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Saturday, August 6, 2011

"The Healthy Skeptic" Gets A Healthy Dose of Skepticism

A couple of weeks ago, I came across this site by a self proclaimed "skeptic" promoting health and nutrition called, 'The Healthy Skeptic'. At first, I was enthralled to find another skeptical podcast that could be a potential source which I could listen to about nutritional information from a scientifically inclined perspective. As I began listening to a podcast episode, it did not take me very long to notice a few instances of my skeptical "spidey sense" going off. Upon closer examination, I saw that the main website had some interesting claims about acupuncture under the special "myth busting" section. Chris Kresser is a licensed acupuncturist who calls himself the "Healthy Skeptic", so I was more than intrigued to learn more about his premise that "everything we’ve been taught about Chinese medicine in the West isn’t accurate and is a functional, flesh and bones medicine based on the same basic physiology as western medicine." (Kresser 2010) Of course I wanted to see the evidence, after all, he does have the word "skeptic" in his title and it was provided for me in a series of six separate sections titled "Chinese Medicine Demystified". The following is a great example of some common logical fallacies, that ANY intelligent person can make, and includes my critique of what I encountered upon reviewing each section.

Chinese Medicine Demystified (Part I): A Case of Mistaken Identity
:

"Because Chinese medicine is in fact a complete system of medicine that has successfully treated many common health conditions for more than 2,500 years." (Kresser 2010)

This quote is a great example of the Argument from Antiquity/ Appeal to Tradition. The simple notion of a practice being used for any length of time is not considered to be scientific evidence in itself. There must be some sound methodology used to support a claim to be considered as scientific evidence. The mere fact that the Chinese have used this particular practice for any length of time is irrelevant if it is wrong.

"Most doctors and patients have simply been unable to accept the explanation they’ve been offered for how acupuncture works. The result is that acupuncture has come to be seen as either a mystical, psychic medicine or a foofy, relaxing spa-type treatment." (Kresser 2010)

The argument here is considered to be a Straw Man Argument. This fallacy can be described as developing an argument around a position that is intentionally set up to be easy to argue against, instead of dealing with the actual position of those with the opposing view. For example, the idea of doctors, or anyone for that matter, seeing acupuncture as being mystical or some form of "woo" is not based on acceptance of the explanations provided by acupuncturist. It is actually because when isolating for the variables, there has been little to no convincing evidence supporting any measurable effect greater than the placebo.

"It was used by emperors and the royal courts to help them live into their 90s and stay fertile into their 80s at a time when the average life expectancy in the west was 30 years." (Kresser 2010)

Actually there are a few other variables not being considered here, such as diet, environment, and lifestyle. So, once again this is another claim which is not to be considered as scientific evidence. This could very well be a case of confusing correlation as being causation. This is another logical fallacy, sometimes noted as post hoc ergo propter hoc (after this, therefore because of this, Latin) Just because one thing precedes another does not mean the initial event caused the other. This is also sometimes phrased as,"correlation does not imply causation".

"The Chinese were performing detailed human dissections where they carefully measured the blood vessels and weighed the internal organs at a time when western physicians thought the body was made up of “humors”. These dissections helped Chinese physicians to discover the phenomenon of continuous blood circulation 2,000 years before it was discovered in the west. The discovery of blood circulation is still considered the single most important event in the history of medicine." (Kresser 2010)

This point is rather irrelevant and does not provide support to the claims that this form of Chinese medicine works the way it is said to by acupuncturists. The ancient Greeks actually knew of this concept of blood circulating thorough the body in the form of a “life force of vitality”, pre-dating the Chinese, which is where the theories of practicing blood letting arose. They even knew about things such as atoms!

"The first evidence of the type of medicine that led to the Chinese Medicine in use today dates back to about 6,000 BC, which was during the neolithic (new stone age) period. Stone tools from this period have been found that were specially shaped for making small incisions in the skin, which was the early form of acupuncture. That’s 8,000 years of uninterrupted use. To put this in perspective, western medicine as we’ve come to recognize it today wasn’t even invented until the 1350s (the middle ages), which makes it less than 700 years old. Ah hem." (Kresser 2010)

This is not very critical or consistent logic. This quote provides us with the examples of two common logical fallacies that every critical thinker should know, the Argument of Antiquity and a Non-sequitor. The first mentioned fallacy I have already covered, but the following is Latin for “doesn’t follow”. This can be found in fallacious arguments when a claimant implies that a conclusion to a finding was the direct result of another without any logical connection. For instance, the age of “western medicine”, or simply medicine, is irrelevant because the evidence supporting science-based medicine far outweighs the amount of time it has been around. The credibility should be based on sound evidence to support the claim, not how long a claim has been around. The age of “western medicine”, or simply medicine, is irrelevant. The evidence supporting science-based medicine far outweighs the amount of time it has been around. The "tools" that are mentioned in this quote by Kressler are actually thought to be used for practicing blood letting, which is by no stretch of the means a form of acupuncture.

