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The History of Veterinary Acupuncture: It’s Not What You Think

Posted on July 11, 2010 by skeptvet

One of the most common arguments made in support of using acupuncture on animals is that veterinary acupuncture is an ancient art practiced and refined in China for thousands of years. On one website providing referrals for acupuncturists, the claim is made that,

Acupuncture has been used on animals for over 4000 years. Legend has it that veterinary acupuncture was discovered when lame horses used in battle were found to become sound after being hit by arrows at distinct points. In any event, there is evidence that Chinese “horse priests”, the caretakers of the army’s horses, practiced acupuncture during the Zang and Chow Dynasties around 2000-3000 BC.

Acupuncture may be defined as the insertion of needles into specific points on the body to cause a desired healing effect. This technique has been used in veterinary practice in China for at least 3000 years to treat many ailments. The Chinese also use acupuncture as preventive medicine against such problems as founder and colic in horse.

Of course, the notion that the length of time a methods has been in use is somehow proof of its safety or efficacy is fundamentally unsound. Unsafe and ineffective treatments (bloodletting, various forms of burning or “cauterization,” faith healing and, I would argue, acupuncture) often endure for centuries, even millennia despite having no benefits and even being harmful, due to the many, many reasons people are prone to making inaccurate judgments about such things. Even if acupuncture has endured for thousands of years, it has failed in all that time to extend our life expectancy, reduce infant and childbirth mortality, eliminate any infectious disease, or accomplish any of the other dramatic improvements in human and animal health scientific medicine has given us in the last 200 years.

Still, it is understandable why people might find the tenacity of a method to be a strong argument for it being effective. Unfortunately, in the case of veterinary acupuncture, the appeal to longevity argument is not only misleading, it doesn’t happen to even be true!

A recent article in the German science history journal Sudhoffs Archiv makes a strong and detailed case that most of the sources cited to support the argument that the Chinese have practiced acupuncture on animals for thousands of years are actually describing bloodletting and cauterization practices that have no meaningful relationship to what is considered to be acupuncture today. The authors also argue that many of the veterinary techniques these Chinese sources describe using on horses correspond closely to techniques found at the same time or even earlier in Greek, Egyptian, Arabic, and Indian sources, and that they may have derived originally from Western practices or had common sources. The article’s authors include two professors of East Asian history and an equine veterinarian, Dr. David Ramey, who has written extensively on equine medicine in generally and on complementary and alternative veterinary medicine.

Buell PD, May T, Ramey D. Greek and Chinese Horse Medicine: Déjà vu All Over Again. Sudhoffs Archiv. 94(1);2010:31.

According to the authors, the earliest written records of Chinese veterinary medicine, from the 3rd century BC, concern primarily herbal treatments. By the 6th century recommendations concerning bleeding and cauterization are found, though herbal therapies are still the primary treatments recommended for animals. The earliest surviving Chinese text specifically devoted to veterinary medicine dates from 1384, though much of the material it contains appears to have originated in the 11th and 12th centuries. none of these early texts refer to anything that could be considered acupuncture in the modern sense. The IVAS defines acupuncture as, “the insertion of needles into specific points on the body to cause a desired healing effect.” Though there are a variety of techniques, including using heat, laser light, and electricity on supposed acupuncture points, most commonly veterinary acupuncture takes the form described by the Australian Veterinary Acupuncture Group: “Acupuncture is the technique of using very fine needles that pierce the skin at specific points in order to treat or prevent disease.”

There is no evidence for such techniques in the early Chinese veterinary texts. Though the term “zhen” used in such texts is often incorrectly translated as “acupuncture,” it is clear from a thorough reading of these texts that the term was used to refer to bleeding, cauterization, and even surgical interventions, not acupuncture as applied to people and animals today. Such interventions become more prominent in later Chinese veterinary texts, however these texts also do not describe anything that can be reasonably called acupuncture. Methods resembling modern veterinary acupuncture apparently were not widely practiced in China until the 1960s.

The historical Chinese texts do describe specific interventions at specific points on the body of the horse, and they include detailed charts and diagrams to guide these interventions. Such charts are often presented in modern works, without translation of labels or inclusion of accompanying text from the original works, as evidence of historical acupuncture point designations. Actually reading the text associated with such diagrams makes it clear that these are not charts showing acupuncture points or meridians. In reality, most such charts for animals date back no further than the 1970s. (For a more detailed look at the history of veterinary acupuncture, see Dr. Ramey’s book Complementary and Alternative Veterinary Medicine Considered).

The authors of the Sudhoff Archiv article also describe some of the remarkable similarities between Chinese veterinary practices and those described in Greek, Roman, and other Western cultures. I don’t have the expertise to judge the plausibility of their suggestion that some of this similarity may be due to the spread of ideas from the West into China via Arab or Indian sources. Though I would not be at all surprised if disparate cultures came up with very similar theories about unseen forces responsible for disease and methods of manipulating these forces, it is an interesting hypothesis that the similarities are more direct.

