Thursday, September 11, 2008

Medicine, shmedicine

kw: book reviews, nonfiction, alternative medicine, medical studies

I visited a chiropractor a few times, when several sessions of physical therapy did nothing to alleviate neck pains. I know what the problem is: all day looking at a computer screen and lots of evening hours reading. I do various stretching and loosening exercises, but little relief results. Nothing has really worked except copious intake of ibuprofen. So I asked my family doc if he thought chiropractic would help, and he said it was worth a try.

I'd heard a talk by a chiropractor who claimed to distinguish between "manipulation" (forcible) and "adjustment" (gentler) of the spinal joints. I went to see him, and he started by using some electrical device connected to his computer to map my spine. The device seems to measure nerve impulses and muscular twitches or heat. It showed where I supposedly had nerves being pinched. I'll come back to this.

I'd heard about the risks of manipulating the neck joints, so I asked him to refrain from any but the most minor "neck work". As it turned out, part of each therapy session was five minutes of massage, and this did me more good than anything else. However, the chiropractor gradually ramped up his procedures as he thought I was tolerating them. At some sessions he did some milder "neck crack" moves that I judged within the safe zone, but I could tell he was gradually increasing them.

At my last session, he used more force than I wished, and ended with one of those wrap-arms-and-crunch-in-mid-spine moves that really hurt. It also made a loud pop. He looked so proud of himself that I was speechless. I picked up my coat and left, then phoned back that I would not be returning. The spot he crunched hurt for three days. Again, none of this alleviated my neck pains, except the massage. But my insurance program will not pay for massage-only treatments, even "therapeutic massage".

Like nearly everyone, I've had various other encounters and experiences with alternative medicine. The most bizarre was the tendency of my mother to follow the advice of Adelle Davis (main book, Let's Eat Right to Keep Fit, with almost religious intensity. Fortunately I'd moved out by the time she began to concoct a protein-vegetable juice mix my younger brothers called Lion Milk, and which they loathed. Proper nutrition is good, but I've determined that much of Ms Davis's advice is scorned by real nutritionists, such as taking lots and lots of extra calcium if you have arthritis—you need instead to do something about how your body uses the calcium it has already (maybe she mistook arthritis for osteoporosis...?). I do take some nutritional supplements, and that is fodder for later on also.

Chiropractic is one of four major alternative medical methods discussed by Simon Singh and Edzard Ernst in Trick or Treatment: The Undeniable Facts About Alternative Medicine. The other three are acupuncture, homeopathy, and herbal medicine. They also have an appendix with one-page surveys of thirty-six less prominent techniques and methods.

Their first chapter is a very good discussion and explanation of evidence-based medicine and the scientific method, introduced by a cogent quote from Hippocrates:
"There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance."
So what is evidence-based medicine? It is the application of genuinely scientific methods to the study of medical therapies. The biggest hindrances to such work are
  • The placebo effect, which expresses the tendency of a treatment to cause improvement solely due to the expectation of the patient that "something is being done."
  • The Hawthorne effect, which is the tendency for a person to respond positively to any attention at all, as compared to being ignored or getting little attention.
Thus, human effects can totally swamp the effect we are trying to evaluate. For this reason, a proper scientific study, called a clinical trial when it is medical, must have these elements:
  • A sufficiently large group of patients that good statistics can be produced. For example, the expected scatter in numbers "helped" is about ten if 100 patients are tested, and about 30 if 1,000 are tested. Thus if you give treatment A to 100 people and treatment B to another 100 people, and the difference between those who improve is less than ten, you can't say there is a useful difference. However, had you used two groups of a thousand, and the difference is something like 100, this is much larger than the expected "error" or scatter of 30, so you can say you have a useful result.
  • Proper control: One treatment is either a known treatment with known efficacy, or is a non-treatment (a sugar pill or water injection for example), while the other is the treatment being evaluated.
  • None of the patients knows which treatment he or she is receiving. This means the placebo effect will be the same for both sets of patients.
  • None of the doctors performing the treatment knows which is which either. This means the treatments must be prepared by a third party and given to the doctors in a way that doesn't clue them in. This means a treating doctor won't behave differently with one or another patient, so this negates the Hawthorne effect. These last two points are the "double blind" you might have heard of: both doctors and patients are blind to what is being done to whom.
There are many clinical studies of all kinds of alternative therapies. However, there are very few that fit the criteria above, and in particular, even well-controlled and blinded studies often had too few patients to produce good statistics. But a method called meta-analysis can combine the results of several studies to produce better statistics. One study with two sets of 100 patients may not yield a definitive result, but if there are ten well-done studies that total two sets of about 500 or more, the statistical power is multiplied.

So what is the result? Of the four major areas of alternative medicine, only herbal medicine has any effective treatments, and only a very few of the many herbal medicines being sold can be said to help by any measurable amount. Secondly, chiropractic treatments can help some cases of back pain, but only a little more than just resting the back for a few weeks.

The authors have bent over backward to avoid their own biases, and give credit where it is due. The one area in which no credit due can be found is homeopathy. This is the practice of taking a substance that, in some quantity, will cause the problem being observed, and using a very small amount for "like treats like" therapy. For example, ipecac causes vomiting, so the idea is that a tiny dose of ipecac might alleviate a vomiting spell. However, homeopaths take that word "tiny" to an extreme. They use successive dilutions to produce "medicines" that probably don't contain even a single molecule of the substance.

