Quackademic medicine invades the military again

As much as I write about the infiltration of quackademic medicine into medical academia, there is one particular area that is being increasingly invaded by such quackery. It’s an area that you wouldn’t necessarily expect, although anyone who’s read The Men Who Stare at Goats might not be so shocked. Yes, I’m referring to the military, and, as I’ve documented time and time again, increasingly our men and women in uniform are being subjected to abject quackery. What they need and deserve is the very best science-based medicine that we as a nation have to offer. Instead, what more and more of them are getting is “auricular acupuncture,” or, as it’s sometimes called, “battlefield acupuncture.” Indeed, a few years ago, while the conflict in Iraq was still raging, the Air Force began teaching physicians being deployed to that conflict “battlefield acupuncture.” Under the malign influence of a Colonel named Richard Niemtzow, a radiation oncologist and Air Force physician who has “pioneered” (if you can call it that) the introduction of this particular form of woo into the military and sold it with an evangelical zeal, the hard-nosed military doctors who want evidence and science to show them the best way to treat wounded soldiers are increasingly being seduced by the lure of alternative medicine.

And now the virus is spreading beyond soldiers with acute and chronic pain syndromes, which was the first population upon which Col. Niemtzow and his acolytes plied their wares. Now, it would appear, acupuncture is being sold for post-traumatic stress disorder (PTSD). Worse than that, though, it’s no longer just acupuncture. It’s reiki. Actually, it’s healing touch, but given that all “energy medicine” modalities, such as healing touch, reiki, and several others, are merely variations on the theme of vitalism, it doesn’t much matter. The only difference between reiki and healing touch is that reiki involves the practitioner’s making symbols with his hands, and healing touch doesn’t necessarily require that. Otherwise, both involve channeling mystical energy from a “universal source” through the healer and into the patient to heal him. At, least, that’s what healing touch practitioners and reiki masters claim to be able to do. Now this quackery is being touted as helpful for soldiers suffering from PTSD:

Healing touch combined with guided imagery produces significant measurable reductions in post-traumatic stress disorder (PTSD) symptoms for combat-exposed active duty soldiers, according to a recent study.

The study, led by the Scripps Center for Integrative Medicine in San Diego, California, involved 123 returning active-duty Marines at Camp Pendleton, California from July 2008 to August 2010.

To be eligible for the trial, participants were screened to confirm that they were currently experiencing at least one of the following PTSD symptoms: re-experiencing of trauma via flashbacks, nightmares, intrusive thoughts, exaggerated emotional responses to trauma, emotional numbness, insomnia, irritability, exaggerated startle response or avoidance of people or places that remind them of the trauma.

Writing in the journal Military Medicine the researcher say they found that patients receiving these complementary medicine interventions showed significant improvement in quality of life, as well as reduced depression and cynicism when compared to soldiers receiving treatment as usual alone.

The healing touch is described thusly:

Healing touch (also called therapeutic touch or Reiki) is an energy-based, non-invasive treatment that restores and balances the human energy field to help decrease pain and promote healing. It is often used as an adjunct to surgery and other medical procedures to assist in pain reduction, decrease anxiety and elicit relaxation.

Yes, indeed. Quackademic medicine somehow found its way into Camp Pendleton!

Now, guided imagery in and of itself might not be quackery. There’s some evidence and some plausibility that it might be helpful for some things, although for most applications it’s probably not ready for prime time yet. Not that that stops woo-meisters from using it liberally, of course, and, as in this case, combining it with more hard-core quackery. And few forms of quackery are as seriously quacky as therapeutic touch, a concept so dumb that even an 11-year-old girl can design a study that demonstrates that it doesn’t work. Apparently the doctors involved with this study don’t read the literature—or don’t care.

As I repeat so often that my audience either yawns or gags every time I do it, whenever I see a study like this described in the lay press, I have to go to the source. I have to look up the original study and see if it actually shows what it is claimed to show. Whenever I do this, quite commonly I find that what the study concludes and what the news report says the study concludes are related only by coincidence. Alternatively, what I frequently find is that the study has at least one fatal error that renders its conclusions not supported by the data. What will it be in this case? Will this be a case in which a well-designed study actually finds that therapeutic touch has objectively measurable effects so compelling that they force us to reconsider the utter implausibility of theapeutic touch?

