Evidence-Based Canine Allergy Treatment

Posted on June 8, 2010 by skeptvet

Allergies are an incredibly common, and frustrating, problem in pet dogs. Unlike humans, respiratory manifestations of environmental allergies are not usually very noticeable. Dogs with allergies get itchy skin, and they scratch like crazy as a result. The underlying inflammation and the scratching both lead to secondary infections, especially of the ears and skin.

There are several categories of skin allergies, including allergy reactions to fleas, to foods, and to general environmental allergens such as pollen, dust mites, and so on. There are, not surprisingly, a lot of myths about allergies, and a lot of CAM treatments recommended, as is always the case with chronic disease science does not yet have definitive cures for.  In the future I hope to address some of these, but right now I want to discuss some evidence-based recommendations for treatment of atopic dermatitis (AD: environmental allergies, as distinguished from flea or food allergies).

The veterinary dermatology community seems to have adopted not only the rhetoric but the actual practice of evidence-based medicine more effectively than the profession as a whole. There are a number of published evidence-based reviews of therapies for various skin diseases, and a new review recently appeared titled Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. (Olivry T, Deboer DJ, Favrot C, Jackson HA, Mueller RS, et al; for the International Task Force on Canine Atopic Dermatitis. Treatment of canine atopic dermatitis: 2010 clinical practice guidelines from the International Task Force on Canine Atopic Dermatitis. Vet Dermatol. 2010 Apr 23 [Epub ahead of print].) After discussing what is known about the cause and mechanisms of AD, the report reviews various treatments for acute and chronic atopy and grades the evidence and strength of the recommendations for them. I have reproduced the grading scales for evidence and recommendations and then collated the findings in the chart below.

Table 1. Categories of evidence and strengths of recommendation

Category of evidence

Ia. Evidence from meta-analysis or systematic reviews
Ib. Evidence from at least one randomized controlled trial
IIa. Evidence from at least one controlled study without randomization
IIb. Evidence from at least one other type of quasi-experimental study
III. Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies
IV. Evidence from expert committee reports or opinions or clinical experience of respected authorities or both
LB. Evidence from laboratory-based studies

Strength of recommendations

A. Directly based on category I evidence
B. Directly based on category II evidence or extrapolated from category I evidence
C. Directly based on category III evidence or extrapolated from category II evidence
D. Directly based on category IV evidence or extrapolated from category III evidence
E. Directly based on category LB evidence
F. Based on consensus from Specialty Task Forces
Modified from: Leung DYM et al. Ann Allergy, Asthma, Immunol 2004; 93:S1–21.

Therapy Recommendation Strength of Recommendation
Acute Flareup    
Identify & avoid allergens Treat for fleas, rule out food allergies, avoid known environmental allergens, beneficial  D
Antibiotics, Antifungals Topical or oral drugs for identified secondary bacterial or yeast infections beneficial  D
Bathing Probably washing more important than shampoo used, beneficial  B
Topical glucocorticoids Short courses very beneficial A
Oral glucocorticoids Short courses if symptoms too severe for topicals, beneficial  A
Antihistamines Not beneficial –
EFA (e.g. fish oil) Not beneficial –
Tacrolimus Not beneficial –
Cyclosporin Not beneficial –
     
Chronic Treatment    
Diet trial for food allergy Beneficial if food allergy part of problem  D
Flea Control Beneficial D
Allergy testing Skin or blood testing may detect allergens (not foods) that can be avoided or guide immunotherapy  C
Dust mite control Theoretically beneficial but unlikely to clinically help most dogs  C
Antibiotics, Antifungals Topical or oral drugs for identified secondary bacterial or yeast infections beneficial  D
Bathing Probably washing more important than shampoo used, weekly, beneficial  D
EFA (e.g. fish oil) Helpful in conjunction w/ other therapies, not alone, no particular dose or product, oral only; mildly beneficial  B
Topical glucocorticoids, tacrolimus Beneficial, some adverse effects especially older products  A
Oral glucocorticoids, cyclosporin Beneficial, lowest effective dose to minimize side effects  A
Injectable interferon Beneficial A
Immunotherapy (allergy shots) Beneficial  A
Phytopica (herbal) Steroid sparing effect Ib(evidence)
Antihistamines Not beneficial –
Pentoxifylline Minimal benefit, risk too high Ia(evidence)
Misoprostil Minimal benefit Ia(evidence)
Tepoxalin Minimal benefit Ib(evidence)
Leukotriene inhibitors Not beneficial Ia(evidence)
Dextromethorphane Not beneficial Ia(evidence)
Capsaicin Not beneficial Ia(evidence)

Obviously, the text of the review discusses the details of these interventions and the supporting evidence (or lack thereof). The evidence is often of low quality and quantity, but the Task Force has effectively followed the principles of evidence-based medicine in basing recommendations on the best evidence that is available and acknowledging the shortcomings of this evidence where appropriate. Obviously, the strength of their recommendations, and the confidence we as practitioners place in them, should be proportional to the quality of the supporting evidence.

The therapies with the best-documented efficacy, glucocorticoids and cyclosporin, are of course those with the best understood side effects. There is no free lunch in physiology! However, it is also notable that the supposedly safer therapy almost universally recommended in general practice, antihistamines, have little to no evidence of meaningful benefit. It seems likely we give these out mostly in response to the pressure, from the owner and from ourselves, simply to do something. The evidence seems pretty clear that we need to give up this unsupported practice.

Essential fatty acid supplements (EFA, usually fish oils) do have some demonstrable efficacy, but their effects are relatively small and best used to reduce the need for other therapies, such as glucocorticoids, not as primary therapeutic agents. One herbal preparation seemed to have a steroid sparing effect based on a single well-designed clinical trial (Phytopica), but the Task Force was careful to state clearly “Whether or not similar observations would be made with other nutritional supplements has not been established, and care must be taken to not extrapolate these findings to other untested products.”

Such a review is very helpful for the ordinary vet in practice, and while the quality of the evidence is not what we would desire, having it reviewed and explicitly graded in this way is a fine example of how evidence-based medicine can and should be applied in the veterinary field even with the limitations we face.

