As noted above, the most recent wellpowered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture. The simplest explanation of such findings is that the specific therapeutic effects of acupuncture, if present, are small, whereas its clinically relevant benefits are mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.

Translation – acupuncture does not work. Why, then, are the same authors in the same paper recommending that acupuncture be used for chronic low back pain? This is the insanity of the bizarro world of CAM (complementary and alternative medicine).

Let’s break down their conclusions a bit. They have reviewed the clinical evidence, as I and others have done before, and found that when real acupuncture is compared to various forms of sham acupuncture (the acupuncture version of a placebo) there is no difference. As I have written many times before – it doesn’t matter where you stick the needles, or even if you stick the needles. Since acupuncture consists of sticking needles in acupuncture points, the only reasonable conclusion from this evidence is that there is no specific effect from acupuncture – acupuncture does not work.

The phrase, “contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient.” is a fancy way of saying “placebo effects.” In other words, there are some non-specific subjective benefits to getting attention from a practitioner. There is this assumption, however, that these benefits are real and worthwhile. However, they are likely to be illusory – an artifact of observation and reporting, not a real improvement in the patient’s condition. In real science-based medicine, that is the underlying assumption – placebo effects are largely illusory – a variable to be controlled for.

But there has been recent controversy over the role of the placebo effect in ethical and evidence-based practice. This is, in my opinion, largely a back door attempt to justify CAM treatments that do not work. The claim is that placebo effects are real and useful. But a systematic review of the placebo effect in clinical trials 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.

In other words – for any objective outcome, there is no important placebo effect. For outcomes that are subjectively reported by patients, there is a highly variable placebo effect. It is plausible that the expectation of benefit could result in the release of dopamine and endorphins and produce a physiological decrease in pain, for example, in a subset of people, and there is some evidence for this. But this is, at best, a transient symptomatic effect – not therapeutic.

Such effects are also non-specific – meaning they do not derive from the intervention itself, but from the therapeutic ritual surrounding the intervention. Even treatments that do not work may therefore provide these non-specific benefit. My opinion is that the non-specific benefits of the ritual of treatment should be combined with an actually effective treatment, not magic pretending to be medicine. There are many reasons for this. One is the ethics of patient autonomy and informed consent – giving a fake treatment to a patient violates the patient’s rights, in my opinion.

Further, there is potential downstream harm from convincing patients that fake magical treatments are effective, because of placebo effects. Then using obscure language to hide the fact that the treatment actually does not work. This distorts the public’s view of medicine, and of what works, and sets them up to be victims of fake treatments when their ailment is not subjective or self-limiting. In other words – refer them to an acupuncturists when they have back pain and they may rely upon acupuncture, or some other non-scientific intervention, when they have a more serious illness.

The authors of this article recommend:

He has specifically requested a referral for acupuncture, and we would suggest a course of 10 to 12 treatments over a period of 8 weeks from a licensed acupuncturist or a physician trained in medical acupuncture.

This contradicts their own conclusions. Why is training in acupuncture necessary? That training largely consists of identifying acupuncture points, knowing which points to use on an individual patient, and knowing the technique of needle insertion – but none of these things matter. The sham ritual is all that matters – you can literally fake it and get the same response. I bet a 10 minute video is all that is necessary. In fact I bet even that is not necessary – you could probably fake it well enough to get a maximum placebo effect without any prior demonstration.

What the authors of this article have done is something that is increasingly common in CAM (when it is trying to infiltrate academia and peer-reviewed journals like the NEJM) – reviewing the evidence, admitting that the CAM treatment does not work, then making an elaborate and misleading appeal to placebo effects, and ending with a recommendation to use the treatment that does not work. Specifically, they not only recommend using the treatment, but in its fullest magical form, complete with all the disproven claims (that is what “medical acupuncture” is). It’s a bait and switch con game, nothing more. Come for the placebo effect, then be treated with magical nonsense.

I will get to the “meat” (perhaps tofu is a better term) of his claims in a moment, but first will recap the exchange. The exchange began with this blog post in which I reported the accusation that Maloney complained about another blogger who was then temporarily shut down by his blog host. Maloney denied the accusation, which I reported as soon as he did, and clarified that the accusations were only alleged. It then came to light that another CAM practitioner, Andreas Mortiz, was responsible for complaining about the blogger, and I immediately updated my original blog post with that information. That is pretty standard blogging practice, and in fact was rather diligent in providing updated and corrected information as it became available.