Nope. The current laws of physics that proclaim therapeutic touch and other forms of energy healing to be physically impossible are safe. There are no data in this paper that make us wonder about them at all because the study does indeed have a fatal flaw, which I’ll get to very soon. In fact, I’d be shocked if my regular readers don’t see it immediately just by reading the abstract:

Post-traumatic stress disorder (PTSD) remains a significant problem in returning military and warrants swift and effective treatment. We conducted a randomized controlled trial to determine whether a complementary medicine intervention (Healing Touch with Guided Imagery [HT+GI]) reduced PTSD symptoms as compared to treatment as usual (TAU) returning combat-exposed active duty military with significant PTSD symptoms. Active duty military (n = 123) were randomized to 6 sessions (within 3 weeks) of HT+GI vs. TAU. The primary outcome was PTSD symptoms; secondary outcomes were depression, quality of life, and hostility. Repeated measures analysis of covariance with intent-to-treat analyses revealed statistically and clinically significant reduction in PTSD symptoms (p < 0.0005, Cohen's d = 0.85) as well as depression (p < 0.0005, Cohen's d = 0.70) for HT+GI vs. TAU. HT+GI also showed significant improvements in mental quality of life (p = 0.002, Cohen's d = 0.58) and cynicism (p = 0.001, Cohen's d = 0.49) vs. TAU. Participation in a complementary medicine intervention resulted in a clinically significant reduction in PTSD and related symptoms in a returning, combat-exposed active duty military population. Further investigation of GT and biofield therapy approaches for mitigating PTSD in military populations is warranted.

Did you figure it out? Did you guess even before you read the abstract? Yes, notice how this is a completely unblinded study, which renders is virtually useless. There are a lot of other serious flaws, but that’s the fatal one, particularly in a study of a condition where objective measures are hard to come by. It’s so bad that I wonder why they even bothered to do the study. In fact, it’s so bad that I wonder why any IRB would have approved it, as it’s unethical to do a study with such an implausible mechanism and a design guaranteed to provide no answer to the hypothesis being tested. Yes, I realize that it’s only a pilot study and that it was only meant to look for indications of efficacy, but that makes it even worse. It also doesn’t help that the authors completely buy into the pseudoscientific rationale behind therapeutic touch:

Participants randomized to the intervention group received a combined intervention of HT+GI. The purpose of combining these interventions was to provide the participant both with practitioner-based treatment (HT) to establish a “safe space” using a nonstigmatizing touch-based therapy aimed at eliciting the participant’s own healing response, whereas also engaging in a self-care therapy (listening to GI CD) that helped the patient to work with trauma-related issues including trust and self-esteem. HT is a type of biofield therapy that involves gentle, noninvasive touch by trained practitioners, who utilize specific techniques with the intention of working with the body’s vital energy system to stimulate a healing response. Two nurses certified in HT, with several years of experience in using HT with patients, provided the HT intervention. Practitioners met on a regular basis to discuss use of specific techniques and ensure intervention delivery consistency. Practitioners utilized three specific HT techniques: Chakra Connection (involving techniques used along the body, intended to stimulate movement of vital energy through the body), Mind Clearing (techniques performed on the head, intended to stimulate mental relaxation), and Chakra Spread (an advanced technique utilized by HT practitioners and generally reserved for patients with more severe symptoms, intended to promote deep healing for emotional and/or physical pain).

Chakra Spread? I had never heard of it before. Fortunately, the power of almighty Google rapidly educated me. You really have to get a load of the nonsensical description that I just linked to. It includes instructions to “focus on the love that God has for this person while slowly spreading both hands outward as far as possible three times”; “pull access energy off the legs and feet by placing your hand over each leg and moving slowly downward”; and “visualize energy being pulled up from the earth through your spine and spreading throughout your body.” I suppose I should be relieved that the Chakra Spread is one of the approved Healing Touch interventions, which also include: Magnetic Clearing, Chakra Connection, Ultrasound, Laser, Scudder, Pain Drain, headache, back and neck techniques, Spiral Meditation, Hopi Techniques, Mind Clearing, Wound Sealing, Chelation, Etheric Clearing, Lymphatic Drain, Full Body Connection, Etheric Vitality. Also remember that this nonsense is taught in quite a few nursing schools and used by nurses in many hospitals. So seeing it in the military is, albeit disappointing, not entirely unexpected. Seeing it used in a quackademic clinical trial at Camp Pendleton is enough to make a marine cry.

