CAM and relative harm

Many supporters of Complementary and Alternative Medicine (CAM) note that the low incidence of harm from these practices pale in comparison to the horrors of other human activities such as alcoholism, poor diets, religious dogma, and smoking. The general conclusion being that efforts should therefore be more focused on these problems rather than the more “benign” CAM medical practices- even if most seem to be ineffective modalities whose ‘actions’ fall within the realm of placebos (other posts will discuss the relative value of CAM -if any- and the context outside of medicine in which some of it’s services might be provided).

While these types of comparisons may seem to make sense- most of us want to address humanities problems in some way- we need to look a little deeper before we let the CAM modalities run amok over the medical landscape.

Implying that CAM modalities are comparatively benign and can thus be allowed as a legitimate choice in medicine begs the question; because they are benign; then they are benign. In addition, there is a bit of over-reporting of the facts in claiming that CAM is, when compared with major social ills, an insignificant harm. Although not the major point, if one wants to go there, history is replete with examples to the contrary.

The crucial issue here is that critical thinking has allowed for solid and palpable progress in many areas of human endeavor. The progress in modern medicine is due in large part to utilizing this skill to derive effective modalities from the realm of science- a discipline that has given us the closest picture of the true nature of things we have as of yet.

If you take into account the significant harm non-science based medical practices have wrought throughout history using combinations of ineffective and often harmful therapies, the importance of minimizing the bubbling cauldron of ignorance in medicine today becomes ever more urgent- even if these therapies “appear” harmless compared to demonstrably effective medicine.

Without the self critical, self correcting methodology of science, modern medicine stands to become another recent socio-cultural phenomenon- a postmodern paper tiger. Conflagrating consumer “choice” in medicine together with the gory details of humanities frailties, socio economic missteps, religiosity, and often schizophrenic behavior misses an important point. That is, where critical thinking has flourished; it has been possible to better navigate reality as it is.

Freedom of choice brings with it a huge responsibility; especially regarding others. Add to this the fact that freedom of choice in medicine is further tempered with society’s demanding expectation (for the most part) that it provide the most effective practice possible- no matter what a person “believes”.

To date science provides the clearest roads to this end. Unlike religion, politics, or cultural roots, science reflects universal realities (i.e., you breath oxygen, are structurally bipedal, and communicate using a complex recursive language). In kind, scientific medicine strives to derive knowledge and treatments based on these truths. Not a religion or cultural dogma, it can flex, bend, and change- based on expanding scientific understanding.

If medicines imposed science based limitations are removed, society will again be open to a plethora of competing false realities among which the placebo- that ghostly deception- reins supreme. Indeed, this type of medical “anarchy” silences the all important need for honest discourse. Instead of a place where human touch, emotional acknowledgment, and real communication can truly thrive- even under the harsh light of reality- a thick fog of magic, dogma, and ideological suggestion would smother any effective medical progress, and turn even simple human behavior against itself.

CAM and higher education

A tragedy in the making?
During the course of clinical practice, veterinarians (and physicians) often encounter a variety of circumstances that affect the daily course of administrating care to a patient. They can either be a hindrance or a help towards the goal of attaining the most appropriate medical treatment for a given individual.

For example, refusing a blood transfusion or declining blood work can greatly impede ones ability to treat or diagnose whereas people jumping in line to donate an organ opens the doors to previously impossible therapies. Such is the way of clinical practice as the doctor blends his or her experience, current available science based knowledge, and the patients (or owners) perspectives in order to come up with a “do-able” strategy. These approaches vary depending upon the balance between these spheres of influence and often translate into unique therapeutic approaches. The ultimate goal is to find an effective balance that is heavily tempered with the hammer of scientific methodology.

In other words, even though an elected therapy may vary in some way depending upon a given situation, it needs to “pass muster” so to speak. It needs to demonstrate a level of effectiveness, plausibility, and repeatability that results from steady and rigorous inquiry from a serious- admittedly imperfect- community of humans involved in an intense endeavor; the search for reality based solutions.

This has been the responsibility society has given to the medical community, especially in the last century. Though the nature of healing may have a seemingly infinite set of variable influences and built in uncertainties, it has been wisely placed under the guiding light of methodologies that allows for consistent and tangible results.

Herein lays the growing concern when faced with a set of practices that walk away from these hard won lessons regarding healing. Though science is not a cult, religion, or some particular “post-modern” version of reality there are those who think that it is one or all of these things. Due either to misunderstandings, misrepresentations, and mostly, a lack of adequate science education many people falsely compare the hard won knowledge of modern medicine equally with archaic and implausible modalities such as homeopathy, the five elements, and most of chiropractic theory.

The alarms of reason and truth should be sounding all around the halls of higher education as these types of belief based and unreasonable systems gain a foothold within the realm of hard won legitimacy- without having any!

Dr RW discusses this very concern regarding the uncritical teaching of alternative therapies in US medical schools noting the alarming trend towards incorporating Complementary and Alternative Medicine (CAM) courses into their regular curricula. Are these courses being critically examined for plausibility and efficacy? The unfortunate answer is no! Sampson (University School of Medicine, California) cites in a 2001 study:

"Advocacy and non-critical assessment are the approaches currently taken by most U.S. medical schools in their courses covering what is commonly called "complementary and alternative medicine" (CAM). CAM therapies are anomalous practices for which claims of efficacy are either unproved or disproved. The author's research indicates that most medical schools do not present CAM material in a form that encourages critiques and analyses of these claims. He presents the reasons for the unwarranted acceptance of CAM. These include the CAM movement's attempt to alter standards of evaluating therapies. A survey of CAM curricula in U.S. medical schools in 1995-1997 showed that of 56 course offerings related to CAM, only four were oriented to criticism. The author's course at Stanford University School of Medicine approaches CAM with the skepticism and critical thinking appropriate for unproven therapies. The author concludes by calling on all medical schools to include in their curricula methods to analyze and assess critically the content validity of CAM claims.”