Overall, the article is a detailed scholarly look at the truth about early Chinese equine medicine, and veterinary medicine more generally. It is particularly helpful in challenging the many inaccurate claims about the antiquity of veterinary acupuncture. While I do not believe the antiquity of a medical practice is useful in assessing its validity, it is a compelling argument for some, so knowing the truth about this particular practice is of more than just academic interest.

Posted in Acupuncture | 9 Comments

A New Tool for Evaluating the Effects of Arthritis Treatments in Dogs

Posted on July 7, 2010 by skeptvet

There is an excellent article in the current issue of the Journal of the American Veterinary Medical Association which I wanted to draw attention to, both for its conttent and the design of the study.

Brown,D.C.; Boston,R.C.; Farrar,J.T. Use of an activity monitor to detect response to treatment in dogs with osteoarthritis. J.Am.Vet.Med.Assoc. 2010, 237, 1, 66-70.

A perennial problem in the evaluation of any therapy for arthritis in animals is the difficulty in assessing effect. Most studies use subjective evaluations by investigators or owners, which are subject to many kinds of bias and almost always show a benefit of every therapy for at least some of the multiple measures of function evaluated. A few studies use force plate analysis, where the dog walks over a device that measures how much weight they place on an arthritic limb. But this is a complex and often difficult measurement to take. The recent article describes a study using a small accelerometer to measure activity at home over a prolonged period. This is potentially a very useful tool in evaluating the efficacy of arthritis treatments in dogs.

The study was very well designed, and the authors clearly recognized the importance of controlling for investigator and owner bias even when using an objective measurement tool. The patients were randomized to treatment either with an agent already clearly established as effective (the NSAID Rimadyl) or an identical placebo, and both investigators and owners were blinded to the group assignment. Confounding factors were controlled for by selecting a study population newly diagnosed and not already treated, and by using statistical techniques to account for factors such as age, weight, and so on.

The results showed an expected increase in activity for the patients given Rimadyl (about 20% greater activity than before treatment) and no change from baseline for the placebo group. Interestingly, some of the dogs in the placebo group did show an increase in activity (20% of the dogs in this group had an increase of 10-30% in activity from the baseline period). As the authors explained, this sort of change likely represents the phenomenon of regression to the mean. For many chronic diseases, including arthritis, the symptoms wax and wane, getting worse and better alternately around an average, or mean, degree of severity. People tend to seek medical treatment, for themselves and their pets, when their symptoms are especially bad, and so the natural course of the disease tends to lead to an improvement in symptoms following an intervention regardless of whether the intervention is actually doing anything. Add to this the tendency for people to behave differently when involved in a medical study, usually exhibiting better health habits than they usually do, and it is routine for studies to show improvement with placebo therapies that aren’t actually doing anything. This is a significant contributor to the so-called “placebo effect.” It also explains why adequate controls are critical to showing real treatment effects, and why poorly controlled studies tend to find effects where they don’t really exist.

I am hopeful that the monitoring device discussed in this article will make it possible to more easily and inexpensively evaluate the effectiveness of the various purported osteoarthritis treatments currently in use as well as new treatments. I am less hopeful that such future studies will be as carefully designed and controlled as this one. Objective measures and all the statistics in the world don’t make experimental results real or useful unless human bias is adequately compensated for through techniques such as random allocation of subjects, blinding of investigators and owners, and placebo controls, or ideally a combination of active and placebo controls as well as no treatment at all. This study is a nice example of how such techniques should be used, as well as a demonstration of why they are needed.

Posted in Science-Based Veterinary Medicine | 3 Comments

Raw Pet Diet and “Natural” Pet Product Recalls

Posted on July 6, 2010 by skeptvet

One of the comments often made in defense of raw diets and challenging the safety of conventional commercial pet foods is, “If those foods are so safe, why are they always being recalled?” The implication, of course, is that a recall is an indication a food is unsafe. The reality is that while this is sometimes true, many recalls are precautionary, and a real health threat is often not found when the recalled product is analyzed. This information, however, rarely gets the widespread coverage in the media or on the internet that the original recall did.

In any case, even if the suggestion that how many recalls one can remember for a given company or type of food was a reliable guide to safety, it is simply not true that alternative products or those marketed as “natural” and so on are not recalled. I don’t have any statistical analysis comparing the relative rate of recalls, precautionary or related to confirmed health threats, for all the pet food products out there, but it is easy to find examples of recalls involving raw diets, “natural” diets and supplements, and other products marketed as safer or healthier than conventional foods and treats. Dr. Susan Wynn, a veterinarian with specialty training in nutrition and an advocate of many veterinary CAM approaches, frequently reports such recalls on her blog, including several recently involving a raw diet for cats contaminated with Salmonella, and a long list of vitamins and supplements, also with possible Salmonella contamination.

These particular products may or may not present a danger to animal or human health, and certainly if there is a possibility that they do then voluntarily recalling them is the responsible thing for their manufacturers to do. But it’s important to remember that the claims of greater safety or health benefits from raw diets or supposedly “natural” food products are not substantiated by any evidence, and that these products, like any other, can have risks.

