Arrgh, Fake Number!

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Do you remember that Seinfeld episode when Elaine admits to giving a fake telephone number to guys she meets but doesn’t want to date? The purpose, of course, is it allows her to avoid a confrontation either at the time of the initial meeting or on the phone later during which she would need to tell the prospective suitor she is not interested.  Instead of dealing with the real issue honestly and head on, she manufacturers a piece of false evidence so she can avoid dealing with the real problem.

The other day I received in the mail something that looked like a new chiropractic research journal. With a traditional medical journal type cover, there was no flash, no pictures, just a listing of the articles inside and their authors. The journal was entitled, “The Industry Compendium of Chiropractic Research” vol 56, no. 9.

Hell, I was impressed. How did I not hear that a new chiropractic journal was started, produced so slickly and mailed to chiropractors who hadn’t even paid for subscriptions? I have also been hearing how difficult and expensive it can be to keep a print journal afloat and how many medical journals are finding it necessary to move to electronic, on-line only versions.

Something wasn’t quite right.

The smaller print on the cover of this “journal” said, “Supplement to Chiropractic Economics,” a trade magazine known for glossy ads and fluffy articles. Everything changes once the Compendium is actually opened. Just about every article, some of which are lacking authors names, all of which are lacking statements of funding support, is followed by an advertisement for the very product discussed in the article.

A topical analgesic does well in a clinical trial, there follows an ad for that analgesic. Next, an article on the efficacy of a nutritional supplement followed by an ad for that nutritional supplement. In all, it was insulting that the word “research” was placed on the cover. Worse yet, there are a lot of people in chiropractic who will mistake this magazine for actual, high-quality research.

There is a significant body of research attributable to the chiropractic profession but there is much more that needs to be accomplished. Currently, there is a lack of financial resources and a shortage of qualified individuals necessary to carry forth the work. The fact that a trade publication, Chiropractic Economics, is interested in advancing the body of research within chiropractic is noble and welcomed. They could make a donation to private researchers, develop an award for research, support fellowships or one of a thousand other ways they could actually advance research within the profession. Like Elaine and her fake phone numbers, Chiro Eco’s fake journal avoids dealing with the problem head on and instead, they produced a fake research journal in the hopes of advancing their vendor’s agendas at the expense of intellectual honesty and impartiality.

Dr. Brett L. Kinsler is a chiropractor in Rochester, NY who had to look up the word compendium and finds it ludicrous it appears on the cover of this catalog.

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Bad Advice

Not so long ago, my office manager asked me to take a phone call.  Someone was asking if we do a certain technique. This was not an uncommon scenario — people call all the time wanting to know if we can do what their doctor in Peoria did.  Many times we can, sometimes we don’t but it never hurts to ask.

This particular person was asking about a chiropractic technique my assistant had not heard of so she punted it to me. My feeling, and the research generally agrees, that most chiropractic techniques get you to the same place.  The old-timers used to say it didn’t matter if you took a bus, car or train — they all get you to about the same place eventually. So, whether someone adjusts your spine with the push of a hand or the thump of an instrument, whether the table moves with the adjustment or lights up like a winning slot machine, most chiropractic techniques can eventually help patients in pain.

However…the techique this person was asking about is, well, bull. Plain and simple. If you saw it done, you would laugh your ass off.  Seriously. Right off. Gone. It’s disproven, silly and so far from the realm of scientific reality it would make Stephen Barrett squeal like a little girl. Of course I took the call.

“Hello Ma’am. Yes, I heard that’s what you were looking for. Oh, I’ve heard of it alright. Oh boy. Well, you do know there is absolutely no scientific evidence supporting that technique, right? No, none. It’s garbage. Huh? Right, so you know it’s a complete waste of your time and money? Okay, well I certainly don’t use that procedure in my office and I really don’t respect anyone who does. I couldn’t possibly. Why?!? Because they are basically criminals; lying to patients and tricking them with pseudoscientific jargon and useless tests that are light years beyond ridiculous.  In fact, anyone who uses that technique would have to be the worst chiropractor in town. What’s that now? Really? You’re kidding me?”

