Chiro quackery - now on bebbies!

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Re: Chiro quackery - now on bebbies!

Postby qetzal » Wed Oct 23, 2013 2:46 pm UTC

davidstarlingm wrote:This may have already been answered somewhere else, but I haven't been able to find out.

In studying the efficacy of synovial spinal manipulation for the treatment of back pain, how would one begin to control for the placebo effect? The identification of areas with inflammation or low ROM is made by the practitioner at the same time as the manipulation itself, and the process is typically very noticeable. You can't double-blind an "adjustment". The only thing I could think of would be to have the patients placed under anesthesia, and then have the control group receive no treatment while the experimental group receive the manipulations....but that seems awfully risky.


Hah! I ran across this when looking up Dr. Kawchuk from earlier in the thread:

A true blind for subjects who receive spinal manipulation therapy

It's exactly that - SMT under general anesthesia. Tiny study though (n=6). Pretty unimpressive to see Canada's Research Chair in Spinal Function trying to draw conclusions from a study consisting of two groups of three!

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Re: Chiro quackery - now on bebbies!

Postby Chen » Wed Oct 23, 2013 3:01 pm UTC

qetzal wrote:It's exactly that - SMT under general anesthesia. Tiny study though (n=6). Pretty unimpressive to see Canada's Research Chair in Spinal Function trying to draw conclusions from a study consisting of two groups of three!


The conclusions weren't about SMT though. It was whether or not anesthesia could be used as a blinding technique. The important conclusions were more that the people didn't recall anything that occurred when under the anesthesia.

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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Wed Oct 23, 2013 3:06 pm UTC

Chen wrote:
qetzal wrote:It's exactly that - SMT under general anesthesia. Tiny study though (n=6). Pretty unimpressive to see Canada's Research Chair in Spinal Function trying to draw conclusions from a study consisting of two groups of three!


The conclusions weren't about SMT though. It was whether or not anesthesia could be used as a blinding technique. The important conclusions were more that the people didn't recall anything that occurred when under the anesthesia.
qetzal isn't commenting on the efficacy, but the blinding technique. That said, N=6 not exactly rigorous.
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Re: Chiro quackery - now on bebbies!

Postby qetzal » Wed Oct 23, 2013 4:27 pm UTC

Chen wrote:The conclusions weren't about SMT though. It was whether or not anesthesia could be used as a blinding technique. The important conclusions were more that the people didn't recall anything that occurred when under the anesthesia.


Money quote from the Conclusions section of the cited abstract:

Short-duration, low-risk general anesthesia can create effective blinding of subjects to the provision or withholding of SMT.


Based on n=3 people who received SMT under anesthesia, plus n=3 who did not. Note that if either group was able to correctly identify which group they were in, the blinding would fail. So the authors' conclusions rely on getting the correct outcome from two n=3 groups at once. No way in h*ll does that justify the statement quoted above. If the authors had said something like "These data suggest that short-duration, low-risk general anesthesia may be an effective blinding technique," I wouldn't quibble. But such an unqualified assertion as theirs is really quite ludicrous, even given the well-known tendency of abstracts to overstate things.

And while we're at it, there's also this line from the abstract:

Some SMT subjects reported pain reduction greater than the minimally important clinical difference and greater than control subjects.


Are you kidding me?! "Some" of the n=3 subjects reported "greater than minimally important differences" that were greater than the n=3 controls? What does that mean? One subject? Two? And "greater than minimally important clinical difference?" Seriously? If you're going to talk to me about results from n=3/group, it better be a situation where someone survived when everyone was expected to die, or something similarly remarkable. Don't talk to me about how one or two people out of three said their back felt better!

How anyone could, with a straight face, put a line like that in an abstract for peer-reviewed publication is beyond me.

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Re: Chiro quackery - now on bebbies!

Postby Chen » Wed Oct 23, 2013 4:46 pm UTC

Reading the whole article, I have to agree with you that the conclusion definitely seems overstated. Especially since in the middle of the discussion they have

Although the results of this study suggest a promising new approach, larger studies are needed before short-duration anesthesia can be considered to be an effective blinding strategy for SMT.


Seems to me that sentence should be the conclusion, rather than the one they have there.

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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Wed Oct 23, 2013 6:09 pm UTC

Yeah, truthfully, the probability of randomly guessing whether you were in the control or the SMT group here is too high to make any claims about whether or not it's even an effective means of blinding the experiment.
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 6:13 pm UTC

In the trial using standardized forces, the control group problems make me skeptical.

The use of anesthesia does seem promising, though (not that their incredibly small sample size proves much of anything). Now we just need to get a few thousand people with LBP willing to undergo general anesthesia once or twice a week for several months.

