The SkeptVet Blog

I have tried to avoid this topic since it is not by even the most tortured stretch of the imagination really about medicine, even most forms of alternative medicine. Unfortunately, all too often I see people making medical decisions for their pets based on what supposed pet psychics (or “animal communicators” which seems to be the currently favored marketing term) tell them, so I feel obliged to state the seemingly obvious: No one can communicate psychically or telepathically with your pet, and you should not pay someone to make up stuff about what your pet is supposedly thinking! You certainly should not make decisions about your pet’s healthcare or about euthanasia and quality of life based on what a psychic tells you your pet is thinking.

The details of the fraud and self-deception engaged in by pet psychics really are no different from those employed by people who claim to speak with the dead, divine the future, and otherwise know things through mystical mind powers. Joe Nickell, a well-known investigator of paranormal phenomenon, has addressed the subject of animal communicators in his article Psychic Pets and Pet Psychics. Such charlatans use a variety of techniques, but the bulk of their show consists of cold reading, a set of strategies designed to take advantage of the subject’s desire for the psychic to be right and to help them communicate with their pet. Some of these strategies are described by Nickell in his article:

1. Noting the obvious. Fitzpatrick (2002) visits an animal clinic with a couple and their infant daughter to tell them which dog is right for their family. After the selection is narrowed to three choices, each is brought out in turn. The first is ambivalent; the second ignores everyone; and the third, Patty, greets the couple and nuzzles the child. Sonya writes her choice on a slip of paper and it proves to be the same the couple made: Patty. The audience applauds: Patty was apparently their choice too! (I know she was mine!)

2. Making safe statements. Fitzpatrick (2002) announces that one pooch “says” he wants to go out more often, and the dog’s owners accept the assertion. Similarly, Gerri Leigh (1992) tells the owner of an outgoing little dog, who immediately licks Leigh’s hand, that the animal “fears no one”; but then she quickly adds that it is “not an unconditional lover.” She continues by stating that the pet is “independent” and “not a yes dog.” Such virtually universal declarations are not apt to be challenged.

3. Asking questions. Psychics frequently seem to provide information when they are in reality fishing for it. The asking of a question may, if it is correct, credit the reader with a hit; otherwise it will seem an innocent query. For instance, Fitzpatrick (2002) asks a dog owner, “When was there someone who was with him who went away?” (Unfortunately, this is too good a hit, since the young woman seems puzzled and replies that it could have been various persons—possibly, one imagines, former boyfriends or other acquaintances.) Questioning also keeps the reader from proceeding too far down a wrong path and allows for mid-course correction.

4. Offering vague statements that most people can apply specifically to themselves. Alleged psychics take advantage of what is known as “the Barnum effect”—after showman P. T. Barnum who strove to provide something for everyone (French et al. 1991). They learn that people will respond to a vague, generalized statement by trying to fit it to their own situation. Thus Fitzpatrick (2002) tells the owner of a pet iguana that the creature had experienced “a move.” Now most people can associate a “move” with their pet: either when they acquired it, when they changed residences, or when they left it with someone to go on vacation, etc. Thus the pet psychic was credited with a hit (never mind that she incorrectly referred to the female iguana as “he”).

5. Returning messages to animals. People who are convinced pets give information to psychics may be willing to believe the reverse. Thus Fitzpatrick (2002) claims to give animals “messages”—for example a clarification of something by the owner—by silently concentrating for a moment.

It doesn’t take much effort to expose the shallow and vacuous nature of the “communication” a psychic is having with an animal. Karen Stollznow illustrates this with a simple experiment she has written about as The Ballad of Jed (and the Pet Psychic). She borrowed a neighbor’s cat and invited a psychic over to perform a reading. The interview was a series of guesses, attempts to fish for information, and confabulation of vague but plausible stories about the cat. Almost none of the few details offered by the psychic were correct based on the known history of the cat.

The video below is a good example of such a cold reading (at least in form, though since the breeder and the psychic worked together to produce a series of videos demonstrating the psychic’s work, it could in fact be an example of a hot reading, in which the psychic has advance information about the subject they are reading).

The psychic begins by noting the obvious, that the pet (who is clambering all over the owner wagging her tail and licking) is affectionate and loves the owner. She makes a series of vague and relatively neutral statements like “she is something else.” She starts talking about how the dog “likes to be seen” but doesn’t necessarily like to be petted or shown affection by strangers since it might “mess up my hair” (at which point the dog leaves the owner and jumps on the psychic to get some attention). She says the dog is “happy and loving” but also “conservative,” “very playful, but not too much so,” and so on. Such descriptions could be easily applied to almost any dog of this age exhibiting the kind of behavior she shows in the video, and they certainly don’t require any special telepathic communication or insight. At one point, the psychic suggests the dog could be used in one kind of service work (“canine good citizenship”) and when the owner offers “I was thinking of using her in therapy work,” the psychic responds that she was just about to say that.

I don’t suggest that most animal communicators are deliberately lying, though undoubtedly some are. Often, psychics believe they really are in touch with the living or dead animals they claim to communicate with. That they are deluded rather than lying does not do much, unfortunately, to mitigate the fact that they are deceiving people, often pet owners in grief or struggling with heartrending decisions concerning their pet’s well-being.

When I am asked why it matter whether someone gets comfort from untrue information about their pets’ thoughts, I have to answer on both a philosophical and a practical level. Philosophically, I believe the truth matters and that deception, intentional or not, is wrong. Even comforting false beliefs are still false, and they are cheats that deny us the chance to face honestly and directly the truths of our lives. I don’t recommend my clients lie to their children when a pet dies, telling them it “went to the farm,” because it seems wrong to me to try and avoid pain by denying the true nature of reality. Likewise, I cannot convince myself that it is ok to lie to a pet owner and claim to be hearing the thoughts or feelings of their pet.

Such philosophical objections are, of course, personal and subject to debate. However, there are also more pragmatic reasons to disabuse people of the myth of pet psychics. People often consult psychics during times of stress and uncertainty seeking information to help them make decisions. They may want to know if their pet is in pain so they can make decisions about medical treatments. Or an owner may be thinking about euthanizing a severely ill pet and want some guidance from the pet concerning its feelings or opinions about the quality of its life. These situations and decisions are difficult and painful, and at such times people are even more easily deceived by their own needs and desires and by the tricks of psychics and mystics.

