Dr. Carol begins, as proponents of such nonsense treatments so often do, with a meaningless heartwarming anecdote.

Dr. Carol Osborne has seen first-hand the effects a coffee enema can have a dog – and in one particular case, the effect was nothing short of miraculous. When a friend and clients dog suffered acute liver failure, other veterinarians recommended euthanasia. Unable to part with her pet without at least a second opinion, the pet’s owner contacted Dr. Carol as her last resort. In addition to the administration of intravenous fluids, Dr. Carol gave the small dog a coffee enema. Not only did the dog improve, he began to thrive.

Anyone who follows this blog is familiar with the unreliability of such stories, and all the reasons why bogus therapies may seem to work when they really don’t. Acute liver disease is a classic example of a problem which often, and sometimes unexpectedly, resolves on its own with only supportive care (such as IV fluids), due to the regenerative capacity of the liver. I always find it strange that proponents of alternative medicine frequently talk about the body’s innate healing abilities and yet always seem fine taking the credit when a patient gets better.

The arguments Dr. Osborne gives for why this therapy ought to be helpful are no more valid or convincing than the opening anecdote.

Coffee, when administered via enema, stimulates the production of glutathione by the liver. Glutathione is required by the liver to function properly. When the liver fails, glutathione production ceases. By stimulating production of this vital nutrient, the coffee enema helps the liver to once again perform.

Coffee enemas also work as a detox… 

The walls of the intestines, once thin and clean, will become thicker over time with the debris that sticks to the walls preventing the body from digesting and absorbing vital nutrients.

If something is not done to counteract the thickening of the intestinal walls due to residue and debris the pet or person will gradually begin to lose their energy and the ability to function normally…  

Interesting theory. Also complete nonsense.

Glutathione is, of course, present in the liver and important for normal liver functioning, along with thousands of other chemicals. The evidence does not support the assertion that coffee enemas increase glutathione levels in humans. (1) There is mixed evidence for changes in glutathione levels from oral coffee intake, with some human and rat studies finding and increase and others not. (2) There is no evidence that coffee can increase this enzyme in dogs. And there is no evidence that any increase in glutathione which might happen from some kind of intake of coffee has meaningful clinical benefits. So this claim is probably wrong and would be of questionable significance even if it were true.

The argument that coffee enemas are “detoxifying” is based on the vague and mythological understanding of “toxins” that underlying many quack therapies. This mythology is not a legitimate understanding of the cause of disease, and it is not a sound rationale for coffee enemas. (3, 4, 5) The colon is not a primary site of digestion and absorption of nutrients, though there are some nutrients that are absorbed there (notably B vitamins) as well as water. And it does not become caked with debris over time which impedes its functioning. The notion that we are fundamentally incapable of normal health without some periodically flushing out our large intestine is simply ridiculous.

So is there any evidence that coffee enemas have health benefits despite the lack of a plausible theory why they should? Nope! The subject has been debated in human medicine for some time, particularly due to claims that coffee enemas can be beneficial in cancer treatment. There is no credible evidence to support this claim and clear evidence against it. (6, 7, 8, 9, 10) And, of course, there is no clinical research of any kind in dogs or cats to test this therapy. And there shouldn’t be!

While not having shown any benefits, coffee enemas unquestionably can cause harm. There are numerous reports of serious harm done to human patients, including dehydration and electrolyte disturbances, tears of the colon and rectum, burns in the colon and rectum, infections transmitted by the procedure, and death. (11, 12, 13, 14, 15)

The fact that caffeine, a prominent chemical in coffee, is a well-known and serious toxin in dogs makes the notion of coffee enemas in these species even more insane, if that is possible.

While it seems as if it shouldn’t even need to be said, clearly coffee enemas for pets are a bad idea. The theoretical reasons for using them range from unproven to completely crazy, there is no evidence in humans or veterinary patients of any benefits, and there is ample evidence of potentially serious harm, including death. Recommending this treatment for pets is irrational to the point of being indefensible.

References

1. Teekachunhatean S, Tosri N, Sangdee C, Wongpoomchai R, Ruangyuttikarn W, Puaninta C, Srichairatanakool S. Antioxidant effects after coffee enema or oral coffee consumption in healthy Thai male volunteers. Hum Exp Toxicol. 2012 Jan 16. [Epub ahead of print]
   
2. http://www.ncbi.nlm.nih.gov/pubmed?term=coffee%20glutathione
3. Chen TS, Chen PS. Intestinal autointoxication: A gastrointestinal leitmotive. Journal Clinical Gastroenterology 11:343-441, 1989.
4. Green, S. A critique of the rationale for cancer treatment with coffee enemas and diet. JAMA. 1992,Dec 9; 269(13),1635-6.
   
5. Ernst, E. M.D., Ph.d., F.R.C.P. (Edin). Colonic Irrigation and the Theory of Autointoxication: A Triumph of Ignorance over Science. Journal of Clinical Gastroenterology. 24(4):196-198, June 1997. (Make sure to follow the references to the primary sources).
   
6. Alison Reed, Nicholas James and Karol Sikora. Mexico: Juices, coffee enemas, and cancer. The Lancet. Volume 336, Issue 8716, 15 September 1990, Pages 677-678.
   
7. M. E. Shils and M. G. HermannBull . Unproved dietary claims in the treatment of patients with cancer.N Y Acad Med. 1982 April; 58(3): 323–340.
    
8. Brown BT. Treating cancer with coffee enemas and diet. JAMA. 1993;269:1635-1636.
9. Cassileth, B. Gerson Regime. Oncology, Volume 24, Issue 2, 2010 Page 201.
   
