This week’s Parade magazine, distributed to millions of U.S. households in their Sunday newspaper, contains an article called “Alternative therapies that really work,” by Mark Liponis, an M.D. who’s promoting his books on how to live longer. I haven’t read his books, and based on this article, I certainly wouldn’t recommend them. He claims that he's found 3 alternative therapies that “have scientific backing and have passed the litmus test of rigorous medical inquiry” (Parade, Dec 14, 2008): acupuncture, meditation, and biofeedback. Let me just address the first one.
According to Dr. Liponis, “stimulating an acupuncture point in the toe may even help to correct the breech position of babies in the last trimester and allow more women to avoid C-sections, according to a study in the Journal of the American Medical Association.” This is so astonishingly stupid that I had to look it up. Is there really an article in JAMA that supports this?
Well, sort of. The study that Liponis refers to – I don’t know if he read it – is an old 1998 study by F. Cardini and H. Weixin (JAMA 1998;280:1580-1584). It’s a poorly done study, without placebo controls and without blinding (meaning the patients knew if they were in the “treatment” or “control” group), and it was done in a Chinese hospital.
What did they do? They burned the herb Artemisia vulgaris (mugwort) to stimulate acupuncture point BL 67, located beside the outer corner of the fifth toenail. Why? Because “traditional Chinese medicine” claims that this will encourage fetuses in breech presentation (feet down) to turn around so that they will be born normally; i.e., head first. Crazy, right?
Well, the 1998 study claimed that the treatment worked, although it was a small study and the authors admitted that there were methodological problems. To the lead author’s credit (but not to Dr. Liponis's), he conducted a follow-up study much more recently, this time in Italy, and reported on it in April 2005 in the British Journal of Obstetrics and Gynaecology (Cardini et al., BJOG 112(6): 743-747). This time none of the women were Chinese. And this time, there was no positive effect from this bizarre therapy. As the authors wrote, “The results of this study do not confirm those of the original study.”
So no, Dr. Liponis, stimulating an acupuncture point in the toe does not correct the breech position of babies in pregnant women. If you were even the slightest bit skeptical, you’d never have reported this in your article in Parade. It didn’t take me long at all to find the followup study. And the claim itself is so laughably stupid that it’s hard to see how an intelligent person could repeat it without embarrassment. But it’s clear from your article that you believe this nonsense.
I’ll bet that the Parade article – written by someone with the title “Dr.”, after all - convinces at least some pregnant women to seek acupuncture. Liponis should be embarrassed, but somehow I doubt that he is.
I'm thinking of making "astonishingly stupid quack claim of the week" into a recurring blog topic - the popular press seems to provide plenty of material for me.
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This is Steven Salzberg's blog on genomics, pseudoscience, medical breakthroughs, higher education, and other topics, including skepticism about unscientific medical practices. Here's where I can say what I really think about abuses and distortions of science, wherever I see them.
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Steven –
ReplyDeleteThanks for reading the Parade article and for the additional research.
But just because we don’t understand something doesn’t mean it’s not true.
Here’s some more research:
In the 2005 study you mention (Cardini et al., BJOG 112(6): 743-747) the authors state: “The study was interrupted when 123 participants had been recruited (46% of the planned sample). Intermediate data monitoring revealed a high number of treatment interruptions. “… “They do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.” http://tinyurl.com/6hcdmp
In a systematic meta-review of 65 citations including six RCTs (randomized controlled trials) authors of this April 2008 review conclude: Our results suggest that acupuncture-type interventions on BL 67 are effective in correcting breech presentation compared to expectant management. Here’s the source from pubmed: http://tinyurl.com/6pvhks
A review by Cochrane database in April 2005 (3 RCTs involving 597 women) concluded: “Moxibustion may be beneficial in reducing the need for ECV (external cephalic version), and decreasing the use of ocytocin” although numbers of participants precluded statistical analysis. http://tinyurl.com/56kbky
An April 2004 study of 240 women published in the Journal of Maternal Fetal and Neonatal Medicine concluded; “Acupuncture plus moxibustion is more effective than observation in revolving fetuses in breech presentation. Such a method appears to be a valid option for women willing to experience a natural birth.” Here’s the pubmed reference: http://tinyurl.com/6fq7w9
I have no idea how it works, it just seems to work, somehow. Also, as a physician (MD) who sees patients and works with acupuncturists I have also seen many patients helped by acupuncture. I don’t presume to understand how it works.
Here’s more:
http://www.usatoday.com/news/health/2008-02-07-acupuncture-fertility_N.htm
So I’m not sure if that makes me stupid, gullible, a “quack” or if I just care about my patients because I’d rather them not have a C-section or need their babies turned at the time of delivery. I don’t know if you’re married but I’d bet even you would be willing to try moxibustion/acupuncture if your baby was breech at 34 weeks and your wife and baby were facing a C-section.