Another recent 2007 survey reviewing preclinical students at Georgetown University School of Medicine reflects a possible receptivity to CAM and illustrates that science based education and critical thinking skills may be lacking in earlier formal education:

“Interest in and enthusiasm about CAM modalities was high in this sample; personal experience was much less prevalent. Students were in favor of CAM training in the curriculum to the extent that they could provide advice to patients; the largest proportions of the sample planned to endorse, refer patients for, or provide 8 of the 15 modalities surveyed in their future practice.”

This 2002 survey explored the apparent lack of familiarity in US medical schools of CAM and the disconcerting assumption that these modalities are effective therapies:

“A wide variety of topics are being taught in U.S. medical schools under the umbrella of CAM. For the most part, the instruction appears to be founded on the assumption that unconventional therapies are effective, but little scientific evidence is offered. This approach is questionable, especially since mainstream medicine owes much of its success to a foundation of established scientific principles.”

Another eye-opening reason to be concerned about the infiltration of uncritical thinking and associated CAM modalities into medical education is the example of the insidious growth of CAM in the nursing profession as described by Sandy Szwarc.

“…it is also important that the public understand what is happening and that we hear the voices of nurses who are concerned about the growing adoption into nursing practice of alternative modalities that have no scientifically valid theoretical underpinnings or proven medical efficacy.”

Together, these observations reflect important warning signs the medical community needs to take seriously if the foundation of a reality based/critical thinking education is to continue to hold its proper role as the gateway to effective modern medicine.

Veterinary chiropractic

Human spinal manipulation and the jump to animals
The practice of Chiropractic medicine continues to be a controversial treatment modality in spite of persisting efforts by the Association of Chiropractic Colleges (ACC) to “integrate” into general science based mainstream medicine. One of the main problems is that the foundational theory and basis for chiropractic rests upon tenuous non science based concepts.The “Chiropractic Paradigm” proclaims on the ACC web site that the theory of the "subluxation", a nebulous entity not demonstrated to exist (let alone be the originating cause of a plethora of human and animal diseases) as integral to the practice of modern chiropractic:

"Chiropractic is Concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.

A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.

A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence."

In spite of efforts by more evidence based chiropractic practitioners such as Samuel Homola DC who strive to limit the extensive scope of unfounded treatment claims, a significant proportion of chiropractors continue to implement pseudo scientific methodologies.

One of the dilemmas for this profession is that a large part of its work involves spinal manipulative therapy (SMT) a separate practice often erroneously assumed to be only chiropractic in scope. In fact, physiatrists, orthopedists, sports medicine practitioners, physical therapists, athletic trainers all employ SMT in their practices. There seems to be some evidence that SMT relieves back pain to an extent and can be traced back to ancient history. Though this technique has beneficial qualities it does involve some components of the placebo such as the laying on of hands and perceived variations to pain.

Chiropractic differentiates itself from traditional SMT by prescribing to specific implausible theories such as the subluxation and that this entity is the root of nerves impingement's that lead to disease. Though the present chiropractic society strives to dress this concept with scientific legitimacy, the bottom line is that such theories have not met the criteria of quality research. Therefore, chiropractors who are working to reform the practice and limit its scope are faced with having to completely shift the “chiropractic paradigm” in a big way- a daunting task:

"The dilemma reformers face is that chiropractors do not perform any service or deal with any condition not covered by some other health profession. State laws that enable them to practice either specifically mention the subluxation theory or describe it as the basis for chiropractic as an entity. Renouncing chiropractic's theoretical basis would eliminate its justification for existing as a separate profession.

Reformers acknowledge that they offer mainly the specialized skill of SMT. They believe that SMT is underutilized and that a substantial market exists for their skills. Although other health professionals can legally perform SMT or treat functional back disorders, most do not. To become skilled at SMT requires more time and effort than most physicians or physical therapists are willing to invest, especially when they feel that they may achieve the same clinical results over the long term with less demanding modalities."

Chiropractic medicine has origins specifically from the strange metaphysical pondering of one layman; Daniel Palmer who speculated that most disease was caused by spinal subluxations that impinged nerves thereby leading to disease:

“Obsessed with uncovering "the primary cause of disease," Palmer theorized that "95 percent of all disease" was caused by spinal "subluxations" (partial dislocations) and the rest by "luxated bones elsewhere in the body." Palmer speculated that subluxations impinged upon spinal nerves, impeding their function, and that this led to disease. He taught that medical diagnosis was unnecessary, that one need only correct the subluxations to liberate the body's own natural healing forces. He disdained physicians for treating only symptoms, alleging that, in contrast, his system corrected the cause of disease.

Palmer did not employ the term subluxation in its medical sense, but with a metaphysical, pantheistic meaning. He believed that the subluxations interfered with the body's expression, of the "Universal Intelligence" (God), which Palmer dubbed the "Innate Intelligence." (soul, spirit, or spark of life). [9] Palmer's notion of having discovered a way to manipulate metaphysical life force is sometimes referred to as his "biotheology."