10. Atwood, K. “Gonzalez Regimen” for Cancer of the Pancreas: Even Worse than We Thought (Part I: Results). Science-Based Medicine Blog, Accessed May 13, 2012 at http://www.sciencebasedmedicine.org/index.php/gonzalez-regimen-for-cancer-of-the-pancreas-even-worse-than-we-thought-part-i-results/
11. Keum, B. et al. Proctocolitis caused by coffee enemasAm J Gastroenterol. 2010 Jan;105(1):229-30.
12. Lee, C.; Song, S.; Jeon, J.; Sung, M.; Cheung, D.; Kim, J.; Kim, J.; Lee, Y. (2008). Coffee enema induced acute colitis. [The Korean journal of gastroenterology] Taehan Sohwagi Hakhoe chi 52(4): 251–254
13. Eisele, J.; Reay, D. (1980). Deaths related to coffee enemas. JAMA: the Journal of the American Medical Association 244(14): 1608–1609.
14. Sashiyama, H.; Hamahata, Y.; Matsuo, K.; Akagi, K.; Tsutsumi, O.; Nakajima, Y.; Takaishi, Y.; Takase, Y. et al (2008). Rectal burn caused by hot-water coffee enema. Gastrointestinal Endoscopy 68(5): 1008–1009
15. Jones LE, Norris WE. Rectal burn induced by hot coffee enema. Endoscopy.2010;42 Suppl 2:E26.

The Second Sight Blog-
Bowen Therapy 1: Introduction
Bowen Therapy 2: Evidence

A Canna’ Change the Laws of Physics
Bowen Therapy and the ASA

What Is It
Apparently, Bowen therapy is the invention of yet another self-taught misunderstood genius, this time in Australia. Tom Bowen invented a technique whereby the therapist gently massages certain key points, which may or may not be associated with acupuncture points (which are themselves likely imaginary), meridians, chakras, and other such mystical energy medicine concepts. This supposedly alerts the brain to the presence of a problem which it somehow did not otherwise know about (despite the pain or other symptoms which brought the patient to the therapist), and the brain then repairs the damage on its own. Apparently, the brain is shy because it is supposedly necessary for the practitioner to leave the room periodically during treatment so the brain has the opportunity to respond to the messages they are sending it.

The review at Second Sight goes into more detail, evaluating the theoretical explanations on the Bowen web site, but the bottom line is that these explanations are vitalistic and pseudoscientific, along the lines of those for other similar energy therapies such as traditional acupuncture, Reiki, healing touch, and so on.

Does It Work?
From the point of view of plausibility, there is no reason to think this therapy is effective. The theoretical explanations for it are inconsistent with established science. And as usual, for the veterinary applications of Bowen Technique, I have not found a single published study of any kind. Unless one exists that I am unaware of, the use of this technique in animals is based solely on anecdotal experience, which is deeply unreliable.

There have been a handful of clinical trials in humans, which the blogs cited above review in detail. My own reading of them agrees with these reviews. Almost all are uncontrolled studies highly subject to bias. If you apply a treatment to a bunch of people and something changes about their health, you can’t simply assume the treatment is the reason. So most of these are useless for establishing safety or efficacy.

There is one controlled trial which evaluate the use of Bowen therapy on healthy volunteers by measuring their hamstring flexibility before and after treatment. The study does show that healthy people will stretch farther after they think they’ve received a treatment to enhance flexibility compared to people who haven’t been given any treatment. This doesn’t really say anything at all about whether Bowen technique has any physiological effects or any benefits in treating disease.

Is It Safe
There is no evidence concerning safety for this method. Some practitioners subscribe to the “healing crisis” notion also found in homeopathy, where patients are expected to get worse as a sign they are responding to treatment, so some negative symptoms have been reported anecdotally after treatment. However, without controls or systematic monitoring, there is no way to know if these experiences have anything to do with the treatment.  Of course, with Bowen therapy as with most unproven and implausible approaches, the risk that comes with applying an ineffective therapy and failing to seek real medical care in a timely fashion must be considered.

Bottom Line
There is no good reason to think this approach works based on the theoretical explanations offered for it, which are unproven and mostly pseudoscientific or vitalistic. There is no evidence for or against it in veterinary species, apart from unreliable anecdotes. There is no controlled clinical research in humans showing a benefit, though uncontrolled trials with high risk of bias appear to show some effects. And there is no evidence concerning the safety of the practice. A classic case of a therapy made up out of thin air by a lone “visionary,” the claims for which must be taken entirely on faith.

An issue that I don’t often address is the question of whether or not patients (or in the veterinary context, clients) are satisfied with the care they receive. This is an important concern, particularly since poor patient satisfaction is probably one of the factors driving people to seek CAM therapies regardless of the evidence concerning their safety and efficacy. It might be that would be less likely to seek unproven or bogus therapies in addition to, or in lieu of, science-based medicine if conventional medicine could do a better job of helping people cope with their disease.

There are efforts to do this, under the label of “patient-centered care,” though there are also efforts to turn this movement into a Trojan horse for providing unproven therapies just because patients sometimes want them. However, the assumption is often made that CAM generally makes patients happier than conventional care, and I’ll admit I am often inclined to believe this is true. But this impression is not based on much evidence, so I’m always keeping an eye out for research that addresses the question of whether or not patients using CAM are more satisfied with their care than patients who are not.

I recently ran across an article that addresses both the issue of CAM efficacy and of patient satisfaction with CAM treatment.

Scott D. Ramsey^, Steven B. Zeliadt^, Catherine R. Fedorenko, Megan E. Fairweather, Cara L. McDermott, David F. Penson, Stephen K. Van Den Eeden, Ann S. Hamilton, Neeraj K. Arora. Complementary and Alternative Medicine Use, Patient-reported Outcomes, and Treatment Satisfaction Among Men With Localized Prostate Cancer. Urology. 2012; 79(5):1034–1041.

The study recruited men newly diagnosed with prostate cancer in California and Washington state and surveyed them about CAM use and about their satisfaction with their treatment at diagnosis and 6 months later. The survey also evaluated patients’ functional outcome after treatment. These data were then analyzed to determine the variables that were associated with functional outcomes and patient satisfaction.

One problem that arises in surveys of CAM is defining what constitutes CAM. In other surveys (e.g. 1, 2), CAM use appears much higher when one counts practices that are not always properly understood as medical therapies, such as spiritual practices and some nutritional, exercise, or relaxation techniques. In this study, 52% of men reported CAM use when the following interventions were included.

