Scott Fausel's Letter to Compendium
 
 

Lamoille Valley Veterinary Services
278 VT 15 E
Hyde Park, VT 05655

December 21, 1997
Douglass K. Macintire, DVM, MS
Small Animal Editor, Compendium
Department of Small Animal Surgery and Medicine
College of Veterinary Medicine
Auburn University, AL 36849
 

Dear Dr. Macintire,

I'm writing you in response to the article entitled Acupuncture Therapy in Small Animal Practice. It concerns me deeply that an article on a veterinary pseudoscience was presented in a heretofore scientific veterinary journal. Endorsements such as this, and the perplexing AVMA stance on acupuncture (and "alternative medicine" in general), only serve to falsely enhance the credibility of these scientific pretenders. Allow me to offer a point-by-point critique of the article and cite examples demonstrating the dangers of treading into such scientifically unsound waters.

The article opens in typical fashion by offering a long history of acupuncture. The clear implication is that, since acupuncture is an "old" therapy that has changed little in millennia, it must be valid. This is a clear-cut logical fallacy. Were it a reasonable argument, we might also endorse ritual cannibalism! ("Practitioners" of this particular "alternative therapy" believe it's a means of acquiring the strengths and virtues of kinsmen and adversaries.) After all, ritual cannibalism persists in parts of the world unchanged through countless centuries. Therefore, advocates "know it works" without the benefit of objective scientific data, and presumably we should take their word for it. By the same standards, the scientific "validity" of astrology has also been established beyond reasonable doubt.

Describing U.S. History, the author mentions the National Association for Veterinary Acupuncture (NAVA) which "conducted research, treated clinical cases, and conducted courses in acupuncture for veterinarians until 1978. The organization became inactive because acupuncture developed into an accepted modality available in conventional veterinary practices." Where is the data obtained by NAVA, and what did it indicate? The reference for this paragraph is only a brochure! How or why did acupuncture develop into an "accepted modality?" There are no answers to these questions because as we will see, there is little or no data to support the claimed clinical efficacy of acupuncture. The very name of the organization suggests NAVA is an acupuncture advocacy group rather than an open-minded and objective group of scientists trying to investigate the subject.

This trend of claiming scientific merit by endorsement is common to all branches of pseudoscience, and the technique is used throughout this article. It is one variety of "argument by appeal to authority." Such offerings are made in lieu of objective evidence or compelling rational argument. According to your article: "The favorable change of attitude is best reflected by the fact that chapters on acupuncture are now included in reputable veterinary medical texts and journals, mainstream publishing companies are publishing veterinary acupuncture textbooks, and the AVMA has changed its recommendations on veterinary acupuncture." Later we read: "The most current change in the guidelines was approved by the AVMA in 1996 and reflects the change in attitude regarding veterinary acupuncture." The argument is circular: acupuncture is accepted by certain groups, therefore it must have scientific merit and therefore it should be accepted by more groups, and so on. Somewhere we forgot to ask for a "minor" detail known as evidence!

The author asks "Does Acupuncture Really Work?" The question is so general as to be meaningless. Even if there were good evidence that acupuncture is effective above placebo at treating a specific condition (and there is not), that still does not give one liberty to extrapolate its usefulness to the treatment of other disease processes. The author claims: "Clinical studies and experimental reports indicate that, if used properly and competently, acutherapy is a safe and effective modality for specific conditions." What are these specific conditions, exactly? Furthermore, it is stated: "In veterinary medicine, a wide variety of reproductive, musculoskeletal, pulmonary, gastrointestinal, neurologic, and dermatologic disorders have been treated with considerable success in many species." These are scientifically unsubstantiated claims. The references cited in the article consist mostly of review articles, textbook chapters, "how-to" books, letters, reviews and anecdotal reports. Moreover, they are redundant (e.g., many of the references are contained within the two Ettinger references), circular and even duplicate (Klide). The few clinical trials cited demonstrate poor experimental design wherein little attention is paid to proper application of the scientific method (e.g. Wright, et. al.).

