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

When it comes to acupuncture, the clinical research evidence is vast and highly variable in terms of quality and results. Overall, the preponderance of the evidence seems to support the conclusion that acupuncture is not superior to placebo treatment and exerts very broad, non-specific physiological effects indistinguishable from other kinds of mild traumatic or irritating stimulation (e.g. 1, 2, 3).

One way to help decide whether extensive further efforts to sort out potential clinical benefits of acupuncture through expensive and laborious clinical trials is to look at the potential justifications for why the practice might or might not be helpful. Obviously, anecdotes and testimonials are the primary reason people believe in the usefulness of acupuncture despite the lack of strong support from clinical research. However, these are only useful in generating hypotheses in medicine, not in proving or disproving them. Every therapy every used has been able to claim anecdotal evidence of an effect, and since it’s clear that many therapies turn out not to actually work when objectively studied, reliance on anecdotal evidence is a big mistake.

There are a couple of ways to approach the theoretical explanation of possible mechanisms for acupuncture. The traditional explanations are purely vitalistic. Mystical life energy (Ch’i) that is undetectable by scientific means, explanations about balancing non-physical, spiritual concepts such as Yin and Yang, metaphorical explanations involving Heat, Cold, Damp, Wind and so on are all part of the theoretical structure many practitioners use to explain and justify so-called Traditional Chinese Medicine, including acupuncture. These explanations are part religion, part folklore, and no scientific examination suggests they have any physical reality or any relevance to health and disease as it is understood in scientific medicine. Employing such explanations makes one’s practice essentially a religious rather than a medical one.

However, other acupuncture advocates claim a solidly scientific explanation for the proposed effects of acupuncture, involving identifiable anatomic structures, such as nerves, biochemical effects involving substances naturally produced in the body, and so on. This is a more promising theoretical approach, but despite some effort, there is not yet a consistent and convincing body of evidence to validate the clinical practice of inserting needles in specific locations (with or without twirling them, burning herbs on them, passing electrical current through them, and all the other varieties of acupuncture seen) in order to effect health. Putting needles in animals undoubtedly has some measurable physiological effects. But whether these are specific, predictable, controllable effects that have a meaningful impact on health is not established.

One question that has been investigated many times is whether the supposed acupuncture points, specific locations on the body where insertion of needles is proposed to have a particular effect, can be consistently identified by acupuncturists or associated with identifiable anatomic structures.  Even among those who believe acupuncture to be clinically useful, there is controversy about whether specific locations for needle insertion are real or necessary (e.g. 3), and of course some acupuncturists argue that acupuncture points do not need to correspond to identifiable anatomic or functional locations since they follow the vitalist model in which the focus of acupuncture is on the Ch’i rather than the body per se.

There are some scientific papers that purport to identify real structures or other measurable characteristics at some traditionally used acupuncture points. Many of these reports come from China, where negative studies about acupuncture (or other alternative therapies) are almost never published, so the potential for bias in this source has to be considered. A review of the literature presented at the 2000 meeting of the American Association of Equine Practitioners by veterinarian David Ramey found no consistent body of scientific evidence to support the notion of specific identifiable functional or anatomic acupuncture points. A recent paper seems to add support to this conclusion.

A.F. Molsberger, J. Manickavasagan, H.H. Abholz, W.B. Maixner, H.G. Endres. Acupuncture points are large fields: The fuzziness of acupuncture point localization by doctors in practice. Eur J Pain. 2012 Apr 10 [Epub ahead of print]

This study took the approach of testing whether properly trained and experienced acupuncturists could consistently identify commonly used acupuncture points on a single patient. Twenty-three common points were selected and identified by the 71 test subjects. The area within which specific points were identified by 95% of the acupuncturists ranged from 2.7cm in diameter to 41.4cm in diameter.  Because of the variability with which experienced acupuncturists identified common acupuncture points, the authors concluded that to stimulate fake points as a placebo control for a clinical trial, it would be best to stimulate the skin at least 6cm away from the spot identified as the real point on the face or hands and at least 12cm away from a proposed real spot anywhere else on the body.