Special diets, such as low fat or mostly vegetarian diet
Herbs or dietary supplements (such as saw palmetto, lycopene supplements, or selenium). High-dose vitamins or mega vitamins (such as vitamin E) (do NOT include 1-a-day multivitamins)
Homeopathy
Movement or physical therapies, such as yoga, tai chi, massage, chiropractic therapy Oriental therapies, such as acupuncture, acupressure, qigong, or shiatsu Mental health counseling or psychotherapy
Personal prayer
Faith healing, laying on of hands, or any other spiritual or religious group experience Mind/body therapies such as guided imagery/visualization, biofeedback, meditation, Relaxation techniques, hypnosis/hypnotherapy, energy healing, therapeutic touch, or music therapy

 

This list illustrates the questionable “big tent” approach to defining CAM. I am a vegetarian, I meditate, and I have occasionally had a massage, but I did not seek any of these as medical treatments, and I would not consider myself as using CAM as a result. Likewise, prayer and psychotherapy hardly seem like activities predominately aimed at treating disease. Though they may have some impact on health, and certainly one’s sense of wellbeing, it is a mistake to lump together nonsense like homeopathy, unproven but plausible therapies, and activities intended to be comforting as if they were all the same thing.

The authors did acknowledge this problem to a certain extent, and they conducted several of their analyses both including and excluding prayer. For example, when prayer was excluded from the definition, only 39% of subjects reported CAM use. I imagine the number would be even lower if psychotherapy, massage, and other such activities that have little to do with most forms of alternative medicine were excluded.

Unsurprisingly, CAM use was not associated with any difference in functional outcomes, such as urinary continence, sexual function, and bowel function. There were clear differences in these variables based on which, if any, conventional therapy was employed.

Perhaps more of a surprise is the finding that CAM use was not associated at all with patient satisfaction. Most men were satisfied with the care they received (78% reported completely or very satisfied), and the variables that seemed most strongly associated with this were measures of the quality of the communication between doctors and patients.

The authors also cite a number of previous studies of CAM use in patients with prostate cancer, which also suggest that the automatic association between CAM and patient satisfaction may not be justified.

For example, Eng et al asked patients with recently diagnosed prostate cancer who used CAM about their perceptions of its effectiveness. More than one half (60%) of the respondents believed they were better or a lot better on measures of energy level, stress, sense of control over disease, and PSA level. The remainder reported that their CAM therapies had no effect or worsened these measures. When asked whether their use of CAM therapies minimized the side effects of conventional treatments, one third of the CAM users (34%) reported improvement, 56% reported no effect, and 10% reported they believed the CAM treatments had made their side effects worse. Ponholzer et al found CAM users reported lower treatment satisfaction, quality of life, and health status than patients who did not use CAM.

Certainly, one study such as this is by no means definitive regarding either the effectiveness of CAM therapies or their impact on patients’ perceptions of their care. But it is one more piece of evidence to consider in evaluating these issues.

Part 1. Science Works: How We Go Wrong and How Evidence-Based Medicine Can Set Us Right

The first segment illustrates the limitations of unstructured evaluation, such as personal experience, trial and error, and historical traditions, and introduces the principles and techniques of evidence-based medicine.

Part 1 Powerpoint Presentation

Part 2. What is Complementary and Alternative Medicine?

The second part of this series investigates the philosophy and ideology of alternative medicine in preparation for applying the principles and techniques of evidence-based medicine to these practices.

Part 2 Powerpoint Presentation

Part 3. Apply a Science-Based Approach to Evaluating Specific Alternative Practices

The final part of the presentation applies a systematic science-based evaluation to several examples of alternative medical approaches, incuding Reiki, Homeopathy, and Probiotics.

Part 3 Powerpoint Presentation

Dr. Karen Becker, a prominent CAVM vet who writes for one of the most notorious sites promoting quackery through denigrating conventional medicine, Mercola.com, recently blogged about the much-reported decline in veterinary office visits. In this article, she makes a number of assumptions for which there is little or no evidence, and several accusations about the inadequacy of conventional veterinary care.

The accusations essentially amount to saying that conventional medicine ignores preventative care apart from given vaccinations and selling pest-control products, both of which Dr. Becker frequently cites as significant health hazards for our pets.

Perhaps a reason for fewer vet visits is the new canine vaccination guidelines which will hopefully put an end to the dangerous and unnecessary practice of yearly re-vaccinations.

I suspect another reason (aside from today’s tough economic climate), is because many traditionally trained DVMs practice ‘reactive’ veterinary medicine.

This means they don’t have much to offer pets unless and until they’re good and sick…

…preventive medical care in the mainstream veterinary community has evolved to mean not much more than yearly vaccines and chemicals to discourage pests and parasites like fleas, ticks and heartworm.

There is rarely discussion between vets and pet owners about nutrition (because vet students receive almost no education in the subject), exercise and other physical therapies, or the importance of a strong, resilient and balanced immune system.

This also raises the cliché about conventional veterinarians being ignorant in the area of nutrition, which is nonsense. The definition of ignorance most likely meant here, is simply a failure to agree with specific theories about what constitutes a healthy diet, including the unsubstantiated beliefs often promoted about the benefits of raw diets, the dangers of grains, and so on.

This then leads to the suggestion that alternative veterinarians do a better job of preventative care, because they promote “wellness” therapies.

For some reason the methods used to maintain a pet’s vibrant good health – everything from species-appropriate nutrition to maintenance chiropractic care to homeopathic remedies and herbal supplements – fall into the category of ‘alternative medicine.’

Isn’t it strange that natural modalities used not to cure illness (although they do that, too), but to maintain health are thought of as ‘alternative,’ yet chemical drugs and invasive surgery are considered mainstream health care?

Actually, it isn’t strange at all. There is no reliable scientific evidence for the preventative health benefits of maintenance chiropractic care, homeopathic remedies or herbal supplements. These products are touted as “wellness” care based solely on the personal beliefs of the vets who use them and the beliefs of previous generations of vets and animal owners. This is the same level of evidence that has supported such winning strategies as bloodletting, purging, and animal sacrifice as preventative health measures.

What is strange is that someone with medical training can so blithely denigrate preventative and therapeutic methods proven to work and wonder at the failure of mainstream medicine to accept without proof her belief that these alternative therapies are better.

I recommend twice yearly wellness examinations to my Natural Pet clients.

A thorough nose-to-tail professional checkup every six months is the best way for you and your vet to detect and stay on top of any changes in your pet’s health. This is especially true for older pets.