Posted in Nutrition | 5 Comments

Vet Stem’s Stem Cell Therapy and Chemaphor’s Oximunol Join Forces

Posted on June 30, 2010 by skeptvet

I recently ran across a press release which identified a business relationship I found interesting. Apparently, the Canadian company Chemaphor, maker of the nutritional supplement Oximunol which I have discussed in the past, has entered into a licensing arrangement with Vet Stem, an American company marketing fat-derived stem cells in animals as a treatment for arthritis and other orthopedic problems as well as, potentially, just about any other disease under the sun. This will make it possible for the Vet Stem process to be marketed in Canada.

I haven’t addressed the Vet Stem marketing issue directly here, but I’ve been involved in some discussions on the subject elsewhere. As I pointed out in my recent post about stem cell therapy in general, the approach has significant biologic plausibility and some supportive in vitro and animal model evidence to suggest it may someday be a valuable clinical therapy. Unfortunately, the selling of it as a product for humans and, primarily via Vet Stem, for pets, is far out in front of the evidence that this hope will be borne out in the real world. For example, the only clinical research I have yet found concerning autologous fat-derived stem cell treatment for dogs is two papers, both funded by Vet Stem.

1. Black, L. L., Gaynor, J., Adams, C., Dhupa, S., Sams, A. E., Taylor, R., et al. (2008). Effect of intraarticular injection of autologous adipose-derived mesenchymal stem and regenerative cells on clinical signs of chronic osteoarthritis of the elbow joint in dogs. Veterinary Therapeutics : Research in Applied Veterinary Medicine, 9(3), 192-200.

2. Black, L. L., Gaynor, J., Gahring, D., Adams, C., Aron, D., Harman, S., et al. (2007). Effect of adipose-derived mesenchymal stem and regenerative cells on lameness in dogs with chronic osteoarthritis of the coxofemoral joints: A randomized, double-blinded, multicenter, controlled trial. Veterinary Therapeutics : Research in Applied Veterinary Medicine, 8(4), 272-284.

The first lacked a placebo or standard treatment control, blinding, and randomization, so it essentially amounted to an uncontrolled case series funded and evaluated by the company selling the therapy. Both investigator and owner subjective evaluations showed changes in some measures, up to about 30-40% improvement at the most. This cannot be distinguished from a non-specific experimental effect with this design.

The second was reported as a double-blinded, placebo controlled randomized study, though the details of these controls were not reported. There was a 14% dropout, which is not excessive though it is difficult to tell if it would have changed the statistical outcomes given that dropouts in studies tend to be treatment failures. Of 13 measures evaluated by investigators, there were statistically significant differences in 3 when the data for all investigators was pooled (none for investigators singly, obviously with smaller sample sizes). Of the subjective owner evaluations, 13 measures graded on a 5-point scale, 1.9 measures improved by >/= 2 points in the placebo group and 4.7 measures by >/= 2 points in the treatment group, but this was not statistically significant (and 5 of the 18 dogs that completed the study were not included in this evaluation for a variety of reasons).

Both of these studies do provide some support for the claim that fat-derived autologous stem cell injections may have clinical benefit for the conditions examined, but the evidence they provide is very weak due to limitations in the study size, design, and possible biases. My concern is that such weak evidence, even added to the suggestive pre-clinical information and to study results from other species, does not justify selling an invasive and expensive medical procedure to pet owners. At best, the therapy should be offered as an experimental intervention with strict informed consent guidelines and a system for evaluating outcomes that is as objective as possible and as independent as possible of the company hoping to profit from the therapy. The situation is similar for other species that Vet Stem offers to treat, though there is a bit more clinical evidence for horses.

Similarly, the Chemaphor product Oximunol is supported only by theory and in vitro studies with no published clinical trial evidence to suggest safety or efficacy in veterinary patients. Even under the lax standards of regulation applied to nutritional supplements, the company would likely not be allowed to make the medical claims for the product they make in marketing materials, but they specifically acknowledge pursuing the veterinary nutraceutical market partly because they face “lower regulatory hurdles” than the human market. In their current press release, the company states ” With the recent announcement of the Vet-Stem stem cell licensing arrangement, Chemaphor is evaluating the establishment of a sales team to promote the use of Oximunol(TM) Chewables as well as the Vet-Stem products for companion animals.”

The two companies clearly see a synergy between their products and corporate philosophies. Unfortunately, the common bond seems to be a desire to rapidly and effectively market medical therapies in advance of adequate safety and efficacy data. The regulatory structures applied to medical devices and drugs in the U.S. by the FDA are not capricious bureaucratic hurdles, they are the response to a series of medical tragedies in which the public was harmed by therapies that had not been adequately tested. The exemptions to this process offered by DSHEA, and by the pragmatic inability of the FDA to enforce existing rules in veterinary medicine, should be understood as weaknesses and a danger to the public, not opportunities. I have little doubt that the promoters of these therapies believe they are safe and beneficial, and the current state of the evidence does not by any means show they are wrong. But the history of medicine makes it clear that such faith often turns out to be misplaced, and that shortcutting the process of vetting new therapies does more harm than good. We can only hope that does not turn out to be the case with these products.