I have trouble believing the Compendium editorial staff reviewed these references with a critical eye. Dr. Carl Osborne (on your editorial board) has written several fine articles concerning the dangers of assuming cause and effect between temporally related events. That is one reason why we cannot and should not accept subjective "clinical impressions" based on anecdotes, personal observations and uncontrolled trials as evidence for the efficacy of acutherapy or any other modality. Several well-designed studies refute or show no evidence for the efficacy of acupuncture. Even more significantly, a number of excellent meta-analytical studies clearly demonstrate grave flaws in those studies which appear to support the efficacy of such alleged therapy. Consider the following:

J Clin Epidemiol 1990;43(11):1191-1199
Acupuncture and chronic pain: a criteria-based meta-analysis.
ter Riet G, Kleijnen J, Knipschild P

A literature search revealed 51 controlled clinical studies on the effectiveness of acupuncture in chronic pain. These studies were reviewed using a list of 18 predefined methodological criteria. A maximum of 100 points for study design could be earned in four main categories: (a) comparability of prognosis, (b) adequate intervention, (c) adequate effect measurement and (d) data presentation. The quality of even the better studies proved to be mediocre. No study earned more than 62% of the maximum score. The results from the better studies (greater than or equal to 50% of the maximum score) are highly contradictory. The efficacy of acupuncture in the treatment of chronic pain remains doubtful.

Publication Types:

Meta-analysis

And:

Semin Arthritis Rheum 1985 May;14(4):225-231

Acupuncture for rheumatoid arthritis: an analysis of the literature.
Bhatt-Sanders D

Despite the claims that acupuncture is beneficial in the treatment of stages I and II rheumatoid arthritis (RA), few satisfactory double-blind controlled studies exist. A review of the world literature showed eight studies examining the efficacy of acupuncture in RA. Five studies claim that acupuncture treatments give significant pain relief. Two studies claim that there is no significant difference between real and placebo acupuncture in RA. One study claims that acupuncture has anti-inflammatory effects. Analysis of problems related to study design demonstrates that methodological flaws invalidate in varying degrees the broad spectrum of conclusions. The need for a more effective therapeutic armamentarium in the treatment of RA makes it imperative that satisfactory trials of acupuncture for RA be conducted in the future.

Publication Types:

Clinical trial

Review

And:

Br J Rheumatol 1986 Aug;25(3):271-275
A controlled study of acupuncture in neck pain.
Petrie JP, Hazleman BL

Twenty-five out-patients with chronic neck pain participated in a prospective, randomized trial of acupuncture versus placebo transcutaneous nerve stimulation. A single-blind, non-cross-over design incorporated several outcome measures in an attempt to determine any particular facet of pain that responded to acupuncture. No significant difference between the two treatments was found either post-treatment or at follow-up. Whilst the small population studied limits the conclusions that may be drawn, these findings suggest that acupuncture may have no greater effect than that of a powerful placebo.

Publication Types:

Clinical trial

Randomized controlled trial

In the most rigorously scientific journals and literature, articles along these lines far outnumber ones supportive of acupuncture. In other words, the preponderance of high-quality scientific studies clearly refute acupuncture efficacy rather than support it. In fact, a striking inverse correlation exists between the scientific rigor of the studies in question and the likelihood they will offer support for the efficacy of acupuncture. One cannot help but notice as well the absence of supportive studies for acupuncture in the more rigorous journals. The scientific method is the "acid test" for "conventional medicine." Objective evidence derived from properly controlled, blinded, randomized and statistically significant studies is the "gold standard." Why shouldn't "alternative" therapies be held to the same standards?

I can tell you why I think that they should be held accountable. The growing use of unproven "alternative" therapies and remedies in place of those based on science is, in my opinion, unethical and poses a real danger to the very patients we have promised to help. There is a place for experimental medicine: where proven therapy is unsuccessful, too expensive or does not yet exist. It has no place in the "front line" treatment of patients and no right to claim scientific validity in the absence of any evidence to support it. Consider these recent (and very public) "recommendations" offered by alleged "authorities" on "alternative veterinary therapies" in a popular nation-wide veterinary forum: (emphasis added)

"The only part of the 5 Element cycle I would use on this dog is the Liver Invading the Earth causing Stagnation and the accumulation of Damp (aka Phlegm) in the MJ. The stomach has now become a phlegm bucket and thus not moving (Stagnation) and since the ST Qi can't move downward and it is fill up, oops the vomit. Go to Zangfu pathology and 8 Principles for the easier way to diagnose this one."