This is undoubtedly great for the bottom line, but again there is no evidence that biannual or annual wellness examinations recommended for all pets is an effective or efficient strategy for preventing disease or extending length and quality of life. In humans, the evidence in fact is building against the value of annual exams for well people. There is no evidence either way in veterinary medicine, so while I myself think it likely that regular examinations could have some benefit, there is no objective reason for a strong recommendation of this kind. And certainly such visits are not a substitute for the “chemical drugs” and vaccinations that have been far more effective than any other measure and reducing disease and preserving health in our companion animals.

…Proactive vets are typically obsessive about clinical pathology…most proactive vets recommend annual vector borne disease testing instead of waiting until lyme disease has set in, causing incurable auto-immune polyarthritis.

This is a completely irrational and baseless recommendation. Screening tests without an appropriate reason for doing them waste money and cause far more harm than they prevent. There is a strong movement in human medicine now to reduce exactly this kind of misguided thinking. So to imply that the care such alternative vets provide is superior to that of conventional veterinarians because the former recommend unproven preventative measures and unnecessary testing is misleading and unethical. Given the complaints so often made by CAM vets about the purported financial motivation behind many mainstream practices, it is quite ironic that this sort of advertising promotes far more aggressive, and likely expensive, use of approaches with no proven value.

More and more often, I’m being asked to be that token skeptic. It’s not a very satisfying role, since the chances are slim of seeing a final article that reflects the reality of veterinary CAM as a marginalized practice with little convincing scientific evidence behind it. Still, presumably having even a sanitized token skeptical voice in these pieces is better than having none. Right? Hmm, well I hope so anyway.

Here are a couple of examples.

This piece from New York Magazine, preciously titled Dogupuncture, includes 4 positive quotes, 1 negative quote, and a graphic right up front purporting to show the rising popularity of acupuncture among vets. Out of all that I have written about acupuncture, the quote chosen was the conclusion from a systematic review which concluded there was insufficient evidence to reach a conclusion!

I have added a comment to give at least a bit of a response to some of the inaccurate implications of the pices, but that will likely only draw more angry responses from “satisfied customers” of veterinary acupuncture, rather than start a substantive discussion of the evidence.

The claim of ancient veterinary acupuncture is false: http://skeptvet.com/Blog/2010/07/the-history-of-ve… And it’s irrelevant anyway since bloodletting and slavery have been around as long or longer, and that doesn’t make them good ideas.

Even though animals don’t have beliefs about their care, there are absolutely placebo effects in veterinary care. The simplest is the Placebo by Proxy, in which the owner or vet thinks the pet is better because they want or expect it to be, and after all they are the ones who decide if the pet looks like it feels better. There is also Regression to the Mean, the Hawthorne Effect, Classical Conditions, Non-Specific Effects of Human Contact and many other factors that make bogus therapies look like they work.

Even in humans, acupuncture has not been shown to be more effective than fake acupuncture, and the evidence is even weaker in animals. (http://skeptvet.com/Blog/category/acupuncture/)

The bottom line is that belief in acupuncture, the popularity of acupuncture, and the length of time people having beein using acupuncture are all meaningless in terms of deciding whether or not it is useful. And despite decades or trying and a huge number of studies, scientific evidence still hasn’t shown it to be any better than placebo in controlled trials.  So the strength of the evidence for acupuncture is no better than that for faith healing, psychics, bloodletting, and lots of other healthcare practices that lots of people have believed in for a long time.

Unfortunately (for our pets), these things last because we so easily fool ourselves, and unreliable personal experiences are far more compelling emotionally than scientific data.

I’ve written previously about a Veterinary Practice News article on the Academy of Veterinary Homeopathy lawsuit against the American Association of Veterinary State Boards. It too is an example of a clearly one-sided piece with a token skeptic selectively cited in order to portray the skeptic position as weakly as possible.

The Veterinary Practice News reported on this lawsuit in early August. In a roughly 2000 word article, the author extensively quoted five supporters of homeopathy and of the lawsuit. She also quoted an official at the AAVSB who was not free to comment on pending litigation. And finally, she interviewed me for the article as the sole critic of the AVH position.

I was quoted as saying that homeopathy was not a science-based intervention, which is accurate. I was also quoted as saying that, “Alternative medicine providers are often better at treating psychological aspects of a medical incident an owner is dealing with, and there’s no doubt they are caring and compassionate…”This is partially correct in that I did acknowledge that alternative practitioners are undoubtedly as caring and compassionate as other veterinarians, but it misrepresents the point I was making that the reason methods like homeopathy are popular with a small percentage of the pet-owning public is not because they actually work but because of the psychological effects, essentially a placebo-by-proxy, that the interaction with the practitioner has on the owner.

Lastly, I was quoted as saying that, “these therapies are not taught in veterinary schools.” This is followed by a “gotcha” list of veterinary schools that offer elective courses in “integrative medicine” or have “holistic medicine” student organizations. This is clearly intended to undermine the credibility of my comments. However, this is again a manipulative misrepresentation of my position.

Homeopathy is clearly not part of the core veterinary curriculum, nor is it generally accepted as a valid approach to medicine at U.S. veterinary colleges. The AVH does not dispute this in their complaint. And of the four veterinary schools (out of 28 in the U.S.) mentioned in the article as having “elective courses in CAVM or integrative veterinary medicine,” I could not find any that actually do have a course in homeopathy, though CSU does offer an elective called “Critical Overview of Complementary and Alternative Medicine” taught by Narda Robinson, who is a vocal critic of homeopathy. It is possible, of course, that a couple of schools do have credulous individuals on faculty who teach that homeopathy is scientifically legitimate, but if so these represent a rare minority opinion which is discounted by the overwhelming majority of veterinary scientists. The article was a barely disguised propaganda piece for the AVH position with only a superficial nod towards the idea of journalistic neutrality.

There are a few other similar pieces I’ve been involved with that haven’t come out yet, but only one that I expect may be of higher quality than the usual sort like these.

Perhaps it’s the intrinsic character of the subject matter. Alternative medicine presents a simplistic and comforting face, and science is naturally complicated, ambiguous, and seemingly hypercritical. Or perhaps it’s the declining number of well-trained reporters specializing in science-journalism. After all, most veterinary stories appear in the Lifestyle section of magazines and newspapers, where the standards are lower than in the science, health, or news sections. In any case, as long as even a token skeptical voice is included, perhaps this will at least offer some comfort to those who value the messy truth over a good story.