Respectfully,
Dr. Liponis
Dr. Liponis,
ReplyDeleteThanks for posting a detailed rebuttal. I looked at the articles you cited, and I’m afraid I’m still not convinced – not even a little bit. Here’s why.
1. In the first study, it’s true that the authors concluded that their results “do not support either the effectiveness or the ineffectiveness of moxibustion in correcting fetal breech presentation.” But that’s what one always has to say with a negative result. You can’t prove there’s NO effect – as with all sham treatments, all we can say is that we failed to find an effect. A proper scientific response is to remain skeptical.
2. You cited a meta-analysis (http://tinyurl.com/6pvhks) as more evidence. This review appeared in a low-quality journal (Complementary Therapies in Medicine) that has a pro-CAM bias, and meta-analyses are notoriously unreliable, even when done well. But more tellingly, the 9 studies they pooled together “suggest that acupuncture-type interventions … are effective” only when compared to doing nothing. In other words, none of the studies was placebo-controlled. I’m seeing a typical pattern here: small studies, poorly done, report an effect. As with other acupuncture claims, I expect that a well-done study, if it ever gets done, will find no effect. And the 2005 study I cited already found exactly that: no effect. So I’m not at all convinced by this meta-analysis.
3. You cited a Cochrane review in 2005 of 3 studies. Cochrane reviews do tend to be better than other meta-analyses, so what did this review actually conclude? They wrote, “there is insufficient evidence to support the use of moxibustion to correct a breech presentation.” And they also wrote “there is a need for well-designed randomised controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety of the intervention.” In other words, their conclusion is that the evidence doesn’t support an effect, and well-designed studies are needed. (I would argue that well-designed studies are a waste of time and money, but never mind that.)
4. Lastly, you pointed to a 2004 study in the the Journal of Maternal Fetal and Neonatal Medicine. I looked at this study too, and like the others it is poorly done, with no placebo control and insufficient (or no) blinding, much less double-blinding. It would be easy to create a placebo control – for example, experimenters could simply use another herb (not moxibusion) and try burning it near the wrong toe, or a finger. None of these studies have proper controls. Why not? Perhaps because a properly done study will fail to find an effect.
In your comment, you made three comments that I have to address directly. First, you wrote that “just because we don’t understand something doesn’t mean it’s not true.” Yes, of course – but as a scientist, the proper reaction to a claim should be skepticism, and an expectation that anyone making a claim will have to prove it with good data. So this comment is a bit of a non-sequitur.
Second, you wrote “I have no idea how it works, it just seems to work, somehow. Also, as a physician (MD) who sees patients and works with acupuncturists I have also seen many patients helped by acupuncture.” To this I respond that anecdotal evidence is not scientific evidence. And multiple anecdotes still don’t make something true. We know how to gather scientific evidence, and informal observations don’t cut it. And I have to point out that there is no known physical, biological, or chemical mechanism to explain why burning an herb near a woman’s toe would have any effect whatsoever on her baby’s position! Such an extraordinary claim demands extraordinary evidence.
Third, you wrote “So I’m not sure if that makes me stupid, gullible, a “quack” or if I just care about my patients because I’d rather them not have a C-section or need their babies turned at the time of delivery….” Well, I’ll grant that you’re not a quack, but I’m afraid you are indeed gullible for believing that these poorly-done studies support a claim that, if true, would radically change our understanding of biology, physiology, and physics. (Acupuncture is based on a mystical force, Qi, that supposedly flows through the body - and that has never been demonstrated to exist.)
By the way, saying that either you’re “gullible” or “I just care about my patients” is a false dichotomy – obviously you can be both.
And yes, I’m married with two children, but no, I’d never suggest that my wife try moxibustion or acupuncture – or any medical treatment that has no demonstrable benefit.
Damn, he left the same comment nearly word for word on my post about the Parade article.
ReplyDeletehttp://spacecityskeptics.wordpress.com/2008/12/15/more-alternative-medicine-in-the-news/
I wish I hadn't read yours because it will be difficult to write a rebuttle that doesn't make me feel like I'm just repeating your excellent reply. I think I've got a few original thoughts but man you took the wind out of my sails. Keep up the great work.
skepticpedi
Greater Houston Skeptical Society
The article is now pulled from Parade online.
ReplyDeleteskepticpedi
Greater Houston Skeptic Society
I noticed this too - you can't access this from Parade online any more. Does this mean that Dr. Liponis thinks perhaps the article is misleading and should be pulled? Or is that too much to hope for?
ReplyDeleteEither he did it or the editors did I suppose. Either way it is a victory for skepticism and testament to what a couple of blogs can achieve, but I think that a retraction would be more appropriate than simply pulling the thing. And don't forget the millions of people that have read and own the print version.