The most benign of pet psychics are merely psychological mirrors; they reflect the owners feeling much like a psychotherapist. But others go farther and make definitive statements about an animal’s thoughts or wishes. I once saw a dog with bone cancer in severe pain whose owners denied the obvious symptoms of limping and crying and were convinced their homeopathic pain medication was working, all because according to a pet psychic the dog said he was comfortable. And I’ve seen terminally ill dogs suffering terribly whose owners refused to consider euthanasia because an animal communicator told them their pet wanted to stay with them longer. Decisions based on fairy tales and deception are not likely to be good decisions. And because our pets truly cannot speak for themselves, the stories told by charlatans who claim to be speaking for them are not likely to represent their real feelings or to further their interests.

For those who have read what I have previously written about probiotics, you’ll know that I am cautiously optimistic about their potential usefulness as a medical therapy, despite the tendency towards overstating the results of the limited clinical trials so far done in veterinary species. The theoretical principle, that administering living organisms orally can have beneficial effects on the GI tract and, potentially, systemically, is certainly reasonable. And there is clinical evidence supporting benefit in humans for some causes of diarrhea and other GI tract disease. The literature concerning veterinary use is very limited and preliminary, with both possible risks and benefits reported but no clear, indisputable evidence for clinical benefit. Still, I certainly think additional research is warranted, and I do sometimes use some probiotic products in my own patients for antibiotic-associated diarrhea.

However, I have a number of concerns about probiotics. Little is known and less understood about the composition and function of the normal GI flora, and what role, if any, organisms not normally found in the gut can have when given therapeutically is unclear. Independent testing of many probiotic  products has also identified serious quality control problems, so it is currently impossible to trust that what you think you are getting is really in many of the commercial probiotics. However, my biggest concern about probiotics is that their widespread acceptance and use goes well beyond what is justified by the available evidence, and this can easily lead to direct harm and even more easily to the kind of indirect harm that comes from substituting unproven remedies for well-demonstrated ones. Exaggerated claims and unscientific, deceptive marketing practices are common in the promotion of such products, and this raises the chances of their doing more harm than good.  The assumption of safety and efficacy that is often made about CAM products has certainly proven, in the case of some such products, to be unfounded, with real harm resulting.

One of the most egregious examples of this is a product which I recently looked into after hearing a number of my clients talking about using it in their pets. Primal Defense is marketed by Garden of Life, and the marketing materials are a laundry list of exaggerated and unsupported claims. Some examples:

“Healthy people usually have a ratio of approximately 85% good to 15% potentially harmful organisms in the intestinal tract. In some cases, even those who appear to be well might have an unfavorable ratio as a result of daily exposure to environmental toxins and a modern lifestyle. “

Here we have the usual vague “toxin” gambit, suggesting that normal life is full of poisons that we need their product to protect us from.

” Large scale use of pesticides, herbicides and other chemicals has changed the bacterial balance of the soil. In order to obtain the benefits we historically acquired from consuming foods cultivated in healthy soil, Garden of Life developed a Homeostatic Soil Organism Probiotic Blend utilizing 12 species of beneficial microorganisms.” 

The idea that modern agricultural practices can affect soil ecology is pretty obvious. The suggestion that this somehow creates deficiencies in nutrients or human/pet gut ecologies that we need this product to correct is totally manufactured and unsubstantiated in any way.

The very use of the term “Homeostatic” is a bit of pseudoscience marketing, since this term has no recognized meaning with regard to probiotics and was apparently made up just for the purpose of making this product sound “sciency.”

The story, however, gets a lot scarier. The marketing of this product involves a great deal of outright lying and deception. The founder of Garden of Life, Jordan Rubin, was fined by the Federal Trade Commission (FTC) for false advertising in connection with Primal Defense and other product in 2006. This including fabricating claims about clinical research studies to support his product claims. He was also ordered by the Food and Drug Administration (FDA) to desist from making false and unsubstantiated health claims in 2004. Mr. Rubin has also claimed to have several academic credentials, including a NMD (naturopathic medical doctor) and PhD. Both degrees, and other credentials he has claimed, come from unaccredited correspondence schools, one of which was actually ordered to close by the state of Hawaii in 2003 for fraudulent practices.

Marketers of Primal Defense frequently state that there is clinical evidence to support their claims for the product. However, no real clinical trials seem to have been published in any recognized scientific journals. For example, claims are made on a number of websites regarding a clinical trial of Primal Defense supposedly published in the journal Progress in Nutrition (Goldberg, P.A. “Primal Defense Homeostatic Soil Organisms As Applied To Medically Unresponsive Chronic Disease Conditions In Adults” Progress In Nutrition Supplement Volume 4 January 2002). The journal is not listed on PubMed, Science Citation Index Expanded, or any other resources listing legitimate scientific journals. The accusation has been made that it is a fake journal funded by Garden of Life, but I cannot confirm this. In any case, it is clearly not a legitimate peer-reviewed scientific publication, and the author is a chiropractor who seems to publish predominantly in chiropractic journals and newsletters, not real science journals.

A bit more investigation into Mr. Rubin explains pretty clearly his lack of respect for legitimate scientific research or academic credentials. He is the paragon of faith-based medicine whose books, including The Maker’s Diet and Patient Heal Thyself, detail his belief that his own GI disease was cured through a combination of prayer and changes in diet based on “biblical principles.” As he puts it:

“My father had just gotten through telling me he had spoken to an eccentric nutritionist on the phone. My father didn’t want me to get my hopes up so he had investigated the man’s program himself. The nutritionist told my father he believed I was ill because I was not eating the diet of my ancestors, based upon Biblical principles.

When my father told me about all of this, naturally, I was curious…It fit into my belief system. In an effort to start all over, I took myself off all nutritional products and read the Bible to see what people ate thousands of years ago. I also learned that the longest living cultures in the world had one thing in common: they consumed living foods that abounded with beneficial microorganisms.

A few weeks later, I got on a plane, still bound to my wheelchair, and headed for southern California to live closer to the man who would teach me how to eat from the Bible. After integrating into that particular nutritionist’s program some of my own findings about nutrition and health from the Bible I saw some improvement…During my forty days and nights of parking my motor home close to the beach, I prayed, listened to music and planned everything around buying, preparing and eating my food…The combination of the Biblical diet and the HSOs had restored my health.”

The use of science to try and justify Mr. Rubin’s unscientific nutritional theories are pure marketing, taking advantage of the respectability that real science has earned through the results it produces. His approach is ultimately based, as so much CAM is, on personal revelation, and supported primarily through anecdote and testimonial. His books, his Garden of Life company, his Biblical Health Institute, and all the other pieces to his lucrative nutrition business are paradigms of snake oil marketing.  