Posted in Science-Based Veterinary Medicine | 42 Comments

Uncertainty-What It Means and What It Doesn’t

Posted on June 8, 2010 by skeptvet

It is in the admission of ignorance and the admission of uncertainty that there is a hope for the continuous motion of human beings in some direction that doesn’t get confined, permanently blocked, as it has so many times before in various periods in the history of man.
Richard P. Feynman

I’ve written before about uncertainty and how it affects medical decision making and also about why pet owners often prefer simple, unambiguous answers to the messy uncertainties of reality. But I’d like to take a slightly different perspective on the issue of uncertainty in science and medicine. The fact that science is incomplete and imperfect is undeniable. Unfortunately, some people take this fact as justification for throwing out the whole enterprise of trying to understand and acquire real facts and knowledge. If vaccines don’t protect us completely, this means they are useless. If science doesn’t know everything, than anything must be possible. These naïve arguments ignore the very clear fact that uncertainty and the impossibility of knowledge are not the same thing.

There are different kind of uncertainty in science. One is the uncertainty of what we don’t know. A big part of what makes science fun is that the universe is so vastly more complex than our little brains that we are never going to be in danger of running out of new things to learn and discover. I like to imagine my own ignorance as a vast abyss yawing before me. Every day I throw in a few grains of sand, but it shows no sign of being filled in. So there is no denying that the surprising and unexpected is out there waiting for us.

But that is not the same thing as saying anything we can imagine is likely to be true. Most of our guesses about the nature of reality turn out to be wrong. Until science came along, this left us fighting over belief systems and led to a bewildering proliferation of different, interesting, and usually mutually incompatible mythologies to explain the world. Now, science is creating the kind of knowledge that works everywhere, in every culture, and that endures through time. Sure, such secure knowledge is only tidbits compared to the vastness of reality, and there is plenty that falls by the wayside. But never before have we been able to have even this much enduring knowledge. Barring the complete collapse of human civilization, we are always going to know that the heart circulates blood, that emotions live in the brain not the heart, that smallpox used to be caused by a bacterium, and so on. What we don’t know is an opportunity, not an invalidation of what we do know.

Another kind of uncertainty, though, is the uncertainty about what we know. Scientists like to say that all knowledge is provisional, tentative and subject to revision. This is true, but non-scientists tend to overread this and believe it means all knowledge is ultimately just opinion and is unreliable. Sure, theories of gravity have changed from Newton’s day to our, but if you have to leave your 8th floor apartment, you can rely confidently on the knowledge that it is better to do so by the stairway than the window. It is possible that gravity will stop working tomorrow, but I wouldn’t bet on it. So while proponents of bizarre ideas like to make much of the fact that scientific explanations are “only theories,” they ignore the fact that those ideas that endure and are refined over time can reach a point where having confidence in their truth makes a lot more sense than doubting them.

A different flavor of uncertainty about the known is statistical or probabilistic uncertainty. I recently put my age, gender, total cholesterol level, and a few other factors into a nifty little calculator that told me I have a 3% chance of dying of a heart attack in the next 10 years. So does anyone know if I’m going to die of a heart attack or not? Can anyone tell me with certainty that I will if I stop taking my fish oil and baby aspirin every day, but I’m safe if I keep taking them? No, of course not. Much scientific research generates knowledge and conclusions that are statistical, that apply reliably to groups but don’t give precise predictions for individuals. So, does this mean such knowledge is worthless for helping us decide what to do as individuals? Of course not.

If you go to a casino in Vegas and play roulette, the odds are you’re going to lose. Sure, you could win. Some people do. But most people don’t. This is a truth, though it is only a statistical or probabilistic truth. So is it worthless in helping you decide whether or not to bet the farm on red? Not at all. Casinos make lots of money betting against you, and you’re a lot more likely to be able to afford that Winnebago when you retire if you play the odds and don’t play roulette. Even though statistical truths apply imperfectly to the individual, they are real and useful guides for our choices. The uncertainty of probabilities does not justify ignoring the odds and doing whatever we like.

Uncertainty is inevitable, in science as in all areas of human life. But this doesn’t mean knowledge is an illusion and blind belief is as good as facts in deciding what to do or not to do. Human beings have changed our planet and our own lives, both for the better and for the worse, through the power of discovering and applying knowledge about the physical world. Such knowledge is limited, incomplete, tenuous, and a damn site better than guessing or hoping. And science has generated more reliable, trustworthy knowledge in the past couple centuries than hunches, guesses, and trial-and-error managed in all the rest of human history. Place your bets, ladies and gentlemen. I’m placing mine on science.

Posted in General | Leave a comment

The Placebo Effect In Song

Posted on June 5, 2010 by skeptvet

Happy Birthday, SketpVet! 🙂

Today marks the first anniversary of this blog. Not a momentous event for the world at large, but yet another reminder of the fleeting nature of time for me. Apparently, in the last year I have put up 135 posts and the site has been visited 7468 times. I’ve certainly learned a great deal, about medicine and about writing, and I’ve met a number of interesting people. I hope it has been interesting and useful to at least a few of you.

As an anniversary post, I thought I’d put up something I started on near the beginning but never actually posted.

Last summer, I spent a week at Lark Camp, a folk music workshop/festival/party in the Mendocino Woodlands. I tend to refer to it, affectionately, as Hippie Drum Camp, mostly because I went with the idea of learning to play the bodhran (hence the “drum” part; the “hippie” part should be self-evident). Apart from a brief and agonizing (for me and everyone around me) flirtation with the clarinet in grade school, I have never played an instrument. But I’ve always gone to Celtic cultural events (and pubs) and I know all the songs, so I wanted to learn more about the music. It was a fantastic experience, and I’ve spent the last year trying to learn a couple of instruments so I can go back this summer and participate more fully.

One of the folks I met there was a fiddle player who shared a song he had written called The Placebo Effect. We had a very interesting conversation about his experiences with managing his own diabetes and trying to avoid medication, and about all of the things he had investigated or tried as part of this experience. I had just started this blog, and I thought the song offered some eloquent and funny insight into the issue of placebo effects and unproven or alternative therapies from the perspective of an intelligent, educated non-scientist. At the time, I wasn’t certain he would welcome my making the lyrics public, but I recently found he did so some time ago on his own blog so hopefully he won’t mind.

Apart from the internal merit of the wit and humor, the song illustrates how someone can come to look at the complex relationship between individual experience and scientific knowledge. It is always difficult to argue with someone who feels better after using a therapy, even if the facts are pretty clear that the therapy doesn’t work. Feeling better is real whether or not it means what the person thinks it does or has any relationship to actual physical health.