Posted in General, Herbs and Supplements, Science-Based Veterinary Medicine | 6 Comments

Edzard Ernst on How to Spot Medical Nonsense

Posted on June 25, 2010 by skeptvet

Edzard Ernst is well known as an “insider” in the world of alternative medicine who has come to see the need for rational, scientific analysis and evidence to justify inflicting any treatment of whatever provenance on patients. His book, with Simon Singh, Trick or treatment: The Undeniable Facts About Alternative Medicine, which I have previously reviewed, is a model for how to look scientifically and CAM, and it is an indispensible resource for anyone interested in the truth about alternative approaches.

Ernst has a new short article in the oxymoronically named journal Evidence-Based Complementary and Alternative Medicine. The unfortunate title of this otherwise useful article is Winnowing the Chaff of Charlatanism from the Wheat of Science.

In his article, Ernst suggests a possible strategy for evaluating medical claims. It is not especially novel, but it’s a clear introduction to some of the key methods by which nonsense can be distinguished from real science.

The first test is Karl Popper’s time-honored concept of falsifiability. At its simplest, this just means that it is possible for a claim to be proven false. If, for example, all disease is claimed to be caused by vertebral subluxations, then showing that any disease has another cause demonstrates this claim to be false. Many CAM approaches rely on mystical “energies” that can only be intuited, and many practitioners claim that the methods or even the skeptical attitudes of scientific researchers interfere with their treatments, so these treatments can never be tested and are, in either theory or practice, unfalsifiable. Unfortunately, many CAM proponents will argue that their approaches are theoretically falsifiable but we simply do not yet have the technology or methods to test them, so they squirm out of meeting this criterion.

Ernst then suggests moving on the test of plausibility. This is one of the concepts which separates the close but not identical domains of evidence-based medicine from more generally science-based medicine. If an idea is inconsistent with well-established scientific knowledge, then we can reasonably dismiss the idea right there, without wasting resources testing it empirically. The theories of Alternative Flight are sufficiently implausible that no one has serious suggested we test them. This criterion will also not successfully contain all pseudoscientific nonsense, because it is always possible to claim, with some justification though disingenuously in most cases, that what is plausible is based on current knowledge, and this is incomplete and imperfect. Powered human flight would have seemed extremely implausible 500 years ago, and yet it is possible, so plausibility is not always by itself a sufficient basis for final judgment of a claim.

Finally, Ernst moves on to warning signs of quackery as another criterion to help separate real science from pseudoscience. I have written about these a number of times (my own partial list, and Dr. Walt’s list), and there is significant overlap between other lists of such signs and Dr. Ernst’s. He refers to advocates of quackery as Proponents of Absurd Claims (PACs), and he describes some of the red flags they often wave about:

Intolerance: Many PACs are consumed with evangelic zeal and find it hard to accept or even consider well-reasoned criticism or debate. Anyone who has tried to have a rational discussion with someone making irrational claims will have experienced this phenomenon. As intolerance can exist everywhere, its discriminating power is, of course, low and further criteria are required.

Selectivity: Most PACs tend to ignore facts that contradict their own assumptions. Instead they favor selected anomalous data or anecdotal findings which apparently support their notions. Clinical trials, for instance, are designed to overcome the many biases associated with simple observation. Whenever their results fail to confirm their belief, PACs insist that, for this or that reason, case reports, observational studies or years of experience are preferable. In arguing their case, PACs often seem to first formulate their conclusions, then selectively identify those bits of information that apparently confirm them.

Paranoia: Many PACs believe in conspiracy theories which posit that ‘the establishment’ is determined to suppress their views or findings. The world wide web, for instance, is full with suggestions that ‘big pharma’ is conducting a campaign against ‘alternative cancer cures’ such as laetrile or shark cartilage. Anyone who points out what the evidence really shows is likely to be accused of being part of the conspiracy.

Misuse: Some PACs misuse science, for instance, by using terminology like energy, chaos theory, quantum mechanics or entanglement in inappropriate contexts, devoid of their actual meanings. Accepted standards are rejected and double standards are proposed for their own area. In case this strategy fails, other means might be employed, including outright fraud.

I wouldn’t suggest Ernst’s criteria are foolproof, and neither does he, but it is a nice simple starting point, especially for those not steeped in skepticism and already familiar with the many dodges, obfuscations, and deceptive marketing techniques of the CAM world.

Posted in General | 13 Comments

Stem Cell Therapy– Still an Uncontrolled Experiment on our Pets

Posted on June 23, 2010 by skeptvet

Dr. Steven Novella at Science-Based Medicine recently posted about a publication from the International Society for Stem Cell Research which cautions people seeking stem cell therapies that most such treatments are unproven and experimental. This is an especially compelling advisory coming, as it does, from an organization committed to the study of stem cell therapies, and so presumably positively biased in favor of these treatments, at least in principle. It shows an impressive degree of scientific integrity.

The portions of the document that are most telling are the general introduction and the discussion of the limitations of current evidence for stem cell treatments, as well as the discussion of the need for detailed informed consent prior to any use of such therapies, given that they are experimental. In the introduction, the organization states:

We have all heard about the extraordinary promise that stem cell research holds for the treatment of a wide range of diseases and conditions. However, there is a lot of work still needed to take this research and turn it into safe and effective treatments.