“Ma’am, are you actually asking me to refer you to the crappiest, most dishonest, clinically incompetent doctor I know? Please hold for the number…”

And so it went. Clearly there was a huge disconnect between what this woman wanted to hear and what she needed to hear. I thought I was doing her a favor by smoking her beeline to quackville. Instead, she just wanted the information she wanted in the way she wanted it.

I have a friend who told me he stopped going to his primary care physician since she always gives the same advice.  He once went in for an ankle sprain and he swears she told him to diet and exercise.  He’s the same wiseguy who when she questioned how he was working on his type 2 diabetes, he responded “Positive thinking?”  The problem is that patients frequently don’t want to heed lifestyle changing advice even if that’s what they need to hear the most.

Recently, I was asked for advice on how someone could lower her cholesterol without medications. I told her to try a low-fat, whole foods, plant-based diet. She tried it — for one meal. Then she gave up, citing it as too difficult, and reverted right back to what she was already doing. Six months later she had her blood retested. Shocked! Shocked! that her cholesterol was even higher that it had previously been!  I was again asked for advice on how to lower this skyrocketing cholesterol.

“I am not going to answer this question since you already know my advice,” I said. “If you want some new advice, you really should be asking someone else.”
“Oh, not the vegan thing again,” she sighed, “I was hoping you would tell me something different.”
“Yeah,” I said, “but that is the absolute best advice I have for you. I can give you bad advice. Is that basically what you’d like? Some bad advice? Okay. You should be performing the Mexican Hat Dance during all lunar eclipses in months with a R in their names. That will shoot down those triglycerides like a cartoon anvil falling out of a helicopter. And while you’re at it, smear peanut butter between your toes every night before bed. That will ward off the evil aliens from the planet Cholesterak that inject cholesterol into your blood while you are sleeping.”

I can be chock full o’ bad advice.  Piece of cake. But it’s a metaphor, isn’t it? It’s always a freaking metaphor. I’m chock full of those too.  We know the answers to so many questions in our lives but choose to look the other way. Often, we have the solutions to our health problems but we simply do not want to hear the answers that will actually help. 

How about you? Are you just looking for the advice you want and ignoring what you need?

Is there something you haven’t heard lately?

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Spinal Screaming

Scene: Shopping Mall.

Wedged in between the Yogan Frooz (motto: made up Scandinavian words tastën groövi) and the Cell-U-Cessories cart (motto: I’m a bored guy on a stool) one can occasionally spot what is commonly called a chiropractor performing what is commonly called a “spinal screening”. Step right up and you can get your spine checked for problems. No back pain? No problem! These little spine problems are sneaky buggers and have a funny little way of creeping up and kicking your ass. You may not even know you’ve got one until it’s too late. Like appendices that always seem to be removed seconds before they were going to burst (whew, thank God! The size of a grapefruit you say?) these spinal boo-boos can wipe you out! What’s that, Miss? You just had a checkup at your medical doctor’s? Last week? And he didn’t find any spinal problems? Didn’t he? Well, that’s okay – you’ve got to be a chiropractor in order to finds ‘em and fixes ‘em. Here’s my card. We’ll see you at 9:00 am tomorrow. NEXT vict- I mean screening subject!

You might be asked to stand on two modified bathroom scales, one foot on each. Notice how the weight isn’t the same on the two scales? AH HA! Structural imbalance! Or, you might stand against a metal frame with strings going across it and the chiropractor will slide the strings to match up with your shoulders and hips. You step down and AH HA! Those strings aren’t level! Spinal problems! Or perhaps Dr. RightbySears is taking the high tech approach and running a scanning device up and down your spine and them shows you on the computer screen what looks like a bar graph coming out of both sides of your back. Some areas are blue, some yellow and uh oh, you’ve got red ones! You need to come in to my office Monday morning and turn those red things into blue.