In trying to promote science-based medicine, my ultimate goal is always to steer people toward what will truly help them or their pets and to steer them away from false hope and the harm that comes from mistaken ideas about cause and effect. But I try always to remember that CAM is popular because it meets a need. It provides hope, even false hope, and it addresses the psychological dimensions of illness in ways that mainstream medicine doesn’t always (though I think this is less true in veterinary medicine for a variety of reasons). I think we can have the best of both worlds–effective science-based medicine and humane, affirming care. But to do this we have to try and understand what appeals to people about CAM and what about scientific medicine pushes them away even when it is the more likely to help them.

This song touches on the issues of uncertainty in medicine, on the fact that general data can’t always predict what will help or harm the individual, and that the slow process of scientific progress, though it is far more likely to reach the right answer in the end, is often too slow to help those who are suffering right now. None of this justifies unproven or outright bogus medicine, but it does explain a bit why even ineffective therapies can be popular, and it reminds us of some of the limitations to scientific medicine that we have to deal with in the effort to guide people towards the best, real therapies available. It also reminds us that CAM is not the sole province of the ignorant, gullible, or stupid. I don’t necessarily agree with the writer’s take on science and knowledge, but from our conversation and his blog I have no doubt he is smart and well-informed. We must be careful not to make the mistake of caricaturing or patronizing those who don’t see the issues around CAM the way we think they are best seen. This blog is as much about learning for me as it is about trying to teach others, and from this fellow and his song I think I have learned a few valuable things.

Oh, and did I mention it’s funny?

In the woods on a sunny day late in July,
all the air was abuzz with mosquito and fly.
In an effort to cope I was spraying some DEET
on my arms, elbows, shoulders,
legs, ankles, and feet,
when a fiddler came by and said
“Don’t waste your time —
there’s no evidence that that stuff
works worth a dime”.
I explained to him I wouldn’t
care if there was,
’cause it helps me so long as
I think that it does.

Chorus:
I would never reject any fake remedy;
the placebo effect is what works best on me.

If I take enough fish oil, I
need not grow old,
if I take echinacea I won’t
catch a cold.
And if I should come down with a
cold anyway,
a few doses of zinc will soon
make it okay.
Now as far as I know there’s no
clinical study
showing zinc really makes you feel
one bit less cruddy.
So it might not be true, yet
I’ve heard that it’s so.
In such matters as this there is
no way to know.

I would never reject any fake remedy;
the placebo effect is what works best on me.

If you can’t afford insulin,
I have heard tell
that ground cinnamon does the job
perfectly well.
There are herbs with strange nicknames
in English and Latin
which I’ve heard are as useful
as Pfizer’s new statin.
I suppose that some day we will
know for a fact
how a body exposed to such
cures will react.
By the time that these answers are
finally found,
I’m afraid I’ll already be
under the ground.

I would never reject any fake remedy;
the placebo effect is what works best on me.

All this week in a tent, yet my
back feels just fine
I assume all that yoga
protected my spine.
And it seems my blood pressure has
come down a bit;
I conclude making music can
help me stay fit.
These are only assumptions, they
may not be true,
and if I wanted proof, well,
my options are few.
For, to test your health habits, there’s
one thing to try:
life your life over different
and see if you die.

I would never reject any fake remedy;
the placebo effect is what works best on me.

And it really is not just good
health that’s at stake,
for the thoughts that we live by
are most of ’em fake,
and we get through each day by
accepting as right
every half-assed conception
we dreamed up last night.
If I master this dance, then it
means I’m no fool,
if I wear the right clothes it will
mean that I’m cool,
and if I could play well every
tune on this list,
it would prove to me I have a
right to exist.

I would never reject any fake remedy;
the placebo effect is what works best on me.

Though to say it out loud here takes
plenty of gall,
I think music’s the greatest
placebo of all.
For as long as we’re playing we
think life is fine
and the wide world around us is
not run by swine.
Through a skeptic might ask what
this fake joy is worth,
at least fake joy’s the kind you can
have here on earth.
So that moral that I would leave
with you is this:
do not seek tragic wisdom
where bullshit is bliss!

I would never reject any fake remedy;
the placebo effect is what works best on me.

Posted in General, Humor | 4 Comments

JAVMA Article on Electroacupuncture for IVDD

Posted on June 2, 2010 by skeptvet

A couple of readers have asked me to comment on a study that appears in this month’s Journal of the American Veterinary Medical Association, Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing neurologic deficits.

The study was performed in Brazil at the School of Veterinary Medicine and Animal Science in Sao Paulo, where a similar study published last year and another in 2007 were also performed. The authors created 3 study groups, all of which consisted of dogs that had severe neurological disease of >48 hours duration attributed to intervertebral disk disease (IVDD). Group 1 (DSX) was a group of dogs (N=10) selected retrospectively from patients that had undergone surgery for IVDD at the authors’ hospital between 2003 and 2006. Group 2 (dogs treated with electroacupuncture-EAP, N=19) and Group 3 (dogs treated with both surgery and electroacupuncture-DSX+EAP, N=11) consisted of dogs seen at the hospital between 2006 and 2008, and patients were assigned to these groups based on their owners’ choice.

All dogs were treated with oral steroids. Dogs in Group 1 were treated surgically with a couple of different techniques and presumably with whatever unspecified medical treatment and post-surgical care the individual surgeon elected. Dogs in Group 2 were treated surgically (and again presumably with additional unspecified followup care) and were also treated with electroacupuncture. This treatment consisted of the insertion of metal electrodes into the body at points determined by “traditional Chinese theory.” Electrical current was passed through these electrodes for 20 minutes weekly for from 1-6 months. Scores were assigned to quantify the level of neurologic dysfunction initially and at 6 months after the beginning of treatment. Improvement was judged based on decrease in neurologic score and regaining the ability to walk unassisted.

The results can be summarized as follows:

  DSX EAP DSX+EAP
Score Unchanged 6/10 4/19 3/11
Score Improved 4/10 15/19 8/11

 The text indicates that the proportion of dogs in the DSX group that improved was statistically significantly lower than in the other two groups, and the proportion of DSX dogs that remained unchanged was significantly greater than in the other groups. From this, the authors concluded that “EAP was more effective than DSX for recovery of ambulation and improvement in neurologic deficits in dogs with long-standing severe deficits attributable to thoracolumbad IVDD.”

