In my treatment of this patient, I did some research on shoulder subluxation, as you do when you are an evidence-based practitioner. A Google search of “treatment shoulder subluxation” found me this as the first entry.

Prolotherapy

Wikipedia describes “prolotherapy“ as having “conflicting evidence about its effectiveness”. I agree with that analysis (in fact, I would go even further and say the evidence is poor). So given the state of the evidence, the website should probably not be saying things like: “Prolotherapy offers the most curative results in treating chronic pain” or “Nearly all pain conditions can be successfully treated with Prolotherapy” [emphasis added] following misrepresentations about other treatments for pain.

Let’s examine the claims:

Traditional modern medical treatment for shoulder subluxation or instability involves rotator cuff strengthening exercises, specifically of the supraspinatus muscle, which is the primary muscle responsible for the external rotation of the shoulder. Although rotator cuff strengthening exercises help strengthen shoulder muscles, they usually do not cure the underlying problem, ligament laxity, and, thus, do not alleviate the chronic pain that people with this condition may experience.

I find the use of the term “traditional medicine” interesting when used in contrast with the word “natural” to describe their therapy elsewhere on the page. This is marketing language. Rather than objectively discussing the therapy on its merits, if any, slick and subtle language convinces the reader that this natural treatment is innovative, cutting-edge, and effective where other cold, sciency treatments fail.

However slick the marketing, they lose themselves in the anatomy. First, while supraspinatus is involved in rotator cuff stability, it is actually an abductor of the shoulder. Primary external rotators are deltoid, infraspinatus, and teres minor. …unless they are referring to abduction as external rotation, which is just bizarre. Also, if the intent is to improve shoulder stabilization, infraspinatus should have been mentioned.

Second, the pain they are describing is usually associated with bursitis, with the gleno-humeral joint being compressed, stretched, or twisted oddly due to improper movements with the humeral head out of position (a result of subluxation). So their description of “ligament laxity” as an “underlying cause” is a little misleading.

All that aside, I would not recommend an invasive treatment for shoulder subluxation unless a patient is not responding to non-invasive treatments and precautions, especially if they are apparently targeting the wrong tissues and failing to present the context of exercise in therapeutic treatments: preventing frozen shoulder and maintaining adequate circulation to the tissues through movement.

Another standard practice of modern medicine is to inject steroids or to prescribe anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Although cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration. Plus, long-term use of these drugs can lead to other sources of chronic pain, allergies and leaky gut syndrome.

Though they are correct in their assessment that cortisone shots offer merely temporary pain relief, there is no evidence (that I am currently aware of — correct me if I’m wrong, please) that the treatments do more damage than good or that they directly result in long-term loss of function and chronic pain. This seems like causes have been mixed with effects. If a patient is in sufficient persistent pain to seek cortisone shots, they were likely a patient at risk for chronic pain in the first place. And, again, context is missed. Sometimes shots are recommended because patients are in too much pain to participate in therapeutic exercise and they help the patient tolerate exercise at key stages of healing.

I also agree with them that external management of pain (meds, etc) is not a desirable outcome, but not because they are not effective and cause dubious ailments (see leaky gut syndrome), but because it is not a sustainable solution for the patient. Current chronic pain management techniques incorporate self-management of pain through increasing self-efficacy, decreasing pain focus, and providing education about how pain occurs (spoiler: in the chronic pain stage, the tissue is a red herring distracting from the real problem — the brain). However, medication is an appropriate treatment for acute pain and there is no need to scare patients away from effective treatments that have appropriate applications in particular situations.

It is somewhat irresponsible to overstate the risks of acute pain management while at the same time failing to mention the risks of injection: infection, temporary discomfort at the injection site, damage caused by improper injection, and allergic reaction.

When all else fails, patients who experience chronic pain as a result of shoulder subluxation may be referred to a surgeon. Unfortunately, surgery often makes the problem worse. Surgeons will use x-ray technology as a diagnostic tool, which does not always properly diagnose the pain source.

More irresponsibility. “Dear patients, you could go to a surgeon, but good luck because your shoulder will just end up looking like a pulled pork sandwich.”

Where do I even start…

Surgery is invasive (i.e., risky) and expensive. It must be decided upon consultation with a qualified surgeon on a case by case basis after the patient has obtained the appropriate and relevant diagnostic tests. While true that X-rays are limited, soft tissue damage is imaged through other methods such as MRI and ultrasound. So their statements regarding surgery are not only misleading, but seem to suggest that surgeons are not aware of basic diagnostic technology, which is absurd.

A better approach is to strengthen the ligamentous and shoulder capsular structures with Prolotherapy. In fact, shoulder subluxation or instability is one of the easiest conditions to treat with Prolotherapy.

“Better” is one of those words that needs to be appropriately backed up with evidence. Not only must prolotherapy be demonstrably effective, it must be more effective than standard treatment for that statement to be accurate.

Prolotherapy supposedly involves deliberately irritating a part of the body to increase the body’s defenses in that area to accelerate the rate of tissue repair. So essentially they are trying to heighten the body’s normal healing response. But how effective is the treatment? A Cochrane review of 5 available studies  showed conflicting results, as did a review of several low-quality RCTs (an abysmal publishing rate considering the salesmanship).

The mere possibility of effectiveness as determined by potentially flawed anecdotal observation (what I like to call the “this rock keeps tigers away” effect) does not justify an invasive treatment nor does it justify misleading claims about competing therapies that have much better supporting evidence. Furthermore, the research seems quite limited to the application of prolotherapy to low back pain, not complex joint pain (let alone the other two dozen other claimed applications). This is like using research about apple seeds to say something about the color of oranges.

Chronic pain is most commonly due to either to cartilage deterioration, tendon weakness or ligament weakness, as is the case with shoulder subluxation.