Of course, the authors are acupuncturists and so must find a way to interpret these results that is supportive of acupuncture as a therapy. Their conclusion is that it would be more meaningful to talk about “acupuncture fields” rather than acupuncture “points.” Since the variance in the size of the area within which supposed points were identified was not associated with the experience or training of the doctor, and could not have been associated with individual differences between patients since the same patient was examined by all the doctors, it seems more reasonable to interpret the results as indicating that no specific locations associated with traditional acupuncture points can be reliably identified even by trained acupuncturists. Likely, such points don’t exist as anatomical or functional entities, especially given the lack of convincing and consistent evidence for their existence despite decades of study.

This by itself does not invalidate acupuncture as a clinical practice. However, it has bearing on the study and evaluation of acupuncture. Many studies using supposed “sham” acupuncture points may now be reinterpreted. Acupuncturists will likely interpret these results to mean that the lack of difference between effects in groups where “real” acupuncture points were used and those in which “sham” points were used is actually due to the fact that both groups benefitted from stimulation in the same “acupuncture fields.” Skeptics like myself are more likely to view this as indicating that “sham” acupuncture points are not a legitimate placebo control since specific acupuncture points can’t even be shown to exist, and so trials comparing real and fake points are simply poorly controlled. In any case, it suggests that if the central tenet of most acupuncture treatment, stimulation of the body in specific locations, is invalid because even acupuncturists don’t know where these locations are, then the concept of acupuncture as a meaningful therapy is even less convincing.

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?

For example, I’ve written previously about Yunnan Paiyao, which is supposed to control bleeding, both topically and systemically. Many preparations of this product don’t even list an active ingredient. I cannot imagine most people being willing to take a medicine when the manufacturer refused to disclose the ingredients, but the same sensible caution doesn’t always seem to be applied to herbal products.

Of course, many Traditional Chinese Medicine products do list their ingredients, but given the problems with label accuracy for other unregulated alternative remedies, such as probiotics, some skepticism about the accuracy of these labels seems warranted. An objective method for determining what such remedies actually contain would be a good start in evaluating their quality control and the potential for harm from undisclosed ingredients.

Some studies have looked at chemical components, including undisclosed pharmaceuticals and heavy metals. A recent pilot study has taken a different approach, trying to identify the plant and animal ingredients through identification of DNA found in the products.

Coghlan ML. Deep sequencing of plant and animal DNA within traditional Chinese medicines reveals legality issues and health safety concerns. PLOS Genetics. 2012;8(4):e1002675.

The authors looked at 28 samples of TCM products seized by the Australian customs service and were able to identify plant and animal components of 15 products. One of the methodological problems with this approach is that databases of DNA sequences, particularly for plants, are not yet sufficiently extensive to allow precise species-level identification of many plants. However, these databases are growing rapidly, and the precision of this technique is likely to be excellent as the reference resources improve.

Examples of the usual sorts of concerns did surface in the study. Plants with known toxic properties were identified in 4/15 samples, including Ephedra, and Asarum, a potential source of aristolochic acid, which is a TCM ingredient known to cause kidney failure and   urinary tract cancer. The authors did not evaluate the samples to determine if these toxins were actually present, though they indicated that combining such standard chemical analysis with their DNA sequencing approach would be the optimal way to evaluate such products.

The study also identified DNA from known endangered species of both plants and animals, including bears and Saiga antelope. TCM remedies made from parts of endangered species are a significant environmental problem which is particularly infuriating since there is no reasonable evidence to suggest the inclusion of these ingredients has any actual health benefit. Sympathetic magic and other mythological foundations for such practices are not legitimate reasons to contribute to the threats to endangered animal and plant species.

Finally, the study identified significant mislabeling. 78% of the samples contained DNA for species of animals not listed on the label. Sheep, goats, water buffalo, and cows were found, among other species, and these likely represent adulteration with cheaper, easier to acquire ingredients replacing traditional ingredients such as those from bear and Saiga antelope. While this may reduce the risk to such endangered species, one can hardly approve of substituting animal products with no demonstrated health effects for other animal products with no evidence of health benefits and then not even honestly labeling the products.

Though this particular study looked at a very limited selection of remedies and only identified a relatively small set of ingredients, it demonstrates both that such methods can be useful in identifying the true constituents of TCM products and also that these products can contain ingredients that are toxic, that come from endangered species, or that aren’t listed on the labels. Such problems aren’t likely to improve without meaningful regulations requiring thorough and accurate labeling, independent monitoring of compliance with label regulations, and ideally requirements for reasonable evidence of safety and efficacy before the products can be marketed at all. Unfortunately, none of these sensible requirements seem likely to be put in place any time soon.

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?).