Such a marketing approach can turn a potentially legitimate, if not yet ready for primetime, therapy like probiotics into pure quackery. If you can’t trust Mr. Rubin’s claims about his own credentials or the research evidence behind his products, why should you have any faith in his products themselves, even if they claim to be something potentially useful like probiotics? CAM marketers like to attack the honesty and ethics of mainstream medical product manufacturers, such as pharmaceutical companies and commercial pet food makers. And all too often, there are real reasons to be skeptical of these industries. But for all that, they have an established, public record of legitimate science behind many of their products, often thanks to vigorous government regulation requiring it. Companies like Garden of Life illustrate why the unregulated supplement industry (aka Big CAM) is not only not entitled to the assumption of better ethics that they often receive, but it quite likely gets away with even more ethically questionable practices than the mainstream medical and diet industries, which are at least better supervised and regulated. I do not often feel justified in prescribing probiotics, but when I do I certainly have no intention of using a product such as Primal Defense marketed by a man who not only bases clearly unscientific advice and products on personal divine revelation but who seems to have no discomfort promoting his ideas and products with obvious and egregious deceit.

A colleague recently saw an older dog who had vomited up roundworms and was doing some coughing. He diagnosed and treated the patient appropriately, but the client later contacted him with questions about some alternative remedies that had been recommended to her by the folks at Native Remedies. The owner had the common misconception that “natural” is a word with a real and precise meaning in medicine (as opposed to a marketing term invented to take advantage of the fear of “toxic” modern life) and that using it to describe a remedy somehow guaranteed safety. The folks trying to sell her such products took full advantage of this idea in their letter to her.

They began by flattering her, “You are to be commended for researching the use of natural alternatives.” They then recommended a host of herbal and homeopathic products.

Several were claimed to be homeopathic products: Respo-K, Sinu-Rite, and KC-Defense. These contain a variety of ingredients all diluted in the usual homeopathic way. 100% safe? You bet! Why–because they’re 100% water! (Well, technically some of the ingredients are diluted less then 12C, so they could possibly contain a few molecules of the original substance, but still quite likely much less than needed to have any measurable physiologic effect). The seller did engage in a bit of deceptive advertising. They repeatedly stressed the products are “FDA registered.” Well, doesn’t this mean they are tested and approved by the FDA?

Actually, not at all. The issue of how homeopathic preparations are regulated is a complex, and fuzzy one. Homeopathic products for human use were grandfathered, without any scientific testing or validation, into the original legislation establishing the FDA and its mandate as a concession to an influential senator who was a homeopath. These products can be marketed with medical claims as long as they have been included in the Homeopathic Pharmacopeia of the Untied States, an index of such remedies maintained by an independent organization of homeopaths which sets rigorous standards for proving the safety and efficacy of water in a way totally inconsistent with the rest of medical science. The over-the-counter sale of such remedies is limited to disease that are “self-limiting” and which an average consumer should be expected to recognize and be able to treat on their own. If the homeopathic “drugs” are used for serious illnesses, they require a prescription, though for obvious reasons they seldom are so used.

With regard to the veterinary use of homeopathic “drugs,” the FDA has stated that it does not considered this activity to be covered under the same rules as the human use of these products, so veterinary homeopathy is technically a use of unapproved veterinary drugs and so illegal, though doubtless lawyers could wade through the voluminous legislation and make all sorts of arguments for and against this claim. In any case, the FDA has neither the will nor the resources to enforce any such position and has generally agreed to ignore homeopathy when used in companion animals.

All of this is simply to illustrate that “FDA registered” when applied to a homeopathic drug 1) implies no scientific testing of safety and efficacy and 2) only properly applies to human use, which was allowed in the 1930s as a political concession. Thus, the term is meaningless from the point of view of legitimizing any claims sellers of these products may make.

Because these remedies are essentially only water, and so harmless in themselves, there is not likely ever to be any interest among politicians in the controversial and thankless task of requiring them to either prove themselves scientifically or be banned. But it is clear that they should not be expected to have any benefit for real disease, nor should they be used in place of scientific medicine which has demonstrated safety and efficacy in a legitimate way.

The other two recommended products were herbal concoctions, and so have some potential to be helpful or harmful. The usual caveats apply to these remedies, namely that they are in no way regulated and all quality control is voluntary, so cases in which the label does not accurately reflect the ingredients and toxic or pharmaceutical contaminates are present are common. I have a long, and growing, list of examples of this problem.

The first nostrum reocmmended was Parasite Dr., which the sellers claim is a mixture of wormwood (Atremesia absinthinium), Cloves (Eugenia caryophyllata), Neem (Azadirachta indica), and Herb of Grace (Ruta graveolens).

Wormwood has been used medicinally and as a flavoring agent for centuries, most notoriously in the alcoholic drink absinthe. Limited in vitro studies have shown some toxicity to roundworms, however, these must always be interpreted cautiously since bleach can poison worms in a test tube too, but that doesn’t make it a safe and effective deworming agent. There is one in vivo trial in sheep conducted in India in which water and alcohol extracts of the plant had some effects on parasite egg counts, but again when one takes extracts from a plant and purifies them, one has a drug, not an herbal remedy. How much of which compounds from wormwood are in this product is completely unknown, so even if wormwood had antiparasitic properties, which is far from demonstrated, that doesn’t mean this product would. As for toxicity, one small rat study found no obvious toxic effects, however neurologic and GI symptoms have been reported from ingestion of compounds in wormwood, so the safety of this product is as much a mystery as its efficacy. No evidence concerning safety or effectiveness in dogs appears to exist.

Clove oil has also had a history of medicinal and flavoring use. The NCCAM has concluded there is insufficient evidence to support any use other than as a mild topical analgesic, and a review of traditional veterinary herbal remedies for GI and parasite problems has concluded there is insufficient evidence to justify its veterinary use. There have also been reports of an increased risk of bleeding, particularly when used concurrently with non-steroidal anti-inflammatory medications, and allergic reactions have been seen. No evidence concerning safety or efficacy in dogs specifically appears to exist.

Neem is currently quite popular among gardeners as an insect repellant, and has a history of use as an anti-parasitic. There is reasonable evidence for its topical use on animals and plants, including one study showing some flea repellent effects in dogs and cats. Extracts have been tested in several trials in sheep, and most have found little or no efficacy in reducing intestinal parasites. (1, 2, 3, 4). A review of the limited safety data available for humans and lab animals finds minimal toxicity, and the EPA has exempted some neem products from its more stringent pesticide regulations under the presumption of safety. However, no data on the safety or oral use in dogs appears to exist.