Again they are not describing chronic pain accurately, focusing on tissues rather than the brain. If the joint is still experiencing inflammation (acute) or the joint integrity is changing (subacute) then the pain condition is not yet chronic. Chronic pain is pain in the absence of acute/subacute factors — in other words, pain that should be gone by now. Any given person can have fairly significant joint degeneration and have no symptoms at all (this is why an MRI must be interpreted with extreme caution). The body is quite good at adapting to changes when they are slow and progress naturally with aging. A quick change, however, will make the brain go “whoa now, what’s up there?” and start to send you warnings about it — i.e., pain — and may continue to do so even after the tissue-level symptoms have subsided.

The safest and most effective natural medicine treatment for repairing tendon, ligament and cartilage damage is Prolotherapy. In simple terms, Prolotherapy stimulates the body to repair painful areas. It does so by inducing a mild inflammatory reaction in the weakened ligaments and cartilage. Since the body heals by inflammation, Prolotherapy stimulates healing.

In theory. This statement is indefensible at the current level of evidence. Safest? Most effective? From what I have seen, these claims are not supported.

Prolotherapy offers the most curative results in treating chronic pain. It effectively eliminates pain because it attacks the source: the fibro-osseous junction, an area rich in sensory nerves. What’s more, the tissue strengthening and pain relief stimulated by Prolotherapy is permanent!

Most curative and permanent… again, this is indefensible. Given that prolotherapy is a relatively new therapy, I have no idea how they can have access to long-term data that proves their statement that the relief is permanent. I also have no idea how they have separated the effects of prolotherapy with natural pain resolution and healing.

Cure Alls

One other issue to point out. In their list of the many, many joints for which prolotherapy can be used, I noticed a few that didn’t seem to fit. To focus on two obvious ones, I’ll mention Carpal Tunnel Syndrome (CTS) and TMJ syndrome. If the effect is to tighten tendons and ligaments, prolotherapy treatment would worsen CTS by further compressing the median nerve and worsen TMJ by further tightening the joint. Again, there seems to be a fundamental lack of understanding anatomy, resulting in a few common ailments being inappropriately included in the treatment list.

Furthermore, rather than highlighting the evidence they do have (which isn’t much), they don’t even bother to cherry pick and go right to the testimonials.

These are not signs of a solid, evidence-based therapy.

Conclusion

If prolotherapy has weight to it, fine. But websites like this are misleading. That is not to say they are intentionally misleading. Sometimes excitement and the desire to help people gets in the way of objectivity. So its entirely possible to be accidentally misleading based on good intentions.

But my main problem with this website is that they don’t say “this a new treatment that is currently gathering evidence that might work for you and here are our sources so far”, they say/imply “traditional treatments will hurt you, so you should do this instead”. Negative aspects of traditional care are highlighted and at times exaggerated, while not mentioned for prolotherapy. Similarly, positive aspects of traditional care are played down or not mentioned at all, while exaggerated beyond the evidence for prolotherapy.

That is wrong. And it comes up second only to Wikipedia on a Google search for the problem. I originally found this website 3 years ago, and nothing significant has changed. In science, with a new supposedly up-and-coming therapy, this fact alone is very strange.

The first issue is in the title: Non-Allopathic (Non-Conventional) Therapies in Medical Practice-Revised Draft Policy. The term “allopathic” was coined by homeopathy inventor Samuel Hahnemann and is used as a pejorative by members of the alternative medicine community to refer to doctors. The term is also used by people who do not fully appreciate the context of the word, using it simply to refer to “conventional medicine practitioners” as a way to accentuate the differences between modern doctors and alternative health practitioners. In any case, the words “doctor” and “medicine” already suffice and it is frankly bizarre that the CPSO chose the word “allopathic”.

Also, though the policy seems to be encouraging patient rights, inclusion, and other nifty and friendly-sounding things, there is no clear stance taken on the current proof of efficacy of alternative medicine remedies nor is there detail on the threshold of evidence that is required for them to consider a so-called “non-allopathic” remedy to be effective. Therefore, for all the suggestive wording of patient empowerment and protection, basic policies such as evidence thresholds and standards of quality are not explicitly discussed.

Other issues are apparent in the survey with misleading, loaded, doublespeak questions like:

• “If physicians recommend non-allopathic therapies, do you think their recommendation should be supported by scientific evidence?” These therapies are already called “medicine” and “health care”. If something works (i.e., has the scientific evidence to prove efficacy), it is adopted into mainstream medical care. Why wouldn’t it be?
• “Do you believe that physicians must only propose non-allopathic therapies that: Take into account patients’ financial status when patients are paying for treatment directly?” It is distressing to see the CPSO imply that more well-off individuals may receive different recommendations than those less well-off. Though discussion of affordability with several options is completely appropriate, depending on context, overall recommendations should remain the same with every effort made to go through appropriate parties to attempt to secure treatment funding.

The CPSO is trying to have their cake and eat it too: On the one hand, participate in the currently fashionable placation of alternative medicine adherents despite a crippling lack of robust supporting evidence, but on the other hand insist that recommendations be science-based. If the recommendations were truly science-based, then the entire policy seems superfluous except to say essentially what the succinct 2-page College of Physicians and Surgeons of BC’s policy says:

“Complementary and alternative therapies differ from conventional medicines because they are generally unproven. When an alternative treatment undergoes rigorous testing, for example in a controlled and randomized trial, then the results dictate whether the alternative treatment becomes conventional treatment, whether the unorthodox becomes accepted, and whether the unproven becomes proven. Assertions, speculations, and testimonials do not substitute for scientific evidence.

Physicians who consider using complementary and alternative methods should recall that, although some untested remedies may be harmless, the absence of good evidence about a given herbal or other agent makes recommendation of that treatment unethical. The optimal environment for the use of an unorthodox therapy is within a clinical trial designed to establish the therapy’s safety and efficacy.”

The CPSO policy (highlights here) needs extensive clarification on its stance regarding alternative medicine, medicine, physician responsibilities, and patient rights. BC managed to do that in 2 clear, unequivocal pages. The CPSO took 9 pages to say much less. I challenge the CPSO to do better: At the very least, remove the ridiculous word “allopathic” from the document entirely and revise and clarify evidence policies rather than vaguely saying “supported by scientific evidence” (what kind? how much?) and making appeals to popularity. The CPSO policy, as written, does not adequately address issues of efficacy, thresholds of evidence, or accountability for either recommending or referring to practitioners of alternative medicine remedies.