While I’ve posted several lists of warning signs of quackery (1, 2, 3), and discussed a number of individuals and companies whose marketing activities exemplify some of the specific signs on these lists (such as Eric Weisman, Gloria Dodd, Nzymes.com, and others), seldom have I seen such a paragon of quack medical self-promotion as Dr. William Inman’s Veterinary Orthopedic Manipulation and Laser Therapy Roadshow.

I became aware of this operation through a direct mail solicitation to attend a training workshop in Dr. Inman’s special style of cold laser therapy. I’ve written about cold laser before, and the bottom line is that while there is some plausibility to the idea that low-frequency lasers might have beneficial effects, based in preclinical research, the clinical trial evidence is mixed and inconclusive in humans and non-existent in veterinary medicine. So no firm conclusion about the efficacy of this treatment is justified by anything more than speculation and anecdote. Despite Dr. Inman’s revolutionary new “Chaos Conversion Therapy” (a term he apparently invented, since I can find no other use of it) that has apparently made lasers even more effective for allergies, endocrine disease, and cancer, I was not tempted to attend. I was also not tempted to write a post about it, until I checked out his website.

Apart from having apparently devised a whole new theory to dramatically improve the effectiveness of the questionable practice of cold laser therapy, Dr. Inman has made great strides (and a good deal of money) reinventing the even more questionable chiropractic theory of subluxations and devising an entirely way to waste your time and money banging on your pet to cure every imaginable ill caused by this imaginary abnormality.

According to his web site:

Veterinary Orthopedic Manipulation (VOM) is a healing technology that locates areas of the animal’s nervous system that has fallen out of communication, and re-establishes neuronal communication and thus induces healing. VOM is singularly the most simple, effective and safe healing modality in veterinary care to date.

Wow, sounds cool! So what can it fix? Well, apparently almost any musculoskeletal, gastrointestinal, glandular, or behavioral problems, ear infections, allergies, and just about anything else.

And how does it work? This is the fun part. Some proponents describe it as simply a variation of veterinary chiropractic, in which the imaginary vertebral subluxation complex interferes with either nerve conduction or the mysterious spiritual force known as innate intelligence, thus causing disease in almost any body system. This disease is supposedly treated by “adjusting” the spine to fix the undetectable subluxation and restore the body’s natural state of health. Apart from some evidence that chiropractic is about as useful for back pain as other kinds of physical therapy, over a century of research has failed to document the subluxation or any other benefits to this therapy.

This lack of evidence hasn’t much hampered the work of chiropractors in human or veterinary medicine, however apparently selling just another variant of chiropractic isn’t good enough for Dr. Inman. He even went so far as to found his own organization, the International Association of Veterinary Chiropractitioners, and  according to his web site:

Is Veterinary Orthopedic Manipulation (VOM) chiropractic care?

No! VOM exists in between veterinary medicine and chiropractic care. It has similarities to some of the chiropractic modalities and functions by restoring function by reducing “subluxations” as is done in chiropractic care. It uses a hand-held device that is used in a popular human chiropractic technique called “Activator Methods” but it is not to be confused with that technique. The differences between VOM and Chiropractic care are significant and distinct.

VOM exists in a gray area between both professions (Veterinary and Chiropractic) and benefits from the positive aspects of both, a hybrid, and thus more effective than either by themselves.

Ah, so it is neither chiropractic nor veterinary medicine, and naturally this means it’s better than either one. (?!) In an article on the subject Dr. Inman published in the Journal of the American Holistic Veterinary Medical Association, he expands on his notion of the subluxation.

The location of the subluxation phenomenon is not the nerve or the bone, but it is the neuronal interference that exists at the interneuron of the dorsal horn of the facilitated spinal segment. 

It cannot be seen on x-ray, cannot be imaged by ultrasound or MRI, but can be readily demonstrated with the application of a simple diagnostic protocol using a hand-held device….

Subluxation is only a switch that can potentially be turned back on. This is simply done by providing adequate force to the interneuron through the mechano-receptor inputs into the dorsal horn. (Please see diagram). Note: this is mechano-receptor force, not motion, thus the process is inherently safe and amazingly effective.

…Thus 100% of all subluxations can easily and objectively be located and evaluated using the VOM Diagnostic Technology and neurological subluxation signs.

…The VOM Diagnostic Technology is amazingly accurate. Diagnostic reading patterns are demonstrable weeks to years before radiographic and other diagnostic technique will verify.

Now any medical approach which fixes a problem that cannot be detected except by the special methods of that approach and that does so with perfect accuracy, absolute safety, and “amazing” effectiveness is by definition either a miracle or bullshit. It would seem likely that if this one was in the miracle category, it would have succeeded in replacing the rest of veterinary medicine in the 30-odd years since Dr. Inman claims to have begun developing the technique in 1982. Certainly, many revolutionary new medical practices have gone from ridicule to dominance in that amount of time. But Dr. Inman has some thoughts on both the fact that VOM sounds too good to be true and why it hasn’t achieved the recognition it deserves.

How can VOM be that easy?

Why not? Who says that a healing modality has to be complicated, difficult and expensive? Who says it should take hundreds of hours to learn and perfect? A technology that goes to the root of the problem, a simple technology that relies on the animal’s innate ability to heal itself, one that re-establishes communication with the pet’s ability to heal itself, will be easy, powerful and effective. 

Why haven’t I heard of the VOM Technology before?

Because it works! That may not make sense at first, but consider this: if the VOM Technology does what it appears to do, it makes a lot of techniques, surgeries and medications obsolete. The professionals that provide those techniques, surgeries and medications will be placed in academic and financial jeopardy. These are the people that control publications in the field and control licensure and applications. AKA politics.

Ah, of course, the Dan Brown Gambit, in which a vast conspiracy suppresses the miraculous truth out of fear and greed. Sure.

So what sort of evidence is offered for the quite grandiose claims made for VOM? As usual, pseudoscientific ramblings based on bogus theories and piles of anecdotes, which (as Dr. Mark Crislip has pointed out in a different context) don’t become evidence by force of numbers any more than piles of cow dung become gold when enough is collected. VOM is apparently a one-man vision with no need for input from science or any formal clinical research.

VOM was developed in a vacuum, meaning it was developed with a trial and error approach in a clinical setting without input from other sources. Dr. William Inman has been the sole source of the VOM Technology.