The International Society for Stem Cell Research (ISSCR) is very concerned that stem cell therapies are being sold around the world before they have been proven safe and effective.

Stem cell therapies are nearly all new and experimental. In these early stages, they may not work, and there may be downsides. Make sure you understand what to look out for before considering a stem cell therapy.

Remember, most medical discoveries are based on years of research performed at universities and companies. There is a long process that shows first in laboratory studies and then in clinical research that something is safe and will work. Like a new drug, stem cell therapies must be assessed and meet certain standards before receiving approval from national regulatory bodies to be used to treat people.

In answer to the question “For what diseases or conditions are stem cell treatments well established?” they write:

The range of diseases for which there are proven treatments based on stem cells is still extremely small. Disorders of the blood and immune system and acquired loss of bone marrow function can, in some cases, be treated effectively with blood stem cell transplantation.

Doctors have been transferring blood stem cells by bone marrow transplant for more than 50 years, and advanced techniques for collecting blood stem cells are now used clinically. Umbilical cord blood, like bone marrow, is often collected as a source of blood stem cells and is being used experimentally as an alternative to bone marrow in transplantation.

Other tissue-specific stem cells may also play a role in tissue transplants that have been performed for several years. For tissues and organs such as skin and cornea, stem cells contained in these tissues contribute to long-term regeneration.

Other stem cell treatments are still experimental. This means that it has not yet been shown that this treatment is safe or that it will work.

This is clearly all the more true in veterinary medicine, where the sources of stem cells are sometimes atypical (such as fat-derived autologous cells) and the amount of good quality clinical research on the safety and effectiveness of such treatments is close to nil. And yet, these therapies are being sold and used in clinical practice, quite likely without the kind of detailed informed consent, assiduous follow-up, or other controls for bias and risk that would be expected in a clinical trial.

Once again, this is an example of a plausible therapy rushed to market without adequate evidence of safety or benefit. Such therapies rarely live up to their initial promise, and they expose the public to unnecessary risk as well as false hope. They also expose the professions of scientific medicine to rightly criticism about the impact of profit motive on our behavior, and to less legitimate criticism about the dangers of conventional medicine (and you know what will be suggested as the alternative….). We have a responsibility to our patients, clients, and our profession to be cautious in utilizing unproven treatments and in making sure clients understand the uncertain risks of such procedures.

Posted in Science-Based Veterinary Medicine | 11 Comments

Pheromone Therapy for Dogs and Cats–What’s the Evidence?

Posted on June 22, 2010 by skeptvet

Behavioral problems, especially fear and aggression in dogs and elimination in the house in both dogs and cats, are a major reason for people to give up or euthanize their pets, so they represent a serious medical condition. There are many methods of treating such disorders with behavioral modification, and medications can sometimes be helpful, though our understand of which medications might help for which problems in which patients is very poor. However, the sad truth is that we have very limited success in alleviating many of these problems.

In the face of serious medical problems for which there are not strikingly effective scientific therapies, more questionable methods can become widely used. Some, like Bach flower essences, such as Rescue Remedy, or homeopathic treatments are clearly useless nonsense. Others are plausible scientifically, but not really shown to work in definitive ways. One such treatment is the use of pheromones.

Pheromones are chemicals animals produce that can affect the behavior of other members of the same species. They are believed to be common and important in coordinating social behavior in animals, especially mammals. The role, if any, that they play in human behavior is less clear, though they may be involved in the synchronizing of menstrual cycles in women living together. In any case, it is clearly reasonable that such substances might have an impact on the behavior of dogs and cats and so might be useful in managing behavior problems. Notice all the “mights” in that statement? The devil, of course, is in the details

It has become quite common for veterinarians to recommend use of synthetic pheromone analogs, that is chemicals made to be structurally natural pheromones, to help treat behavioral problems. The most common products are Feliway, and analogue of the facial pheromone cats leave behind on furniture and people the rub their faces against, and DAP, short for Dog Appeasing Pheromones, a pheromone nursing mothers release which is believed to calm puppies. These are sold with dramatic claims of efficacy for a wide range of conditions, but of course the claims of folks selling the product have to be viewed as perhaps less objective than other forms of evidence.

In the most recent issue of the Journal of the American Veterinary Medical Association, a systematic review was published which evaluated the research evidence for the use of these products.

Frank,D. Beauchamp,G. Palestrini,C. Systematic review of the use of pheromones for treatment of undesirable behavior in cats and dogs. J.Am.Vet.Med.Assoc., 2010, 236, 12, 1308-1316.

The purpose of a systematic review is to evaluate all the published data on the basis of quality, and then evaluate the results of studies that meet a reasonable minimum quality. In this review, studies were excluded that did not meet minimum quality standards or that were conducted by researchers working for the company selling the product under study. This left a total of 14 studies, 7 in cats and 7 in dogs.