To comment, this link is for the rather leading CPSO survey which can be filled out between 5-20 minutes, depending on how much commentary is offered. Or the CPSO can be contacted by email at ComplementaryMedicine@cpso.on.ca for a more prose-style comment that is not limited by the format of the survey.

There’s a petition to sign. I’m not really partial to those, however there is also information on how to contact CBS directly and through Twitter with the hashtag #VaxCBS.

Longer answer:

Psychics/mediums are people who claim to predict the future and/or talk to the dead using paranormal powers. There is no evidence (despite years of investigation) that people have these abilities. There is evidence that psychics/mediums use a technique called “cold reading” – even when they aren’t aware of it - which is a technique that allows psychics to gather information from their client/mark using body language, other cues, and a clever tongue. This allows the psychic to appear very accurate in their information, requiring no supernatural ability. Anyone can learn to do this.

People’s self-ignorance of using a trick may seem odd, but most people haven’t tested their “abilities” under controlled conditions. This allows them to legitimately believe that they have supernatural powers through thinking errors, like one called confirmation bias (remembering hits more than misses). Unfortunately, as with most things, there are also people who are downright frauds, using cold reading with intentionally-practiced skill. They may even go so far as to use “hot reading”, where the psychic cheats by surreptitiously gathering information about their mark before their reading. Examples of psychics and their techniques can be seen in Penn and Teller’s Bullshit! episode about psychics here.

Psychics operate on a scale from small local shops to vast phone networks to a much grander scale: national TV. One example of the latter is John Edward (previously busted using both cold and hot reading techniques on his former show Crossing Over), who was recently featured on the Dr. Oz show in a segment entitled “Are Psychics the New Therapists?“, hence this topic coming to the attention of a  health blog.

Edwards and Oz essentially present the argument that grief is like a cancer that, if left “untreated”, will metastasize, and psychics/mediums are helpful in this regard. But even this one claim contains several assumptions:

• First, as discussed above, there is no respectable evidence that psychics can talk to the dead.
• Second, even if we assume that psychics abilities are real (or at least non-harmful), there is no evidence that they are helpful.
• Third, in relation to the segment title, can psychics be so helpful as to replace professionally-trained therapists with evidence-based skills in grief counseling?
• Fourth, even if psychics are real, can John Edwards – specifically – really talk to the dead? Does he deserve to be featured on this show given his history using (intentionally or not) known reading tricks?

Their “yes” arguments are less than compelling, with Dr. Oz stating:

“as a heart surgeon I have seen things about life and death that I just cannot explain and that science can’t study.”

And later:

“I can’t make up an explanation for what John Edward does. And, again, what was most eerie was his level of detail, the concreteness of it all.”

In other words, “I’ve never heard of cold reading and I assume science can’t study some things, therefore I assume psychics are real/helpful.” Dr. Oz’s ignorance about the topic and his allowance that psychics abilities “can’t be studied” (they have – psychics just don’t like the results) allows him to imply to his trusting audience that psychics are a valid form of grief treatment.

So put down your psychology textbooks and peer-reviewed clinical research, young health students, the “new therapists” are helpful because we can’t explain how it might work. ???

Forget your degree, learn cold/hot reading.

The position of critical thinkers, as with anything, is that evidence comes first. There’s no evidence that John Edward or any other psychic/medium has the capability to provide consistent therapeutic benefit for grief, let alone as much benefit as a trained professional.

Psychics/mediums are not a health profession, they have no standards of practice or code of ethics (which are required of any legitimate health provider to protect people), and they have no oversight to ensure their customers that they are legitimate (which is impossible, due to lack of supporting evidence) or that they are effective in providing their services. They likely have no training in psychology and therefore no appreciation for the harm that may be done by (intentionally or not) implanting false memories or altering existing memories of dead loved ones with their claims.

It’s unfortunate that a doctor, particularly one with such a large reach, would devalue therapeutic professions and lend authoritative “legitimacy” to the claims of unproven psychics/mediums, particularly when actual people’s lives, emotions, and personal well-being are on the line. It just goes to show how easily anyone can buy into unproven claims, no matter what their degree, if they do not practice critical thinking.

First, I want to praise Marketplace for not offering false balance on the issue. Homeopathy is not something about which there is any serious scientific debate. The evidence is clear that homeopathy is not physiologically/chemically/physically possible, has no defined mechanism of action, and does not work beyond a placebo effect. It would be wonderful if it did work, but it doesn’t.

The show opened with an intrepid band of skeptics who decided to overdose on homeopathy, 10-23 style. After consuming bottles of remedies, they waited. The host cut back to the skeptics periodically through the episode, who stood patiently waiting for something, anything, to happen.

Next came the anecdotes. While countless people use homeopathy for things like colds, headaches, cuts, scrapes, and other self-limiting conditions and have “seen results”, there is no distinction between what was supposedly done by the homeopathic medicine and what would have happened on its own, without the remedy. One woman interviewed even mentioned that homeopathy takes longer to heal ailments than conventional medicine. In other words, homeopathy is like paying to watch your body heal itself.

It seemed clear from some of the short interviews, as well as from comments on the Marketplace website, that many users believe there are actual ingredients, at small amounts, in homeopathy. But unlike herbal medicine, homeopathy is diluted such that most remedies don’t contain a single molecule of the original ingredient. Within alternative medicine, herbal remedies (having a mix of chemical constituents) are the polar opposite of homeopathy (having sugar, shaken water, and nothing else). The lab testing the show commissioned showed this – two different remedies were chemically indistinguishable.

Proponents claim that, however it works, homeopathy is some form of “energy” that science can’t measure. Fine. Set aside the idea that homeopathy “remembers” the original substance, yet forgets the memory of everything else that the water has ever encountered. Is it having an effect on the person taking it? If yes, then the effect is measurable! But when we try to measure it, using rigorous studies that control for biases, homeopathy behaves exactly like what one would predict for sugar pills: it’s as effective as a placebo.

