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.

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

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