In general, as is too often the case in veterinary medicine, the methodological quality of the studies overall was lower than expected in human medicine, with no studies reaching the highest standards. But as the authors wisely note, imperfect information is better than no information, so we must make our judgments based on the best available evidence even if it is prone to errors that better studies would avoid. I will spare you the interesting but complex details of the various study designs and their strengths and weaknesses, though reading the full review is recommended for anyone interested. Having read through the full report, I am convinced that unlike others I have reviewed, the conclusions of the authors of this systematic review are supported by the methods and results they detail elsewhere in the paper.

Of the 7 cat studies, none provided convincing evidence of a benefit. Some decrease in urine spraying occurred in some cats, but the significance of this was muddied by failure to follow up on cats which dropped out of studies, which were probably cats who didn’t improve with the treatment, and other methodological flaws in the studies reviewed. Pheromone therapy also was not clearly of benefit in cats with interstitial cystitis (a condition in which irritation in the bladder causes symptoms much like those of a bladder infection). The pheromone also did not seem beneficial in calming cats in the hospital or facilitating the stressful process of placing IV catheters in hospitalized cats.

In dogs, one study found some evidence that pheromone therapy might reduce anxiety in puppies during training. Other than that, no convincing evidence of benefit was found for anxiety associated with veterinary care, anxiety in shelter dogs, or barking and elimination indoors by recently adopted dogs.

The limitations in the quality of the evidence mean we cannot definitively declare that pheromone therapy doesn’t work. What we can say is that based on the best evidence to date, it does not appear to have a benefit. Further study is certainly reasonable, but as always I question the wisdom and the ethics of widespread sale and use of products which, despite years of testing, don’t seem to have much evidence that they work. These products appear harmless, and if clients wish to spend money rolling the dice on a treatment that is not well supported by the limited clinical research available that is certainly up to them. But when veterinarians recommend such products, it does tend to convey the impression that they are legitimate, validated therapies, and I think we do a disservice to our clients if we make such recommendations without a clear statement of the limitations in the evidence. Thanks to this paper, it is now easier to make such a statement.

Posted in Science-Based Veterinary Medicine | 71 Comments

Dr. Walt’s Warning Signs of Quackery

Posted on June 17, 2010 by skeptvet

I ran across a series of posts from a physician which I think do a thorough job of identifying warning signs of unscientific, irrational or outright quack medical treatments. They’re not organized in a particularly systematic way, but they cover a lot of important ground. Below are the specific headings grouped under the post in which they appear, with the details to be found on Dr. Walt’s page.

Warning Signs- Post One
1. Is the product or practice promoted as a “Major Breakthrough,” “Revolutionary,” “Magic,” or “Miraculous”?

2. Do the promotions try to simply elicit an emotional reaction rather than present clear information to help you make an informed decision about the product?

3. Is only anecdotal or testimonial evidence used to support claims of effectiveness?

4. Are claims made about scientific support without giving specific details?

5. Is the information about the therapy or product being provided by a professional lacking in the proper credentials?

Warning Signs- Post Two
6. Are technical words used without a clear definition?

7. Would a treatment require you to abandon any well-established scientific laws or principles?

8. Do proponents claim that a medical system is so flawless (“airtight”) that there is no need for further testing?

9. Is the treatment said to be effective for a wide variety of unrelated physiological problems?

10. Is the product a quick and easy fix for a complicated and frustrating condition?

Warning Signs- Post Three
11. Does the proponent of the therapy claim to be criticized unfairly?

12. When challenged, do defenders attack the critic instead of responding to the challenge?

13. Do proponents claim that research will prove their therapy is effective as soon as studies are conducted?

14. Is training to provide the therapy offered only at obscure private institutions instead of accredited professional schools?

15. Do proponents use expertise in other areas to lend weight to their medical claims?

Warning Signs- Post Four
16. Is a therapy encouraged simply because it’s been used for centuries by people in some remote place?

17. Do proponents use statements that are basically true but unrelated to the therapy?

18. Do proponents blame failed tests of effectiveness on skepticism or outright nonbelief of observers?

19. Do proponents claim it is too difficult for most to understand how a therapy works, or that only the “enlightened” can understand?

20. Does the proponent disguise the truth with vague and misleading statements?

Warning Signs- Post Five
21. Does the product you’re considering require advance payment?

22. Does the advertisement promise a “money-back guarantee”?

23. Is the therapy available only in other countries?

24. Are there conflicts of interest?

25. Is the term “natural” the main advantage of the remedy?

Posted in General | 15 Comments

Holistic Vet Asks, “IF CAM doesn’t work, why is it allowed?”

Posted on June 16, 2010 by skeptvet

A certain “holistic” veterinarian about whom I’ve written before (here, here, here, and—well, you get the idea) has asked a couple of good questions on his own blog, though not surprisingly I don’t find his answers at all convincing. I’m interested in talking about these questions not so much as a response to the fellow himself, who is beyond even considering any weaknesses in his own philosophy or view of the world, but because they are truly good questions, and they provide an opportunity to look at some key elements to the persistence of ineffective veterinary treatments despite their lack of efficacy.