This is where Marketplace got a little sidetracked. They focused a lot on mechanism and not enough on efficacy. Homeopaths love to deflect criticism of mechanism with testimonials about how it “worked for so-and-so”. I wish there had been more focus on the numerous clinical trials that have shown no significant measurable benefit, though they did mention the recent British Evidence Check into Homeopathy, an extensive review that concluded:

The Committee concurred with the Government that the evidence base shows that homeopathy is not efficacious (that is, it does not work beyond the placebo effect) and that explanations for why homeopathy would work are scientifically implausible.

The show also, to its credit, excelled in documenting the actual and potential risks of homeopathy. Advocates love to say “What’s the harm?” or “At least I know there’s nothing harmful in it because it’s diluted”, but there can be a real harm to ignoring proven medical treatments. They talked to one woman who believes her son is vaccinated because she gave him homeopathic “vaccinations”. (A simple blood titre test would tell her otherwise.) The show also pointed to the tragedy of Gloria Thomas, a baby born perfectly healthy who died of septicemia because her parents treated her eczema with homeopathy instead of proven medicine. (The parents were later convicted of manslaughter.) They also spoke to a few homeopaths who alarmingly claimed they could cure cancer and found more Canadian homeopaths making these claims online. Let’s get this straight right now: delaying early stage cancer treatment can absolutely kill people and there is no evidence – none – that homeopathy can cure cancer.

Marketplace also put homeopaths, and the manufacturers of homeopathic medicine, on the spot to prove their products work. They got answers like “[So you can't explain how homeopathy works?] Not exactly, no, I just use it”, “There hasn’t been a lot of demand for clinical studies”, “Perhaps science hasn’t developed to a point where they can detect the medicine”, etc. One homeopath offered to send scientific papers to Marketplace, which they report were never received. This is what homeopaths credit for the supposed miracle that can cure cancer? Gut feelings and excuses for a lack of any credible evidence for the remedies they sell?

An Ontario government spokesman, Josh Tepper, looked clearly uncomfortable defending the decision to regulate the practice of homeopathy. Granted, the government is in a bit of a tough situation: regulated, homeopathy can be potentially monitored to minimize the harms; unregulated, homeopaths seem to have free reign to make claims like cancer cures. Why a practice like homeopathy deserves the government stamp of legitimacy wasn’t answered. Surely there are existing measures in place to stop people from offering fake cancer cures.

Perhaps, when it comes to homeopathy, the decision flows from the actions of Health Canada, the federal authority that has determined that homeopathic medications are “safe and effective”. Failing to question Health Canada on exactly how sugar pills are deemed to have medicinal effects was the biggest omission from the program. It was a major shortcoming to not link the products they tested on the show with Health Canada’s separate approvals of indistinguishable sugar pills. But you can only do so much in a half-hour.

All in all, this was a big win for health skepticism and scientific inquiry. The potential dangers of homeopathy were outlined (false claims of cancer cures, false claims of vaccination, examples of past harm, etc), the problems with the purported mechanism were outlined, the lack of convincing evidence were mentioned (though unfortunately there was too little time to go into detail), and consumer rights issues were brought to the forefront. And the skeptics? The overdose was deemed a success – all lived.

Why bother to take this on? The facts of homeopathy don’t seem well-understood by the general public, which may explain its appeal. Some of the street interviewees looked surprised and a little unhappy when informed that their preferred remedy had nothing in it. Homeopathy has escaped scrutiny in mainstream Canadian media for some time, and this is where the Marketplace episode ultimately succeeded. It refused to accept a medical double standard for consumers. Why should homeopathy be able to make claims to hopeful Canadians without any justifiable evidence? Short answer: they shouldn’t.

You can now watch the full episode online.

Epilogue

Of course, not all viewers of Friday’s Marketplace were pleased with the results. Before the show even aired, homeopathy advocates were in a furor, going so far as to start comment campaigns (site now deleted) among their a priori criticisms. Bryce Wylde even linked to his same old list of homeopathic evidence, including 21 papers which were already demonstrated to lack scientific rigor and to sometimes have nothing to do with homeopathy at all.

Despite these criticisms, curiously, the show noted that almost all spokespersons for homeopathy organizations declined invitations to appear and defend their practice.

It's said that you can't unring a bell

This article was co-written by Scott Gavura, Pharmacist. Cross-posted at his blog, Science-Based Pharmacy.

Immunization has transformed our lives. This single invention has prevented more Canadian deaths in the past 50 years than any other health intervention. Our parents and grandparents accepted illness and death from diseases like smallpox, diptheria, and polio as a fact of life. Mass vaccination completely eradicated smallpox, which had been killing one in seven children. Public health campaigns have also eliminated diptheria, and reduced the incidence of pertussis, tetanus, measles, rubella and mumps to near zero.

The sickest and most vulnerable in society rely on the immunization of others to protect them from vaccine-preventable disease. When immunization rates are high, it’s much less likely a virus or bacterium will be carried and transmitted from person to person. But when vaccination rates drop, diseases can reemerge in the population again. Measles is currently endemic in the United Kingdom, after vaccination rates dropped below 80%. When diptheria immunization dropped in Russia and Ukraine in the early 1990′s, there were over 100,000 cases with 1,200 deaths. In Nigeria in 2001, unfounded fears of the polio vaccine led to a drop in vaccinations, an re-emergence of infection, and the spread of polio to ten other countries.

There are many reasons cited for refusing vaccination, ranging from fears of needles right through to bizarre conspiracy theories. But one reason that has experienced a dramatic upsurge over the past decade or so has been the fear that vaccines cause autism.