Here’s the thing. The study proposed is designed such that, even if perfectly executed, it can’t falsify its hypothesis. There’s no way to tell whether any improvements in the HT + GI group are due to pure placebo effect or might be due to a treatment effect. Again, there is no blinding whatsoever; so both patient-related confounders (such as placebo effects) and practitioner-related confounders (observation effects, expectation bias) come into full play without anything to check them. That’s leaving aside the numerous other flaws in the experimental design, such as lack of adequate followup, small numbers, lack of adherence monitoring, and low representation from some minority groups. Worse, because the GI is combined with the HT, there’s no way to tell whether any positive result is due to the GI, the HT, or requires both. Ignoring for the moment the utter physical and biological implausibility of therapeutic touch, it is possible to do a study with a rigorous design. Basically, you would set up experimental groups not as TAU versus HT+GI. Rather, you would have the following groups:

1. TAU
2. TAU + HT
3. TAU + GI
4. TAU + HT + GI

In addition, you would have to have additional groups, which, for want of a better term, we would refer to as “sham GI” and “sham HT.” For instance, sham GI could involve giving the soldier incorrect instructions how to do it, and sham HT could involve doing it at the “wrong” places, much as sham acupuncture involves sticking needles into the “wrong” locations. So then we would have the following additional groups:

5. TAU + sham HT
6. TAU + sham GI
7. TAU + sham HT + Sham GI

I realize that’s a lot of groups for a pilot study. If the investigators are so completely convinced that the GI and HT have to go together, the number could be whittled down to two in the simplest configuration:

1. TAU + HT + GI
2. TAU + sham HT + sham GI

Then, if this study is to be rigorous, it needs to be double blind. The patients can’t know what they’re getting, and the investigators assessing their PTSD measures can’t know which patient is in which experimental group. If the authors could do the study they published, they certainly could have done this study if they had really wanted to. Apparently they didn’t really want to. Why, who knows? Yes, it’s a lot more of a pain in the posterior to double blind the experiment, and to include sham HT and GI, but then if they got an answer it might have meant something, although given that HT is nothing more than a form of faith healing any therapeutic effect would have had to have come from the GI. As it is, the results showing less depression, less cynicism, and decreased PTSD symptoms tell us nothing. They could all be due to a combination of placebo effects and observer bias. All that work was done for, in essence, nothing and tells us nothing. The faxt that it is randomized and controlled doesn’t matter; the randomization is completely wasted.

Finally, I wanted to conclude by taking a look again at the rationale for combining the HT and GI. A more pseudoscientific load of—if you’ll excuse me, in light of the recent Vice Presidential debate, I can’t resist—malarkey is hard to imagine:

The decision to combine the two complementary medicine interventions was based on consultations with expert practitioners who, based on prior experience with similar populations, suggested that the combination of both biofield healing and GI would synergize to provide maximum effectiveness in reducing PTSD symptoms in the following manner: the GI, which focuses on creating a sense of spiritual safety and deep relaxation, provides an atmosphere where the participant could allow him or herself to safely and deeply engage into a relaxation response and therefore also gain maximum benefit from the interaction with the HT practitioner. The continued pairing of this relaxation response with the positive and trusting interaction with a health care professional and invitation for spiritual grounding and self-connection would further the possibility of the mind–body to “let go” of the residual conditioning of previous trauma, and thus reduce PTSD symptoms. The underlying rationale for combining the two techniques is not unlike the underlying rationale for many psychotherapeutic approaches, where it is understood that establishing trust, rapport, and often also a sense of relaxation are fundamental to the therapy process—it is thought that with this foundation, the engagement in cognitive or behavioral processes to “process and let go” of traumatic experiences for symptom reduction is more effective. Thus, it may be argued that the main difference between these so-called “traditional” psychotherapeutic approaches and these “complementary medicine” approaches are simply the explicit foci of the therapies (i.e., practitioner focus on cognitive or behavioral techniques vs. practitioner focus on spiritual-energetic techniques).. Whether the actual underlying mechanisms surrounding current psychotherapeutic approaches and many practitioner-assisted complementary medicine approaches are different remains to be elucidated.

Ya think?

This entire lengthy paragraph (and I didn’t even quote the entire paragraph) is the written equivalent of the waving of hands to cast a magical spell, much as Doctor Strange does—or the way that Harry Potter waves his wand around when casting a spell. Heck, healing touch practitioners basically visualize energy flowing through them and through the patient much like this image:

The main difference is that, in the world of Doctor Strange or Harry Potter, magic actually works and has rules. Here, the practitioners of the quackery that is healing touch make it up as they go along, the only rule being, apparently, that wishing makes it so.