That part might be tricky.

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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Wed Oct 23, 2013 6:22 pm UTC

I'm actually surprised they introduce anesthesia as a variable. For all we know, getting knocked the fuck out (as it is) for 30m can have a therapeutic effect in and of itself.

Admittedly I don't know much about it, but accupuncture experiments are conducted by doing 'sham' accupuncture, wherein they simply stick needles in 'non accupressure points'. So, you know, why don't they do something similar to that in mock chiropractic trials?
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 6:30 pm UTC

Izawwlgood wrote:I'm actually surprised they introduce anesthesia as a variable. For all we know, getting knocked the fuck out (as it is) for 30m can have a therapeutic effect in and of itself.

Admittedly I don't know much about it, but accupuncture experiments are conducted by doing 'sham' accupuncture, wherein they simply stick needles in 'non accupressure points'. So, you know, why don't they do something similar to that in mock chiropractic trials?

Probably because there aren't any "sham chiropractic points". You can feel and hear the joint cracking when they "adjust" you, so it would be impossible to fake an adjustment; if they don't apply pressure over a joint, you will know it.

But you're absolutely right: the total relaxation from getting knocked out for half an hour could very easily overwhelm any difference in the immediate pain relief.

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Re: Chiro quackery - now on bebbies!

Postby Chen » Wed Oct 23, 2013 6:36 pm UTC

Izawwlgood wrote:I'm actually surprised they introduce anesthesia as a variable. For all we know, getting knocked the fuck out (as it is) for 30m can have a therapeutic effect in and of itself.

Admittedly I don't know much about it, but accupuncture experiments are conducted by doing 'sham' accupuncture, wherein they simply stick needles in 'non accupressure points'. So, you know, why don't they do something similar to that in mock chiropractic trials?


Seems significantly harder to do when talking about SMT. Plus I imagine manipulating someone's spine badly seems like it could have more problems than putting small needles in "non acupressure points". I mean you can lean over funny and pull something in your back without really trying. I don't see how you're going to be able to pretend to do SMT on someone.

If the anesthetic can be ruled out as any type of influence I think it would be a more definitive answer for things like acupuncture too. Some "sham" acupuncture does still pierce the skin with needles, so there's SOME physical effects. If you could, legitimately compare acupuncture to non-acupuncture with no biases from the subjects it could certainly be more concrete evidence that it's no better than placebo. Or hell maybe it will show that being poked with needles while under anesthesia can provide some sort of benefit.

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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Wed Oct 23, 2013 6:43 pm UTC

By 'sham accupuncture', the studies aim to demonstrate whether the accupuncture itself is doing anything unique, or inducing the placebo effect. Because sham accupuncture and accupuncture alike both induce identical effects, the conclusion is that the process of sticking someone with needles and telling them it's going to cure their $issue induces a placebo effect that has therapeutic benefits. The take home is not that accupuncture does nothing; it's doing something, but it's not doing something because it balances qi or whatnot.

Chiropractic treatment for everything but lower back pain and evidently maybe migraines is similar, except spinal manipulations are significantly more dangerous, I would say, than skin deep needle sticks.

It's the same with homeopathy and raike; the goal isn't necessarily 'prove that it does NOTHING', but 'prove that it is no better than the placebo'. It's an important distinction, because a lot of alt med will try and prove it's efficacy by demonstrating it does something, without using a placebo as a control.
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Re: Chiro quackery - now on bebbies!

Postby Chen » Wed Oct 23, 2013 6:54 pm UTC

Izawwlgood wrote:By 'sham accupuncture', the studies aim to demonstrate whether the accupuncture itself is doing anything unique, or inducing the placebo effect. Because sham accupuncture and accupuncture alike both induce identical effects, the conclusion is that the process of sticking someone with needles and telling them it's going to cure their $issue induces a placebo effect that has therapeutic benefits. The take home is not that accupuncture does nothing; it's doing something, but it's not doing something because it balances qi or whatnot.


Except in this case we still have an unknown variable. Piercing the skin with tiny needles. Sure intuitively this shouldn't do anything and we can attribute the benefit to placebo. But if you managed a trial where you could compare poking with needles to NOT poking with needles (in fact no doing ANYTHING) it seems like you could say for certain it was all placebo effect. I believe they have some sham acupuncture where they don't actually pierce the skin either. I'm not sure how conclusive those studies were (they pretended to pierce the skin, somehow).

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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 7:08 pm UTC

Chen wrote:Except in this case we still have an unknown variable. Piercing the skin with tiny needles. Sure intuitively this shouldn't do anything and we can attribute the benefit to placebo. But if you managed a trial where you could compare poking with needles to NOT poking with needles (in fact no doing ANYTHING) it seems like you could say for certain it was all placebo effect. I believe they have some sham acupuncture where they don't actually pierce the skin either. I'm not sure how conclusive those studies were (they pretended to pierce the skin, somehow).