Human chiropractic today, under the cover and dressage of “science” still has not gone past many of these implausible notions. It is therefore easy to imagine why other peculiar modalities such as odd and implausible diagnostics (applied kinesiology, contact reflex analysis, “nutritional” consultations, reflexology, and hair analysis among others) have taken root in chiropractic medicine.

The relationship to spiritual world views of the soul at least suggests that expanding these concepts beyond the human body were not immediately considered. Animal chiropractic and animal souls seem not to have been an initial part of the theory for this treatment modality. The leap to animals however, did take place using a similar “intuition” and integrative approach used in other alternative practices (Note the resemblance to the “natural correspondence” theory and “energy” pattern and flow concept of the "qi" found in TCM).

The transposing of chiropractic to animals seems to have little basis in research and relies on the general precepts of the slippery “subluxation” theory. In addition to being an unproven entity in humans it is interesting to note that “No part of chiropractic education deals with animals, and no part of veterinary education deals with manipulative forms of physiotherapy.”

However, a veterinarian or chiropractor can be “certified” to practice animal chiropractic after complying with about 150 hours of coursework. These educational courses are offered at five locations approved by the American Veterinary Chiropractic Association. A quick scan of two of the websites indicates that the concept of the “subluxation” is alive and well in the arena of animal chiropractic:

"Integrated Case management " -6.5 hours – (All of the following are addressed by lecture, in small group discussion and/or with expert panel debate through an open question forum.) Review of the chiropractic theories and the contemporary vertebral subluxation complex; define assess and apply animal chiropractic diagnosis of the vertebral subluxation complex; and, investigate the creation and application of appropriate clinical goals and applying them to our integrative treatment protocols.”-

"What is animal chiropractic? "
Animal Chiropractic understands the relationship of the spine and nervous system to proper function and over all well-being of small and large animals. The application of this art utilizes a small amplitude, high velocity thrust to areas of spinal subluxation in order to facilitate proper function of the nervous system resulting in enhanced performance and quality of life".

The jump from one mans “epiphany” for curing disease through spinal manipulations is difficult to comprehend. The leap to animal chiropractic becomes even harder to grasp, especially if you consider the enormous variation in body types and sizes found in the animal kingdom.

Though animal based chiropractic education seems to address some anatomical topography, there continues to be a theoretical gap in the transition from human focused approaches to animal techniques. Additionally, the obvious fact that human body architecture is based on a bipedal mechanics and the vast majority of other animals are quadrupeds needs serious attention when considering practical and functional chiropractic transitions from human treatment theory to the rest of the animal kingdom.

Chiropractic medicine seems to continue to base its efficacy more on a priori knowledge, belief, testimonials, and pseudo scientific modalities rather than on scientific plausiblity and quality evidence based research. It is prudent to review some of the basic strategies the American Veterinary Medical Association has developed for veterinarians that are considering alternative modalities:

"AVMA Guidelines for Complementary and Alternative Veterinary Medicine

(Approved by AVMA House of Delegates 2001; revised by the AVMA Executive Board April 2006)

Introduction These guidelines are intended to help veterinarians make informed and judicious decisions regarding medical approaches known by several terms including "complementary," "alternative," and "integrative." Collectively, these approaches have been described as Complementary and Alternative Veterinary Medicine (CAVM). The AVMA recognizes the interest in and use of these modalities and is open to their consideration. The AVMA believes that all veterinary medicine, including CAVM, should be held to the same standards. Claims for safety and effectiveness ultimately should be proven by the scientific method. Circumstances commonly require that veterinarians extrapolate information when formulating a course of therapy. Veterinarians should exercise caution in such circumstances. Practices and philosophies that are ineffective or unsafe should be discarded."

This is is a call to veterinarians (and in essence, to all health providers) that we have a responsibility to provide effective and sound options to a public that entrusts us to find and offer them. Human and animal chiropractic medicine for the most part, has not met those standards.

Ref:

www.chirobase.org/01General/controversy.html

www.chirobase.org/05RB/BCC?update.html (dated, though good assessmant )

Animal therapy over the ages2. chiropractic 3. homeopathy. Haas BK. Veterinary heritage. 1999 Nov; 22(2):38-42

www.chirobase.org/06DD/chirovet.html

www.avma.org/issues/policy/comp_alt_medicine.asp

Veterinary acupuncture

Brief Overview

Today, veterinary acupuncturists of all types are literally every where. As human acupuncture practice has become more popular in the last 20 years, the consumer seems to have increasingly sought similar treatment for their pets. It is now common place to observe some type of alternative medicine, of which acupuncture seems quite common, being offered even in non-alternative oriented practices.

There is also seemingly no end to the maladies and conditions in animals that acupuncture can treat or support. These claims embrace many different animal species and include such diverse disease as equine colic (abdominal pain) and canine arthritis to reproductive and metabolic disorders.

One problem though, is the huge vacuum of any substantiated evidence (damned pesky word again) that might back these claims in animals ( including humans). There are recent acupuncture studies that claim positive results regarding, for example, points associated with metabolic mechanisms or 'epigenetic' effects. However, extreme care should be taken in interpreting these results until quality evaluations on them can be done.

Interestingly, there appears to be country based bias problems to overcome in addition to quality assessment when evaluating many of these studies. Overall, there is precious little in the way of well constructed studies in veterinary medicine or even in human medicine that take a good look at acupuncture effects, or for that matter, veterinary acupuncture technique. There are systematic reviews that conclude that the many studies that do exist involving domestic animals are of low quality and have equivocal results. Also, the higher quality studies out there point to more negative results with regard to the efficacy of acupuncture.