"Let me ask you this. Do you think Chinese medicine would have survived for more than 3,000 years and spread to every corner of the globe if it wasn’t a powerful, complete system of medicine?" (Kresser 2010)

Again, this is irrelevant and is not scientific evidence supporting the claims of acupuncture, which has been tested and still does not show any significant scientific evidence in its validity. This is yet another example of the fallacy, the Argument from Antiquity. Blood letting was practiced for 2,000 years, so does this argument hold for that as well? Could the majority of people believe in something that is false? Yes. Can beliefs that are false survive over the span of thousands of years? Yes.


"The reason Chinese medicine isn’t more popular in the west is that it’s completely misunderstood even by the people who practice it. And as long as acupuncturists continue to promote the “energy meridian” model as the explanation for how Chinese works, it’s destined to remain a fringe alternative modality."
(Kresser 2010)

Actually, the reasons why Chinese “medicine” isn’t popular in the west is that it does not show any significant results from rigorous testing, which we hold to the same standard of the scientific method, that are any greater than placebo. When tests isolate for variables such as, where the needles are placed and if the needles even puncture the dermis, the results have consistently shown that it doesn’t matter. If the needles are intentionally placed in the wrong place, it doesn’t matter. When toothpicks are used to mimic needles, not even puncturing the skin, it doesn’t matter. Therefore, it doesn’t work. The more rigorous the testing, the smaller in significance the results become. This is what is often seen in psi research as well.


“Biology is the study of living things. There is no biological basis for acupuncture as a way to make people healthy. Still, many people around the world say acupuncture works. What they mean is that they feel better or think they feel better after getting acupuncture. Many scientific studies have shown that when patients are stuck in the wrong acupoints or aren't even stuck at all (though they think they are being stuck), they say they feel better. If a scientist has only the word of those who got either real acupuncture or fake acupuncture, she would not be able to tell who got which. About the same number in each group will say it works.” (The Skeptic's Dictionary 2010)


The section, Chinese Medicine Demystified (Part II): Origins of the “Energy Meridian” Myth, along with the following Chinese Medicine Demystified (Part III): The “Energy Meridian” Model Debunked, are pretty much concerned with summing up some of the reasons how the translating of how “chi” has evolved over time. I do not find these areas to be terribly relevant to the mechanisms of acupuncture because they do not discuss or provide any direct, supporting evidence of how acupuncture induces these specific claims of biological effects, so I will not bother getting into in the details. While it may be interesting to some, personally, I found the historical account titled, "Acupuncture: The Facts" by Robert Imerie, to be far more extensive, thorough, and critical in looking at this specific information of energy and meridians.

Even after doing a bit of digging into the area's surrounding the origins of acupuncture, I found that this subject seems to be rather convoluted as well. As Robert Imrie states in his collaborated work, Acupuncture: The Facts, he concludes that,

"Most people think acupuncture started in China thousands of years ago, but the truth is we don't know when and where acupuncture began." (Imrie et al. 2006)


Chinese Medicine Demystified (Part IV): How Acupuncture Works:

"As methods of scientific inquiry have progressed, the mechanisms of acupuncture are beginning to be more clearly understood." (Kresser 2010)

Actually, I would add to that and re-state it as,

As methods of scientific inquiry have progressed, the mechanisms of acupuncture are beginning to be more clearly understood that it does not show any effect greater than the placebo, therefore, it doesn’t work the way that acupuncturist's say that it does.”

In this fourth section of the acupuncture series, Kresser goes on to make the following claims of acupuncture,

"Broadly speaking, acupuncture has three primary effects:
1. It relieves pain. 2. It reduces inflammation. 3. It restores homeostasis." (Kresser 2010)

However, these “three primary effects” are all related to things such as “pain” which may be subjective and surround the effects of placebo.

Kresser goes on to provide the following definition,

"Homeostasis refers to the body’s ability to regulate its environment and maintain internal balance. All diseases involve a disturbance of homeostasis, and nearly all diseases involve some degree of pain and inflammation. In fact, research over the last several decades suggests that many serious conditions like heart disease previously thought to have other causes are in fact primarily caused by chronic inflammation. If we understand that most diseases are characterized by pain, inflammation and disturbance of homeostasis, we begin to understand why acupuncture can be effective for so many conditions." (Kresser 2010)

This is also attributed to lots of forms of therapeutic effects from other forms of psychology surrounding the ritual of various treatments, but not the specific treatments themselves. Homeostasis, as it is used here, can be interpreted as “balance”. Often this is phrased as returning your body to a proper “balanced state”, represented by the yin and yang.