So is this conclusion justified? I believe not. To begin with, of course, we must decide what if anything this paper has to do with “acupuncture.” Electroacupuncture has been referred to as a bait-and-switch, because it is arguably not acupuncture at all. Obviously, the ancient Chinese lacked electricity, so the theories and guidelines developed for acupuncture in humans are not really relevant to the effects of electricity on the body (there were no specific guidelines for animals, and despite claims to the contrary it does not appear the Chinese routinely practiced acupuncture on animals before the mid 20th century). There is, however, a scientific medical therapy involving electrical stimulation to treat pain, transcutaneous electrical nerve stimulation (TENS). The only difference between TENS and electroacupuncture appears to be the selection of electrode location. TENS places electrodes in locations associated with known nerves, and in electroacupuncture the electrodes are placed at acupuncture points with no consistent relationship to any identifiable anatomic structures. However, by chance or perhaps some trial and error experience, some acupuncture points do happen to coincide with the locations of nerves, so it is possible that electroacupuncture might effectively be the same thing as TENS in some cases. So one might justifiably question whether any benefit seen in this study represents a validation of the theory and practice of acupuncture or an example of TENS with irrational selection of electrode locations.

However, there are other reasons to view the authors’ conclusions skeptically. A major methodological flaw of the paper is the process of selecting and assigning subjects. It is highly likely that there are biases inherent in allowing owners to choose what treatment group their pets should be in and in selecting one group retrospectively from one period of time and another prospectively during a different time period. This process does not allow the owners or researchers to be blinded in any way to the treatment, and it makes it likely that the patients and the treatment they receive in the various groups will differ with respect to many variables other than the one of interest in the study. The lack of blinding is of particular concern since the research center has consistently produced papers showing positive results for electroacupuncture and thus the researchers likely have a strong a priori bias in favor of the approach.

Very little information is presented to allow us to evaluate whether the patients differed in meaningful ways in terms of the medical therapy, surgical care, and post-surgical care they received. We do know that the EAP and DSX+EAP subjects received weekly treatments at the hospital for from 1-6 months after the onset of the study, and it is likely that they received much more intensive followup and post-surgical care (for the DSX+EAP group) as well as better owner compliance due to seeing the doctor so often after the study commenced. It is also quite possible that the differences in outcome were due to any number of differences in the populations of the various groups or the biases of the authors since these were not controlled for effectively.

There are other methodological problems, particularly the small number of subjects, but overall the two factors already discussed are enough to make me question the strong conclusions the authors draw from their results. It is certainly possible that electrical stimulation of some parts of the body could have a beneficial effect on outcome for dogs with neurological deficits attributable to IVDD. Better studies involving random prospective allocation of subjects, more consistency in the treatment of the subjects, blinding of the researchers and owners, and perhaps more precise assessment criteria would be valuable. I would be particularly interested, if there turns out to be some value to so-called electroacupuncture for this condition, in seeing a comparison of this procedure with electrode locations selected according to anatomic structures such as nerves compared with locations selected according to traditional Chinese medicine principles (insofar as such principles can be called “traditional” with respect to treating animals with electricity). It would take a robust and repeatable superiority of treatment at traditional acupuncture points compared with locations selected according to the principles of TENS to convince me that this procedure has anything to do with acupuncture.

Posted in Acupuncture | 19 Comments

Shocking Study! Chiropractors Make Unsubstantiated Medical Claims!

Posted on June 2, 2010 by skeptvet

A new study by Edzard Ernst and Andrew Gilbey recently appeared in the New Zealand Medical Journal surveying Internet advertising claims made by individual chiropractors and major chiropractic organizations from Canada, the U.S., New Zealand, and The U.K.

They divided the claims into those for which there is reasonable evidence of some benefit (lower back pain) and those for which no good evidence of efficacy exists (headaches, migraines, colic, asthma, ear infections, neck pain, and whiplash). What is not surprising is that chiropractors, and the professional organizations that represent the profession generally, routinely suggest or outright state that their manipulations can treat conditions which they cannot. 95% of individual chiropractic websites made at least one such claim, and all of the professional associations did as well. 38% of the chiropractors made treatment claims concerning all of the conditions in the survey which chiropractic has not been shown to actually treat.

What is a bit more surprising is that many of the sites and organizations did not promote chiropractic for lower back pain, the one condition for which the evidence of some benefit is decent. Only 28% of the individual sites and 4 out of 9 association web sites specifically mentioned lower back pain. One would think they would be most aggressively advertising their treatments for the diseases for which the best evidence exists that they actually help. But remember, chiropractic is, for the most part,  really a faith-based practice founded on the non-existent subluxation and the vitalist “innate intelligence,” not an evidence-based medical specialty. It is true some individual chiropractors are exceptions to this rule and limit themselves to treating musculoskeletal pain. And there are some signs that the profession may be moving to downplay the subluxation mythology. But in general, the practice of chiropractic is still dominated by 19th century spiritualist notions and isn’t much interested in the verdict of science on its efforts.

So how do we explain the apparent de-emphasizing of the most reasonable claims chiropractic could make? I suspect that there is a deliberate effort on the part of the chiropractic profession to avoid getting limited in the public’s mind to treatment of musculoskeletal pain. Chiropractors want to be seen as an alternative choice to conventional medical providers, and they want to be involved in much more than just the treatment of musculoskeletal pain. So despite the lip service they may pay to the concept of evidence-based medicine, in reality they are convinced their treatments work for all sorts of problems regardless of the lack of evidence, and they want to protect and nurture the false impression the public may have that chiropractic is good for more than just back pain.

Posted in Chiropractic | 22 Comments

Don’t Be Such a Scientist or The Negating Culture of Science and its Costs

Posted on June 1, 2010 by skeptvet

I recently finished reading Randy Olson’s book Don’t Be Such a Scientist, and I definitely recommend it. It is an entertaining read and has a number of useful insights into the perennial problem of communicating complex, nuanced, and incomplete scientific information in a way that is engaging and accessible and still in some meaningful sense truthful. I won’t say I agree entirely with Olson’s take on the subject, of course. Sometimes I think he lets the public off too easily, expecting too little from the intelligent lay person. And as always when making generalizations, he seems to stray sometimes into caricature and stereotype. Still, there is no denying that there is currently an enormous divide between mainstream culture and the subculture of science. The days of standing room only public science lectures, such as those of the 19th century, are gone. And the days of scientists being seen as respected and trusted white-coated heroes who invented antibiotics, stopped the scourge of polio, and won the Second World War are over too. There is now a profound suspicion of science, and intellectualism generally, in the U.S., and scientists can no longer take for granted that they will listened to, trusted, or supported by the general public unless they can compete in the busy and bewildering media from which most of us get our understanding of complex issue.