The point is….where?
One of the more salient details in animal acupuncture though is the problem of acupuncture meridians and points. How were animal meridian charts developed? Veterinary acupuncture seems to be a much more recent phenomenon than assumed by many of its practitioners.

This opens up a hopeless quagmire of contradictions between present day acupuncture and the historical acupuncture record. Chinese historians of human acupunture describe ancient acupuncture as manipulating qi (vapors) running through mai (conduits) by puncturing the skin with needles. The first theories regarding what developed into human acupuncture are described in the Huang Di nejing (Inner Classic of Huang Di) between the 5th and 8th centuries. This work introduced the idea that the human body contains "depots" connected by a series of conduits that allowed for qi to flow. Revealingly, there is no mention of similar theories concerning animals.

The oldest veterinary therapeutic description of anything close to needling can be found in Song times during or well after 1000 AD. Sources such as the Famma zuan yanfang (Compendium of Efficacious Recipes from the Nomadic Tradition) described needling in regards to cauterization and blood letting similar to what was practiced in Western historical medicine. Later in the 17^th century the Yuan Heng Liaoma ji (Collection for Treating the Horse; circa 1608), an important veterinary text, described needle points in relation to bleeding, cautery, surgery, or divination...but not acupuncture. Additionally, it indicates -whatever the type of needling used- that human and animal treatment points were not the same. In any case, these ancient texts bear little resemblance to the type of veterinary acupuncture practiced today.

“Modern” veterinary acupuncture history utilizing meridian and point concepts can actually be traced, in large part, to 19^th century Europe. The association of the historical vital vapor qi as being a form of energy was not made until 1939 which was when the term meridian was created (in human acupuncture as well). Interestingly, animal acupuncture meridians dates only to the 1970’s and were invented for Western practitioners. At this point, it was Western authors, for the most part, that formulated the various meridian charts for a variety of domestic animals by transposing human meridian charts to each animal species.

That the whole idea of acupuncture and "vitalism" oriented meridians can be transposed from humans to any species is one of many modern “intuition” oriented discoveries that gave form to today’s veterinary acupuncture. The actual historical record contradicts the common "appeals to ancient knowledge" often associated with acupuncture. It seems that modern veterinary acupuncture utilizes recently formulated meridian charts that were basically made up. In essence there is no real point… to put the point.

Historical reference: Complementary and Alternative Veterinary Medicine Considered, Ramey D, Rollin.B

Veterinary Nutrition on the Fringe

Introduction

The last decade has seen a veritable explosion of animal nutritional products of all kinds as innumerable food and supplement companies ply their wares to a largely eager public. A simple stroll through many pet stores illustrates this fact as evidenced by the quantity of options readily available to a consumer already accustomed to variety and choice.

There is an endless array of different colored and sized bags ranging from economy priced to “designer” categories of foods featuring premium grade ingredients. There is no end to the list of “special” additives such as nutraceuticals, herbs, and anti oxidants featured on many pet food bags claiming improved joint function, shinier hair coat, or increased intelligence. There are a variety of general movements within the mainstream pet food industry as well as along its margins that promote specific diets such as the “archetypal” dog food or raw food diets . There are even companies that enthusiastically support the concept of breed specific and gender based diets .

This is only the tip of the ice berg where the world has seemingly gone mad churning out a mind boggling array of all types of nutritional supplements, vitamin mixtures, herbal concoctions that include liquids, powders, pills, or capsules. There is sensory overload of images that can blunt any rational consideration of what to buy.

Through the years, there were occasions along the way when I got caught up in the latest furor regarding a nutritional concept or whole heartedly supported a fictional or unsubstantiated food paradigm because "it made sense". I was sometimes swept away by attractive jargon or beautiful ideas that later proved far too simplistic. This experience has helped me sort out that the basics; moderation and balance are the keys to solid nutrition. I know-boring, but true!

Michael Shermer in “Why People Believe Weird Things" describes his experience with alternative nutritional and medical practices during his career as a cyclist. With the attitude “it can’t hurt and maybe it will help” Mr Shermer experimented with a plethora of strange medical practices such as colonic therapy, metabolic supplementation, and a form of live blood cell analysis to mention a few. Realizing over time that these approaches had no obvious effect and sometimes even seemed to have a negative impact, he eventually became deeply skeptical. Hence his fascination as to why do even smart people support dubious and questionable practices?

Its a no brainer many very intelligent people readily get caught up in odd concepts and fuzzy intellectual ideas. Without the right tools to probe the reality of ones surroundings it is extremely easy to stray. Add to this the confounding factors of human emotion and ego and it becomes a wonder we can ever get things even close to how they really are!

What does this have to do with nutrition? By creating a set of basic foundational concepts, whether they are based on fact or not, one can create a skewed view of reality and construct vast, complex worlds that may have a tenuous hold on the truth and little to do with the way things actually are. By making false assumptions or establishing weak relations as fact it is not difficult to explain any idea. The hard part is deconstructing a false model one has worked so hard to put together, especially if it becomes deeply ingrained in your psyche or begins to mesh intimately with your beliefs.

This is the genesis of extraordinary paradigms and, on the surface, apparently solid ideas. In the case of religiosity, they might be survival mechanisms, they might be by-products or something else. In nutrition these paradigms are clearly delusional and can be described as “Paranormal” constructs of nutrition.

If these “Paranormal” nutritional concepts are expanded upon and sprinkled with half truths and occasional facts, the "big picture" of animal and human nutrition can become just a pretty mirage. Add to this the alluring siren call of major monetary income and you have a hell of a mess.