However, I would re-state this and add to Kresser's internal message to one with a more critical outlook on these claims of acupuncture as the following,

If we try to manipulate people's understanding into fitting the notion that most diseases are characterized by pain, inflammation and the disturbance of homeostasis, we can begin to understand why acupuncture can be applied to so many conditions and be so effective in attracting so many people, especially if they don’t understand how the mechanisms of human biology actually work”


This section gives a clear example of some of the faults that evidence-based medicine presents, compared to science-based medicine. Often people can get caught up in the technical sounding terminology and find themselves working backwards to prove a position by cherry picking the data to fit their initial claims, rather than seeking contradictory evidence to falsify their own claims to establish “scientific validity.”

In section four of "How Acupuncture Works", Kresser makes the following quote,

"While I agree that we don’t yet fully understand how acupuncture works, I think it’s vital that practitioners of acupuncture are able to explain what we do know about it from a biomedical perspective to their patients and colleagues in the medical profession."
(Kresser 2010)

I would actually almost agree with this, if it was restated as,

We don’t yet fully understand how placebo works, I think it’s vital that we do explain what we do know about it from a scientific and biomedical perspective to their patients and colleagues in the medical profession, which is that there is sufficient evidence to conclude that acupuncture doesn’t work they way acupuncturist's say that it does.”


While in this fifth section Chinese Medicine Demystified (Part V): A Closer Look At How Acupuncture Relieves Pain, and the last sixth part Chinese Medicine Demystified (Part VI): 5 Ways Acupuncture Can Help You Where Drugs and Surgery Can’t, Kressler gives a rather detailed description of the mechanisms in biology that surround our concepts of pain, once again, there is no clear explanation or direct evidence supporting the claim that acupuncture works in the way that it is said to in the premise. Instead, the supporting "evidence" comes in the form of the following example,

“But ultimately acupuncture is a remarkably simple technique that depends entirely upon one thing: the stimulation of the peripheral nervous system. It’s important to point out that when nerves supplying acupoints are cut or blocked there is no acupuncture effect.

A large body of evidence indicates that acupoints, or “superficial nodes” as they are more accurately translated, have abundant supply of nerves. According to Chen Shaozong, 'For 95% of all points in the range of 1.0 cm around a point, there exist nerve trunks or rather large nerve branches'.”
(Kresser 2010)

The following is a list, proposed by Kressler, as being some of the identified "mechanisms" of acupuncture that have been identified so far;

• Acupuncture promotes blood flow.
• Acupuncture stimulates the body’s built-in healing mechanisms.
• Acupuncture releases natural painkillers.
• Acupuncture reduces both the intensity and perception of chronic pain.
• Acupuncture relaxes shortened muscles.
• Acupuncture reduces stress.


(Kresser 2010)


However, these supposed "biological mechanisms" have never been identified through sufficient, rigorous scientific examination to support the specific claims that acupuncture affects human biology through “the stimulation of the peripheral nervous system.”

As for the notion of acupoints (acupuncture points), Felix Mann, the founder of Medical Acupuncture Society and First President of the British Medical Acupuncture Society, has come out as saying,

“if modern acupuncture texts are to be believed, there is no skin left which is not an acupuncture point.” (Imrie et al. 2006)


In 1996, Mann also stated in his book, Reinventing Acupuncture: A New Concept of Ancient Medicine,

“…acupuncture points are no more real than the black spots that a drunkard sees in front of his eyes.” (Imrie et al. 2006)


While acupuncture may be growing here in the West, it has steadily been decreasing in the East. There is a somewhat simple explanation to why most modern medical establishments in China use modern medicine. The more traditional eastern “medicine” that is predominately used by the poorer communities, simply cannot afford a trip to a hospital. Matter of fact, the government aimed to modernize medical practice in China and attempted to ban acupuncture a number of times starting in 1822. The Japanese did the same in 1876. (Imrie et al. 2006) In 1911, the Chinese Imperial Medical Academy stated that,

“acupuncture was no longer a subject for examination.” (Imrie et al. 2006)


Many scientific studies have shown that medicine isn't the only thing that makes people feel better. Sometimes people feel better because of how they are treated. This is a known psychological effect of the placebo. As Dr. Corrinne Burns found in her article on Chemicology, "The Rituals of Medicine",

The placebo response, induced by medical language and ritual, can produce marked biochemical changes in the human brain – changes that are very similar to those induced by the active drugs themselves.” (Burns 2011)

Studies like the fore mentioned have shown that this notion is a more plausible explanation for what is seen in acupuncture by providing valid scientific evidence. Kylie Hill has also covered this topic and stated the following on the Science-Based Life article titled, "Ancient Chinese Secret Huh?"