The one concept that struck me most forcefully in Olson’s book, was the image of science as fundamentally a negating enterprise. For all the reading and writing I’ve done on the subject of medical research and the dangers of simply seeking to confirm our preconceptions, I never fully appreciated the implications of this for the appearance of science to non-scientists.

It is very difficult to reliably prove an idea true. Certainly informal assessments of our personal experiences almost always confirm our pre-existing beliefs. Confirmation bias, the availability bias, cognitive dissonance, and a host of other such factors make this inevitable. But even scientific research studies, with all their attempts at controlling personal bias, will almost inevitably prove true whatever investigators set out to prove. The best way to get to the truth is to attempt to prove ideas wrong. A negative finding, especially from a source predisposed in favor of the hypothesis, is worth more than a positive finding. Of course, technically one cannot prove a negative. But the failure to disprove an idea with multiple, vigorous attempts is certainly more reliable an indicator of the idea’s veracity than multiple studies set up to confirm what is already believed to be true.

The implications of this for the culture of science, and the barriers to effective communication between scientists and non-scientists, are profound. Scientists expect criticism and see it as a sign that they and their ideas are being taken seriously. Sure, we are human and so as full of ego and narcissism as anyone else. But by training and experience, most of us acquire relatively thick skins, and we come to see strong challenges to our ideas as a good thing, a kind of intellectual personal trainer that will cause us pain but ultimately make us stronger.

I have been through the peer review process for several publications I have written, and it isn’t pretty. Seeing something I have put months of hard work into torn apart, and facing the prospect of more work to revise what I was sure was perfect to begin with, causes lots of hurt and anger. But at the end of the process, I am generally grateful that the final product is better and that I have been saved the embarrassment of public error. I understand that the criticisms are not personal (the reviews are anonymous, of course, which helps) and I accept the ego bruising as a fair price to pay for weeding out bad work and weak ideas. Likewise, I try as hard as I can to give up beliefs and practices that have been reasonably shown to be wrong, even if I am attached to them and personally convinced of their value. I trust the process, based on the logic of the underlying philosophy and the evidence of history, and this helps me to appreciate the value of the sometimes painful experience of having my ideas and work criticized.

As part of this enculturation, I also feel it normal to respectfully but aggressively criticize the ideas of others. I’ve discussed before how proponents of CAM often resent such criticism and see it as fundamentally unfair and inherently personal. In the culture of faith-based medicine, where truth is judged on the basis of one’s personal experiences or the received wisdom of one’s mentors, challenging someone’s beliefs is the same thing as challenging their intelligence, honesty, or worth. In the culture of science, no one’s beliefs are beyond challenge, at least theoretically (though of course scientists are political animals like all humans, so this principal isn’t always followed). This is one of example of the clash between the negating culture of science and other, non-scientific ways of looking at health and disease.

Olson also makes a big point of talking about how unlikeable scientists can seem to the rest of the world. This is particularly a concern for an endeavor like this blog, which is to a great extent devoted to identifying ideas which are not true and therapies which don’t work. It is far more pleasant to hear proclamations of hope and optimism than to hear all the reasons why something which purports to offer hope really doesn’t. Debunking is inherently negating, and it is easy to see why this leads to the image of skeptics as sour, curmudgeonly, and willfully choosing not to believe in anything. Of course, anyone the least bit of a skeptic themselves knows this isn’t true, just as anyone who actively practices science knows how positive and affirming it can be. The sense of wonder and discovery and the joy of figuring things out is a big part of the rewards in doing science, but for some reason they are less often communicated to the public than the contempt many scientists feel for bad ideas supported by wishful thinking, sloppy logic, and few facts. Science communicators, one might even say science entertainers, like Carl Sagan and Neil deGrasse Tyson are notable exceptions.  

So I agree with Olson that in many ways the culture of science is built on negation, on aggressive intellectual attack and defense of ideas, on a disrespect for those who make stuff up, botch their facts, and show more concern for what they wish to be true than for what really is true. This kind of negativism is not a bad thing, of course, since it is what enables the discovery or real, practical truths that benefit us all. And the negating aspects of science are not all there is to the enterprise. There is a great deal of awe and wonder, creativity, community, and true hope for meaningful progress and improvement in the world. But the negating aspects of the scientific approach do present a public relations problem. Most people seem to take a pretty quick dislike to dispassionate, cerebral, fact-based exposition and to the negation of hopeful, feel-good ideas no matter how nonsensical.

So what do we do about this? Abandoning reality for wish fulfillment doesn’t strike me as a good choice, so we are stuck having to challenge bad ideas no matter how popular. But as Olson suggests, this can at least sometimes be done with humor and humility and with frequent reminders of the elegance, wonder, and real benefit inherent in pursuing and defending the truth. While I think Olson sometimes goes too far in the degree to which he seems to suggest we simplify our messages and make them more entertaining and less instructive, nevertheless his underlying point is valid. The positions staked out by science and reason must compete in a marketplace of ideas, and some of the competitors they face are much more marketable.

The advances of science are often more complex and less obvious than the early triumphs of vaccination and antibiotics, which make them less self-evidently proof that the approach is the right one. And the misuses of scientific knowledge and technological progress are better understood, which further tarnishes the image of science. But the fundamental nature of science as a method which relies on challenge and disproof is itself a weakness from a public relations point of view. And the cultural reverence for factual accuracy and distaste for excessive, hyperbolic, and ultimately unjustified claims also sets those of us promoting science-based medicine at something of a disadvantage. Yet all of these marketing weakness are strengths from the point of view of discovering real and useful truths, so we cannot give them up.