For example, to make a homeopathic ipecac tincture, put 1g of the syrup in a liter of distilled water. This is a 1/1000 dilution. Put one gram of this stuff in a liter of distilled water. The new liter's dilution is 1/1,000,000. Repeat ten times. The number below the slash now has thirty zeroes. The trouble is, the number of molecules in the original gram of ipecac is a number with 22 zeroes. That means, if you were to prepare 100,000,000 liters of the final dilution, there would only be one of them, or perhaps two, that contained a single molecule of ipecac. The rest would be pure, distilled water.

This "medicine" might be sold for $50 per liter, making that single molecule of ipecac worth billions of dollars! The primary disease that homeopathy treats is an excess of riches. This may seem to be no more than a harmless placebo, but if a person trusts only homeopathy when there is a real, but treatable, condition, an unneeded tragedy is likely.

There is a ray of hope for alternative medicine: every genuine remedy began as an "alternative", and most of our effective medicines are either plant extracts or are derived from them with a little chemistry. For example, aspirin is a chemically-modified version of salicylic acid, which has much more severe side effects. Yeah, aspirin might cause a bit of stomach bleeding in some folks, but the raw acid causes lots of stomach problems in almost everyone. So there is always a chance than a treatment now considered "alternative" will someday become "normal medicine".

However, even though some herbal medicines are effective, most have troubling side effects. Let us remember, plants have no incentive to produce chemicals which are good for humans. All the chemicals they produce are good for themselves. A few are incidentally helpful for our uses. I don't like to hear, "But this stuff is Natural!" So is nightshade, which will stop your heart; so is strychnine which will either kill you, very painfully, or just ruin your brain so your loved ones have to take care of a near-vegetable for a few decades.

The appendix summarizes 36 treatments, of which these few are at least a little effective, and their side-effects are at least not deadly:
  • Aromatherapy can help you relax, but has no other benefits.
  • A few techniques of Ayurvedic medicine are a little effective, but most are without value. Lotsa studies are needed to figure it all out; it is even more complex than Chinese medicine. Chinese medicine is treated in passing in the Herbal Medicine chapter, and is a similar situation; too complex to deal with as a whole.
  • Some Food Supplements are helpful, but very few of those that are not known to be vitamins are any good at all. Be careful not to overdose, particularly on the B vitamins.
  • Hypnotherapy and Autogenic Training (self-hypnosis) can help you relax, and that's the limit of their effectiveness.
  • Massage Therapy, ditto, also as attested by my experience.
  • Meditation, double ditto.
  • Osteopathy, because it is not just skeletal but also takes account of the muscles, can be more effective than chiropractic for spine and joint pain. I used to see an osteopath as my primary physician, and he showed me an exercise for sciatica that is very helpful.
  • Relaxation therapies...did you note that five of these items are for relaxation. Many of our aches and pains can be helped by a little relaxation and rest. To those who like Biblical examples, Jesus frequently took his disciples out to the desert to get away from the stress of dealing with crowds. It didn't always work, but he practically invented the Retreat.
Now, if you've read this far, and want to know more about my experience, I find the spine-measuring device rather fascinating, but I don't for a minute believe it does what its proponents say it does.

The chiropractor pressed a probe with two low metal buttons against each joint between vertebrae, and held down a foot pedal while watching a wavy line on the computer screen. When he let go, a number got recorded. It didn't take long for me to figure out that he was letting the waviness settle down, but usually not for long enough to get a really stable number. I have pretty good short-term memory, so I could see that his early stoppage of the reading had more to do with the final number than if he'd let the waviness really settle down, which he occasionally did. Had he done so throughout, my spine's report would have been pretty bland. A repetition of this test after several sessions seemed to show I was improving. You couldn't prove it by how I felt. The only time I felt better was the ten minutes after a bit of massage, and before any "adjustments".

I think that, at best, the device used is more like a Ouija board, producing results that arise in the doctor's imagination rather than the patient. At worst, it would be easy to produce any result you like. Just a little difference in pressure changes the range of the wavy readings quite a lot, and the timing of "release" can produce almost any result also. So I still have my neck pain, and probably will until I retire. The only thing that alleviates it is to rest with my head propped up just so. I can read in such a position, so I do more of my reading while reclining these days.

Now as to supplements.
  • In addition to a multivitamin I take "just in case", I use a Glucosamine/Chondroitin pill for my joints. I had a bad shoulder for ten years until I began using these, then in a few weeks I got better. Too bad they don't do anything for my neck (or maybe it would be lots worse?!?).
  • I also use extra calcium, at my doctor's recommendation.
  • Finally, I use a large amount of an Omega-3 fish oil extract, also my doctor's idea. This last plus exercise seems to be making by blood chemistry better than a cholesterol medicine I took for a few years, and I weigh less now because the cholesterol medicine boosted my appetite, a lot.
Finally, a specific warning: There is a popular Chinese herb called Aristolochia or birthwort or pipevine. Don't use it. It has killed numerous folks by destroying their kidneys, over a few months' time.

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