If one looks over the panorama of food and supplement companies in this country (USA) you are literally inundated with information supporting this or that claim for whatever product is being peddled as the consumer is presented with an array of effective communication techniques. How can anybody differentiate the chaff from the wheat amongst the glossy brochures, posters, radio and TV adds, expert opinions, and exuberant testimonials ?

The many tenants and facts permeating "paranormal" nutrition are based more on belief and opinion than reality. After coming across too many contradictions and unsupported facts, as a one time "believer", I finally humbly returned to being a cautious “hopeful” skeptic.

Many nutritional ideas might have a solid factual basis and convey intriguing possibilities in preventing or improving disease. Generally though, proponents tend to jump the gun, often skipping fundamental limitations, while highlighting convenient facts over contradictory ones to reach tenuous conclusions.

In coming posts, I will touch on specific examples of how nutritional ideas can take unusual paths and discuss how some food and supplement companies bypass label claim limitations using "nutritional seminars", alternative medicine providers, and even science based veterinarians and physicians.

Alternative medicine: a ghostly illusion

Most of Complementary and Alternative Medicine is built on a house of cards
A nicely worded post at Panda Bear, MD (sadly, no longer blogging for now) succinctly describes many of the problems I have encountered through the years while attempting to put my finger on just how alternative medicine is defined. Many personal discussions with alternative practitioners and fairly extensive research of alternative medicine texts has continually left me with no real tangible how, when, and why answers.

"Almost everything about Complementary and Alternative Medicine (CAM) is bunk and its purveyors are at best deluded and at worst quacks and charlatans who would make the snake oil salesmen of olden days blush from shame. Maybe a hundred years ago you could make a case for magic potions and mysterious cures from the East but today we should know better and only don’t because of a combination of scientific illiteracy and an ingrained bias against rational Western thought. What little benefit patients can derive from most of the quackery being sold to them is not worth a fraction of the money spent and the same effects could be achieved without the smoke and mirrors if people paid as much attention to diet, exercise, and all around clean living as they do to looking for an easy fix."

Unfortunately, this mirrors my experience in the veterinary world as many clients, swayed by their own perceptual biases, often search out these fallacious "other ways of knowing". I would like to make it clear that science based medicine is not perfect, nor does it have all the answers. Additionally, we need to consider all medicine as one concept, and look at all of it with the same critical attitude. Alternative Medicine steers clear of this rigorous approach and it became clear to me why as I realized it is mostly nothing more than myth, belief, and nostalgic notions of ancient wisdom.

"CAM exists in an alternate universe from real medicine. It wants to be legitimate but manages to avoid the responsibilities and liability of real medical practice. As most CAM treats nebulous symptoms with equally nebulous modalities, there is no measurable standard for efficacy of any of the treatments. "

This is one of the key problems that I have run into time and again. How can we know that what we are doing as practitioners is doing any good without having a reliable mechanism to steer our often imperfect attempts at helping and healing the sick?

"The real medical profession while imperfect like all human endeavors is not so conservative that ineffective or ridiculous therapies are not discarded. This is the whole basis of evidence based medicine. There is no evidence based Complementary and Alternative Medicine. It exists in the absence of and often despite the evidence. When challenged, its practitioners will retreat like the sweaty televangelists to anecdotes and testimonials. Either that or they will cite the placebo effect, that last hope and refuge of medical scoundrels and upon which rock they will cling as their last handhold in the rational world."

What is often not realized by many, is just how seriously many of these modalities have been and are considered, analyzed, and tested by "traditional" medicine. That they are mostly discarded is a function of efficacy, plausibility, results, and repeatability.

Another growing issue that needs confronted are the many implausible approaches are sucking up precious monies that could be better spent in other ways. For example, the current federal allocation for the National Center for Complementary and Alternative Medicine (NCCAM)is around $110 million/year. The NCCAM has had among its research agenda projects related to cranial osteopathy, in vitro investigation of distant Qi Gong, Gonzales therapy for cancer (consisting of coffee enemas, pancreatic enzymes, hundreds of dietary supplement pills, and hair analysis), and magnetic therapy. In comparison, consider the $5 million /year allocated for spinal muscular atrophy, a devastating pediatric disease.

The beckon call from most physicians, veterinarians, scientists, researchers, and probably the majority of people in general is that we critically evaluate what we do, constantly question our methods, modify and change them as needed, and strive for the goal of attaining the very best, most effective, and humane medicine possible.

Science

…and how to know it when you see it
Every once in a while it is good to briefly review the general concept of what science is and how to separate it from other non-science based concepts.

Science involves a set of cognitive and behavioral methods designed to describe and interpret observed or inferred phenomenon- past or present- that are aimed at building a testable body of knowledge open to rejection or confirmation(1), The crucial part of this is that science- the best system of gathering knowledge we have- grows over time as useful features are retained while non-useful items are eventually discarded based on the rejection or confirmation of the gathered testable knowledge.

Put another way, testable knowledge -a theory for example- needs to satisfy two fundamental requirements. First, it needs to explain the observed phenomenon better (more comprehensively) than other competing theories. Second, it has to be able to make testable predictions that are correct.

Non-science/pseudoscience
Michael Schermer put together ten questions(2) worth asking when trying to define the boundaries between science and non/pseudo-science that serve the inquiring mind well in the search for reason among, for example, the plethora of medical claims and therapies out there. They are as follows:

1)How reliable is the source of the claim?

2)Does this source often make similar claims?

3)Have the claims been verified by another source?

4)How does the claim fit with what we know about how the world works?

5)Has anyone gone out of the way to disprove the claim, or has only supportive evidence been sought?