Over the past 18 years and represented by over 45,000 clinical cases (on file and available on computer) the patterns for over 250 disease conditions have been recognized and tested for reliability.

Wow! One doctor, 45,000 clinical cases, and not a single published clinical trial. Why is that again? Oh yeah, the obstinate oppression of the medical establishment. Uh huh.

Well, at least VOM is an efficient form of quackery and easy to learn. As Dr. Inman points out,

Unlike AVCA certification and instruction that takes 150 hours and five modules to complete, a veterinary Chiropractitioner (VCP) can adequately apply VOM after a “VOM Small Animal Module One” seminar attended in their home town in a weekend.

Apparently, Dr. Inman no longer practices so he can devote himself to teaching:

In 1996 he began teaching the VOM, VMR, Somato-Visceral, and Myofascial Release fulltime in lieu of clinical practice. Currently he is not licensed in any jurisdiction and limits his efforts to teaching only. He does not consult on specific cases as that infers clinical practice.

Of course, this might have something to do with his history of legal troubles:

The license of Dr. William Inman, Seattle veterinarian, has been suspended for a minimum of five years and he has been fined $10,000 by the state Department of Health’s Veterinary Board of Governors…The board found Inman displayed “incompetence, negligence or malpractice”….The action is believed by longtime veterinarians to be the harshest ever taken in this state.

Dr. Inman has maintained that the Board identified his technique as safe and effective even while disciplining him for other reasons. However, news reports claim, “The board in its report, however, made “no conclusion” whether the technique was improper conduct.”

And the record of his appeal of the veterinary medical board case indicates:

The Board found twelve violations, four of which are not at issue on appeal: the failure to keep adequate records; unprofessional conduct in failing to perform a proper work-up on a cat named Mickey; surgery that did not conform to the appropriate standard of care; and misrepresentation to Mickey’s owners that veterinary orthopedic manipulations were effective when Dr. Inman should have known they were not.

The appeals court affirmed the veterinary medical board’s findings and after a review of the procedures found the judgment and punishment appropriate. These findings include gross misconduct including deliberately encouraging staff to falsely identify parasites patients did not actually have and giving medications and vaccinations in clearly inappropriate circumstances. Apparently, unable to practice conventional medicine appropriately, Dr. Inman chose to invent his own alternative approach to healthcare and sell that instead.

Of course, Dr. Inman and his supporters will undoubtedly dismiss my criticism and his legal troubles as mere vindictive attacks by those threated personally and financially by his revolutionary invention. And undoubtedly many anecdotes will be presented from satisfied pet owners and veterinarians convinced that VOM works wonders and that Dr. Inman is unjustly accused.

But the pattern seen in this case is strikingly similar to that seen in the other examples of snake oil salespeople I have discussed here. Lone misunderstood genius offers revolutionary therapy supported by theories inconsistent with established science and anecdotes. This therapy makes money and converts but is either not tested in any formal scientific way or fails such testing. Lone genius is undeterred and continues practicing. Said genius then persecuted by the establishment and accused of gross misconduct or incompetence unrelated to revolutionary invention and switches from clinical practice to full-time promoter of said revolutionary practice. Supporters claim genius is misunderstood martyr and critic are frightened, greedy, or just plain mean.

One has to wonder whether this pattern can be said to indicate the seemingly obvious: Each of these people is either deluded or deliberately deceiving the public, and the reason their therapies are not accepted with adulation by the mainstream is because there is not good reason to think they work. Isn’t this more likely than the alternative the each and every one of them has discovered something original and miraculous that should be accepted widely without any proof beyond their say so and the testimonials of their clients?

Still, the idea that unnecessary screening tests hurt more people than they help is a tough sell to those who don’t understand the complexities of reliability, validity, predictive value, and other factors involved in evaluating the risks and benefits of disease screening. Anecdotes about individuals who had a potentially serious disease detected by screening and believe that the subsequent treatment saved their lives are very compelling. They seem to get more coverage and have more impact than stories about people harmed by unnecessary treatment after detection of lesions that likely would never have caused them any problem. Nevertheless, unnecessary diagnostic tests not only cost a lot of money, reducing the resources available for providing necessary healthcare, but they also do harm many individual patients who are forced to go through unneeded secondary testing or treatment for diseases that either don’t exist or would never have made them ill.

A new organization of physicians has been formed to try and educate both clients and doctors about this problem and to make sound, evidence-based recommendations about diagnostic testing. Choosing Wisely has gotten a fair bit of media coverage lately for promoting lists of specific procedures that are often done unnecessarily, and for suggesting that these only be done when certain criteria are met. The lists also address some therapies which may be unnecessary, including the ever-popular excessive and inappropriate use of antibiotics.

These lists have generally avoided particularly controversial subjects, and so far haven’t been greeted with the panic that some of the USPSTF recommendations have. Hopefully, the effort will have some impact on physician behavior and consumer expectations. And once the organization and its approach is familiar and gains some credibility, perhaps they will be able to take on more controversial subjects, such as the lack of evidence to support annual physical examinations in adults without symptoms of illness (or even CAM therapies and tests not supported by evidence?).

But there is a downside to this abundance of choices. We are stuck trying to figure out which products might help our pets, which might do nothing for them, and which might even be dangerous. The government does little to monitor the veterinary market or to require that individuals or companies selling products demonstrate they are safe and effective or that the marketing claims they make are true. And while veterinarians are often the best resource for information about how to care for our pets, they can’t know everything about all of the thousands of products pitched to pet owners. The primary responsibility for making smart choices for our pets lies with us.

Having investigated many of the nutritional supplements, herbal remedies, and other products claimed to benefit our pets’ health, I have developed a checklist that simplifies the process of evaluating unfamiliar pet care products. While this can’t replace a thorough, detailed investigation of a product and the evidence for claims made about it, this checklist can give you an idea of whether something is promising enough to be worth looking into in more detail 

1. What is it?
2. Does it make sense?
3. What’s the evidence?
4. Is it safe?
5. Any Warning Signs?

What Is It?
The first question to ask when you hear about a healthcare product for your pet is, “What is it?” This means, what are the ingredients, how is it made, where does it come from, who discovered or invented it, how is it supposed to be used, and anything else that will help you understand what it is you are being asked to give or do to your pet. Certainly, the manufacturer of a pet health product should be eager to give you as much information as you want about what they are selling. If your questions are not answered, if the ingredients or processes are a secret, if you are offered a snowstorm of technical language and no one is willing to explain in plain English what the product is, that’s a reason to consider walking away right at the start.