Perhaps you can "tap" the skin with something like a needle that doesn't actually penetrate, and they demonstrated that people aren't able to tell the difference between an actual penetration and a tap? That's all I can think of.

There's also an element of uncertainty with respect to choosing "mock points" to begin with, as many people who have experienced acupuncture (or even learned a little about it) know where the points are supposed to be. Most of them correspond to real, actual pressure points which most people are aware of. So blinding is still going to be an issue, since you may not always be able to fool your patient.

Honestly, it seems VERY unlikely to me (absent interference from the therapeutic effects of anesthesia) that a properly-controlled anesthetized SMT for LBP trial would come up with zero correlation. SMT typically produces noticeable warmth/tingling followed by a sense of endorphin release, similar to a good stretch. It's not like non-touching Reiki, where there's literally no physiological event whatsoever.

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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Wed Oct 23, 2013 7:09 pm UTC

I thought I referenced this experiment already, but I must not have. I'm trying to find it now, but all I can find are studies comparing the efficiencies of sham to the accupuncture as similar... I find the 'mo needles is 'mo better finding to be kind of hilarious.

The study I'm thinking of now split women trying to get pregnant into three groups; the 'control' went into a dark room once a week and calmly and quietly lay down thinking positive thoughts about getting pregnant, the experiment was a group getting sham accupuncture, and a group getting accupuncture for fertility.

All three groups saw an increase in the fertility over the norm, but the two that were stuck with needles saw identical, increased, increases.
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 7:16 pm UTC

Izawwlgood wrote:The study I'm thinking of now split women trying to get pregnant into three groups; the 'control' went into a dark room once a week and calmly and quietly lay down thinking positive thoughts about getting pregnant, the experiment was a group getting sham accupuncture, and a group getting accupuncture for fertility.

All three groups saw an increase in the fertility over the norm, but the two that were stuck with needles saw identical, increased, increases.

Of course they did. The ones who were stuck with needles felt like something was being done to enhance their fertility, and so their bodies reacted accordingly. The effectiveness of a placebo is proportional to the cost, difficulty, and pain of the placebo. Getting needles jabbed into you is pretty high on the scale.

Obviously, there was no real effect beyond what they thought was happening, so there was no difference between the sham and the real acupuncture. Then again, you never know: the method of sham acupuncture might somehow be producing an actual physiological effect stronger than the real acupuncture. Or maybe it wasn't entirely sham. Or maybe getting pricked with needles actually increases fertility, but the location of the pricks doesn't matter.

Then again, I think other studies have shown a direct correlation between "location of prick" and pregnancy, so....

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Re: Chiro quackery - now on bebbies!

Postby qetzal » Wed Oct 23, 2013 7:25 pm UTC

There have been studies that used sham acupuncture needles that retract when they contact the skin, and don't actually pierce. One such study did indeed find more improvement in the sham group than in the real acupuncture group. See here for a non-scientific description with a link to the actual study.

I don't actually believe that sham works better, though. I think it's just a demonstration that clinical trials can be sloppy and give unexpected results. You shouldn't normally believe something works until it's been demonstrated consistently in multiple good studies.

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Re: Chiro quackery - now on bebbies!

Postby gmalivuk » Wed Oct 23, 2013 7:43 pm UTC

davidstarlingm wrote:But you're absolutely right: the total relaxation from getting knocked out for half an hour could very easily overwhelm any difference in the immediate pain relief.
Which, as with sham acupuncture (some of which does involve things like retracting needles, so it still feels the same but doesn't involve the actual puncture part), is why you compare the intervention to placebo, rather than to doing nothing at all.

If anesthetic with and without chiropractic manipulation has the same effect, we can conclude that the manipulation isn't what caused it.
If feeling the poke of a bunch of needles has the same effect whether or not any puncturing happens, we can conclude that the puncturing isn't what caused it.
If taking a pill has the same effect whether or not there's anything inside, we can conclude that whatever's inside isn't what caused it.

Sure, proponents of the intervention will claim this still shows efficacy, but people doing real clinical research know that no advantage over placebo implies no advantage from whatever one thing differed between the two groups.
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A more extreme example of this sort of "therapeutically active placebo" can be found in certain cancer treatment studies. Because it would be unethical to take anyone off treatment completely, what they do is continue treating everyone with whatever they're already on, and then add the experimental therapy or a placebo on top of that, to see if there's a difference in outcome. Of course everyone is still getting better or holding state largely because of the treatment they're already getting, but you can still test whether the additional therapy has any additional effect or not.