6)Does the preponderance of evidence point to the claimant's conclusion or to a different one?

7)Is the claimant employing the accepted rules of reason and tools of research, or have these been abandoned in favor of others that lead to the desired conclusion?

8)Is the claimant providing an explanation for the observed phenomena or merely denying the existing explanation?

9)If the claimant proffers a new explanation, does it account for as many phenomena as the old explanation did?

10)Do the claimant's personal beliefs and biases drive the conclusions, or vice versa?

Here is another short list of considerations to have handy that help identify non-science based claims that was put together by Langmuir(3,4). It's another set of tools that helps cut through much of the confusion when perusing the literature:

1) Claimed effect being studied is often at the limits of detectability.
Subjective visual observations replace objective instrumental measurements.
The maximum observed effect is produced by an agent of barely detectable intensity.

2) Investigators readily discard prevailing ideas and theories and disregard criticism of their new ideas and theories.
Investigators concoct new ad hoc theories to account for the phenomenon.

3) Investigators do not attempt critical experiments that could refute their new theory by determining whether or not the effect is real.
Experiments done by others that refute the new theory are disregarded.


Ref:
1) Shermer M. The triumph of the scientific method: The most precious thing we have. Skeptic 1(1):34-49. 1992
2) Shermer M , Scientific American, 285:5, November, 285:6, December2001
3) Dr. Irving Langmuir, 1932 Nobel Laureate, as condensed by DL Rousseau in: "Case Studies in Pathological Science: How the Loss of Objectivity Led to False Conclusions in Studies of Polywater, Infinite Dilution and Cold Fusion," American Scientist 80:54-63 (1992))
4) Ramey, DW (1998). Pathological Science. World Eq Vet Rev 3(2):25-27.

Beyond the Illusion

Natural variations of disease:
Phenomena often mistaken for medical treatment success
Understanding the natural history of disease sheds a light on how well a given treatment is really working. This is an area where many people, professional health practitioners or not, often get tripped up by erroneously attributing improvements in a disease to whatever treatment is being used. Elaborating a little on the "Chasing Placebo's" post, I'd like to touch on some specific phenomena that are easily confused for treatment success in medicine and especially alternative medicine.

Spontaneous improvement: As simple as this sounds, it is common for diseases to completely or temporarily improve through a variety of natural processes. A virus "burns itself out" or a failing organ reaches a plateau and begins to work reasonably well. The body has thousands of possible solutions to reach for when confronted with pathology, many times it attains good results with little outside help.

Regression to the mean: Many diseases, especially chronic and slowly progressive ones tend to have a waxing and waning behavior. This is the classical good day/bad day scenario often observed by the medical world. Reading too much into our efforts can lead to inappropriate assumptions.

"Post hoc, ergo propter hoc" or "after this, therefore because of this": This is a very common fallacy associated with this natural cyclic behavior of many diseases. I treated with x, and the patient improved, therefore it was because of x treatment.

Hawthorne effect: This is a perceived improvement following a treatment. It has to do with psychosomatic influences related to illusory cognitive perceptions. The term originates from a 1924 experiment at the Hawthorne General Electric plant where employees were told that the lighting levels would be manipulated to study their effect on production. Whether the lighting increased or decreased production seemed to increase.

Additional treatment: This is a very common fallacious association. Many alternative practices are implemented along with other evidence based approaches, but any positive response is associated predominantly with the alternative therapy. "Coincidence does not equal certainty" as Michael Shermer noted."Doc, ever since I started taking Sammy to the acupuncturist he started walking so much better! By the way, I need more of those arthritis pills, without them he can't move..." This makes me want to hit my head against a wall, but amazingly, it is a very common scene at the hospital.

Conditioning and Expectancy: This is another perceptual illusion, and can be the basis for supposed improvements in some animals. It is a form of learning an training where a conditioned response can be confused with some type of improvement in a chronic disease. "Spot perks up every time after seeing you..." could be nothing more than a change in that persons or animals routine.

Perception of the client and Practitioner profiles: How a disease affects a persons well being can be influenced implementing simple social interactions. By listening, touching, and spending focused time on a patient, they may be better able to confront the challenges of that disease.This is a delicate subject because the health provider needs to walk a fine line between inadvertently creating false hope, and setting realistic goals. If you have a ready response for everything-"Well, if this doesn't work, we'll do this other thing"-something positive might fall into your lap. However, the risk of creating "delusional" illusions and, consciously or not, falling into deceptive practices seems alarmingly high.

Ref:
Why People believe Weird Things. Shermer, M. Henry Holt & Co. New York. 2002Complementary and Alternative medicine Considered. Ramey, D, Rollins,B. Blackwell Pub. Iowa. 2004

Traditional Chinese Medicine- part 2

中醫學

Chinese Medicine: then and now (cont. from TCM part 1)
The earliest known traditions related to Chinese medicine date from the 17th to 11th centuries BC during the Shang dynasty and involved ancestral influences. It was believed that ancestors had influence over the living and were able to directly endanger and destroy human life. The focus of healing practice was directed at, not only the living, but the deceased.

Ancestral ritualistic healing practices were later supplanted by more generalized yet still identifiable entities such as demoniacal, magical, and supernatural beliefs. These forces were thought to be the cause of disease. For example, "swellings" were thought to be caused by possession and healing practices utilized instruments such as needles in an effort to purge the affected body of the demon.

The Han dynasty was a period of significant importance to historical Chinese Medicine and is described as being the most formative period of its development. During the 2nd century BC to the 2nd century AD, a Chinese intellectual elite attempted to categorize and explain the world and its phenomena to a reduced number of causes and effects. An attempt to supplant "demonological forces" with so called natural laws gained momentum.