Public screenings are an important tool in improving the public health. True, screenings for prostate and breast cancer have taken some hits in the literature but the practices are changing in alignment with the scientific evidence (slowly, but responding). The spinal screenings you see in the mall are not the same as having your blood pressure checked by the volunteer ambulance outside the Stop & Shop. Elevated blood pressure has a clinical correlation with chronic disease and the blood pressure cuff is a proven method of detecting hypertension. The evidence for using two bathroom scales for determining the need for future spine care? Clearly demonstrated in the American Journal of Notsomuch. That fancy scanning thing that produces the sideways colorful bar graphs? Just saw it in last month’s New England Journal of Maybenot. Unproven to be anything other than a marketing gimmicks.

Screening is a public health activity with the aim of detecting disease before symptoms appear. Screening has the potential to save lives and improve quality of life through early diagnosis of serious conditions but can only be ethically used in cases where the screening procedure can actually detect what it proposes to find and the early detection will actually make a difference in the progress of the disease. For example, more than half of seniors have hypertension. One could be accurate half the time waving a magic wand over a group of people over 65 and declaring a diagnosis of high blood pressure in half of them. Accurate? Yes. Ethical? Hardly.

To call these advertising booths ‘screenings’ is a slap in the face to true public health measures. Screenings should identify or prevent a public health concern – not create patients through scare tactics, confusion and deceit.

I have no problem with people marketing their businesses as long as they call it what it is. When I see an ad in the newspaper for a cafe that says it has the world’s best coffee, I’m pretty sure there wasn’t a scientific poll organized to determine it. But it’s different when a doctor does it. It needs to be different.

Setting up a booth in a mall looking for people who will believe what you are selling is not a screening for public service. It’s a store.  And if you sell items or services by lying, then not only is it not a screening but it’s a self-serving  fleecing. These people should have telemarketers for older brothers so they’d have role models to look up to. Run away. All the way to the Gap if you have to.

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On the Wire: TENS Unit Controversy

A recent headline on WebMD, a popular source for online medical information, states that TENS is no longer recommended for chronic low back pain.  The article quotes Richard M. Dubinsky, MD, MPH, of Kansas University Medical Center, “from the systematic review of the literature, based on the strength of the studies, we can say that TENS does not work for low back pain.”  TENS stands for transcutaneous electrical nerve stimulation.  This means it applies electrical current through the skin (via electrodes) for pain control.  Most sources consider the use of TENS to be a non-invasive safe treatment that has very few side effects when used as directed (not over the eyes, broken skin, pregnant uterus, etc.).

TENS is often confused with Electric Muscle Stimulation (EMS).  The confusion is understandable as they both are electrical devices applied using two or four electrodes to the affected area.   TENS is for blocking pain pathways while EMS is for stimulating muscles to relieve muscle spasm, hence reducing pain and improving function.

Here lies the problem with this headline.  Dubinsky is also quoted as saying, “We can’t say that TENS will not work in any patient with chronic low back pain.  We can say there is proof it doesn’t work in groups of patients with chronic low back pain.”   So, it probably works for some patients but not a large enough proportion to be recommended.  Why not?  Here is a safe non-invasive treatment with very few side effects that may work for some patients.  If there was a long, scary list of side effects it wouldn’t be worth the risk.  For patients that have back pain, a treatment that doesn’t require drugs or surgery and could make them more comfortable is an important tool to have in the physician‘s toolbox.  Patients will know immediately if they get any relief.  If they do, great.  If not, stop using it.

A TENS unit is inexpensive (well under $100) and doesn’t require refills other than changing the electrodes and batteries once in a while.  It can be used right before driving or handling heavy machinery.  It doesn’t cause stomach upset or make you feel “loopy” like some of the commonly prescribed pain meds.  Does it fix your back? No.  Could it make you more comfortable? Maybe. Does it deserve to be crossed off the list?  Certainly not.

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Raw Milking It

Raw milk. It reminds one of my friends of the Weird Al video for Amish Paradise” where he milks a cow directly over a bowl of cereal. Actually, this isn’t too far off. Raw milk is cow’s milk that hasn’t been heat-treated for pasteurization or homogenization. According to the true believers, the health benefits of moo juice direct from the mooer are tremendous. People have reported positive health effects for allergies, asthma, Crohn’s disease and other digestive problems, osteopenia and, of course, the holy grail of any good dietary alteration, autism.