Maloney, however, wanted something more. I think he just liked playing the role of the injured party. Meanwhile the substance of my original blog post (and a subsequent one naming Maloney) was about the health claims that Maloney was making on his website (more on that below).

In any case, this sparked the exchange that Maloney is now calling “The Novella Debates.” Incidentally, as further evidence that Maloney doesn’t “get it”, he reproduces my entire blog post, and many comments from my blogs, on his site without my permission, and without even the minimal courtesy of a link back to my website. This is considered stealing content – Maloney, the accepted practice is to provide an excerpt or leading paragraph with a link back to the original post. I officially request that you change your website accordingly, and provide a link back to every comment you quote.

That breach aside, Maloney spends a lot of time dodging the substantive questions put to him by whining about my lack of attention to his comments. Actually, he simultaneously claims that I should be too busy as an academic to give him any attention, and then complaining that I am not giving his comments enough attention. He seems to think that I monitor and actively participate in every comment section of every post I have written, without limit. He also seemed perplexed by the notion that I “let” my readers debate for me. Well – I was not aware we were in a debate. He does not seem to understand the blog format: I write a blog post, and then readers are free to comment and discuss among themselves. I comment occasionally as warranted, but am always putting up new posts and therefore don’t follow all my old posts.

But let’s get to the substance of Maloney’s claimed “victory.” Initially Maloney, apparently trying to bait me, and engaging in the tu quoque logical fallacy, claimed that science-based medicine kills patients and does not work. He gave as examples the treatment of hypertension, depression, and ear infections. I and many readers pointed out that the references he selectively quoted did not support his position – he misinterpreted the very evidence he gave to back up his points. In fact, modern treatments for hypertension work. For depression, you have to divide between major depression (good evidence for efficacy) and minor depression (weaker and controversial evidence for efficacy). And for ear infections he did not seem to get the fact that I support the evidence-based standard of care and criticize those physicians who deviate from this by overprescribing antibiotics.

But finally (because the name “NeuroLogica” and the description of this blog as being about neuroscience, and my bio were not enough clues for him) Maloney got the fact that I am a neurologist and so we focused on neurological treatments. He wanted to discuss 5-10 neurological diseases (because he likes the Gish Gallop), but I focused on one – ALS. I wrote:

But if you want to play – let’s focus on ALS. Tell me what magical new treatments you have for ALS that I have somehow missed.

The challenge I put before him, because this was relevant to our discussion, is to inform me about an effective treatment for ALS that derives from naturopathy/alternative medicine that I missed because of my focus on science-based practices. The details here are important because, as you will see, Maloney later moves the goalpost. This was his response:

Turns out your colleagues in Seattle already came across the same idea, but I don’t think you’re using it yet. It involves Clostridium difficile causing a portion of the ALS cases. I came across this idea when I was researching possible ALS support and I found a small study on stool analysis of ALS patients. About 1/3 had significant Clostridium overgrowth, but I can’t find the study on medline listed under Clostridium. I assume the Seattle neurologists must have found the same study.

So here’s the thought: if a portion of ALS patients (peripheral onset?) are genetically susceptible to the relatively mild Clostridium difficile toxins then a stool analysis would give a possible treatment option: systemic antibiotics and the addition of Sacchromyces boulardii. Previous trials with antibiotics and ALS haven’t focused on the possibility of an antibiotic resistant organism causing the problem. I think the addition of S. boulardii is essential to provide competition to C. difficile regrowth.

Maloney references a paper in Medical Hypotheses – a journal notorious for publishing highly speculative notions of dubious scientific merit. In fact, the journal editor was recently replaced over this, with the promise of better peer-review in the future. You see what Maloney did – I asked for a treatment for ALS and he sent me a wild speculation. Further, this speculation comes from mainstream scientific medicine – not naturopathy, and not anything that can be considered “alternative” – even by the fuzzy definition of that term. So he failed to meet the two criteria of my challenge.

He then tried to turn it back on me – saying that I should somehow take up his suggestion as a research priority. This is a hopelessly naive statement. I belong to an ALS research consortium. The primary purpose of this group is to discuss and determine clinical research priorities for ALS. This is important because resources are limited. Specifically, ALS is a rare disease and patients do not survive long, so it is difficult to get large numbers of patients into trials. This means that we need to focus our clinical research on the most promising approaches. Maloney, however, with no expertise and no involvement in ALS research, thinks he can set our research priorities after a few minutes of searching on Medline. (He also does not understand that ALS clinical research requires cooperation among many centers, as no one center sees enough patients to enroll sufficient numbers into a trial.)