The first question was, “If natural therapies don’t work, and I continue to market them to the public and use them in my practice, am I guilty of ripping off the public?” The short answer, is “Yes!” which is part of why I write this blog.

Of course, I have made it clear many times that I doubt most vets, or others, practicing ineffective nonsense therapies like homeopathy, energy medicine, and so on, are actually intentionally lying. I accept that most of them truly believe that what they do is helpful, for all the reasons we all make poor judgments and delude ourselves from time to time. I don’t fault them for their mistaken beliefs, only for their arrogance in refusing to consider the evidence against them.

Rather than offer any evidence for the effectiveness of his methods, the author instead asks a series of somewhat ridiculous rhetorical questions.

Why have I never been prosecuted and convicted of being a con artist?

So the failure of the local DA to prosecute him for fraud proves that what he does works? No, it simply proves that what he is doing is (probably; he rarely offers specifics) not illegal and that he likely really believes it works and so is deceiving his clients unintentionally.

But the issue of illegal claims made on behalf of herbs, nutritional supplements, medical devices, and other CAM interventions is a real one. The law does limit what providers of such products and services can claim. Claims of being able to prevent or treat specific disease conditions are subject to laws and regulations requiring such claims be demonstrated by legitimate scientific evidence. The FDA, Federal Trade Commission, and other state and federal agencies have complex and overlapping webs of jurisdiction over such claims. Unfortunately, these organizations are understaffed and underfunded, and they have neither the resources nor the political will to police individual practitioners or organization.

I once asked a representative of the FDA’s Center for Veterinary Medicine how to best go about reporting illegal claims about veterinary therapies. She sighed and indicated that apart from large companies selling compounded drugs on a large scale, or products that might conceivably be a risk to human health directly or through food production, the agency was unlikely to be able to investigate or respond to such claims. I have, in fact, filed a number of complaints about egregiously and clearly illegal marketing of unlicensed therapies to the FDA and the FTC, and I have never had so much as an automatic email in response. There are many reasons, practical and political, why unproven therapies are not subject to control by law enforcement, but their underlying effectiveness is not one of these reasons.

Why do my patients improve when conventional doctors can’t help them?

Of course, he assumes this is true and would like us to assume so along with him. Once again, he offers no evidence of it, and we have no reason to believe it is so since the sorts of alternative approaches he advocates range from the possible but unproven to the outright ridiculous and impossible.

In the absence of any scientific study, CAM providers can claim what they like about the results of their treatments without fear of contradiction, and they frequently do. I could certainly advertise that I save lives where alternative therapies have failed. In fact, I believe I do! But such claims are not themselves proof of anything. Rarely are there direct comparisons of the effectiveness of a CAM treatment versus a scientific treatment, since this is precisely the sort of evidence CAM providers do not seem to feel they need.

Why does the public continue to come to me, seeking the kind of care I can offer their pets that they can’t get elsewhere.

This is indeed a good question, though the implication that people seek his care proves it must work is no more reasonable than the argument that people play the lottery so they must be winning. There are many reasons why people seek alternative medical care:

1. Desperation-As I’ve discussed before, people facing an illness that cannot be effectively treated by scientific medicine will resort to anything that gives them hope or the promise of a better outcome. This is understandable, and no one can be faulted for wanting their beloved pets to be better. Unfortunately, unproven and bogus therapies offer only false hope and often come with the risk of making things worse.

2. Comfort- I don’t know this particular vet, but I do know that many CAM practitioners seem to meet the psychological needs of their clients better than many conventional doctors. A caring demeanor, asking detailed and lengthy (even if medically meaningless) questions about every aspect of the patient’s life, a non-traditional, non-clinical consultation environment, and many other factors can make the genuine caring a CAM doctor feels for their patients clear to the clients.

It is a shame that the traditional medical environment and the time pressure many vets work under, as well as the lack of effective training in communication, sometimes mask the equally genuine caring science-based vets feel for their patients. And, of course, science-based vets are limited in the comfort they can offer by their need to be honest with clients about the uncertainties and limitations of medicine, whereas believers in miracles and magic can freely claim nothing is ever beyond hope of a cure.

3. Philosophy-Many clients seek alternative medical providers because they themselves are believers in vitalistic philosophies or are suspicious of science and conventional medicine for personal or political reasons. I once saw a clients whose dog was in great pain from a bone tumor. the dog would not walk on the affected leg, and he cried piteously when I touched it. The owner had come to me out of desperation after none of the alternative therapies she had chosen to pursue first had made the disease go away. I had some therapies to offer, though not a cure, but she refused to consider amputation, radiation, or other such conventional treatments because she believed them to be unnatural and harmful rather than beneficial. What struck me the most about her beliefs, though, was that she refused to consider any pain medication for her dog and seemed surprised and offended when I offered it. She was having acupuncture done to the dog and using a homeopathic remedy, and despite the obvious pain the animal was in, she really believed these were working, and she certainly believed they were better than “toxic drugs”. People will ignore great even powerful and obvious information if it contradicts what they believe or wish to believe.