During this period, there were varying attempts to systematize the natural world by creating grouped contexts or constructs associated with the natural environment. This led to the creation of systems and thought in which the practice of healing could be connected with these now categorized phenomena. Here there are glimpses of a more rational approach to medicine. Alas, the earlier magical influences would not be eliminated and eventually a hybrid version of naturalistic/magic Chinese medicine began to take root.

There erupted a plethora of different world views, healing practices, and methods. These approaches often contradicted each other in sometimes fundamental ways. Unfortunately, this intriguing period of inquiry and observation never led to further developments and refinements of Chinese medical theory. The bubbling pool of thought that could be considered a "pre-enlightenment" era never reached a point of general consensus and no method to move toward a reconciliation ever developed.

Concepts such as the ying/yang and the five elements were combined with healing practices creating a confusing litany of disarticulated therapies. During this era, practitioners created forms of "systematic correspondence" which were comprised of assumed links between a practitioner’s perception of the natural world and the human body.

There followed a period after the Han dynasty where two general schools of thought came to the fore. A traditional view of "systematic correspondence” continued creating often baroque and elaborate intuitive theories. Interestingly, it is at this point that acupuncture literature begins to frequently appear in the historical record. These worldviews supported the belief that all things were related through some unseen web of connection and the body for example, could be influenced by changes elsewhere in this system.

"If in winter one behaves as one would in summer, bad things might happen"

In some ways, these systems like many other ontologies – even today- have some empirical seed of truth to them but then proceed to commit the error of fallacious or magical thinking. One big fallacy at the time was confusing correlation and causation –“correspondence”- the results of which produced a realm of completely fictional medical paradigms.

The other area of thought concentrated on a more pharmaceutical approach to medical treatment exploring herbal medicine, and was initially more promising. Unfortunately, this early methodology continued to emphasize very basic and erroneous themes. Disparate and conflicting concepts such as qi, yin/yang, and the five elements are intermingled with the use of herbs and they loose therapeutic coherence and potential refinement as reason and observation give way to assumption and belief.

There was an attempt, especially between the 12th and 15th centuries to reconcile these two traditions but they were ultimately unsuccessful and the whole of Chinese medicine theory remained stagnant and irreconciled from that time on. Epler (CAVMC, ch2, pg 22) elucidates;

" In the history of Chinese Medicine, rather than progressing from a reasonable, although incomplete knowledge of the body to a more detailed one by systematic dissection, the medical writers go in the opposite direction, under the sway of the cosmologists, to a less accurate picture."

It is important to note that until recent times, Western and Eastern medicine had similar belief based origins. Ramey and Rollins note “It is only in modern times, with the development of science-based medicine in the West, and the subsequent discarding of metaphysical approaches to medicine, that Chinese (Eastern “traditional”) and Western practices have been brought into opposition.”

In fact, Chinese traditional medicine is actually beginning to fade in China as a primary practice with the country’s rapid progression towards modernization. Some estimates reveal that about 15-20% of people in China presently use only traditional therapies contradicting the claims of many alternative practitioners.

In Western countries, the Traditional Chinese Medicine actually observed and practiced is based on a westernized version of Zhongyi, or "modern Traditional Chinese Medicine". Zhongyi is in turn a distillation, a "best hits" version of the more rational parts of Chinese Medicines vast and disarticulated past. Much of Zhongyi was put together from the 1950's to the 1970's at which point the West eagerly received what they thought of as "ancient medicine".

According to Ramey and Rollins “…the transformation of Chinese traditional medicine into Traditional Chinese Medicine from the 1950s and 1970s did much to bring Chinese medicine closer to modern rationality…the vast heritage of Chinese traditional medicine that directly contradict modern science and rationality have been omitted from the many publications on zhongyi published in the People’s Republic of China since the mid-1970s. Hence, Westerners returning from China in the late 1970s and 1980s took home a “gift”, which they considered to represent two millennia of Chinese medicine while in fact it was a streamlined body of concepts adapted to modern rationality. It is this streamlined body, then, which was once more modified in the West to meet the expectations of Western audiences.”

Here the tale loops to the beginning of the West’s current fascination with Traditional Chinese Medicine or better said a twice removed, manipulated, and designer made Western version of Traditional Chinese Medicine.

Ref:

Complementary and Alternative Veterinary Medicine Considered (Ramey & Rollin)

Traditional Chinese Medicine- part 1

中醫學

A large part of alternative veterinary medicine and much of its philosophical foundations base themselves on a rather loose jumble of historical Chinese theories that concerned themselves with the universe and humanities role in it. Many of these systems had their own unique take on diseases and to how treat them.

If you look at the span of time from ancient to modern day China one notes a fascinating and irregular waxing and waning of effective medical progress. Periods of “endarkenment” intermingled with those of “enlightment” where literally dozens of medical paradigms –like the faddism of today- came and went. That most of these practices represented medicine in the pre-scientific age is often not considered by many of its western proponents.

Many Complementary, Alternative or Integrative Veterinary Medicine (CAIVM) supporters seem to have cherry picked and modified ideas from one or another of these archaic nonmedical/beliefs based systems and gathered them under a broad conceptual umbrella called “Traditional Chinese Medicine” (TCM).

It is interesting to note that modern China is rapidly entering an increasingly scientific era regarding medicine and the country as a whole is experiencing an age of unprecedented growth and modernization transforming itself in the process.