Finally Rue or Herb of Grace is primarily known in traditional herbal use as a substance used to induce abortion. There is limited data on it’s safety and efficacy, and nothing to support its use for parasites or gastrointestinal disease generally. Some pretty serious toxicity, including photosensitivity (blisters and ulcers developing with sun exposure after use of rue) and potential mutagenic and carcinogenic properties have been reported.

So the pattern is clear. Minimal or no evidence of effectiveness, limited evidence of safety or even known risks, and no assurance of any particular ingredient or dose or the absence of toxic contaminants. Yet we are supposed to rest comfortably in the confidence that because it’s “natural” it must be good regardless of whether there is any evidence either way.

The folks at Native Remedies are very tricky in their marketing of this and the other products recommended. When one searches their web site for Parasite Dr, for example, the search turns up a clear (and illegal) medical claim: 

However, when one follows the link to the actual page, they are very careful only to make allowable “structure and function” claims, such as these:

Parasite Dr. Benefits:

• Promote digestive health and balance
  Calm and soothe the digestive system
• Cleanse and detox the digestive system and improve digestive functioning
• Cleanse the blood
• Support correct balance of intestinal flora
• Act as a tonic for the entire digestive system
• Support the immune system

They even go so far as to note, “ Disclaimer: Testimonials have been edited to comply with FDA regulations. While positive results are likely, the testimonials used are general results and are not intended to represent or guarantee that anyone will achieve the same or similar results – individual results may vary.”

Unfortunately, this is merely an effort to comply with the letter of the law, and they show no restraint in making illegal and unethical claims in their e-mail to the client. The nostrum is promised to “rid your pet of unhealthy infestations of internal parrasites without the unwanted side effects sometimes associated with synthetic parasite medication…As an added bonus, Parasite Dr . also helps to cleanse the system and contains herbs with antifungal properties, thus helping to reduce systemic yeast infections which compromise health…” Clearly, the evidence supports none of these claims, and the old saw about “yeast infections” as a cause of illness is a bit of popular CAM mythology which has nothing to do with this patient’s problem.

The most disturbing and ethically offensive part of the marketing materials, however, concerns heartworm disease. This is a serious parasitic infection which is widespread in much of the United States and which is routinely fatal if acquired. There are, however, safe and effective, FDA approved and adequately tested, preventatives in common use. The native Remedies representative, however, claims their product is an effective preventative for this deadly disease, which it almost certainly is not. They also imply conventional preventatives “can undermine the liver” (which is not at all true, while they have risks like any drugs, these have nothing to do with the liver), and they then try to sell another herbal concoction, Detox Plus, to treat this. Any owner unfortunate enough to believe these lies and who lives in an area where heartworm disease is endemic is likely to see their pet die from heartworm infection if they follow this advice. That is why such claims are illegal, not some sinister conspiracy of government and the pharmaceutical industry to deny people effective natural medicines. It is only a pit that the government has not the will or resources to enforce such laws, and that pets and people must inevitably suffer for it.

Call it coincidence, confirmation bias, or a trend, but I once again ran into the issue of a specialist I refer to recommending a questionable therapy for one of my patients. I recently diagnosed a dog with a nasal cancer and sent him to a board-certified oncologist to consult of options for advanced therapy. The particular disease can’t be cured, but radiation and chemotherapy can have some symptomatic benefit and may prolong a reasonable quality of life. The owner, however, didn’t feel the possible benefits justified the risks and costs, which I think was a reasonable decision. So the oncologist was only able to offer minimal symptomatic care. He offered a non-steroidal anti-inflammatory for pain, and also told the owner to go to a human herbal remedy shop and find the Chinese herbal preparation yunnan paiyao to help with the intermittent nosebleeds the cancer was causing.

I expect specialists to be more cognizant of the need for evidence-based practice than general practitioners, but I am beginning to doubt the truth of this assumption. I accept that sometimes, when there is a compelling need to treat and no established effective treatment available or acceptable to the owner, it may be appropriate to try things that have a weak basis in basic or clinical evidence. However, I am still concerned about the wisdom of recommending therapies that we don’t have at least some reasonable evidence are safe or effective.

Absence of evidence is not, of course, proof something doesn’t work. But it is absence of any good reason to think it does. And the reverse is true for safety. Absence of evidence of harm does not mean it isn’t harmful, only that we don’t know whether it is or not. Yet anecdotal experience is used to justify both safety and efficacy despite the clear evidence of history that this isn’t reliable. Of course, this logic is preferentially applied to CAM therapies. If clinical testing of a pharmaceutical company medicine finds no significant side effects, and then rare harm does appear once the drug is in widespread use, this is trumpeted as a failure of the whole scientific testing paradigm and proof of the evil venality of drug companies and the innately poisonous nature of their products. Yet we seem very comfortable prescribing herbal products about which almost nothing is known concerning safety or efficacy, with the assumption that they must be safe and that even if the only evidence they work is anecdotal at least we they can’t do any harm.

So what is yunnan paiyao, and what is the evidence for or against it? It is an herbal concoction apparently invented in China in the early 20th century, and the details of the ingredients are still kept secret. However, it is widely considered to consist primarily of Panax notoginseng of pseudoginseng root, with a number of other possible plant ingredients. Right away I wonder at the wisdom of prescribing a remedy when no one knows exactly what is in it. Can you imagine a major pharmaceutical company getting away with selling a drug that doctors actually prescribed without disclosing the actual ingredients?! And given the well-documented problem of heavy metal and pharmaceutical contamination of Chinese herbal remedies, and the general inconsistency of such preparations, it is remarkable that any doctor, much less a boarded specialist, would feel comfortable assuming the safety of such a product based on personal experience and anecdotes.

There have been a few papers published in China and in some alternative medicine publications that show the substance has some influence on platelet aggregation, an important step in blood clotting. However, you can mix sand or many other substances in a test tube with platelets and they will activate. One of the reasons it is so hard to make a safe artificial heart is that it’s tough to find substances that don’t trigger platelet aggregation. Some studies have compared the effect of yunnan paiyao with wheat flour or other substances to show it is more likely to cause clotting than these others, but the reliability of the tests and the choice of substances doesn’t make a very convincing case. And we have to remember the problem with the reliability of different sources of published research. Publication bias (the publishing of only positive results and “round-filing” of negative studies) is a problem everywhere. But Chinese journals almost never publish negative studies, and CAM journals are especially prone to select only those papers for publication that support the kinds of therapies the journals were started to promote.