(This wouldn't, of course, work with some magical treatment that only works in the absence of any other treatment, but I'm confident enough that no such treatment exists to be okay with the risk of passing it over in the interest of not taking cancer patients off treatment entirely in the interest of testing for it.)
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 7:59 pm UTC

gmalivuk wrote:
davidstarlingm wrote:But you're absolutely right: the total relaxation from getting knocked out for half an hour could very easily overwhelm any difference in the immediate pain relief.

If anesthetic with and without chiropractic manipulation has the same effect, we can conclude that the manipulation isn't what caused it.
If feeling the poke of a bunch of needles has the same effect whether or not any puncturing happens, we can conclude that the puncturing isn't what caused it.
If taking a pill has the same effect whether or not there's anything inside, we can conclude that whatever's inside isn't what caused it.

But in designing your control/blind, you do want to make sure that your placebo and process A) have the lowest effect possible, in order to maximize the sensitivity of your trial, and B) would not in any way interfere with the proposed treatment.

For an example of A): you don't want to involve morphine as a blinding agent for a test of the efficacy of acetaminophen, because the morphine is definitely going to make the patient incapable of noting any difference caused by acetaminophen. The fact that 100 mg of acetaminophen makes no detectable difference in your pain level when you're already on a morphine drip doesn't mean acetaminophen is an ineffective drug.

For an example of B): you don't want to test the efficacy of massage for relaxation when the patient has an epidural, because the lack of information going up the spinal column is probably going to interfere with the mechanism whereby massage helps a person to relax. This does not mean that massage cannot help you relax.

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Re: Chiro quackery - now on bebbies!

Postby The Great Hippo » Wed Oct 23, 2013 8:35 pm UTC

nitePhyyre wrote:Clearly. Your 'definition' of homeopathy includes you editorializing as to whether or not it is bullshit.
My definition includes what homeopaths will happily tell you on their webpages and in their manuals: That homeopathic remedies are not derived from laboratory research, but passed-on knowledge that has been anecdotally confirmed.

The thing about pseudoscience is this: If you listen close enough, it will almost always tell you it's pseudoscience.
nitePhyyre wrote:I think you are vastly underestimating your level of knowledge on the subject. Knowing whether or not there have been advances in the field is more than the definition. Knowing whether or not there are methods to test for data, is more than the definition. Knowing whether or not there are methods to acquire data, is more than the definition. Having talked to a homeopath to let them tell you anything about homeopathy, is more than just the definition. Listening to their claims as to whether the results come from a lab or their magical knowledge, is more than the definition. Knowing even a single one of these points is a chasm away from 'just the definition'.
All the information you've mentioned above is information I've derived from one source: Knowledge that the scientific method is not an integral component to homeopathy. And I know the scientific method is not an integral component to homeopathy, because application of the scientific method is not part of homeopathy's definition.
davidstarlingm wrote:For an example of A): you don't want to involve morphine as a blinding agent for a test of the efficacy of acetaminophen, because the morphine is definitely going to make the patient incapable of noting any difference caused by acetaminophen. The fact that 100 mg of acetaminophen makes no detectable difference in your pain level when you're already on a morphine drip doesn't mean acetaminophen is an ineffective drug.

For an example of B): you don't want to test the efficacy of massage for relaxation when the patient has an epidural, because the lack of information going up the spinal column is probably going to interfere with the mechanism whereby massage helps a person to relax. This does not mean that massage cannot help you relax.
Fair enough, but such tests still give you an important datapoint in regards to chronic pain relief, which is one of the things chiropractics claim to address.

Or to put it another way: If chiropractic cures can't overcome the long-term curative effects of being anesthetized, that tells us something useful about chiropractic cures.

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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 8:44 pm UTC

The Great Hippo wrote:
davidstarlingm wrote:For an example of A): you don't want to involve morphine as a blinding agent for a test of the efficacy of acetaminophen, because the morphine is definitely going to make the patient incapable of noting any difference caused by acetaminophen. The fact that 100 mg of acetaminophen makes no detectable difference in your pain level when you're already on a morphine drip doesn't mean acetaminophen is an ineffective drug.

For an example of B): you don't want to test the efficacy of massage for relaxation when the patient has an epidural, because the lack of information going up the spinal column is probably going to interfere with the mechanism whereby massage helps a person to relax. This does not mean that massage cannot help you relax.
Fair enough, but such tests still give you an important datapoint in regards to chronic pain relief, which is one of the things chiropractics claim to address.

Or to put it another way: If chiropractic cures can't overcome the long-term curative effects of being anesthetized, that tells us something useful about chiropractic cures.