Of course, you aren’t likely to get a balanced or complete picture about a product from someone selling it. It is important to look for other sources of information. While the information one finds on the Internet should always be taken with lots of grains of salt, it is copious and easy to find. A Google search can turn up lots of information. And when evaluating this information, consider the source. Veterinary medical schools, other scientific research institutions, organizations of medical specialists, and others not actively trying to make money from these products are likely to have more objective and balanced information about them 

Does It Make Sense?
This question is a bit more complicated than it seems, since lots of bad ideas seem reasonable, and a few good ones can sound crazy. This question is a way of getting at what scientists call plausibility and coherence. Basically, if the idea behind a product is a reasonable extension of what science already knows about health and consistent with established principles, then it is more likely to work than something which is based on some mysterious or magical process unknown to science and discovered by a lone genius with no medical training working in their garage. As Thomas Edison said, genius is 1% inspiration and 99% perspiration. Once in a while, a new idea springs up out of the blue and actually works. But most advances in medicine are hard won through careful, laborious building on what we already know.

It’s true, science can’t explain everything. But there are some things we can be pretty sure about. Did you know, for example, that scientists don’t really know exactly how gravity works? There are a couple of theories, and the details still aren’t totally worked out. But if someone offered you a magic collar that would let your dog fly, would you buy it? We may not know all there is to know about gravity, but we can be pretty darned sure it’s going to be there every time we jump out a second story window.

So when you read about a product for your pets that is based on a “revolutionary” new idea that scientists only doubt because they can’t understand it, or that works by some vague “energy” or “quantum” process that is exempt from the ordinary rules that govern the medicines or procedures your vet uses to help your pet, it is worth being a little skeptical and looking particularly closely at the answer to the next question, “What’s the evidence? 

What’s the Evidence?
A concept which has come to dominate human medicine, and which is gradually making progress in the veterinary field, is the idea of evidence-based medicine. People have long known that our individual experiences don’t give us a very reliable idea of what works and what doesn’t in protecting our own health. For thousands of years, basing our medical care on personal experience, tradition, and the words of respected and experienced doctors led to an amazing variety of useless, even dangerous treatments. Bloodletting, leeches, toxic “medicines” that poisoned rather than helped us, even ritual animal sacrifice were widespread therapies that patients and doctors believed worked based on their own experience. And yet most babies died before they could reach adulthood, and those that made it were lucky to reach their forties.

In the last couple of centuries, we’ve shifted the basis of our judgments about healthcare practices from experience to scientific research. The result has been an unprecedented level of success. From wiping out polio to dramatically reducing infant mortality to doubling average life expectancy, science has made our health better by relying on the best available research evidence rather than intuition, experience, history, or the wisdom of respected individuals.

Unfortunately, lots of products for our pets base their claims of success on nothing more than the reputations of inventors and celebrities or veterinarians who endorse the products, and the personal stories of satisfied customers. Unsatisfied customers are rarely heard from. And good quality scientific research is rare, especially when companies can make healthy profits selling their remedies without investing in efforts to prove they actually work. Likewise, it is easier to claim “thousands of years of success” than to carry out a good scientific study that actually proves the product works.

So when looking at the evidence for a product you’re considering giving to your pet, you have to look past the testimonials the manufacturer gives you. As emotionally compelling as stories of miraculous recoveries are, they are not a reliable guide to what works and what doesn’t. A trustworthy company interested in really helping your pet will be able to provide references t scientific studies published in reputable journals. Ideally, these will be studies of their actual product in the same species you are thinking about giving it to. Even evidence for some benefit from one of a dozen ingredients given to laboratory rats isn’t a very useful bit of evidence that the combination of all the components will help your dog or cat.

And as always, consider the source. The company can’t be expected to give you information against their own product, or to provide feedback from unhappy customers. So look for independent sources of information, ideally from medical professionals or otherwise with a scientific background able to access and evaluate the scientific evidence. 

Is it Safe?
There is no free lunch in medicine. If something has benefits, it has risks. If it has no possible risks, that means it doesn’t do anything at all. We cannot expect to tinker with as complex and interconnected a system as the physiology of a living organism and only generate the good effects we want. So any choice to give our pets a medicine or other product to protect or restore their health is always a choice that requires balancing potential benefits against potential risks. The more we know about the risks, the better we are able to make sound, informed decisions.

While companies can be expected to downplay the risks and hype the benefits of their products, a good one will admit that there are possible side effects and tell you what they are and about how often they happen. And again, this information is far more reliable if it comes from objective, scientific research rather than just the impressions of people who have tried the product. A list of possible side effects may be scary, but it doesn’t mean we shouldn’t use a treatment if we need to. At least if we know what side effects are possible, we can watch out for them. If we are told something is perfectly safe, we are being reassured at the cost of being totally in the dark about whether the product is safe for our pets. 

Are There Any Warning Signs?
There are a number of sources listing warning signs that should alert us to products which are likely scams or snake oils rather than real medicine for our pets. One of  my favorites is Dr. Walt’s Warning Signs of Quackery and Fraud. These cover some of the subjects I’ve already mentioned, and plenty of others. My own quick summary of the most important is this:

1. If it sounds too good to be true, it probably is.
   I’ve already mentioned that anything with no possible side effects is probably too good to be true. The same goes for anything which promises nearly 100% success. Sure, maybe the company offers a “money back guarantee,” but realistically hardly anyone who doesn’t like the product is likely to go to the trouble to return it if it’s not extremely expensive, and when it comes to your pets’ health, getting your money back does little to make up for something that doesn’t work or hurts your companion.

This warning also applies to claims that a product can treat or prevent a wide range of unrelated disease or works to support or strengthen every system in the body. There is no single, simple cause for every illness, and there is no single, simple cure either. Anyone who tells you something, especially when they are selling something, is not giving you an honest or realistic picture.