And:

"The (PEMPHIGUS) lesion around the vulva could be treated with LIV 5, the Luo pt. Has a special action for puritis(sic) of the vulva. If there is no puritis(sic), this would not be wind and I would use LIV 8 and SP 9 for the Damp Heat. It sounds like Damp Heat on the nose, also. LI4, 11 ST 44 could be used for Damp Heat in the Yang Ming. GB 20 for Wind Heat in the head; YangMing, GV 14, BL 13 for the Lungs. As far as herbs: Lithospermum 15 from ITM (specifically designed for lupus) Clears Toxin, vitalizes Blood and includes some tonic herbs. This condition, besides Damp Heat, could also be Heat Toxin in the skin. Coptis and Scute would be a good formula for this. If the dog is Yin Deficient, you may want to add herbs to clear the Yin Defeciency(sic) as well."

And:

"Hyperthyroidism is characterized in most human TCM books as an imbalance in the Liver energy. Emotional problems cause a stagnation in the Liver which causes heat to rise. This heat dries out the channels in the neck and so the lumps (enlarged thyroid) form. The Rising Liver Fire also causes the hyperactivity and anger sometimes seen in the hyperthyroid individual. So begin your analysis in the Wood element, but see how the rest of the symptom picture looks. Consider treating Liv 3, GB 20, Bl 18. Frequently boosting the Yin will also help to cool the Fire in the Liver channel, so you may want to treat Kidney tonifiers like Ki3. The muscle wasting common to the disease may be due to Blood deficiency from the Liver imbalance and the deficient Yin. Depending on the individual you can try herbal formulas that specifically tonify Yin and bring down Deficiency Fire (like Temper Fire, K'an Herb Co., Scott's Valley, CA) or something to soften the Wood like Relaxed Wanderer aka Hsiao Yao or Minor Bupleurum formula. Remember to treat the CAT not the hyperthyroidism and you will have a much better chance of a positive outcome."

Do you consider this sound advice for the treatment of chronic vomiting, autoimmune skin disease or hyperthyroidism? Yet this is the proverbial Pandora's Box that we are allowing to be opened when we mix science with pseudoscience! I noticed no mention of "Liver invading the earth" or "Stagnation and accumulation of the damp" in the Compendium article. It is, of course, "Mr. Hyde" waiting in the wings while "Dr. Jekyll" attempts to gain scientific respectability. As scientists, we need to ensure that veterinary medicine does not become compromised by pseudoscience. To do this we need to remain vigilant and insist that all the techniques and remedies we employ be held to the same scientific standards. To do less is to make a mockery of medicine and science and lead to a "lawless" scientific society.

I would like to request that you publish an editorial from the viewpoint of "conventional" scientific medicine. The Compendium likely exerts a certain influence on the veterinarians who read it. Certainly it lends the "imprimatur of science" to any therapy advocated within its pages. Many of our colleagues do not have advanced degrees or scientific training and may not realize the paucity and misrepresentation of data "supporting" acupuncture. Likewise, they may be unable to distinguish between honest scientific investigation of therapeutic claims and the pseudoscientific literature of those advocating the use of such alleged therapies without the benefit of valid scientific support. Your article may mislead many to believe that acupuncture is accepted by science when in fact just the opposite is true.

Our patients cannot speak for themselves; we must speak for them. I've enclosed an excellent position paper concerning acupuncture by the National Council Against Health Fraud (NCAHF). Although not aimed directly at the veterinary community, it contains a message we should all heed: "we can either wake up or expect to see scientific medicine -- veterinary and otherwise - become an oxymoron."

Thank you for your attention to this matter. I hope you'll consider the material I've presented. I'm sure it reflects the concerns of a great many scientific practitioners. I would be happy to discuss this matter further or to answer any questions you may have, and I look forward to your response.

Scott L. Fausel, VMD

Cc: Ms. Maureen McKinney, Managing Editor

James N. Moore, DVM, PhD, Equine Editor

M. Gatz Riddell, DVM, MS, Food Animal Editor

Carl A. Osborne, DVM, PhD

Robert Imrie, DVM

David Ramey, DVM

"(I)f we offer too much silent assent about mysticism and superstition - even when it seems to be doing a little good - we abet a general climate in which skepticism is considered impolite, science tiresome, and rigorous thinking somehow stuffy and inappropriate."

Carl Sagan

The Demon Haunted World - Science as a Candle in the Dark (1996)