Indeed it does. :)

Of course, if it was found that regular chiropractic and regular anesthesia both provided equal relief of chronic pain via the same channels, the question might arise as to which one is a safer long-term solution....

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Re: Chiro quackery - now on bebbies!

Postby gmalivuk » Wed Oct 23, 2013 8:55 pm UTC

davidstarlingm wrote:But in designing your control/blind, you do want to make sure that your placebo and process A) have the lowest effect possible, in order to maximize the sensitivity of your trial, and B) would not in any way interfere with the proposed treatment.
Except, trials of cancer drugs violate both of these principles, which means you probably ought to make both of them a bit narrower.
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 9:02 pm UTC

gmalivuk wrote:
davidstarlingm wrote:But in designing your control/blind, you do want to make sure that your placebo and process A) have the lowest effect possible, in order to maximize the sensitivity of your trial, and B) would not in any way interfere with the proposed treatment.
Except, trials of cancer drugs violate both of these principles, which means you probably ought to make both of them a bit narrower.

Yeah, as much as we would like to be able to test cancer drugs more rigorously, it can't always be done.

Then again, there are some things you don't need a double-blinded trial for. Like most trauma surgery. I don't think there have been many double-blind placebo-controlled studies to test the efficacy of emergency laparatomy for abdominal gunshot wounds, but we don't really need them.

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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Wed Oct 23, 2013 9:33 pm UTC

No, but something like trauma surgery has, say, a few different approaches, and you can do patient followups.

I'm not trying to argue specifics here, as frankly, I'm not a trauma surgeon, but I think this notion that you can't apply rigorous testing to virtually all forms of medicine is a little risky. You can, it's just that each thing is going to require a different test. Presumably no one is going to perform the test to ascertain whether or not stopping gushing blood loss has a positive effect on patient survival outcomes, but you can assess whether Double Backed Wingfield Cross Stitches result in a more stable, less infected, smaller scar than Goulies Over Hatch Stitch.

It's this sort of understanding of what experiments are possible that let people test the claims of alt med.
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Wed Oct 23, 2013 9:48 pm UTC

Izawwlgood wrote:Presumably no one is going to perform the test to ascertain whether or not stopping gushing blood loss has a positive effect on patient survival outcomes....

That's really all I was saying, haha. I don't mean to call into question the usefulness of rigorous testing; I was just pointing out that there are at least a few situations where it's either too difficult or simply redundant. Quackery in general does not fit either of those categories, though.
Spoiler:
Though I suppose we can come up with quackeries that just can't be double-blinded. If Shamala the Spiritual Healer claims she can aid digestion by standing in front of a person and shouting "Shamala! Shamala! Shamala!" over and over again while they do jumping jacks, it's going to be pretty tough to properly double-blind it.

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Re: Chiro quackery - now on bebbies!

Postby curtis95112 » Thu Oct 24, 2013 2:49 am UTC

We could have someone shouting Mashala! Mashala! Mashala! and doing backflips.
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Re: Chiro quackery - now on bebbies!

Postby addams » Thu Oct 24, 2013 3:16 am UTC

gmalivuk wrote:
davidstarlingm wrote:But in designing your control/blind, you do want to make sure that your placebo and process A) have the lowest effect possible, in order to maximize the sensitivity of your trial, and B) would not in any way interfere with the proposed treatment.
Except, trials of cancer drugs violate both of these principles, which means you probably ought to make both of them a bit narrower.

Cancer treatment trials?
Double Blind Cancer Treatment Trials?

Two treatments that might or might not work?
That is really blind. Don't mix up your paperwork. It's Research!

Spoiler:
Back to you, Bob. What ya' studying?
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Re: Chiro quackery - now on bebbies!

Postby Jorpho » Thu Oct 24, 2013 3:39 am UTC

Izawwlgood wrote:Chiropractic treatment for everything but lower back pain and evidently maybe migraines is similar, except spinal manipulations are significantly more dangerous, I would say, than skin deep needle sticks.
Oh, there have been fatalities associated with acupuncture. There's one reported case in which a woman with a naturally-occurring hole in her sternum (not an uncommon feature, apparently) was punctured in the heart. References abound.

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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Thu Oct 24, 2013 12:23 pm UTC

Yeah, one estimate I saw claimed about 70 deaths since 2000 due to mishaps in accupuncture. Another claimed over 100 stroke related injuries or deaths (that's vague) since 2000 caused by chiropractors, and gmal's link to boot.

That's >0, sure, but given the demonstrated efficacy of accupuncture in inducing the placebo effect, I personally feel the risk is fairly low. Given the 'more needles = more placebo', it seems like we ought further investigate treatments that invoke the placebo effect more strongly.