The connection between autism and vaccines, in particular the measles, mumps, rubella (MMR) vaccine, has its roots in a paper published by Andrew Wakefield in 1998 in the medical journal The Lancet. This link has already been completely and thoroughly debunked – there is no evidence to substantiate this connection. But over the past two weeks, the full extent of the deception propagated by Wakefield was revealed. The British Medical Journal has a series of articles from journalist Brian Deer (part 1, part 2), who spent years digging into the facts behind Wakefield, his research, and the Lancet paper:

Today, the BMJ calls the fraud over medicine’s missing link: the research linking MMR with autism. Published in a five-page Lancet paper in February 1998, it triggered media campaigns which sent vaccination rates plummeting, and caused the most intractable health alarm in a generation.

Wakefield’s original paper (now retracted) attempted to link gastrointestinal symptoms and regressive autism in 12 children to the administration of the MMR vaccine. Last year Wakefield was stripped of his medical license for unethical behaviour, including undeclared conflicts of interest. The most recent revelations demonstrate that it wasn’t just sloppy research – it was fraud. Unbelievably, some groups still hold Wakefield up as some sort of martyr, but now we have the facts:

• Three of the 9 children said to have autism didn’t have autism at all.
• The paper claimed all 12 children were normal, before administration of the vaccine. In fact, 5 had developmental delays that were detected prior to the administration of the vaccine.
• Behavioural symptoms in some children were claimed in the paper as being closely related to the vaccine administration, but documentation showed otherwise.
• What were initially determined to be “unremarkable” colon pathology reports were changed to “non-specific colitis” after a secondary review.
• Parents were recruited for the “study” by anti-vaccinationists.
• The study was designed and funded to support future litigation.

The accompanying editorial pulls no punches:

Who perpetrated this fraud? There is no doubt that it was Wakefield. Is it possible that he was wrong, but not dishonest: that he was so incompetent that he was unable to fairly describe the project, or to report even one of the 12 children’s cases accurately? No.

However, the public health implications of Wakefield’s actions continue to reverberate:

Meanwhile the damage to public health continues, fuelled by unbalanced media reporting and an ineffective response from government, researchers, journals, and the medical profession. Although vaccination rates in the United Kingdom have recovered slightly from their 80% low in 2003-4,19 they are still below the 95% level recommended by the World Health Organization to ensure herd immunity. In 2008, for the first time in 14 years, measles was declared endemic in England and Wales. Hundreds of thousands of children in the UK are currently unprotected as a result of the scare, and the battle to restore parents’ trust in the vaccine is ongoing.

The Impact in Canada

Damage wasn’t limited to the United Kingdom. It seems to have measurably affected Canadian perceptions of the safety of the MMR vaccine. An interesting paper by Neil Seeman and Mary Seeman recently appeared in the Journal of Participatory Medicine (JPM): Autism and the Measles, Mumps, and Rubella Vaccine: Need to Communicate a Health Study Retraction to Patients. The paper gives a depressing snapshot of public perceptions of MMR vaccine safety. They randomly polled over 5000 internet users from Canada:

Participants were asked to respond to the question, “Do you think the measles, mumps and rubella vaccine causes autism in healthy young children?” The response options were limited to: “yes”, “no”, “don’t know/unsure” and “skip”. Respondents were asked their age (under 18, 18-30, 31-50, 51-65, over 65) and their sex.

The results are not positive.

Click to enlarge

Despite Wakefield’s study being retracted shortly before the survey was conducted, 65% of women and 72% of men surveyed were unsure whether MMR causes autism. Astonishingly, all age groups of men and women gave more “yes” than “no” replies, with the sole exception of women between ages 18 and 50. While samples of Canadians don’t show uptake to be as poor as the survey might suggest, uptake appears to be below optimal levels – so the results are concerning.

The authors put the responsibility on health professionals (i.e., physicians) to clarify the facts about the safety, particularly in light of the retraction of the Wakefield paper. From our perspective that doesn’t nearly go far enough. After all, most physicians do recommend vaccination already, yet many Canadians seem unconvinced. For example, Canadian data demonstrates that consultation with a family physician is strongly associated with annual flu shots.

Much of the public’s understanding has been shaped by a persistent habit of “false balance” in the popular press, who for more that a decade have messaged that there is a scientific controversy about the vaccine’s safety. Presenting what was felt to be a balanced perspective on what is understood to be a “debate” instead resulted in a manufactroversy.

Consider the timeline:

• 1998 – Wakefield paper published
• 1998 – UK Medical Research Council say no evidence of link
• 1999 – Two new papers in The Lancet identify no relationship between MMR vaccine and autism
• 2002-2004 – More data published finding no evidence of link
• 2004 – Brian Deer’s research documents Wakefield had not disclosed conflicts of interest in his paper
• 2004 – The Lancet announces a partial retraction of the Wakefield paper due to undisclosed conflicts of interest
• 2005 – More data from Japan and the UK – no link show
• 2010 – Wakefield paper fully retracted by The Lancet
• 2010 – Andrew Wakefield loses medical license in the UK, determined to have shown “callous disregard” for suffering of children
• 2011 – Extent of fraud perpetuated by Wakefield exposed in the BMJ

After exhaustive evaluation from multiple, independent groups, the MMR vaccine has consistently been show to be safe and effective, with no evidence it is associated with autism. Yet even as the BMJ articles receive extensive media coverage, the false balance continues. For example, CBC’s national radio news followed a story about the BMJ papers with a statement from a Canadian naturopath, linking asthma with vaccination (the data say otherwise).

The key messages? Spread them far and wide:

• The original link between the MMR vaccine and autism was based on fraudulent research. Subsequent investigation has repeatedly shown no relationship.
• From a scientific perspective, there is no controversy about the safety of the MMR vaccine.
• There has never been any credible evidence that the MMR vaccine, or any vaccine, causes autism.

As Dr. Paul Offit has been quoted as saying, you can’t unring a bell. So what’s going to stop this bell from ringing? Perhaps an awareness of its fraudulent basis will do more to change perceptions than a decade of scientific investigation has been able to achieve. For the sake of population health, we hope so.

Enter the “less bad = good” ad/product label.