The same issue arises in considering the few clinical trials in humans. A small number of trials with a small number of patients conducted and/or published in low reliability sources might be enough to justify further research, but not to justify widespread clinical use of the product. And, of course, the testimonials and anecdotes of clinicians and users have the same lack of reliability. If the product has been in use for over 100 years, and in that time we have only a handful of small studies of it, I think that is fair reason to be skeptical. If the drug truly has a dramatic impact on bleeding, topically or orally, it shouldn’t be difficult to conduct and publish a well-designed trial for a mainstream journal. Even one such trial would doubtless excite enough interest, through NCCAM or private industry, to stimulate more. Whether this has never been done because the proponents of such therapies don’t see the need for such evidence, or because the drug doesn’t truly have enough promise to survive such a test, is an open question.

Finally, I have found only two published veterinary trials investigating yunnan paiyao. An abstract presented at the 2002 International Veterinary Emergency and Critical Care Symposium took a group of 6 healthy ponies, and anesthetized them twice to check activated clotting time (ACT) and template bleeding time (TBT). The ACT is a moderately reliable test of blood clotting, though it can be affected by temperature, how vigorously and consistently the test tube is shaken, and a number of other factors. The TBT is a much less reliable and more subjective test in which a lancet is used to cut the patient (usually on the oral mucosa) and the time it takes for the cut to stop bleeding is measured.

The only difference reported in methods between the control trial and the yunnan paiyao trial was the position of the patients. They were on their side in the control trial and on their back in the test trial. I wonder if this might affect TBT since the  blood flow to different parts of the body is affected by body position, but there isn’t any information in the abstract to determine if this is a factor. The study reported to difference in the ACT value with or without the yunnan paiyao but did report a non-chance difference in the TBT.

The other trial was a placebo-controlled trial of yunnan paiyao and another herbal preparation called Single Immortal using five Thoroughbred horses. The horses were run on a treadmill after having received either one of the herbal preparations or the placebo (cornstarch) orally twice a day for 3 days before the experiment. A number of variables were measured, with the main goal to see if there was any effect on exercised-induced pulmonary hemorrhage (EIPH), bleeding in the lungs during exercise. No effect of either remedy on EIPH was seen.

So we have a treatment with uncertain and unregulated ingredients, no demonstrated plausible mechanism of action, a few in vitro and lab animal studies in journals of questionable reliability, a few small human clinical trials in similarly questionable sources, and two very small veterinary trials in equids which found no effect except possibly on a poorly reliable and subjective test of blood clotting. At the same time, we have almost no published reports of adverse effects. There is one case report in a Chinese journal of a contact dermatitis reaction and some suggestion that high doses or chronic use may affect bone marrow cells. And we have a well-established history of toxic contamination and poor quality control in Chinese herbal remedies in general.

For me, this information clearly shows the oncologist’s use of this preparation in my patient to me essentially an uncontrolled experiment with no reasonable assurance of safety or efficacy. It is disturbing to me and certainly shakes my confidence in the judgment and recommendations of this particular specialist, though I fear he may not be at all exceptional but simply part of a larger phenomenon in which anecdote, personal experience, and “expert” opinion is given undue weight and the need for more reliable evidence is underestimated in veterinary medicine.

References:

Epp TS, McDonough P, Padilla DJ, et al. The effect of herbal supplementation on the severity of exercise-induced pulmonary haemorrhage. Equine and Comparative Exercise Physiology 2005;2:17-25.

Graham L. Yunnan Paiyao–Where’s the clinical evidence? Veterinary Botanical Medicine Association Symposium Archive 2005. Available at: http://www.vin.com/Members/proceedings/Proceedings.plx?CID=VBMA&PID=13730&Print=1&O=VIN

Graham L, Farnsworth K, Cary J. The effect of yunnan baiyao on the template bleeding time and activated clotting time in healthy halothane anesthetized ponies. Proceedings International Veterinary Emergency and Critical Care Symposium 2002, San Antonio, TX. Journal of Veterinary Emergency and Critical Care 2002;12(4):279. Abstract only.

Robinson N. Yunnan Paiyao; The following references come from Dr. Robinson’s document:

 1 Bergner P. Panax notoginseng Yunnan bai yao): A must for the first aid kit. Medical Herbalism. 10-31-94 6(3):12.

2 Fratkin J. Chinese Herbal Patent Formulas – A Practical Guide. Santa Fe: Shya Publications, 1986. P. 133.

3 Fratkin J. Chinese Herbal Patent Formulas – A Practical Guide. Santa Fe: Shya Publications, 1986. P. 133.

4 Zheng YN et al. Comparative analysis of the anti-haemorrhagic principle in ginseng plants. Acta Agriculturae Universitatis Jilinesis. 1989;11(1):24-27, 102. [Article in Chinese].

5 Jin H, Cui XM, Zhu Y, et al. Effects of meteorological conditions on the quality of radix Notoginseng. Southwest China Journal of Agricultural Sciences. 2005;18(6):825-828.  

6 Fan C, Song J, and White CM. A comparison of the hemostatic effects of notoginseng and Yun Nan Bai Yao to placebo control. Journal of Herbal Pharmacotherapy. 2005;5(2):1-5.

7 Fratkin J. Chinese Herbal Patent Formulas – A Practical Guide. Santa Fe: Shya Publications, 1986. P. 133.

8 Liu Y, Xie M-X, Kang J, et al. Studies on the interaction of total saponins of panax notoginseng and human serum albumin by Fourier transform infrared spectroscopy. Spectrochimica Acta. Part A. 2003;59:2747-2758.

9 Chan RYK, Chen W-F, Dong A, et al. Estrogen-like activity of ginsenoside Rg1 derived from Panax notoginseng. Journal of Clinical Endocrinology and Metabolism. 2002;87(8):3691-3695.

10 Cicero AFG, Vitale G, Savino G, et al. Panax notoginseng (Burk.) effects on fibrinogen and lipid plasma level in rats fed on a high-fat diet. Phytotherapy Reearch. 2003;17:174-178.

11 Epp TS, McDonough P, Padilla DJ, et al. The effect of herbal supplementation on the severity of exercise-induced pulmonary haemorrhage. Equine and Comparative Exercise Physiology. 2004;2(1):17-25.  

12 Chung VQ, Tattersall M, and Cheung HTA. Interactions of a herbal combination that inhibits growth of prostate cancer cells. Cancer Chemotherapy and Pharmcology. 2004;53:384-390.

13 Chen FD, Wu MC, Wang HE, et al. Sensitization of a tumor, but not normal tissue, to the cytotoxic effect of ionizing radiation using Panax notoginseng extract. American Journal of Chinese Medicine. 2001;29(3/4): 517-524.