I'd be interested in knowing whether the mythos of accupuncture has a strong correlation to the efficacy of the placebo effect; if you take patients who have never heard of it, will it still produce a placebo effect.
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Thu Oct 24, 2013 1:46 pm UTC

Izawwlgood wrote:I'd be interested in knowing whether the mythos of accupuncture has a strong correlation to the efficacy of the placebo effect; if you take patients who have never heard of it, will it still produce a placebo effect.

Studies of the placebo effect are endlessly interesting. It's sort of funny: from a public health standpoint, placebos do improve quality of life and decrease healthcare costs....yet it's unethical to give someone a treatment you know is useless. Perhaps that's why these quackeries aren't more stringently investigated. (if only, right?)

It would definitely be neat to increase the number of patient groups in studies to test some of the particulars about the placebo effect in each case. Instead of two groups (placebo and treatment), have four groups: placebo with treatment explanation, placebo without treatment explanation, treatment with treatment explanation, treatment without treatment explanation. That would give more datapoints, if nothing else.

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Re: Chiro quackery - now on bebbies!

Postby ahammel » Thu Oct 24, 2013 2:03 pm UTC

Izawwlgood wrote:Yeah, truthfully, the probability of randomly guessing whether you were in the control or the SMT group here is too high to make any claims about whether or not it's even an effective means of blinding the experiment.

A quick calculation shows that the probably that all six of the guessed correctly is 1/10, which is pretty thin stuff for an actual paper.

The real result seems to be: "the ethics board will totally let you anaesthetize healthy people for no medical reason, guys!"
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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Thu Oct 24, 2013 2:30 pm UTC

davidstarlingm wrote:yet it's unethical to give someone a treatment you know is useless.
There are a few conditions for which the recommended treatment is placebo. The first article that popped up indicates it's fairly commonly used too, although for things I admit I'm surprised by. I can imagine a few instances where it is a sensible treatment; certain psychological issues or stress related issues may 'just' require someone take the time to talk to you about your problem, listen to your complaints, and reassure you that things will be alright. I put quotes there because I think that's no small thing, and indicate I'm not suggesting stress related or psychological issues are non-existent.

It would be interesting to see how much the effect vanishes when people are aware of the placebo being a placebo though. I keep thinking about how the Bene Gesserit installed a myth/legend around the galaxy as a means to protect future sisters; I wonder if doctors could start seeding myths about less invasive/risky treatments effectiveness.

All kidding aside though, I am extremely interested in the history of medical luddite-ism; throughout history there's been this strange mix of 'old is better' and 'holy shit xrays are rad lets blast ourselves with healing xrays!', but when the establishment touts something, it's something evil. I'm genuinely curious why humans exhibit this anti-authority perspective with some things but not others ("The AMA says it's bad, but the ACA says it's great, fuck the AMA, those guys are just ivory tower elite, the ACA knows all about what's best for me!")
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Re: Chiro quackery - now on bebbies!

Postby addams » Thu Oct 24, 2013 3:14 pm UTC

Izawwlgood wrote:Yeah, one estimate I saw claimed about 70 deaths since 2000 due to mishaps in accupuncture. Another claimed over 100 stroke related injuries or deaths (that's vague) since 2000 caused by chiropractors, and gmal's link to boot.

That's >0, sure, but given the demonstrated efficacy of accupuncture in inducing the placebo effect, I personally feel the risk is fairly low. Given the 'more needles = more placebo', it seems like we ought further investigate treatments that invoke the placebo effect more strongly.

I'd be interested in knowing whether the mythos of accupuncture has a strong correlation to the efficacy of the placebo effect; if you take patients who have never heard of it, will it still produce a placebo effect.

Yes! But; If the patient has never heard of Acupunture,
Only God knows what the effect might be.

It would depend upon so many things.
Placebos can be very powerful.

The skin is attached to the body.
The body is attached to the soul.

The ankle bone is connected to the shin bone.
Spoiler:
I am a little defensive. Adults can sing children's songs.
In Anatomy some people sing that song and turn it into peaces of the body.

I can't do that.
I can barley, on a good day, do gross anatomy with that song.



Spoiler:
I started learning anatomy when my ankles and elbows were giving me Language problems.
I was Four. My brother teased me. I did not know my ankle from my elbow.
If you had a Alien friend; How long would it take you to teach it the words elbow and ankle?

I thought they worked about the same. He was offended that I used the words interchangeably.
"Come on. You can do this. Elllbow. He would touch my elbow.
"AnkeeL." He touched my ankle.

Then he said, "You say it."
I said it. Then we went of to tell, Mom and Pepper.