This is where companies frame their product as better than other products, or better than a previous version of their own product because, for example, the new/improved product might have less fat, sugar, or calories, and more nutrients. The trouble is, often the food is still appallingly unhealthy. Don’t even get me started on fruit juice.

Mayo

I saw a TV ad for Hellmann’s, made with “real ingredients like whole eggs and oil”, now with half the fat. Their slogan is “It’s time for real.” and they boast that their product, Hellmann’s Real Mayonnaise, is:

Made with high quality ingredients, including whole eggs, [...] low in saturated fat, contains no trans fat, and is low in cholesterol.

Mayo is not healthy no matter how it’s packaged, yet they try to convince us otherwise by virtue of it being less bad than regular mayo. But a one-tablespoon serving of this product has 100 calories. Put in perspective, an equal amount of mustard has almost no calories; cream cheese — about 30 calories. Though Hellman’s tries to sell us on the benefits of “healthy fats”, that doesn’t change the fact that mayo is basically processed eggs and oil whipped into submission. Consumers concerned with healthy choices shouldn’t have mayo anywhere on the radar.

Here are some other examples I noticed during a recent trip to the grocery store:

Chips

First, Multigrain Doritos. Now to be fair, the bag doesn’t boast any health claims, but they are certainly banking on the multigrain moniker to sell products. People might be surprised to learn that these chips have 12 grams of fat and 260 calories per 50 gram serving. Multigrain fibre is a tad less healthy when it’s covered in salt and fat…

Another guilty party is baked chips, such as Baked Lays, which have 120 calories and 2 grams of saturated fat per 1 ounce serving — by the way, who eats one ounce of chips (28 grams)? Chips are bad for you, baked or not. Yet the “low in fat” marketing of baked chips seems to comfort people into thinking they are healthier than regular chips. Are they, though? Baked chips do have less fat than regular chips, but they have as much salt (note the serving size when comparing) and about the same amount of calories.

Bread

Another trendy grocery store item are those flattened hamburger buns that are supposedly healthier because… um… they’re flat, I guess. The idea is that they are supposed to have fewer carbs. But they actually have more fat, more calories, and more sugar than regular hamburger buns, despite the “healthy choice” label on the in-store brand. I guess I should point out that if the regular hamburger bun brands bothered to boast about their “nutritional content”, they’d win the fake healthy choice contest hands down.

Cereal

The worst product that I noticed though, is the new Kellogg’s Fruit Loops and Corn Pops. Now with fibre! Super, so they added fibre to their 24 grams of sugar and over 200 calories per cup, boldly stating that “Kellogg’s makes fibre fun” in an ad campaign that is clearly geared toward children (adults generally don’t care if fibre is made fun for them).

If adults are having such a hard time making appropriate food decisions against the onslaught of misleading advertising, what chance do children have? Rather than decreasing the absurd amounts of sugar in their children-aimed breakfast cereal, they’ve added fibre as if this nutrient is a magic shield against diabetes.

Conclusion

I don’t believe there’s anything inherently wrong with the concept of cooking pre-made or packaged food, nor is there anything inherently wrong with having a treat every now and then. But we can’t fool ourselves into thinking that sugar, salt, and fat is healthy or invisible as long as one other unhealthy ingredient has been reduced or some arbitrary nutrient is promoted on the package.

Until companies change the way these foods are produced and packaged, we’re all better off with fresh food. Nutrients don’t necessarily mean healthy, especially when they are foremost a marketing tool.

In the episode “Disability” (Season 5, Episode 7), they really screwed up big time.

Their Argument in a Nutshell

Laws (specifically The Americans with Disabilities Act) that encourage universal or accessible design and attempt to reduce discrimination are unfair because 1) they don’t perfectly encompass all disability, 2) they have led to some absurd applications of the law, 3) the cost, determined by the intrusive government rules, is absorbed by taxpayers and business-owners, and 4) they can sometimes be annoying to able-bodied people.

Yikes.

Where They Go Wrong

The argument is specious from the get-go, particularly their relatively familiar tactics designed to bias the audience towards their point. For example, in the first few minutes as they introduce the topic, they have a muscular man in a cambered, lumbar back wheelchair (for the unfamiliar, this is a chair for a relatively fit person with exceptional trunk control) wheel around several obstacles, easily clearing them.

This is, in short, not an accurate representation of the average wheelchair user. Many people in wheelchairs have comorbidities (or primary diagnoses) such as trunk weakness, inability to maintain midline gaze/head, poor hearing/eyesight/tactile sensation, weakness, etc. due to conditions like muscular dystrophy, cerebral palsy, MA, ALS, stroke, etc. Any number of other issues in addition to “can’t move legs” (which seems to be the only variable P&T took into account) can make navigating a world with steps, narrow doors, round handles, etc. too much to bear on a daily basis.

As usual, P&T have chosen the best possible example that would make their point. To use this man as a fair representation of disabled people is at best disingenuous and at worst ignorant. These kinds of attitudes towards disability have caused decades of marginalization that has been significantly reduced because of laws that enforce inclusive design.

As medical science advances, so does people’s survivability with inevitable consequences such as reduced mobility and other issues. Some people are “lucky” enough to be athletic and have no problem with wheelchair mobility after, say, a spinal cord injury around the low thoracic level. Most people can’t get by as easily. Ignoring the disabled was a community-level ethical issue that was not adequately addressed until there were laws.

The Penn and Teller Perspective, Point by Point

So let’s get to the main points of their argument, individually (note that these phrases weren’t uttered word for word, this is my own summary of the common themes I noticed — if a reader feels I’ve been unfair in this characterization, feel free to comment as such and we can discuss it):

1) ADA doesn’t perfectly encompass all disability.

P&T provide a few examples of disabled people who are well-adapted to their disability and dislike the ADA, too. However, if these people are functionally able to go about their daily business in an adapted way on their own without the need for a law, are they the kind of “disabled” that is the target of laws like the ADA? I would argue that they are not, though they do potentially benefit from the legislation due to associated shifts in community perception and participation.