4. Control-CAM often involves changes in diet or lifestyle that the client is responsible for. This can give them a sense of control, of being able to actively do something to combat the illness their pet is facing. And CAM therapies are often given along with simple and intuitive explanations of the disease and the treatment, which is more appealing then the often complex, abstruse, and nuanced scientific descriptions of the pathophysiology of the disease and treatment. This too makes the client feel more in control and less bewildered by what is happening to their pet.

The second general question our holistic colleague asks is this:

If natural therapies don’t work, then why does the government (FDA, state licensing agencies, AVMA, etc.) allow me to use them in my practice? Why would the government, especially the FDA, knowingly not just allow but also support the use of natural therapies in the practice of medicine unless they are in on the “scam” too? Why does the FDA regulate homeopathic remedies (which the skeptics claim don’t work) just like they do conventional medicines if these homeopathic remedies are nothing more than “sugar pills?”

His answer?

The only conclusion someone can draw from this discussion is simply this: since the government allows doctors to use natural therapies, these therapies must work and have some value in the practice of medicine. Otherwise the government could easily make it illegal to use natural therapies and prevent doctors from using them. Punishment for using these unproven natural therapies would be swift and severe, such as the loss of the license to practice medicine and possibly even criminal penalties. Since this doesn’t happen, it must be that the government recognizes the value of using natural therapies in the practice of medicine.

Not even close. The reality is that government licensing and regulation is far more about politics than it is about science. As I’ve discussed before, homeopathic remedies were grandfathered in to the original laws establishing the FDA for purely political reasons. And technically, the FDA has ruled that this does not extend to the use of such remedies in animals, so they could prohibit them if they had the political will to do so, which clearly they do not.

Similarly, veterinarians are licensed at the state level, and their activities are limited by the provisions of state veterinary practice acts. These acts are written by legislators, who are clearly not scientists, and they rarely specify precisely what is or is not considered legitimate veterinary medicine. And, of course, we wouldn’t want them to since the science is far too complex and continually evolving to expect e could enshrine it in law. Specific interventions are sometimes legally prohibited, such as declawing of cats in some local jurisdictions, but this is uncommon and, again, driven by politics and public opinion, not sophisticated assessment of the scientific evidence for what constitutes effective or ineffective therapy.

And the professional organizations that represent veterinarians are reluctant to make strong statements about what is or is not legitimate medicine. They are primarily concerned with ensuring that whatever treatments are applied to animals, they are exclusively the purview of veterinarians, a position which has some legitimacy in terms of consumer protection but which also smacks greatly of simple economic protectionism.

Attempts by professional organizations to oppose quack therapies have been made in the past, and these have been met with legal and political counterattacks that have had devastating effects. The American Medical Association once tried to suppress the use of chiropractic for both scientific as well as, admittedly, less laudable reasons. The organization lost an anti-trust lawsuit as a result, and quickly got out of the business of aggressively trying to promote scientific standards where CAM was concerned. And the very existence of the Dietary Supplement Health and Education Act and the National Center for Complementary and Alternative Medicine, both political constructs that have effectively protected unproven and bogus therapies despite all scientific evidence against them, is testimony to the inability of the political process to supervise anything like rational scientific standards for medical practice.

The amount of time this particular vet spends responding to skeptical criticism (albeit without providing any facts or sound arguments to counter it) seems to me to be a good sign. It demonstrates that even the most committed proponents of alternative medicine recognize that such criticisms have weight and influence. We will never banish irrationality, but the fact that even CAM proponents attempt to claim that science is behind their approach and that they often attempt to employ the language, if not the methods, of evidence-based medicine indicates that even they recognize that the public believes and trusts science more than they would like us to think. The facts, unfortunately, do not speak very loudly or effectively for themselves, so we who are committed to scientific medicine must speak for them.

Posted in General, Law, Regulation, and Politics | 7 Comments

ACVIM 2010 Forum– Poster: Vaccination and Immune-Mediated Disease

Posted on June 12, 2010 by skeptvet

Apparent Lack of Association between Primary Immune-Mediated Thrombocytopenia and Recent Vaccination in Dogs
A.A. Huang; J. Coe; G.E. Moore; J.C. Scott-Moncrieff

I’ve written about the proposed association of vaccination and immune-mediated diseases, in particular immune-mediated hemolytic anemia (destruction of red blood cells). For that disease, the evidence is contradictory, and in general it seems likely that very rare cases of immune-mediated disease are triggered by vaccination, but this is not a common or widespread problem, and the vast majority of cases occur from natural exposure to triggers in the environment, probably in dogs with a genetic susceptibility since there are breed predilections.

This study looked for an association between vaccination and immune-mediated thromboctopenia (ITP, the destruction of platelets, necessary for blood clotting). Looking back through medical records at dogs diagnosed with ITP and then comparing them to dogs of similar age, sex, and breed with other diseases, the authors did not find that vaccination increased the odds of developing ITP.

Again, all the usual caveats about small, retrospective, case-controlled studies apply, so these results cannot be viewed as the final word on the question. But even this qualified evidence is more reliable than the wild guesses, hunches, and clinical impressions of those who confidently blame vaccines for diseases like ITP.

Posted in Vaccines | 2 Comments