People seem to instinctively know how to teach.
To repeat a thing is to force it into longer and longer term memory.
So; A new thing is told three times.

Then the next time a person might not mess it up.
I know the difference between my ankle and my elbow, now.

Do we know the difference between the body and the soul?
The body has an ankle. The soul has a sense of humor.
See?

In the coulocual;
ya' mess with the ankle, ya' messed with the body.
ya' make someone laugh, ya' messed with the soul.

Placebo effects can be as different as any two or more drugs.
Look at Tattoo! What is that if not acupuncture?

Will a person, really, look you in the eye and say; "These tattoos had no effect on me." Really?
(shrug) Does acupuncture work? Does Tattoo?
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Re: Chiro quackery - now on bebbies!

Postby qetzal » Thu Oct 24, 2013 3:19 pm UTC

It's actually not clear that placebos have any real effect on disease. Remember - just because someone gets better when given a placebo, doesn't mean the placebo made them better. In many (most? all?) cases, they would have gotten better just as fast if given nothing at all. Also, just because someone thinks or says they got better, doesn't mean they really did.

A recent review on this concluded:

We did not find that placebo interventions have important clinical effects in general. However, in certain settings placebo interventions can influence patient-reported outcomes, especially pain and nausea, though it is difficult to distinguish patient-reported effects of placebo from biased reporting. The effect on pain varied, even among trials with low risk of bias, from negligible to clinically important. Variations in the effect of placebo were partly explained by variations in how trials were conducted and how patients were informed.


For a less technical discussion of this, see here.

Note that I'm not personally convinced there is absolutely no such thing as a 'real' placebo effect. Just pointing out that it's controversial, and at least some researchers who study placebos are skeptical that there's anything significant occurring.

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Re: Chiro quackery - now on bebbies!

Postby addams » Thu Oct 24, 2013 3:58 pm UTC

qetzal wrote:It's actually not clear that placebos have any real effect on disease. Remember - just because someone gets better when given a placebo, doesn't mean the placebo made them better. In many (most? all?) cases, they would have gotten better just as fast if given nothing at all. Also, just because someone thinks or says they got better, doesn't mean they really did.

Yes. This is true.
Think about it.

There was a Zen like story.
It was told over and over by Judy.

The common cold has an acute duration of five days.
If you treat the cold it will be acute and begin to subside in five days.
If you do not treat the cold it will be acute and begin to subside in five days.


Who is the Hero? The Nanny that treats the common cold?
Why treat it? Because! It is good for the soul!

Do we need to argue the existence of the soul?
Can we use the word Mind interchangeably with the word soul?

Do you think we should treat people that are unconscious?
The body. If the person is not home, but the lights are on, it is still their home.
I vote for treating it with respect. Even after the lights go out.

Sometimes our treatment of others is good for the giver, more than the receiver.
We can not measure the good to the dead. We can measure the good to the living.

There is hard objective data.
There are soft, subjective statements.

(shrug) Do you want a placebo? What kind?
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Re: Chiro quackery - now on bebbies!

Postby DaBigCheez » Thu Oct 24, 2013 6:13 pm UTC

My understanding is that the placebo effect doesn't mean faster recovery from an infection or whatnot, but lessens associated pain/nausea/stress, which are often a big part of the problem on the patient's end *while* the infection is clearing up on its own. That's the "can influence patient-reported outcomes, especially pain and nausea" bits; if you genuinely think you feel better, is that different in any meaningful way from "actually" feeling better, at least as far as the 'feeling' (e.g. pain) is concerned?
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Re: Chiro quackery - now on bebbies!

Postby Izawwlgood » Thu Oct 24, 2013 6:23 pm UTC

Well, one example; my friend in high school had bad migraines, caused by grinding her teeth. She was grinding her teeth because she was stressed and anxious. Her shrink or doctor or whatever prescribed anti-anxiety meds over the course of therapy, and by taking them, and seeing a therapist, she dealt with her anxiety, which caused her to stop grinding her teeth, which made her migraines go away. Turns out the anti-anxiety meds were a placebo. The idea was that they gave her a sense of control over part of her issues, and again this notion of having a ritual of caring for yourself having therapeutic benefits. /anecdote

So, I dunno. I don't think people generally hold the placebo effect will stop a bacterial infection or cure cancer or set a misaligned broken bone, but psychosomatic disorders are a thing. I'm highly skeptical of accupuncture or chiropractic treatments doing what they claim to do, but anything related to patient stress seems like reducing said stress may have therapeutic effects. The point isn't thus that these treatments work, but that the placebo effect works. If you want to designate a thing as 'placebo effect inducer', that's cool, just make sure it's as minimally risky as possible, and that you encourage patients to seek actual treatment for other treatable issues. If a patient has cancer and migraines, maybe accupuncture or chiropractic treatment will alleviate the migraines; if so, great, but don't also look to accupuncture or chiropractic treatments as a chemo replacement.
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Re: Chiro quackery - now on bebbies!