But in steps that pesky science thing to mess up all the fun. See, other than anecdotal reports, there is no good research in the US demonstrating any health benefits of raw cow’s milk over pasteurized milk. But the reports! Oh, the reports! Remember, people also report on the healing properties of crystals and being abducted by aliens (perhaps they are the same people?). Anecdotal reports of effectiveness are the weakest form of science possible.

I know what you’re thinking: there he goes again ruining people’s fun. This is a free society and if people want to suck the milk right out of a cow since they think it’s healthier, why the heck shouldn’t they? There’s no harm in it….is there?

Firstly, there is also no reason to think raw milk escapes any of the health hazards known to be caused by animal protein present in dairy. But that’s beside the point for this post. The basic facts about raw milk safety are the same as any other food. If the raw milk has not been contaminated by microbial pathogens, it is as safe to drink as pasteurized milk (not very…but I digress). If it is contaminated, then the microbes can sicken anyone who consumes the milk. Contamination can come from bovine diseases, or manure or dirt that is brought into contact with the milk by insects or humans.

Most raw-milk drinkers do take care in choosing the sources of their milk and seek out farmers who take steps to reduce the risks. In contrast, milk that is intended for pasteurization is typically produced in large, confinement dairies that can fall back on the knowledge that any impurities in the milk will be killed during pasteurization. So in theory, the raw milk should be safer as a result of more careful farming.

According to the Center for Disease Control (CDC) numbers, there were 74 outbreaks of illness due to raw milk in the U.S. from 1993 to 2006. These outbreaks led to 1,600 individual food-poisoning cases, including 202 hospitalizations and two deaths. During the same time period, there were 48 outbreaks due to pasteurized milk, leading to 1,223 cases, 30 hospitalizations and one death. These numbers look roughly equivalent until you consider the fact that many more people drink pasteurized milk than the number of those who drink raw milk. Regulators estimate that less than 0.5 percent of U.S. milk is consumed unpasteurized. If that’s the case, assuming the above statistics are accurate, then raw milk is much, much riskier than pasteurized milk.

So what, right? You’re willing to take that risk since the benefits of raw milk are going to be so fantastic!  It’s so much more absorbable when the milky proteins aren’t denatured.  Despite concerns to the contrary, pasteurization does not seem to change the nutritional value of milk. It has not been shown to be more absorbable, have higher calcium or give you magical powers. And, knowing that animal protein is as harmful and carcinogenic as it is in all forms, the odds that any of those risks are actually reduced by not heating the product and removing the bacteria prior to consumption defies logic.  To me, this puts raw milk in the same basket as cigarettes produced with no preservatives: perhaps the tiniest bit more safe but who are you kidding?

Stick to organic soy milk or rice milk and leave the cow’s milk for whom it is intended — baby cows.

Dr. Brett Kinsler is a skeptical chiropractor in Rochester, NY.

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Don’t Confuse Me With the Facts

Food labeling cartoonAs chiropractors, we often get asked about diet and lifestyle in addition to the usual neck and back pain complaints.  In the current word-of-mouse era we live in, patients have access to an unprecedented amount of information only a click away.  Most have done their own research before they bring the subject up in our office.  Sometimes this is helpful.  Other times, it has only served to confuse them.  Some patients choose to follow each and every bit of nutritional news which only serves to drive them crazy.  Today, eggs are bad but coffee is good for you.   Yesterday it sounded like coffee was the Devil’s drink but eggs were the perfect nutritional powerhouse.

So what are they looking for from us?  Google “diabetes”  or “heart disease” and you will get well over ten million hits.  Most likely, after the cereal, shake and snack bar Googlemercials, the next few links will be to popular sources like WebMD.  These have their place but they are supported largely by pharmaceutical ad revenue.  Even if patients found their way to Medline (a source for medical journals) the average person is not used to reading technical and often seemingly contradictory research studies.

What patients are looking for is a way to look out at the endless sea of information and fish out from it the most relevant facts to their own situation.  This should be the role of their health care provider — to assist in this process.  Yet, in many cases, the information from the health care provider does not help in a positive way.