During the recent transnational world congress on Scientific Inquiry and Human Well-Being in Beijing, Ren Fujan, professor at three Chinese universities and executive director of the China Research Institute for Science Popularization noted that “China is now in a great flourish of development in science popularization.” As it struggles with major growth pains, it appears resolute in advancing society with science based methodologies while leaving behind superstition and other archaic belief systems- including those used in medicine.

On the other hand, there are those in the west that pretend to separate medicine instead of considering it of one body. With this in mind, it is important to have a better historical context of Traditional Chinese Medicine. The root of much of the alternative veterinary movement grows from many of these socio-cultural events.

A History Revealed

"How did you get your clothes so clean?...
....Why, it's an ancient Chinese secret!"
Calgon Commercial (circa 1973)

Years ago, a television add parodied the illusion of magic while promoting a cleaning product. Although it was a promotion for a clothes detergent, the skit humorously played on the rediscovered allure the West had for the mysterious orient.

This famous (or infamous) add reflected the remarkable events occurring at the time in the US during the early 1970's. The anti-institutional "Flower Power" decade of the 1960's and its societal effects still reverberated throughout the country. The ongoing Vietnam War served as a backdrop to pacifist protests such as the disastrous Kent State Massacre. The Watergate scandal was just beginning to unfold and would help to push the entire country towards profound levels of disillusionment.

The timing was just right to introduce "other ways of knowing" as the national consciousness yearned for relief and comfort. It is not hard then to imagine, that when President Nixon took his unprecedented trip to the Peoples Republic of China in 1972 the nations interest and attention turned towards things Chinese.

Enter a president eager to demonstrate effectiveness, a naive western media, and a strained "proletariat" communist party keen on representing its uniqueness, stability, and power to the world. Like a perfect storm, these swirling events coalesced into a golden moment capturing the ever fickle US curiosity.

Here the Chinese delegates, knowingly or not, played an ingeniously subtle card capitalizing on China's long history and presented the concept of a unified "Chinese version" of medicine. It was represented as all encompassing, highly effective and based on ancient tradition. The West took the bait hook, line, and sinker!

Hence, was born the seeds of our present day conceptualization of Traditional Chinese Medicine. The smoldering embers of public interest of the unknown were fanned into flame as a new wave of popular fascination took hold of the West. There followed a virtual explosion of thought, theory, publications, seminars, gurus, and wise men that promulgated profound universal concepts that professed salvation based on "ancient Chinese secrets". Traditional Chinese Medicine was the panacea to a perceived cold and impersonal Western style of practicing medicine.

However, fundamental misconceptions of Traditional Chinese Medicine fomented then have, for the last several decades, taken a firm grip on the Western imagination, growing and propagating as allegedly factual.

Some of these alleged facts include the impression that Traditional Chinese Medicine (TCM) is a historically coherent and unified practice, that it is the only or mostly used medical practice in China and that TCM is made up of a large body of well researched "alternative" therapies having similar or equal efficacy to modern Western medicine.

That none of these facts bear out under scrutiny underscores the need to discuss what the actual historical record and evidential data reveal. The next post will touch on the first two points. The efficacy of TCM “alternative” therapies will be considered in due course as this blog posts on specific therapeutic modalities (i.e.; acupuncture, pulse diagnosis, herbal medicine, vitalism).

Traditional Chinese Medicine-part 2

Vetskeptics: a blog

The internet is an easy to use and powerful tool for accessing all kinds of useful information. It represents a real revolution in communications and offers a hopeful way for spreading useful and constructive ideas to a global community.

At the same time, this virtual landscape is littered with misleading and false information that misrepresents and twists the facts to fit all kinds of beliefs, dogmas, and points of view. It is important to have your “thinking cap” on when navigating these sometimes turbulent waters searching for the good stuff- especially when it come to important matters such as medicine.

This brings me to the core of the issue. When it comes to health we are obligated to tread with great care. Medical therapies need to go through a rigorous and continual process that works to keep them “honest”. Therapies in veterinary medicine also have to pass this all important prerequisite. They need to be vetted and put through the filter of scientific methodology- the best tool we have for holding on to and refining that which works while being able to disregard what doesn’t.

This is becoming ever more critical in this -what many would call- an “anti-enlightenment” era of confusion and non-science based pressures which threaten to dilute true medicine with delusional practices and magical thinking- even if they seem well meaning.

The veterinary e-world reflects this frustrating situation especially with respect to Complementary, Alternative or Integrative Veterinary Medicine (CAIVM) where one can find a sea of promotional and apologetic sites supporting its use, but precious little in the way of balanced resources that evaluate them critically. The often over the top claims by CAIVM proponents needs to be tempered with a good dose of science and skepticism of which there is precious little of.

In that regard, Vetskeptics endeavors to provide a haven for those interested in reason and critical thought from where CAIVM or -for that matter- any veterinary topic can be considered and discussed with the goal of open and honest inquiry. There are some excellent veterinary resources that support this goal and I will continually add to our link list as I- and you- discover them.

Initially, Vetskeptics will serve as a concentrated repository for several veterinary topics I have written about in the Wanderingprimate blog site which is developing a broader topic range. I plan to review many of these posts and improve on them here, while others will be archived here for better referencing.

Another goal for Vetskeptics is to encourage and promote new work and posts from various authors. Whether you are a veterinarian, veterinary technician, animal care giver or animal lover this blog is interested in quality writing that will improve on and add to what’s here.

It is our hope that this blog will become one of a growing number of voices that promote science and evidenced based veterinary medicine. With your continued help it can become an ever better critical thinking oasis for the veterinary and animal care community.