We must strive to make what we do and what we stand for as engaging and accessible as possible without cutting the heart out of it. Being open about our own joy and passion for the truth and the scientific path to reach it is an important step, and being always clear that the truth, even when it may not be what we might wish it to be, is the only way to really better all our lives. Millennia of faith and wishful thinking have failed to accomplish what science has wrought in a few generations, and we must not allow the public to forget that. We must being humble, but at the same time not afraid to be definitive where it is justified. Homeopathy doesn’t work, vaccines don’t cause autism, and we needn’t tiptoe around those assertions to satisfy an excessive epistemological caution. And as always in life, we must make the effort to maintain our sense of humor, about ourselves as well as our ideological adversaries. This will not only make our own efforts more enjoyable to us, but it will do a lot to dispel the myth of the emotionless scientist out of touch with ordinary human feelings. We are as driven by our own feelings as anyone, we simply trust in a method of inquiry which diminishes the danger of these feelings misleading us, and hopefully we can succeed at illustrating that and thus humanizing science and scientists.

Posted in Book Reviews, General | 4 Comments

GAO Report on Deceptive Marketing and Contamination of Herbal Products

Posted on May 26, 2010 by skeptvet

The GAO today released a report to Congress that had previously been reported on in the New York Times. The report investigated deceptive or illegal marketing practices among sellers of herbal remedies and dietary supplements. Under the Dietary Supplement Health and Education Act of 1994  (DSHEA), there is precious little restriction on manufacturers and marketers of these products. All supplements are presumed to be safe without any pre-marketing evidence required, and the FDA can only restrict such products or their sale if post-marketing surveillance, which is haphazard at best, indicates a health threat. Marketers of such products can technically only make vague claims about their products, not claiming that they prevent or treat any specific disease unless they pass the stringent standards of evidence applied to pharmaceuticals. However, this report shows that even these weak limits are being widely ignored.

Many examples of deceptive and illegal marketing practices were identified. GAO employees posing as elderly consumers were told that herbal products could cure several diseases, including cancer, that they could be substituted for prescription medications, and that they could be used safely along with medications even when there is evidence this is untrue.

The GAO also tested 40 supplements for heavy metal and pesticide contamination and found contaminates in 37 of them. The levels were low, but because such products are under-regulated, clear standards for safe levels of these substances have not been established, so it is impossible to know how much risk this poses to the consumer. Certainly, the claim that such products are “all natural” and thus safer than pharmaceuticals is belied by these test results. Can you imagine what the alternative medicine folks would say if lead or pesticides were found in prescription drugs? Yet the manufacturers of these products express no concern, and they have effectively blocked attempts by Sen. John McCain and others to strengthen the regulation of their products. So much for the David and Goliath Myth. Big Herb and his buddy Big Supplement are playing the same game as Big Pharma, they just don’t have any referee watching to see if they play by the rules.

Posted in Herbs and Supplements, Law, Regulation, and Politics | 2 Comments

Cold Laser Therapy

Posted on May 26, 2010 by skeptvet

A popular therapy among chiropractors who treat pets is low level laser or “cold laser” treatment. It is an impressive bit of showmanship to pull out a complex-looking device and with a serious expression wave a beam of light over a patient, but the evidence to suggest it is anything more than showmanship is weak at best.

An example of the enthusiasm, and irrationality, of some proponents of this treatment can be found at the joint web site of the International Association of Veterinary Chiropractors and American Animal Adjusting Association.

The article on cold laser begins by anticipating and defying criticism:

Invariably a new technique or process is often fraught with counter-intentions that are usually seen throughout the field of study and across the board.  The relative benefit of such a process or new technology is directly proportional to the amount of consternation, doubt, and criticism that, it in fact receives….This author has seldom seen a technology as valuable and inspiring, as this particular technology appears to be. Suffice to say you are witnessing the emergence of a completely new age in healing and certainly a total paradigm shift in veterinary health care.

So the existence and strength of opposition to the technique should be seen as evidence of its benefits? Interesting logic. And if I haven’t mentioned it before, the use of the term “paradigm shift,” not to mention “completely new age,” are not only examples of ludicrous hyperbole, they are highly correlated with quackery, if not pathognomonic for it.

The underlying theory presented to explain the benefits of cold laser treatment is a bit of pseudoscience known as the Biophoton or Ultraweak Photon Emission idea. It is possible to detect very low energy photons emitted from living cells as the result of biochemical reactions. The significance, if any, of this for health and disease has never been demonstrated, which makes it a gap in real scientific knowledge into which all kinds of mystical nonsense can be stuffed, much like the pseudoscientific misuse of quantum physics. The veterinary chiropractic site advertising this treatment explains it this way:

It has been proven that cells communicate through coherent light.  When a sperm and ovum fertilize, they immediately give off coherent light at precisely 632.8 nanometers.

Cells in the living matrix also communicate throughout the total body living things via a coherent light, and that communication is done instantaneously through the living matrix to direct all aspects of healing, growth, regulation of metabolism, and general cell survival.    

To be able to dial into this communication process via an artificial methodology such as a cold laser is the ability to emulate the exact methodology is that the cells themselves use to heal themselves and also to grow, to change, and to survive. It has been said, “it is the way God talks to all cells, tissues, organisms and creatures.”

None of this is based on any sound science. It is merely vitalist, mystical speculation, which does not, of course, limit in any way the certainty and authority with which the fantasy is presented as scientific fact. This is yet another example of how chiropractic is fundamentally a pseudoscience based on imaginary “energy” and fake abnormalities like the “subluxation.” As such, it is open to any similar sounding nonsense, and any benefits it might have in practice are accidental and unrelated to the irrational and bogus underlying principles.

Like most pseudoscientific therapies, cold laser not only addresses the one true underlying cause of disease, it can also be applied in almost any way. Directly over diseased organs, in the general area of a symptom, even on acupuncture points associated with the meridians connected to the problem area. And since the proponents here are chiropractors, we should not be surprised to find that the use of lasers “is particularly effective in rehabilitating the effects of vertebral subluxation complex and their effects on the myofascial tissues affected by these subluxations.”

What else do these folks claim cold laser can do?

These protocols are designed to enhance a particular disease therapy or can be used in a general sense as the sole treatment of choice.

If a practitioner were to master only these protocols and use only these, he would be still far more effective than any of his colleagues to date using methods other than cold laser.