 The cycle goes something like this:

  • patient gets diagnosis (or is told to “lose a few”)
  • patient finds the latest “diet” and follows it
  • patient loses a couple pounds then hits a plateau
  • patient gets frustrated and goes back to old habits
  • this becomes another “diet” that they tried that didn’t work. 

Any diet can work, especially in the short term.  The problem is most are unhealthy and are being used as a temporary fix.  Even diets like the South Beach Diet, which is very effective at weight loss in the beginning, is not an effective long term plan for health when taking into account factors like cancer and heart disease due to too much reliance upon animal protein and complicated “what you can eat when” charts.

Nutritional science can be very technical and complex.  Even if you make it a full time endeavor, keeping up on all the latest research is nearly impossible.  What is a person to do?  First, forget about the current politics of food.  Using only common sense, imagine what a healthy, nutritional meal might look like.  Chances are you imagined a plateful of vegetables.  Maybe there was some meat or fish on the side but the bulk of the plate was filled with plant foods.  Well, let’s start there.  Make your meals (and snacks) look like that imagined ideal meal.  Dramatically reduce (or eliminate if you can) the size of the animal protein (meat, fish, dairy) you have on the plate.  Push it off to the side and fill the rest of the space with several different plant foods.  Add a heap of brown rice or a plain baked or sweet potato.  Then add sauteed spinach, roast carrots, steamed broccoli and/or peas.  See what you did there?  Without even going to night school to get your Masters in Clinical Nutrition, you just put together a perfectly healthy meal.  Just make sure the vast majority of stuff on your plate is unprocessed and plant based.  Still hungry?  Try some whole grain bread with your meal and some fruit for dessert.  Getting started really is that simple.

Dr. Michalene Elliott is a chiropractor in Rochester, NY who has gotten started.

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Rethinking Cancer Screening

 

Mark Twain sent a note to the New York Journal in 1897 responding to a story error in which the illness of Mark Twain’s cousin was incorrectly reported as Twain’s death. Twain told the Journal: “The reports of my death are greatly exaggerated.”

Dr. Otis Brawley, chief medical officer of the American Cancer Society told the New York Times on October 21, 2009, “We don’t want people to panic, but I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”  In other words, the reports of the benefits of screening have been greatly exaggerated.

The recommendations for mammograms and prostate cancer screening have been off target and set against what the evidence suggested for decades.   An article in the October 21, 2009 issue of Journal of the American Medical Association, titled “Rethinking Screening for Breast Cancer and Prostate Cancer”, says so.  Millions of patients have been damaged by the universal and overly enthusiastic recommendations of early detection programs and screenings.   Oops.  The American Cancer Society’s sorry.  Their bad.  Buy you a drink? 

Enough good scientific evidence to stop these screening programs has been readily available for more than 30 years.  In 1976 Pietro M. Gullino presented his findings on the natural history of cancer, showing early detection is really late detection.  Many other researchers have stated that mammography, breast self-examination, PSA and digital rectal exam are really late detection methods and cannot be expected to save lives by catching cancer before it spreads. By the time these methods “catch” a tumor, the likelihood is that it has already metastasized. 

Sadly, as in so many other fields, there is no money to be made in telling the truth and more than $20 billion is spent annually on screening for breast and prostate cancer.  And while the press may have you believing that there has been a massive breakthrough in the literature leading to the guideline changes, the truth is that the evidence has not changed — only now, more people are willing to tell the truth and give up their chunk of the $20 billion screening pie and hundreds of billions more for the tests and treatments that follow.

And Dr. Brawley (chief medical officer of the American Cancer Society) has “never had a PSA and I do not desire one.” He compares prostate screening to the Tuskegee Experiment—research on the natural progression of untreated syphilis performed on black male patients between 1932 and 1972. This study caused serious mistrust by the black community toward public health efforts in the United States, the ripples of which continue to be evident in some areas today.   Ironically, black males are heavily targeted for prostate cancer screening and treatments.  Brawley has further noted that he is aware of twenty-three different organizations of experts in screening around the world who have considered the question and all have chosen not to make the blanket statement that screening saves lives and men should be screened. Most actually recommend men not get the test because it is not proven effective.