14 Chen FD, Wu MC, Wang HE, et al. Sensitization of a tumor, but not normal tissue, to the cytotoxic effect of ionizing radiation using Panax notoginseng extract. American Journal of Chinese Medicine. 2001;29(3/4): 517-524.

15 Leung KS-Y, Chan K, Chan C-L, et al. Systematic evaluation of organochlorine pesticide residues in Chinese materia medica. Phytotherapy Research. 2005;19:514-518.

16 Leung KS-Y, Chan K, Chan C-L, et al. Systematic evaluation of organochlorine pesticide residues in Chinese materia medica. Phytotherapy Research. 2005;19:514-518.

17 Leung KS-Y, Chan K, Chan C-L, et al. Systematic evaluation of organochlorine pesticide residues in Chinese materia medica. Phytotherapy Research. 2005;19:514-518.

18 Leung KS-Y, Chan K, Chan C-L, et al. Systematic evaluation of organochlorine pesticide residues in Chinese materia medica. Phytotherapy Research. 2005;19:514-518

Some of the most popular forms of alternative medicine are the myriad herbs and “dietary supplements” (a faux category created by the 1994 Dietary Supplement Health and Education [DSHEA] act to allow marketing of unproven drugs without regulatory oversight). These nostrums are potentially more useful than outright quackery like homeopathy or “energy medicine” because they contain actual physiologically active chemicals. Unfortunately, that means these are also the most likely for of CAM to cause direct harm.

There have been numerous examples of this kind of harm in the past. Kidney failure caused aristolochic acid in traditional Chinese medicines, lead poisoning from contaminated Ayurvedic and Chinese preparations, and deaths from ephedra-containing supplements such as ma huang are among the most dramatic and well-publicized examples. Below is an extensive list of references regarding these and other such examples.

Despite this, the perception that such preparations are “safe and natural” still seems widespread, and it seems difficult to disabuse people of this notion. However, I am encouraged by a number of recent indications that the risks associated with untested and unregulated supplement use may be getting more attention. I recently wrote about an article looking at the association of herbal therapy with poorer compliance and quality of life in asthma patients.

Another article on the subject that recently caught my attention was entitled Dietary Supplement Polypharmacy: An Unrecognized Public Health Problem?, published in eCAM. The article is essentially a series of anecdotes, so of course it proves nothing about the overall impact of herbal remedies. However, the theme that emerges from the cases reported strikes me as key to understanding the risks of such treatments. The cases almost all involved people who took herbal preparations for more psychological than medical or rational reasons. They generally took a variety of supplements, often with no systematic dosing or schedule or even any understanding of what they were taking or what the intended effects or possible side effects were. This is only possible because these people accepted the baseless notion that somehow because they were “natural” these preparations could be expected to have beneficial effects without any risk, any dose/response relationship, or any of the usual limitations know to affect pharmaceuticals.

Ironically, the people discussed in the article also commonly reported turning to herbs and supplements because of fears of the side effects of conventional medical therapies. This is similar to the attitude reported in the study of asthma patients. Clearly, any therapy that has measurable effects is going to be tinkering with a complex and massively interconnected system, and this makes it highly likely that unanticipated or undesirable effects will occur as well. In scientific medicine, it is understood that all therapeutic decisions require a cost/benefit analysis, and that while it is appropriate to avoid unnecessary interventions that might do more harm than good, there are clearly many circumstances in which the risks of a treatment are far outweighed by the potential benefit. CAM advocates and users seem to have the notion that these rules only apply to conventional medicine, and they tend to have an exaggerated awareness of risks while taking the benefits for granted. They then fall prey to the irrational and demonstrably false notion that CAM therapies are exempt from the rules of pharmacology and physiology that constrain scientific medicine and that they can somehow get something for nothing–benefits without risk. This is a dangerous notion which must be debunked so that the true potential of herbal medicines can be developed in a rational and scientific way and unnecessary risks be avoided.

Finally, the cases illustrate the sense many CAM users have of not being in control of their medical care when dealing with conventional, scientific medicine. Being able to change their diet, take supplements or herbal remedies guided by their own internal sense of how they are responding, and so on gives them a feeling of having some control over their bodies and their care. This is a challenging psychological issue. Scientific medicine has rightly moved away from the paternalistic model and acknowledges that patients have the ultimate right to make decisions about their own care. However, it is also an undeniable fact that health care have factual knowledge and a overall perspective that make their assessments and decisions about specific interventions generally more reliable than those of lay people with a personal and intense emotional investment in their or their pets health.

Somehow, scientific medical providers need to do a better job of dealing with the psychological aspects of disease in their patients or, in the veterinary domain, their patients’ owners. We must understand and manage the normal psychological factors that lead people into use of unproven or bogus therapies while maintaining a solidly scientific and evidence-based standard for the medicine we employ. And we must do all of this within the limitations of time and resources under which we operate. A significant challenge indeed.

Another article I ran across recently that bears of the dangers of herbal medicine use is A review of the potential forensic significance of traditional herbal medicines in the Journal of Forensic Sciences (Byard RW. 2010:55(1);89-92). This is a nice summary of some of the specific dangers of unregulated and unscientifically used herbal preparations, including direct toxicity, heavy metal poising, adulteration with toxins, interaction effects of multiple active compounds taken together, and interactions with conventional medicines. These risks are exacerbated by the facts that many users of herbal remedies don’t tell their doctors what they are taking (or they may not know themselves), most doctors know little about the possible risks of such remedies, and there is no meaningful regulatory control over the preparation or marketing of these products.

On this last point, a revision to DSHEA has been proposed in the Senate by Tom McCain (R-AZ) and Byron Dorgan (R-ND). While not perfect, this bill would improve the FDA’s ability to monitor dietary supplements and other currently under-regulated supplements and to force removal of these from sale if there is evidence of harm. Given the power of the supplement lobby and their biggest legislative boosters, Tom Harkin (D-IA) and Orin hatch (R-UT), and the general anti-regulation mood of the country, I am not overly optimistic this will become law, but I am encouraged at least that mainstream political figures are at least willing to talk about the inadequacy of consumer protections in the area of herbs and supplements, and this alone may raise awareness of this underappreciated risk.
Coon JT, Ernst E. Panax ginseng: A Systematic Review of Adverse Effects and Drug Interactions. Drug Saf 2002;25(5):323-44 Drug Saf 2002;25(5):323-44

Cupp MJ  Herbal remedies: adverse effects and drug interactions. Am Fam Physician 1999 Mar 1;59(5):1239-45

Debelle FD, Vanherweghem JL, Nortier JL. Aristolochic acid nephropathy: a worldwide problem. Kidney Int. 2008 Jul;74(2):158-69. Epub 2008 Apr 16.