They list a number of general protocols first:

 Arthritis/Spondylitis/Myelopathy Protocol
Neuropathy Protocol
Immune Protocol
Lymphatic Drainage Protocol
Pre and Post Surgical Protocol
Liver Detox Protocol
Hormone Balance Protocol
Acute Pain-Injury Protocol
Sympathetic-Parasympathetic (S-PS) Balance Protocol
Acupuncture Meridian Balance Protocol
Infection Protocol
Allergy Protocol (Specific or General)

If one prefers a slightly more specific indication for the treatment, they can also provide protocols for laser treatment of:

Feline-

Abscesses
Chronic Inflammatory Bowel Disease (CIBD)
Feline Hyperthyroidism,
Feline Skin-Spinal Reflex, Feline Neurodermatitis, Endocrine Alopecia, Milliary Eczema
Kidney Disease, FUS, FLUTD
Megacolon
Pyorrhea

Canine-

Canine Hip Dysplasia Syndrome
Canine Idiopathic Epilepsy
Chronic Inflammatory Bowel Disease
Cushing’s Disease
Canine Wobbler’s Disease
Hypothyroid
Progressive Degenerative Myelopathy
Urinary Incontinence

Equine-

Arthritis, (General or Focal) Sore Back etc.
Bleeder (exercise induced naso-pharyngeal hemorrhage) Elevated Blood Pressure
Bronchitis, Bronchopneumonia, Pneumonitis
Bruising, Subcutaneous Hemorrhage, Wound Reorganization
Bursitis
Colic (all kinds), Bloat
Bone Injury, (splint bone and acute boney injuries)
Dermatosis, Urticaria, Hives, Rain Scald
Ear and Guttoral Pouch Disease
Edema, (general, hypostatic, ventral, extremities)
Equine Protozoal Myelitis (EPM)(see also Neurotropic Herpes)
Facial Nerve Paralysis, Lip Paralysis
Fear, Terrors, Miss-emotion, Training Problems
Hepatitis, Hepatosis
Hock Distension
Heart and Heart Related Conditions
Focal or General Inflammation
Lacerations
Lack of Focus in Training
Laryngeal Hemiplegia
Kidney Disease
Malignant Hyperthermia
Navicular Disease and Laminitis
Neurotropic Herpes (West Nile Virus?)
Proud Flesh, Excessive Granulation Tissue
Sepsis, (General or Focal)

So what is the truth behind all of these claims? Despite the nonsense of the underlying theory, is there any evidence cold laser therapy might have real benefits?

The answer for the vast majority of conditions is “No!” For a few conditions, the answer is more appropriately a “Maybe, but probably not much.”

Extensive reviews of the human literature have been done by the Cochrane Collaboration and the insurance companies Aetna and Cigna. These have found mixed but generally poor evidence for benefit as follows. A review of the veterinary literature on the subject can be found in Ramey 2004.

1. Cochrane Review for rheumatoid arthritis: 6 studies with a  total of 660 people were examined. There was limited evidence for a small benefit, with an improvement in self-reported pain of 1.1 points on a 10 point scale. The studies were short term and methodologically weak and inconsistent, and the conclusion was, as usual for Cochrane reviews, that no firm conclusion can be drawn and more research is needed.

2. Cochrane Review for osteoarthritis: This examined 6 studies, three of which found no effect and three of which found a benefit. The studies were methodologically weak and inconsistent and more research was recommended. The review has since been withdrawn pending analysis of additional evidence and correction of some statistical errors.

3. Cochrane Review for nonspecific low back pain: 7 studies of 384 people. Three studies (168 people) showed very small improvement in pain compared with fake laser. Three studies (102 people) found no difference. All the studies used different treatment protocols and short-term evaluation, so no firm conclusions could be made.

4. Cochrane Review for tuberculosis: One poor quality study from India was available and did not meet even basic methodological standards, so no conclusion could be drawn.

5. CIGNA Review: References 1-36

            A. Musculoskeletal Conditions: A number of studies and reviews in addition to the Cochran Reviews were examined. Generally, they showed no effect from most treatments for most measures but small benefits for a few measures in some trials. Overall, the evidence was weak and of poor quality, and it suggested some small  benefit for discomfort and range of motion might be possible.

            B. Wound Healing: Several systematic reviews were discussed, none of which showed convincing evidence of benefits for wound healing.

            C. Oral Mucositis: Two small studies were reviewed, one of which showed a benefit to laser therapy and the other of which did not.

            D. Other Medical Conditions: Reviews of laser use for temperomandibular joint disease and acute and chronic Achilles tendinitis found no clear evidence of benefit.

Summary: Low-level laser therapy (LLLT) has been proposed for a wide variety of uses, including wound healing, tuberculosis, and musculoskeletal conditions such as osteoarthritis, rheumatoid arthritis, fibromyalgia and carpal tunnel syndrome. There is insufficient evidence in the published, peer-reviewed scientific literature to demonstrate that LLLT is effective for these conditions or other medical conditions.

6. Aetna Review: References 37-81 (duplicates with CIGNA deleted)

” Although the results from large, uncontrolled, open trials of low-energy lasers in inducing wound healing have shown benefit, controlled trials have shown little or no benefit. The analgesic effects of low-energy lasers have been most intensely studied in rheumatoid arthritis. Recent well-designed, controlled studies have found no benefit from low energy lasers in relieving pain in rheumatoid arthritis or other musculoskeletal conditions. Furthermore, although positive effects were found in some earlier studies, it was not clear that the pain relief achieved was large enough to have either clinical significance or to replace conventional therapies.”

Published reviews indicate a lack of evidence for effectiveness for the following conditions:
chronic wounds, arthritis, tuberculosis, tinnitus, pain, smoking cessation, epicondylitis, Achilles tendinitis, plantar heel pain, back pain, and carpal tunnel syndrome.

Some evidence of benefit was found for the following conditions:
Raynaud’s phenomenon, pain following endodontic procedures, palpation sensitivity and passive extension in patients with shoulder pain (but not other measures), swelling following dental extraction when used in combination with steroids, tennis elbow pain in combination with plyometric exercise

Most of these studies were small and had methodological weaknesses, an most of their authors conclded that the treatment was promising but more research was needed to conclusively demonstrate a benefit.