I further pointed out that the lack of follow up publications probably means that the researchers themselves did not find any promising results, or else they would be running with that ball. Essentially, more preliminary research would need to be done to show that this approach would be promising before I would even get involved as a clinical researcher.

Having failed with that response, Maloney then shotguns with supplements:

Megadoses of vitamin E- good safety profile and short term benefits, no long term benefits or long term side effect picture.

Antibody screening for celiac disease- several reports of celiac mimicking ALS

Any of the following supportive therapies: creatine, folic acid, alpha lipoic acid, lyophilized red wine, coenzyme Q10, epigallocatechin gallate, Ginkgo biloba, or melatonin?

Again – Maloney fails to make the case that any of this is “alternative” or derives from naturopaths. In fact, this is all coming from science-based medicine. He further puts his foot in his mouth by writing:

Given Dr. Novella’s dismissal of any possible bacterial link, I’ve moved on nutritional supplements as support for ALS patients.
…I am truly interested if Dr. Novella is using any of the supplements in clinical practice, but I suspect that he is dismissive of any supplementation.

Maloney displays the black and white thinking typical of cranks – I never dismissed “any possible bacterial link” with ALS. I simply pointed out that the hypothesis is not very plausible, especially in light of previous trials with antibiotics in ALS, and that therefore more basic science evidence would be necessary to warrant clinical attention. His suspicion that I am dismissive of supplements is also based on his own prejudices, not mine. He thinks that supplements are somehow alternative – but that is his label, not mine. I had even previously clarified that I subject all claims to logic and evidence, and don’t discriminate based upon the “alternative” false dichotomy. Maloney displayed no comprehension of my explanation.

In fact – I prescribed creatine for a few years to my ALS patients, with full informed consent that it was not a proven therapy and was experimental but with some good animal data. That is – until several clinical trials showed no effect (here is an updated review concluding no effect). The ALS research group to which I belong actually conducted the largest trial of creatine (also negative). I actually change my practice in response to new evidence. The final nail is probably not in the coffin of creatine for ALS, but any possible effect is likely to be so small that it is not worth the risk and inconvenience of taking the supplement (there is the potential for kidney damage if not used carefully).

I also prescribed Coenzyme Q10 to my patients for a while, based upon preliminary evidence and the likelihood of safety. However I stopped after a clinical trial found no effect. In fact, if you look at the list of authors on that study you will find one “Novella SP” – here’s a hint, Maloney – that’s me.

Made clear by this exchange is the difference between the science-based approach and Maloney’s approach, which is typical of naturopaths. I look at all the evidence for plausibility, safety, and the reasonable potential for benefit. If I am convinced that I can offer my patients the probability of benefit in excess of harm, I will use a treatment (no matter how it is labeled) with proper informed consent. But I will then closely follow the evidence and will stop using a treatment if good clinical evidence is negative. Or I will start using a treatment when new evidence shows that it is safe and effective.

Maloney, on the other hand, appears to trade in wild speculation. In my opinion he has demonstrated sloppy, black and white thinking, an inability to understand the implications of published research, a bias against science-based medicine, and a willingness to prescribe treatments based upon the flimsiest of scientific justifications. He then accuses me of being “dismissive” and has the stones to declare victory in our exchange because I eventually tired of his evasiveness and crank tactics.

Further, Maloney, if anything, has demonstrated that the naturopathic/alternative approach has nothing to offer. The science is the science, and properly using scientific research as a basis for practice is the ideal of mainstream medicine. The optimal standard of this is what I have termed  science-based medicine. Maloney, however, is laboring  under the false dichotomy of “alternative” medicine. As evidence of how ultimately worthless this false category is, he pulls from the scientific literature to find alleged alternatives to science-based practice. He claims that supplements are alternative and “suspects” that I would ignore them because of this, when they have received research attention in accordance with the basic-science evidence without discriminating based upon their “supplement” status.

The big picture is that so-called “alternative” medicine is nothing but a deliberate distraction from the thing that really matters when it comes to medical treatments – what is the science behind them. Are they safe and effective, and how do we know?