2. Mysteries, Miracles, and Magic
   We live in an imperfect world where we don’t know everything and we can’t fix or control everything. This leads to anxiety and a search for ways to make ourselves, and our pets, safer. Unfortunately, this also creates an opportunity for marketers to manipulate us by feeding us scary stories about potential health hazards and then offering to sell us something to protect our pets. When the advertising for a product makes claims about such hazards, or about something they offer to protect or restore your pets’ health, there are some red flags to watch out for.

If the claimed threat is dramatic, overly broad, or something your vet and mainstream science supposedly doesn’t know about or is trying to hide, this is a tipoff that it may be an exaggerated or even totally artificial threat, and that someone is playing on your fears to get to your wallet. And if the protection or remedy offered is a “revolutionary” new discovery (especially without any real scientific research behind it), or if it is claimed to be able to save almost any patient even when all other methods have failed, there is reason to be cautious.

Lots of complicated technical jargon isn’t necessarily a signs that there is real science behind the product. Good doctors will want you to be able to understand the disease they believe your pet has and the remedies they offer. Marketers often want to impress you without actually explaining anything. Advertising that clearly plays to your emotions but is short on facts and evidence is advertising to be wary of. The bottom line is that if you’re told something works miracles, that no one understands why, and that evidence beyond testimonials isn’t needed, you’re being given fairy tales, not evidence.

3. Galileo and Dan Brown
   Galileo is best known today for being right about the earth orbiting the sun, and for being made to shut up about it by the religious authorities of the time who didn’t like the idea. He was undoubtedly an exceptional man in many ways, not the least of which is being right when most people thought he was wrong. While sometimes wild ideas that turn our understanding of the world upside down turn out to be true, the vast majority of the time they really are crazy and disappear into history without a trace.

Today, anyone with an implausible or radical idea is likely to answer criticism by comparing themselves to Galileo or the other exceptions in history, not the far more numerous misunderstood geniuses who were actually wrong. Claiming that the only reason an idea or product someone is selling you hasn’t been proven scientifically is because it’s too far ahead of its time and science can’t handle it is more likely to be a sign that you’re dealing with a great ego than with great genius.

Similarly, while I find the intricate conspiracies invented by Dan Brown in his novels, such as The DaVinci Code, very entertaining, I don’t find them very believable. When someone says that they don’t have science to back up their claims because veterinarians, pharmaceutical companies, pet food companies, the government, or a combination of these groups is actively suppressing the truth, they are telling stories more suited to fiction than reality. In particular, the suggestion that veterinarians would rather your pets be sick than healthy, so they can get paid to treat them, is absurd and offensive.

All of the steps on this checklist have to be considered together. An idea that makes sense and is consistent with well-established science can still be wrong, so considering the evidence is still necessary. And if an idea seems crazy but has lots of strong scientific research to back it up, it could very well be true (and it stands a good chance of winning a Nobel Prize, since the highest honors in science are given to those who reveal the errors of the past or break truly new ground).

It is always a good idea to consult your veterinarian if you have questions about a product or service affecting your pets’ health. Hopefully, they will be able to give you solid information to help evaluate the product, or at least to direct you to a reliable source where you could find this information. Veterinarians can’t be experts on everything, but the years they spend studying and working with pets are a resource you should take advantage of.

The frustrating reality is that the vast majority of products out there that claim to preserve or restore our pets’ health are based on guesses or unproven theories and have little in the way of hard evidence to tell us if they are safe or if they can do what they claim. One important rule in medicine is Primum Non Nocere, “First, Do No Harm.” There is ample evidence that unproven or unscientific remedies can be harmful, even if they claim to be safe. When the situation is desperate, and there is a great need to intervene and no well-established treatment available, it may be necessary to reach for something plausible even without strong evidence. But when the need isn’t so great, or when we are treating our own fears as much as our pets, we may be better off not gambling on a product that makes wild claims without hard facts behind them. And when there are well-studied and well-understood options with known risks and benefits, we are better off using these first, and saving the roll of the dice for later, or passing over it entirely.

In any case, as pet owners we are responsible for trying to make the most careful, rational, and best-informed choices possible when it comes to our pets’ health. Following this checklist will give you another tool to help you do this, and hopefully to keep your pets happy and well!

I have received some pretty harsh criticism for suggesting this, so it was satisfying to read a recent editorial in the journal Veterinary Surgery:

Jeffery ND. Is ‘Stem Cell Therapy’ Becoming 21^st Century Snake Oil? Veterinary Surgery 41 (2012) 189–19.

The author begins by cautioning us against “a non-critical acceptance of new advances because of a complacent assumption that previous mistakes regarding poor medical regulation will not be repeated in the modern world.” Obviously, this blog exists precisely because such mistakes, and reliance on prescientific methods of evaluating new ideas through personal experience, uncontrolled experimentation, and trust in authority, rather than reliance on rigorous controlled scientific research, are still widespread in our profession. As Dr. Jeffery correctly points out, the majority of veterinarians rightly deride pseudoscientific methods such as homeopathy (though too many still fall for it’s propaganda). And yet the same approaches to justifying other kinds of clinical interventions, both conventional and alternative, are all too common.

He then goes on to remind us that the promising preclinical research involving stem cell therapies does not justify their widespread clinical use without properly designed and conducted clinical trials. Most research on these therapies published so far has been methodologically inadequate to justify the burgeoning market in stem cells. However, the uncritical reports in the media of preclinical research, and the easy availability of testimonials and uncontrolled anecdotes about stem cell treatment, not to mention the aggressive marketing by stem cell therapy companies, make it “easy to sell to owners as a respectable treatment, even in the absence of rigorous proof of efficacy.”

Finally, Dr. Jeffery emphasizes something with which I conclude most of my own articles about unproven therapies, a call for a stricter standard in veterinary medicine for scientific evidence about our interventions.

Whilst stem cell therapy has rapidly achieved high profile in medicine and therefore even misplaced claims for efficacy are noteworthy it is not the only therapy in veterinary medicine or surgery for which there is insufficient evidence of benefit to support widespread implementation. Novel interventions for common conditions are published frequently in veterinary journals, including Veterinary Surgery. Whilst it is undoubtedly important that new interventions are explained through publication, it is essential that they should subsequently be subject to critical testing of their effectiveness before being widely accepted. This is currently not standard practice in veterinary medicine and surgery… Strict testing of novel interventions must become the norm for veterinarians to be able to maintain our view of ourselves as a ‘science-led’ profession.

I couldn’t agree more.