.e. holism and circularity), vitalistic medicine proves to be both verifiable and reproducible, and thus scientific [p.046...] the criteria of the scientific method can be met by vitalistic medicine [p.046]."

-r.c.

DrWonderful, the problem is that many if not most elderly people *have* sub-clinical or clinical CVD. So would you do the (presumably) only responsible thing and not treat them with this sort of technique if it carries such risks in this population?

Furthermore, there is simply no such thing like healthy arterial tissue in the elderly. Degenerative disease of the arteries is universal (and in part aging is defined by the very presence of degenerative changes). So where do you draw the line?

Kismet- I'm sorry but I am not aware of any cases where an elderly person suffered from a CAD follwing cervical manipulation. I am aware of one gentleman, one case, about 15 years ago who had a stroke in progress and the chiropractor missed it and complicated the situation. Patient presented with acute headache with numbness in the face. This is not a common occurance either, you know. Very, very, very rare. Almost all CAD's in progress are picked up by the treating doc.

Hard to eliminate an effective treatment procedure when there is a very, very, very rare occurance of injury. Unless of course you have a bias and are just looking to over exploit anything you can to dirty the waters. Shall we eliminate NSAID's? Seriously, they are much more dangerous and have no long term benefit whatsoever.

By DrWonderful (not verified) on 05 Sep 2009 #permalink

The chiropractic technique of neck manipulation/cracking provides a good example of a practice not amenable to randomized clinical trials, most obviously for ethical reasons.

It's hard to conceive of a way in which patients could be recruited for such a trial, given a procedure which has little to no proven benefit for any condition and which has demonstrated the potential for devastating harm in a small percentage of cases.

Some post-neck adjustment strokes have occurred in young people without other risk factors, and one wonders how chiropractors can in good conscience blame the patients for having defective anatomy.

By Dangerous Bacon (not verified) on 05 Sep 2009 #permalink

"DrWonderful" might like to peruse these articles about the risk of stroke after chiropractic manipulation

Chiropractic and stroke
Chiropractic Strokes Again! A Landmark Lawsuit in Canada
Chiropractic and Stroke: Evaluation of One Paper
Chiropracticâs Pathetic Response to Stroke Concerns
Adverse Effects of Chiropractic
The Problem with Chiropractic NUCCA
Neck Manipulation: Risk vs. Benefit

Note that one such victim is a 40-year-old woman who is now has locked-in syndrome (described in the article about the landmark lawsuit). Also note that the last two articles I listed were written by a chiropractor.

"It's hard to conceive of a way in which patients could be recruited for such a trial, given a procedure which has little to no proven benefit for any condition and which has demonstrated the potential for devastating harm in a small percentage of cases."

That's the beauty of (S)CAM: you can rely on whatever some 19th century quack pulled out of his nether regions as being some kind of ultimate truth, and not worry about those costly trials or their inconvenient results - if they don't support use of the therapy, you just ignore them and fill the "evidence gap" with faith.

Happ*h's comment was there. I deleted it as soon as it was recognized. That's what I meant when I said "he's gone again." I meant that I had deleted his comment and banned him.

So that's what happened to him Happ*h. Off to the cornfield.

By Sid Offit (not verified) on 05 Sep 2009 #permalink

Sid Offit: At the risk of sounding completely ignorant on a science blog, I'm going to ask if you are the moderator? Regardless, thank you for eliminating Happ*h and I'm sorry for thinking you meant me and happy to have it all explained. I just can't keep up with all this--every blog is different and I haven't been at this one very long.

As for chiropractors, and all the rest, why don't they just go to medical school or become nurses if they want fewer years of schooling? They seem so desperate to "heal". I don't pay a doctor to "heal" me, I pay for the expertise in diagnosis and treatment! Why would anyone pay for some "practitioner" to exercise faith?

By Janet Camp (not verified) on 06 Sep 2009 #permalink

"As for chiropractors, and all the rest, why don't they just go to medical school or become nurses if they want fewer years of schooling? They seem so desperate to "heal". I don't pay a doctor to "heal" me, I pay for the expertise in diagnosis and treatment!"

To be fair, the line about "healing" is one typically used not by chiropractors, but by other woo practitioners who claim to to fix chronic ailments that mainstream medical practice just puts bandaids on for its own nefarious purposes. Chiros realign your poor subluxed vertebrae which continually disalign themselves from birth onwards, necessitating an endless series of maintenance manipulations designed to keep you from collapsing into a useless puddle on the floor. I've never heard a chiro talk of "curing" a patient through adjustments to their spine. An actual cure would defeat the business model of chiropractic.

By Dangerous Bacon (not verified) on 06 Sep 2009 #permalink

I've never heard a chiro talk of "curing" a patient through adjustments to their spine.

See also this post from Dr* T's Thinking is Dangerous about some wording that appeared on a chiropractor's website.