ReplyDeleteI'm afraid the Parade article has re-appeared on their online site - but they've deleted my comment! I just tried posting a new comment there (http://www.parade.com/articles/editions/2008/edition_12-14-2008/4Alternative_Therapies) but it hasn't appeared yet, and I fear they will review and censor it rather than post it.
ReplyDeleteSo it seems that, rather than this being a victory for skepticism and reason, it's a victory for censorship and illogic.
Dr. Liponis, if you're reading this, answer this: did you have anything to do with removing my comment (and others) from your Parade article?
Steven - yes, I'm reading. And no, I have nothing to do with any posts being edited or deleted. As of right now (10:33 AM on Tues) both of your posts are there with my response (seems you duplicated your post or it was duplicated). I did notice that the Parade site was down for a bit this morning; they may have been having troubles on their side.
ReplyDeleteAnyway, I don't think your comments are unreasonable. Of course as a scientist I would have expected scientific comments as opposed to value judgements such as using words like "stupid", "quack" and questioning my motivation or credentials. That's not scientific.
I would also say that if you only allow your family to avail themselves of medical treatment that has "demonstrable benefit" and require a standard above those that you label as "poorly done", then your family would have very little medical care at all, because MOST of the care provided by doctors has not been studied at all, especially so in women and children, and very little to the degree you seem to consider necessary. Most prospective, RCTs are still centered on the effects of drugs and have been funded by the pharmaceutical industry.
Many simple things that we take for granted (vaccines, antibiotic use, primary prevention, CPR, cardioversion, surgical procedures, treatment of back pain, cancer treatment and so many other accepted therapies) have just not been studied by good prospective RCTs. Even if you ask yourself a simple question, like "what if my wife was diagnosed with breast cancer?" you will be hard pressed to find studies that give you clear answers about the right treatment. Even the use of mammography... at what age should you screen? Colonoscopy... the list is very long. And most preventive and screening tests analyses are limited to cost-benefit analysis. Is that what you'd want for your family, also, or would you be willing to pay more to insure better health and safety for your loved ones?
These are common decisions that those of us practicing physicians that take care of patients have to make every day. One day you will be facing similar questions for yourself and your family and I hope you find the studies you are looking for to make you feel better about the decisions you make.
Again, respectfully,
Dr. Liponis
Assuming your critiques of medicine are accurate Dr. Liponis, but to be clear they aren't and are in fact quite naive in regards to science, what does that have to do with your article? You have done nothing but commit a tu quoque fallacy and repeat several tired canards that have been debunked time and time again by scientists and skeptics. Shortcomings in conventional medicine, and there are some, do not equate to proof of acupuncture.
ReplyDeleteYou made a claim that is unsupported by the medical literatue. You held up acupuncture as an alternative modality that worked, that has passed the rigorous test of science. You have now retreated and moved the goalpost back to implying that you can't judge acupuncture just based on science.
If you had written an article about how much you like acupuncture, how you think it works based on personal experience, and how you think it is reasonable for people to try a relatively safe therapy, I might have had a few bones to picks but it would not have deserved the harsh critiques that it has received.
skepticpedi
Dear Skepticpedi -
ReplyDeletePardon my “naiveté."
You are entitled to your opinion.
The studies I’ve quoted were published in peer-reviewed journals.
Because you disagree with the researchers and their peers with expertise in their fields, your opinion is simply that.
Best wishes,
Dr. Liponis
Your position as a medical writer for a magazine with a publication of millions of people places you in a positon of scrutiny. You should be held to a higher standard than most because your audience is so vast. If you do not understand the nature of the peer-review process, and the pitfalls inherent in it,then I would recommend you become familiar or else you will face criticism like this frequently.
ReplyDeleteAs someone who has taken it upon themselves to piece together complex medical topics with a complicated research history like alternative medicine in order to present a condensed version to the public, and to receive a paycheck for doing so I might add, you have to do your homework or you have to at least own up to making a mistake.
Recommened reading for Dr. Liponis:
ReplyDeletehttp://www.sciencebasedmedicine.org/?p=4
Today I read for the first time the article in PARADE. However, I read it re-directed from MSNBC (which has a larger readership than PARADE), this paragraph is what I noticed and prompted me to write to Dr. Liponis:
ReplyDelete"Here are three commonly used mind-body therapies that have scientific backing and have passed the litmus test of rigorous medical inquiry".
Later, I found you blog and others who have commented on the subject.
If Dr. Liponis believes that these "therapies" have passed the Litmust test, his Litmust test bar must be very low. Maybe his next column should be on the great health benefits of Bleeding therapy.
To be fair, I will withhold my personal judgement until he replies, if he so choses.