7. Ramey 2004: References 82-100

Some studies have found evidence of improved wound healing in diabetic mice, dairy cattle, and laboratory rats. Other studies in rats and rabbits find small but clinically insignificant effects, and several studies have found no evidence of any effect on wounds in rats, guinea pigs, pigs, beagle dogs, and horses. A couple of poor quality studies of tendon and ligament injuries in horses have had conflicting results, one showing benefit and the other not. Other unblinded or uncontrolled studies in horses have suggested benefit for a variety of conditions. “Laser acupuncture” has been examined in uncontrolled and unblinded studies in horses, with the expected claims of benefit. Overall, there is weak evidence to suggest possible benefit in wound healing (though this conflicts with the results of higher quality studies in humans), and many claims made based on studies so poorly designed as to be no different from mere anecdotes. There is no good quality clinical research on which to base firm conclusions, or to support the dramatic claims of laser therapy proponents.

Overall, then, the theoretical foundations for low power laser therapy range from questionable to completely nonsensical pseudoscience. The in vitro research does suggest some real effects on living cells, but it does not indicate that such effects would be achievable or beneficial in actual patients. The human clinical research is extensive but of generally poor quality with no consistency to the laser treatment methods investigated, and it provides only very weak evidence of any clinically meaningful effects. The veterinary research is even more limited and of poor quality, ad it to is mixed with little convincing demonstration of real clinical benefits. All of this suggests an appropriate stance towards this therapy would be neutral to somewhat pessimistic, though certainly better quality research could identify some meaningful clinical benefits. The evidence does not support, and in some cases directly contradicts the claims made by the chiropratic organization website and much of the marketing materials on cold laser therapy veterinarians receive.

References-

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62. Kreisler MB, Haj HA, Noroozi N, Willershausen B. Efficacy of low level laser therapy in reducing postoperative pain after endodontic surgery — a randomized double blind clinical study. Int J Oral Maxillofac Surg. 2004;33(1):38-41.

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70. Markovic A, Todorovic Lj. Effectiveness of dexamethasone and low-power laser in minimizing oedema after third molar surgery: A clinical trial. Int J Oral Maxillofac Surg. 2007;36(3):226-229.

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Posted in Miscellaneous CAVM | 86 Comments

Evaluating Medical Advice and Credentials on the Internet

Posted on May 24, 2010 by skeptvet

Dr. Susan Wynn, a veterinarian and veterinary nutritionist who promotes “holistic” veterinary medicine, has put up a couple of blog posts recently which I rather liked, so I thought I’d comment briefly on them. I more commonly find myself disagreeing with Dr. Wynn on questions of veterinary CAM, but she does often present a more rational and scientific approach to the subject than most proponents of “integrative” medicine, and I appreciate the few opportunities that arise to find common ground with those who have a different perspective or approach.

The more recent of the two posts consists of advice on how to critically evaluate veterinary medical information on the internet. I have also written about this subject, and I agree wholeheartedly with Dr. Wynn’s comments. The recommendations generally focus on being wary of excessively optimistic or unrealistic claims, sites with a commercial or rigid ideological bias, sites which rely on testimonials in place of properly published and relevant scientific research, and sites which refuse to disclose relevant information, such as the ingredients in the remedies they sell or the qualifications of the people offering advice. All of this is sound advice when looking for medical information on the Internet.

Dr. Wynn also published a post on the subject of evaluating the credentials of those offering veterinary medical advice, How to Avoid Phony Practitioners. For the most part, I agree with her advice on this subject as well, with an important exception I’ll get to in a moment. It is easy to make up impressive-sounding titles and initials, and not much harder to obtain a meaningless advanced degree through fake diploma mills, and this is common practice among those pushing alternative medical therapies. Not too long ago, I wrote about Primal Defense, a probiotic product marketed by Jordan Rubin, a charlatan who routinely tried to give his advice additional gravitas by acquiring fake degrees from unaccredited correspondence schools. If one is going to seek advice on veterinary medicine, it makes sense to give more weight to the advice of someone with years of training in veterinary medicine. Doctors are just as prone to cognitive errors as anyone else, of course, but we have the advantage of getting much of our information from the most reliable source available, scientific research.

My only disagreement with Dr. Wynn’s advice is that it ignores the importance of evaluating not only the quality and rigor of the training a practitioner receives, but also the plausibility and evidence for the subject matter in which they are trained. A credential from a rigorous and well-supervised program teaching astrology or witchcraft is not worth any more than a diploma mill credential since the approach is itself nonsense, and an expert in nonsense isn’t an expert in any meaningful sense of the word.

Dr. Wynn talks particularly about the various levels of credentialing in Naturopathy, but she completely neglects the fact that the discipline itself is a pseudoscientific, faith-based approach to medicine. In principle, naturopathy is a vitalist philosophy that looks to unseen energy forces to explain health and disease. In practice, it is a hodgepodge of sensible nutritional and exercise advice and loads of CAM, varying from the plausible-but-unproven to the completely bogus. The only common theme to methods used by naturopaths seems to be the notion of vital energies of one kind or another, as found in methods such as acupuncture, chiropractic, and homeopathy, which all rely in theory on mystical energies that no one can prove exist. And while naturopaths are theoretically trained to refer patients with serious medical conditions to conventional doctors, many are suspicious of conventional drug and surgical therapies. It is not uncommon for naturopaths to oppose vaccination and to promote not only supposedly “natural” approaches such as herbal medicine but also bizarre, dangerous, and manifestly “unnatural” therapies such as chelation therapy, detoxifying enemas, and so on. If the theory is nonsense and the specific practices unscientific, it doesn’t matter how rigorous the training is.

The same logic applies to Traditional Chinese Medicine, with it’s vitalist theory, idiosyncratic and unscientific diagnostic methods, and inconsistent and mostly unproven therapeutic practices. Chiropractic, likewise, contains a few bits of useful treatment for musculoskeletal pain and a load of nonsense and outright dangerous practices, and of course homeopathy is utterly worthless.

All the training in the world in a philosophy or method which has no value does not protect the patient from harmful or useless treatments. So while I generally agree with Dr. Wynn in terms of checking into the credentials of anyone offering veterinary medical advice, I would go farther and suggest that pet owners should look into the arguments and, most importantly, the scientific evidence concerning the philosophy and methods a particular practitioner offers as well.

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Voodoo Fog

Posted on May 23, 2010 by skeptvet

Went to an art/craft fair this weekend and saw this painted on the side of a station wagon covered with voodoo dolls:

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