They also go to the other end of the spectrum and demonstrate how a person in an iron lung can’t fit through the doors designed to allow wheelchairs through. They make the argument that because the laws aren’t truly universal, the ADA is pointless. Though it is unfortunate that some people are still unable to participate fully in society because of design limitations, the millions of disabled Americans who have been greatly liberated by these laws may feel differently about the so-called pointlessness of the ADA.

Arguing for improvement is one thing, but arguing that the entire Act is useless because the regulations aren’t truly universal is ridiculous. This argument also ignores other functions of the Act — civil rights improvements and community acceptance through raised awareness.

2) Some applications of ADA are absurd.

P&T provide examples of silliness, such as braille on a drive through sign, as if those examples negate the entire premise that we should be striving for a more universally accessible society. They don’t. Bureaucracy and inappropriate application are not relevant to the spirit and utility of the ADA as a whole.

They also take issue with the fact that people with cognitive deficits can park in handicapped spaces. Who are P&T to judge what levels of disability aren’t disabled enough to “deserve” a parking space? That is, quite frankly, deeply disrespectful to all people living with a cognitive deficit. There are arguments to be made about the difficulty (for some people) or relative ease (of others) in achieving disability status under the ADA, and therefore gaining the associated “benefits”, but to completely dismiss an entire group of disabled people as if they are undeserving of consideration is inexcusable. It is not the fault of the cognitively disabled that some people try to take advantage of the ADA.

3) The cost, determined by the intrusive government rules, is absorbed by taxpayers and business-owners. We can’t legislate compassion; business owners are encouraged to have universal design because it would increase business.

The history of the disabled in America before the ADA begs to differ with the latter part of this argument. In fact, the story about the man who was complaining about the cost of putting in a ramp indicates that priorities tend to center on the bottom line over human compassion. I also take issues with the argument against ramps because they’re ugly. Irrelevant.

Should we abandon the goal of universality because some business owners are not getting appropriate subsidies for ramps and other adaptations? Again, the failure to successfully apply a law is not a reflection on its necessity or overall usefulness. Perhaps there is room for improvement and greater incentives for people to make these changes (as perhaps accommodating fellow citizens is not motivation enough), but that does not mean the law itself is unjust or unnecessary.

4) ADA regulations can sometimes be annoying to able-bodied people.

Handicapped parking spaces. Now, there are admittedly issues with this practice (such as the habit of putting these spaces in the busiest and most dangerous area of the parking lot) that should be addressed, but why shouldn’t people with disabilities be accommodated in public parking areas when it causes very little extra effort (if at all) on the part of able bodied people?

While it may seem silly, I’d like them to try and wheel themselves to and from a grocery store parking lot (maybe even in the snow), weaving their way through cars looming over and whizzing by and compare that to being able-bodied and parked a mere 5-10 extra feet away. Or see a person with a significant cognitive deficit navigate the confusing hustle and bustle of the lot. Seriously.

Regular parking spaces are too small for most adapted cars. So people in wheelchairs can park in a regular space, but they can’t use their ramps to get out. Wheelchairs also tend to have a lot of gear on them and are heavy to cart around.

To complain about a minor perceived inconvenience to an able-bodied person as justification for not accommodating the disabled is extremely selfish. It’s easy to be annoyed with these things when there’s nothing wrong with you.

Accessibility and Politics

We need to get it through our able-privileged skulls that we should be building accessible in the first place. I recognize that there is a significant financial cost to making adaptations in existing buildings, but isn’t it unjust to not be able to leave the house because it’s not possible to get in anywhere? Do handicapped people not have the right to go where they please like the rest of us? While I agree that the ADA may not always be applied in the best way, and there is certainly room for criticism, overall it has seemed to do more good than harm and its faults do not negate its necessity.

Unfortunately, I think that much of this episode stems from libertarian beliefs that government should not interfere with behaviour. P&T seem more annoyed that the government has made a law forcing people to “be nice” than they are with the ADA itself. However, one role of government is to recognize societal issues and deal with them accordingly with the resources they possess.

Conclusion

The American Disabilities Act (ADA) is in place to protect people because, unfortunately, if there were no laws forcing public places to be inclusive, they wouldn’t be. This law was born out of necessity because people in privilege (in this case, the able-bodied) have the luxury of ignoring problems that aren’t theirs until something forces them to pay attention. Had we been inclusive of all people from the get-go, we wouldn’t be in a position to fix public buildings with a 1-inch lip at the door, round doorknobs, no elevators, etc. Disabled people aren’t new, they just couldn’t leave the house, were ignored, were put in “homes”, etc. The ADA has successfully, in my opinion, raised awareness of disability issues.

That is not to say that the issues are gone or that discrimination isn’t still a problem (it’s certainly apparent in this episode of P&T), but these laws have significantly improved the quality of life for many disabled people. Are the laws perfect? Certainly not. Are they always applied in the most sensible way? Not necessarily. But can a person in a wheelchair now board a bus to go to the grocery store? Most of the time, yes. Before these laws, the answer was almost always “no”. So, no the solutions aren’t applicable to every single disability, but they do allow for a majority of people to engage in activities from which they were previously prohibited largely because of noninclusive design.

But my biggest objection to this episode: What is the alternative? Other than to suggest that people should be left to their own devices to ensure that the disabled are able to participate in greater society, which is apparently ineffective, they make no concrete suggestions for improvements to the ADA or for what we should do instead. What a poor argument to tear holes in something that is admittedly non-perfect, but perhaps the best we can do at this point, yet provide no solution. All in order to defend ablist selfishness.

Background
Stress and anxiety are common but relatively nebulous issues that can be hard to treat – especially as the cause of stress can be difficult to localize and anxiety has no direct apparent “cause”. Prolonged psychological stress or anxiety can even manifest a variety of physiological symptoms – high blood pressure, poor cognitive performance, mood problems, gastrointestinal disturbance, changes in eating habits, weight changes, somatic symptoms, and substance abuse.