Emery DP, Corban JG  Camphor toxicity. J Paediatr Child Health 1999 Feb;35(1):105-6

Ernst E Adverse effects of herbal drugs in dermatology. Br J Dermatol 2000 Nov;143(5):923-

Fugh-Berman A Herb-drug interactions. Lancet 2000 Jan 8;355(9198):134-8

Huang WF, Wen KC, Hsiao ML. Adulteration by synthetic therapeutic substances of traditional Chinese medicines in Taiwan. J Clin Pharmacol. 1997 Apr;37(4):344-50

Lai MN, Lai JN, Chen PC, Tseng WL, Chen YY, Hwang JS, Wang JD. Increased risks of chronic kidney disease associated with prescribed Chinese herbal products suspected to contain aristolochic acid. Nephrology (Carlton). 2009 Apr;14(2):227-34.

Lawrence JD.  Potentiation of warfarin by dong quai. Page RL 2nd, Pharmacotherapy 1999 Jul;19(7):870-6

Means C.  Selected herbal hazards. Vet Clin North Am Small Anim Pract 2002 Mar;32(2):367-82

Norred CL, Finlayson CA Hemorrhage after the preoperative use of complementary and alternative medicines. AANA J 2000 Jun;68(3):217-20

O’Connor A, Horsley CA. Yates, KM “Herbal Ecstasy”: a case series of adverse reactions.  N Z Med J 2000 Jul 28;113(1114):315-7

Pittler MH. Ernst, E Risks associated with herbal medicinal products. Wien Med Wochenschr 2002;152(7-8):183-9

Poppenga RH. Risks associated with the use of herbs and other dietary supplements. Vet Clin North Am Equine Pract. 2001 Dec;17(3):455-77, vi-vii

Pies R  Adverse neuropsychiatric reactions to herbal and over-the-counter “antidepressants”. J Clin Psychiatry 2000 Nov;61(11):815-20

Prakash S, Hernandez GT, Dujaili I, Bhalla V. Lead poisoning from an Ayurvedic herbal medicine in a patient with chronic kidney disease. Nat Rev Nephrol. 2009 May;5(5):297-300.

Raman P, Patino LC, Nair MG. Evaluation of metal and microbial contamination in botanical supplements. J Agric Food Chem. 2004 Dec 29;52(26):7822-7

Ruschitzka F, Meier PJ, Turina M, Luscher TF, Noll G  Acute heart transplant rejection due to Saint John’s wort. Lancet 2000 Feb 12;355(9203):548-9

Saper RB, Phillips RS, Sehgal A, Khouri N, Davis RB, Paquin J, Thuppil V, Kales SN. Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet. JAMA. 2008 Aug 27;300(8):915-23.

Shad JA, Chinn CG, Brann OS Acute hepatitis after ingestion of herbs. South Med J 1999 Nov;92(11):1095-7

Smolinske SC J Am Med Womens Assoc 1999 Fall;54(4):191-2 Dietary supplement-drug interactions.

Yang HY, Wang JD, Lo TC, Chen PC. Increased mortality risk for cancers of the kidney and other urinary organs among Chinese herbalists. J Epidemiol. 2009;19(1):17-23. Epub 2009 Jan 22.

Zhang SY, Robertson D. A study of tea tree oil ototoxicity. Audiol Neurootol 2000 Mar-Apr;5(2):64-8

Kidney failure from aristolochia in TCM herbals preparations.

Lead, mercury and arsenic in herbal preparations.

Lead in TCM preparations.

Lead in ayurvedic preparations.

Lead in herbal preparations.

Tea Tree Oil Can be toxic to cats.

Toxic metals in Brazilian herbal preparations.

Contamination of herbal products with undisclosed pharmaceuticals.Widespread contamination of supplements with undisclosed toxins and parmaceuticals

Proponents of CAM often claim that one major advantage to their methods is the absence of side effects seen with conventional medical treatments. This makes little sense since there is no “free lunch” in physiology, and an intervention that affects one part of the system is going to have effects on other parts as well. Those practitioners who claim a “holistic” approach ought to realize this. If the treatment has absolutely no side effects, it’s probably because it isn’t doing anything at all.

And there is plenty of evidence that some CAM treatments can be harmful. While certain therapies, like homeopathy or reiki, may have little direct harm, they can still discourage patients from seeking and complying with more effective, evidence-based therapies. And the very CAM therapies most likely to turn out to have real benefits, herbal preparations, are also the most likely to cause unintended harmful effects, which is why they need to be properly studied before being used in practice.

A recent article in the Annals of Allergy, Asthma and Immunology surveyed primarily low-income inner city patients with chronic asthma to identify use of herbal treatments and any apparent association with how well their disease was controlled. What they found was that a moderate number of patients (25%) used herbal remedies for their asthma. Only about 39% of these people told their doctors about the use or herbal remedies, which raises the concern for unanticipated drug interactions. And about 20% of the herbal medicine users (about 5% of the total number of patients) used herbal treatments in place of their prescribed therapies.

Not surprisingly, the folks who used herbal preparations had a lower quality of life score and were significantly less likely to be complaint with their prescribed treatment regime than those patients who did not use herbal products. The authors also reported a trend towards poorer asthma control scores among herbal users. but this did not achieve statistical significance so it may not be a real finding.

The authors were careful to point out, correctly, that the association cannot identify a causal connection between quality of life and herbal remedy use. The poorer compliance with prescribed therapy can reasonably be suspected to be the causal factor, but it is impossible from this study to rule out a direct harmful effect from the herbal remedies or the possibility that people are seeking these remedies because they are not having an acceptable response to conventional therapy and that their poor compliance came after turning towards the CAM therapy.

However, there was also a correlation between use of herbal treatments and certain beliefs about conventional therapy, including concern about possible side effects and difficulty in following the prescribed treatment regime. This suggests that anxiety about the conventional treatment might be associated with susceptibility to the promises of safe and easy relief often used to market herbal therapies. This paper illustrates the dangers of such marketing strategies, which play into patient concerns which may be perfectly legitimate but which then offer alternatives which do not provide the relief the patient is seeking.

I recently received a tip about a pest control product for pets (and people) that has woo written all over it. Anaglyph over at Tetherd Cow has written about the shooTAG pest repellant device, and has posted a follow-up response to a comment from the company CEO. I have little to add to his comments.