Postby davidstarlingm » Thu Oct 24, 2013 6:46 pm UTC

Izawwlgood wrote:I don't think people generally hold the placebo effect will stop a bacterial infection or cure cancer or set a misaligned broken bone, but psychosomatic disorders are a thing. I'm highly skeptical of accupuncture or chiropractic treatments doing what they claim to do, but anything related to patient stress seems like reducing said stress may have therapeutic effects. The point isn't thus that these treatments work, but that the placebo effect works. If you want to designate a thing as 'placebo effect inducer', that's cool, just make sure it's as minimally risky as possible, and that you encourage patients to seek actual treatment for other treatable issues. If a patient has cancer and migraines, maybe accupuncture or chiropractic treatment will alleviate the migraines; if so, great, but don't also look to accupuncture or chiropractic treatments as a chemo replacement.

And most chiropractors are well aware that encouraging patients not to do chemo or follow other medically-prescribed courses of treatment will get them in big trouble.

A placebo won't stop a bacterial infection, but it may have a measurable effect on recovery time (if, for example, other treatment is not available).

And for migraines or a pinched nerve or soft tissue spinal injury, the elevated placebo effect associated with a chiropractic adjustment may make it the least invasive, most effective means of promoting relaxation of muscles, etc.

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Re: Chiro quackery - now on bebbies!

Postby gmalivuk » Thu Oct 24, 2013 7:00 pm UTC

ahammel wrote:
Izawwlgood wrote:Yeah, truthfully, the probability of randomly guessing whether you were in the control or the SMT group here is too high to make any claims about whether or not it's even an effective means of blinding the experiment.

A quick calculation shows that the probably that all six of the guessed correctly is 1/10, which is pretty thin stuff for an actual paper.
Whereas an accurate calculation shows 1/64, surely?
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Re: Chiro quackery - now on bebbies!

Postby qetzal » Thu Oct 24, 2013 9:56 pm UTC

davidstarlingm wrote:A placebo won't stop a bacterial infection, but it may have a measurable effect on recovery time (if, for example, other treatment is not available).


But that's the point. A placebo won't have a measurable effect on recovery time for a bacterial infection. At least, not if you accept the data such as I linked previously, which says that placebos don't have objective physiological effects.

A placebo might make the patient feel better, or think they feel better, or say they feel better (which are not all equivalent!), but that doesn't mean they objectively are better.

(Maybe that's really what you meant anyway - that a placebo may have a measurable effect on recovery time as reported by how the patient says they feel? Apologies if so.)

gmalivuk wrote:
ahammel wrote:
Izawwlgood wrote:Yeah, truthfully, the probability of randomly guessing whether you were in the control or the SMT group here is too high to make any claims about whether or not it's even an effective means of blinding the experiment.

A quick calculation shows that the probably that all six of the guessed correctly is 1/10, which is pretty thin stuff for an actual paper.
Whereas an accurate calculation shows 1/64, surely?


True. If all 6 correctly identified their group, you could tentatively conclude that the blinding did not work. But it's worth noting that that's really the only situation where you could have any confidence. if 5 of 6 were correct, you couldn't statistically distinguish that from either random guessing or from a situation where 2/3 of participants could reliably identify their group. So even as just a pilot study, doing n=3/group was basically a waste of time. Those six people went through brief anesthesia for a study that really never had a chance to reach a useful conclusion at all!

So I would dispute even the authors' watered down claim that the results are promising. I contend they are essentially useless. Again, pretty lame for someone who is supposedly one of the stars of chiropractic research.

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Re: Chiro quackery - now on bebbies!

Postby Zcorp » Thu Oct 24, 2013 10:58 pm UTC

Izawwlgood wrote:Well, one example; my friend in high school had bad migraines, caused by grinding her teeth. She was grinding her teeth because she was stressed and anxious. Her shrink or doctor or whatever prescribed anti-anxiety meds over the course of therapy, and by taking them, and seeing a therapist, she dealt with her anxiety, which caused her to stop grinding her teeth, which made her migraines go away. Turns out the anti-anxiety meds were a placebo. The idea was that they gave her a sense of control over part of her issues, and again this notion of having a ritual of caring for yourself having therapeutic benefits. /anecdote

I was going to be done with you, but this is just possibly dangerous misinformation.

It is illegal to prescribe a placebo.

Either your friend lied to you, you are lying to us now or your friend - who I assume is a minor? - got signed up for a anti-anxiety drug trial.


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