“In science, and in medicine more specifically, if the effect that you propose cannot out-perform placebo, there is no effect (not the one that you claim). Acupuncture does do something for people, but it is not because of qi, ancient body maps, or pressure points. If your brain can recreate the effect of all this ancient wisdom, simply by being worked on by someone who just looks the part (to create the ritual sensation), and placing needles where ever they want (not following any of the procedures), the procedures do not work.” (Hill 2010)


While the design of acupuncture studies has been improving, it is still not sufficient in isolating the 'placebo effect' and other variables responsible for the inconsistent positive affects that have been seen in past studies. There are still quite a few biases that are not included in any of these studies. It is evident that there’s still a need for a better designed ‘double blind tests’ between receiving acupuncture and not receiving acupuncture at all. In the reprinted editorial adapted by ScienceDaily from materials provided by Harvard Medical School titled, “All Placebos Not Created Alike: In A Trial Of Sham Acupuncture Vs. Oral Placebo Pill, Patients Experienced Greater Pain Reduction From Sham Device”, it concludes with the following,

“Though the results of this study add evidence pointing to the existence of a placebo effect in a clinical environment, Kaptchuk* does not recommend the use of placebos with patients or deception in the doctor-patient encounter. The aim is to understand how the ritual of healing affects health outcomes.” (Harvard Medical School 2006)

*Ted Kaptchuk is the assistant professor of medicine and associate director of the Division for Research and Education in Complementary and Integrative Medical Therapies and the Osher Institute at Harvard Medical School.


The following is a quote and suggestion from the article on NeuroLogica Blog, Does Acupuncture Work or Not?, by Dr. Steven Novella,

“We need to develop an experimental acupuncture needle that is housed in an opaque rigid sheath. This has been done with glass sheaths in some studies because when pressing the sheath against the skin the subject cannot tell if a needle is inserted or not (because of limitations in what we call two-point discrimination – the nerves cannot separate the stimuli). This is a good idea to blind the subject, but now we must take it a step further to blind the acupuncturist. Modify this setup so that a plunger is depressed that either will or will not insert a needle into the subject, in a way so that the subject and the acupuncturist cannot know if a needle was inserted. What this will accomplish is to truly isolate the variable of needle insertion.” (Novella 2007)


So far, what we have seen in the acupuncture literature amounts to “noise”, which does not show any effects greater than the placebo. Which is an extensive and extremely complicated topic in itself, which you can read further about at Discovery: Fit&Health in the special How Stuff Works section by Shanna Freeman titled, How the Placebo Effect Works.

While I sought to read Kresser's compilation of work covering acupuncture with an open mind, hoping to encounter some new scientific evidence showing something that science hasn't shown in past studies, after reading all six parts of this Acupuncture series on "Chinese Medicine Demystified", I was let down in those aspects and it seems this has only re-mystified acupuncture for me. In conclusion, I would say that it is more than obvious that we don’t yet fully understand how placebo works.




Sources:

Burns, Corrine. Chemicology. 2011. The Rituals of Medicine. July 1. Available at http://itsachemicalworld.wordpress.com/2011/07/01/the-rituals-of-medicine/.

Changing Minds.org. 2002-2011. Non-sequitur Fallacies. Retrieved August 9. Available at http://changingminds.org/disciplines/argument/fallacies/a_non_sequitur.htm.

Curtis, Gary N. Fallacy Files. 2001-2010. Post Hoc. Retrieved August 9. Available at http://www.fallacyfiles.org/posthocf.html.

Freeman, Shanna. Discovery Fit & Health. 2008. How the Placebo Effect Works. Retrieved August 8. Available at http://health.howstuffworks.com/medicine/medication/placebo-effect.htm.

Harvard Medical School. ScienceDaily.2006. All Placebos Not Created Alike: In A Trial Of Sham Acupuncture Vs. Oral Placebo Pill, Patients Experienced Greater Pain Reduction From Sham Device. February 8. Retrieved August 9. Available at http://www.sciencedaily.com¬ /releases/2006/02/060206233120.htm.

Helmenstine, Anne Marie. About.com, Chemistry. 2011. Scientific Hypothesis, Theory, Law Definitions. Retrieved August 8. Available at http://chemistry.about.com/od/chemistry101/a/lawtheory.htm.

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Novella, Steven. NeuroLogica Blog. 2007. Does Acupuncture Work or Not?. September 25. Available at http://theness.com/neurologicablog/index.php/does-acupuncture-work-or-not/.

Novella, Steven. Science-Based Medicine. 2011. CAM and Evidenced-Based Medicine. March 23. Available at http://www.sciencebasedmedicine.org/index.php/cam-and-evidenced-based-medicine/.

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