The product promotional materials are entertaining to read if you like science fiction. They freely refer to mysterious “bioenergetic fields,” “resonances,” and, of course, “quantum physics.” They offer testimonials and fanciful pseudoscientific explanations for how the product, which seems from the description to amount to a little strip of magnetic tape like the one on the back of your credit card,  somehow interacts with mysterious energies from the pet and the earth to repel pests. What they don’t offer is anything resembling a plausible scientific rational or actual research evidence to suggest any of their claims are true.

Some examples:

“ shoo!TAG™ represents a paradigm shift in the pest management industry. shoo!TAG™ utilizes Nature’s energetic principles in combination with physics, quantum physics and advanced computer software technology. The key to shoo!TAG™ is the three dimensional electromagnetic field embedded in the magnetic strip.

shoo!TAG™ utilizes the power of the bio-energetic field which surrounds all living things to create a frequency barrier which repels targeted pests for up to four months.

shoo!TAG™‘s magnetic strip is encoded with beneficial frequencies and resonances and an electromagnetic charge bearing a polarized energy signature, which when introduced into the bio-energetic field of the wearer produces results. ”

As always, one must be suspicious of “paradigms shift” language, which basically says, “We’ve found something that contradicts all the know laws of established science and we know it works because we think it works.” Likewise, non-physicists claiming to explain unlikely mysteries by referring to quantum physics is a big red flag. Quantum phenomenon are weird, but they seem only to apply at the atomic level, not the macroscopic level of dogs and fleas, and the mathematics required to truly understand them, as opposed to the metaphors of popularized explanations, is beyond most of us. That makes it easy to refer to a mysterious process as due to “quantum physics,” but it’s just a bit of vacuous pseudoscientific gibberish designed to obscure the lack of a real mechanism of action.

The company web site also makes pretty strong claims of efficacy, which I would think would interest the federal government since such claims have to be backed up by actual scientific evidence or they constitute fraudulent advertising. Sadly, the government rarely has time to investigate and control such small-time mountebanks, and they usually just switch labels and IP addresses and continue selling their quackery.

The only part of the company materials that goes beyond entertaining nonsense to outright irresponsible BS is the frequent claims that if the product doesn’t seem to be working, one should blame not the product but the “toxic” medical treatments the pet may have previously received, such as steroid medication, vaccines, and validated pest control products. Apparently these have not only their know side effects but mysteriously perturb the undetectable energy fields of our pest I such a way as to render the quantum mechanical mechanism of the wooTag–uh, I mean shooTAG– ineffective.

” Please keep in mind that if an animal has recently had a surgery, vaccinations, steroid medication, or you have been using heavy poison products on them it will take longer for your animal to detox and strengthen its energy field. It is important to note that, because the tags work with your pet’s energy field, it is important that they are as healthy as possible. We have found that animals that are on or have recently taken steroid drugs, that have recently had surgery, or are old do not respond well to our products.”

Once again we see a company marketing unproven, and unlikely nonsense through fear and misinformation and rationalizing their own failure by trying to shift the blame to the animals, the owners, or the medical therapies previously given. Truly irresponsible, shameless profiteering at the expense of pet owner’s fears. The people who promote such should be, but apparently cannot be, ashamed.

Back in September, I reviewed the evidence (or lack thereof) supporting claims of benefits from nutraceuticals in cognitive dysfunction. One of the more popular ingredients in many of the products sold with such claims is Ginkgo biloba, and at the time of my earlier review I concluded:

“The clinical trial evidence in humans does not support a beneficial effect for cognitive impairment or dementia, as summarized in a Cochrane review…”

This month, a new study of ginkgo biloba for prevention of cognitive decline in humans has been published in the Journal of the American Medical Association. It is a large, multicenter, randomized, double-blinded, placebo-controlled prospective clinical trial, and thus represents a very high level of evidence. It concludes quite clearly.\

“Compared with placebo, the use of G biloba, 120 mg twice daily, did not result in less cognitive decline in older adults with normal cognition or with mild cognitive impairment.”

Another nail in the coffin for this particular wonder-herb.

At last, the definitive nail in the coffin of chiropractic? Hardly. A recent study in the journal Chiropractic and Osteopathy uses an epidemiological approach to examine the question of whether the founding “lesion” of the chiropractic philosophy, the vertebral subluxation, can be shown to be associated with any disease. Their conclusion reads like a Science-Based Medicine or Quackwatch summary:

“Subluxation was not found to be linked to any one disease complex…There were no studies that offered a biological plausibility that would isolate subluxation as a causal factor in disease. There were no studies linking the subluxation as a coherent construct and supported by generally known facts about the natural history and biology of any disease. There were no studies found that suggested the subluxation as a causal agent similar to other factually demonstrated causal agents…There is significant lack of evidence to fulfill basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of the chiropractic subluxation.”

Short and sweet, the basic abnormality chiropractors claim to fix cannot be shown to exist or to cause any disease. One might think this would be a fatal blow to the enterprise of chiropractic, but sadly that is not the case. For one thing, it has been shown before in other studies that the subluxation cannot be reliably identified by chiropractors and that when pushed to demonstrate it in some objective way, most chiropractors and their lobbying organizations engage in some impressive yoga to cover the fact that they cannot. But as chiropractic is fundamentally faith-based medicine, being unable to demonstrate that the disease they are treating exists doesn’t worry chiropractors. Even those who disavow the subluxation theory happily continue the sort of manipulative practices Palmer originally invented to fix the supposed subluxation, and they simply justify it with the time-honored refuge of all woo, “Well, I don’t know how or why it works, but it works!”

Of course, this conclusion cannot be reliably demonstrated by objective evidence either. Though chiropractic does seem to have some benefit on subjective perceptions idiopathic lower back pain, the fact is it has been shown to be at best roughly equivalent to conventional therapy (rest, NSAIDs, physical therapy, and patient education materials) or to a good massage. If it were truly risk free and presented truthfully as offering mild benefits for back pain, I would have no objections. And a few chiropractors have adopted this approach in an attempt to take what benefit their interventions might provide out of the realm of faith and into that of responsible medicine, but these are a minority and often reviled within their own profession. But while I believe evidence is critical and should be the cornerstone of medical practice, I also understand that it is not as compelling as personal experience for many people, and the first step on the road to recovery from addiction to unscientific therapies is to understand we have a problem and need something better than our own experience and intuition to validate or invalidate the safety and efficacy of medicine. So while this should be a critical study undermining the claims of mainstream chiropractic, it has garnered little attention and will probably have little impact on the popularity of the method.