Prolonged or excessive stress and anxiety are recognized by the DSM as psychiatric disorders if they persist and interfere with a person’s ability to engage in daily activities. Now, that is a gross oversimplification and there are many kinds of anxiety disorders with specific symptoms, but a lengthy description is beyond the scope of this article. For more information, consult the DSM (Axis I).

Due to the discomfort of these symptoms, many people seek professional treatment (some never do). Patients with mild to moderate cases or who are averse to pharmaceutical treatment may seek/require relatively mild treatment methods. In those cases, it is important to consider the efficacy of the interventions used in order to ensure a high quality of health care.

Treatments for stress generally fall into two categories: cognitive behavioural therapy (CBT) and pharmaceutical intervention. Sometimes a combination of techniques is necessary to provide relief and treatment depends on severity of distress and the level of impact on daily life. CBT can incorporate some first-line techniques to help moderate stress and anxiety such as relaxation and meditation.

Some of these techniques are progressive muscle relaxation (PMR), relaxation therapy, meditation, and transcendental meditation (TM). The goal from an OT perspective is, after initial professional training, to give the patient some measure of control over their symptom management and increase independence.

PMR This is basically what is sounds like – tensing and relaxing muscles. The idea is to relieve tension in the muscles, producing a feeling of relaxation and therefore hopefully lessening feelings of anxiety. Also, if the patient is concentrating on their muscles rather than their worries, they focus and relax mentally as well. This is also used as a technique for tension-related insomnia.

Relaxation Therapy The aim of relaxation therapy is to use psychological methods to treat the psychological feeling of stress/anxiety, thereby reducing physiological symptoms. If one can reduce their state of arousal, they could theoretically also prevent themselves from feeling more and more anxious, allowing them to internally recognize and manage their own anxiety before it becomes severe (or develops into a panic attack).

Meditation This is a relatively broad term, but generally involves clearing one’s mind and concentrating on something – usually breathing, a chant, or some other relaxing imagery – in a silent, distraction-free environment. The theory is that meditation reduces the heart and breathing rate. There are also questionable claims that meditation directly reduces the production of cortisol.

TM This is a technique that has basically the same characteristics of meditation, but with added East Indian flair. During this meditation the person concentrates on and repeats a mantra. The goal is to experience different levels of consciousness (note that these levels are derived from spiritual belief and are not supported with research) – specifically the transcendental/pure consciousness (4th) level. TM differs from other methods in that there is a specific target in mind. Whereas the other methods are aimed at reducing anxiety (in whatever amount that may be), this methods seeks to reach a specific level of consciousness with anxiety reduction as a secondary effect.

Effectiveness
What most of these techniques have in common is that the supporting evidence is weak, but generally positive. Note that these techniques are still apparently inferior to other psychiatric interventions (i.e., CBT). They are not demonstrably harmful when used with other therapies, but the objective benefits are questionable. They seem appropriate as a first-line treatment for patients with mild to moderate symptoms, but may not be effective in patients with co-morbid conditions that affect arousal or muscle tone.

However, the evidence for TM is suspect. TM suffers from publication bias – specifically, multiple publications of the same data falsely bolsters evidence of efficacy. Also, there is reason to believe that it is no more effective than regular meditation. Studies of TM that report positive results sometimes fail to incorporate adequate controls to account for this effect. Also, so far there is no support for the varying levels of consciousness proposed to accompany the process. Furthermore, as the aim is to reach a certain level of consciousness rather than to marginally reduce anxiety, patients may actually experience anxiety or frustration if (or arguably, when) they fail.

In all cases it’s difficult to separate the positive effects from the general interactions with therapists. People may feel improvement simply because someone is finally helping them, not because of any specific method used.

Summary
Reducing stress outside of pharmaceutical intervention essentially depends on a person’s ability to self-regulate. Giving a patient some measure of control over their treatment reduces dependence on the therapeutic relationship and increases self-reliance. So it makes sense that interventions would attempt to enhance self-controlled anxiety management. However, evidence for the efficacy of these methods are mixed. They may not work for everyone and they require initial training/supervision by a professional.

There is a plethora of self-help books on the topic of stress reduction, but attempting the techniques above without seeking professional help could lead to exacerbation of symptoms (due to prolonged absence of treatment) and incorrect application of methods. While it’s possible that a well-crafted video or book may guide someone sufficiently on their own, people are generally not skilled at evaluating their own progress. That is where a trained professional who sees these symptoms all the time can also be helpful.

In any case, with regard to TM in particular, there is no evidence that the addition of a mystical belief system increases effectiveness. Certainly if a patient wishes to add a metaphysical element to their own meditation, there is no indication to necessarily discourage it (nor is that our role), but there is also no need to promote it. It is out of scope for a health care practitioner (HCP) to impose spiritual beliefs onto their patients/clients and there is no evidence that there are more positive outcomes with TM over other therapies.

HCPs should avoid language that makes these treatments sound more effective than they generally are. While the results indicate that they are an improvement over doing nothing, they are less effective than regular CBT. They are a good supplement to maintain independent anxiety reduction, to give the patient a measure of control, and possibly reduce feelings of helplessness. But as independent methods, they have questionable efficacy.

Chronic anxiety is a serious health condition and the above techniques require training and commitment, if they work for the patient at all – they aren’t a guarantee. If someone promises to cure anxiety in X number of “simple” steps or claims that a mystical belief added to therapy increases efficacy, be skeptical.

*Cross-posted at Skeptic North.

Despite the dramatic improvements in the extent and quality of our lives, largely owing to modern medicine, our current health care system has fostered a backlash, manifested in part by the emergence of non-science-based “alternative” health care practices . This trend has driven a need for dialogue on how best we should balance evidence-based decisions against demands for consumer choice – regardless of the science. In this presentation, Scott Gavura will discuss how health care decision-making differs from all other goods and services, and how this impacts on the choices we make, both as individuals, and in aggregate. Through an interactive discussion, he will facilitate a dialogue on the opportunities for science advocates to effect positive change in health at the patient- and population-level.

$5, $4 for students, FREE for CFI Members.

See the Facebook Event for this talk.