So when the United States Preventive Services Task Force (USPSTF) announced changing its guidelines for mammography and no longer recommending routine screening for women between the ages of 40 and 49 Brawley seems to have changed his tune somewhat. “The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40. When recommendations are based on judgments about the balance of risks and benefits, reasonable experts can look at the same data and reach different conclusions.” Okidokie, spin doctor.  Interesting how his views change once he is on the payroll for the ACS (his anti-screening opinions were published when he was at the NCI).

The benefits of screening and early detection are theoretically possible for prostate and breast cancer.  But as of yet, these benefits are unknown.  What is known are the risks and harms of screening and the resultant unnecessary treatment for millions that lead to morbidity, mortality, breast mutilation or loss of sexual function.

So the ACS is sorry they have mislead you.  I’m sure they promise never to do it again.  In fact, given the extremely strong evidence linking the consumption of animal protein to cancer, the ACS clearly states that people should, “limit intake of processed and red meats”.  Wow!  Strong words, there.  Limit intake?  Whoa.  Let me process that for a while.  Oh, and we are suggested to “choose fish or poultry”.  Right, because they’re plants, right?  “When you eat meat, choose lean cuts.” 

This is a very interesting strategy on the part of the American Cancer Society.  They are already preparing us for the next big apology.  See, in another 15 or 20 years, they are going to report on the evidence which we already know today.  Animal protein increases cancer rates.  They’re so sorry.  Really. They should have told you that sooner, too.  Buy you a drink?

– BLK

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The Autism Panic!

panicThe sky is falling!  The sky is falling!

Wait, what?

Oh, sorry. 

The sky is rising! The sky is rising!

Wait, sorry.  What now?

Oh, okay. 

The autism rates are rising!  The autism rates are rising!

Alright kids, let’s go over this again.  Autism rates, really the autism spectrum disorder (ASD) rates, are on the increase.  You’ve heard the new 1 in 100 number quoted, right?  I’m not saying that’s inaccurate.  It’s just that there is no real increase represented.  How can that be? Clearly something (or someone) must be to blame for this terrible condition.  Who can we hang?  Quick, after them!

There were two recent studies concerning the prevalence of autism in the US that have attracted a lot of attention.  One study conducted by the CDC (not yet published) reports that the new prevalence of autism spectrum disorder (ASD) is now estimated at 1% or 100 in 10,000 children. This is an increase over the last few years. In 2002 the prevalence was estimated to be 66 per 10,000 (0.66%).

The second study published in the journal Pediatrics was a telephone survey of parents where they asked if they had any children who had ever been diagnosed with an ASD.  This non-clinician scored study estimated ASD point-prevalence at 110 per 10,000.  These are slightly higher numbers than the CDC data but that is to be expected, since diagnoses from the phone survey were not confirmed by a doctor.

There is no argument that the number of ASD diagnoses has been steadily increasing for the last 20 years. The real question is whether or not the increase is  a true increase in the disorder or an artifact of increased surveillance and an expanded diagnosis.  Without a doubt, the evidence strongly supports the conclusion that the increasing autism prevalence is due to increased efforts to make the diagnosis and a broadening of the definition of autism. The evidence is not sufficient to conclude that there is not also a real increase in ASD incidence, but nor is there data to support this conclusion.

Recently, more data have come out of the National Health Service (UK) that looked at a very interesting statistic.  They looked a the prevalence of ASD in adults.  See, if there is a true rise in autism, the adult population should have a lower number of cases than the current children.  Guess what?  1% across the board.  Kids and grown-ups.  Oops.  Sorry conspiracy theorists, move it along…nothing to see here. 

What can be concluded is that 1% is likely close to the true prevalence of ASD in the population.  And, the strong evidence points to the lack of an increase ASD rates.  Let’s continue to use good science to get to the bottom of ASD and not sheer panic and anti-vaccination finger pointing.

 

Dr. Brett L. Kinsler is a chiropractor in Rochester, NY who blogs at www.RochesterChiro.wordpress.com

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