20/20 did a fair job, but it’s hard for me to tell what impression the average viewer will come away with. The first 2/3 of the story was presented from a credulous point of view – essentially just telling Jennings’ story without any hint of skepticism. But then the editorial tone flips, and they give the “other side.” They did a fair job in this section of the segment, and my point of view was reasonably represented. And then at the end they leave the audience with the question – real or fake? Not the best format from a scientific point of view, but it could have been worse.

To summarize the story, Jennings, who was 28 at the time, received a flu shot in August of 2009, after which she started to develop dramatic neurological symptoms including shaking and difficulty speaking. Her story was picked up by a local news station, and from their it was picked up by Inside Edition and became a national story. Jennings spread a considerable amount of unwarranted fear about the flu vaccine, aided by a credulous media who failed to do even basic vetting of her story. In an ideal world, the original reporters would have showed their video to an actual neurologist and the story would have been nipped in the bud right there. But that’s not he world we live in.

Instead it was left to the science bloggers to point out that the video of Jennings was not showing dystonia (a specific type of movement disorder) but a rather textbook case of psychogenic symptoms. This is a difficult concept to get across, so much so that I wrote a dedicated blog entry to help explain it. The 20/20 segment did include my sound bite about this, but talking to people afterward they still have a hard time grasping psychogenic symptoms. Essentially, it is the brain’s response to stress in certain people, responding with very real neurological symptoms. But they are not based in any biological damage to the nervous system, rather it is a functional psychological disorder.

I also had a hard time getting the 20/20 producers to fully understand this, and further my degree of confidence about this. Jennings is actually a textbook case. I have now viewed considerable video of her symptoms, and showed it to various colleagues. There are a finite number of ways the brain and nervous system can malfunction (there are many more underlying causes, but only so many symptoms that can be produced). In other words, if one circuit in the brain is damaged (by whatever cause) it will produce a certain constellation of neurological findings with specific features. Jennings’ movements, evolving speech patterns, etc. do not fit into any known pattern of neurological damage. Rather, they have all the features of psychogenic symptoms.

The one that is perhaps easiest for people to understand is her vaguely British accent. She claims this simply results from her difficulty speaking, but again there are only so many ways that speech can be neurologically abnormal – none of them make you sound British.

The problem with the news reporting and public reaction is that it has fallen into a false dichotomy, and even the 20/20 story is headlined with “Medical Mystery or Hoax.” In fact, it is likely neither. The anti-vax community, which has embraced the story for its propaganda value, uses the hoax argument as a straw man. None of the science-bloggers discussing this case are making the claim that this is a hoax. But it’s clear that Jennings is not suffering from neurological damage (specifically mercury toxicity) from a flu vaccine.

There are some new tidbits that came out in the 20/20 report. First, we learn that Jennings did not discover that she can run, walk backwards or sideways until she read online that this can be a feature of dystonia. Although I knew this, I think this was also the first time it was reported that Jennings did not receive a diagnosis of dystonia at Johns Hopkins. She was diagnosed by her neurologist there with a psychogenic disorder – Jennings first heard the term dystonia from the off-hand comment of a physical therapist. She then latched onto that as her diagnosis.

For me the most interesting part of the 20/20 segment was the interview with Rashid Buttar, the doctor who treated Jennings with  chelation therapy. Buttar’s response to challenges from the interviewer were right out of the quack playbook. When asked why he is not doing any science to back up his extraordinary claims he responded, “Nobody said it was science.” Buttar tried to defend his unscientific practices, as purveyors of dubious treatments tend to do, by appealing to anecdotes. When confronted with the fact that anecdotes are not scientific evidence he essentially responded by saying – talk to my patients. That’s right – his answer was a further appeal to anecdotal evidence.

The 20/20 segment also did a fair job of making the point the Buttar uses chelation therapy to treat just about anything. They then brought on a toxicologist to explain that Jennings was exposed to less mercury in the flu vaccine that you would get in a tuna fish sandwich.

Unfortunately, the 20/20 exposure (although I saw it as negative) will likely just send more patients to Dr. Buttar.

Conclusion

I remain sympathetic to Desiree Jennings. She is an unfortunate women who is being exploited by the media, dubious doctors, and the anti-vaccine movement. What she needs is the delicate management of science-based practitioners who know how to deal with such cases. What she doesn’t need is a media frenzy that invests her in her psychogenic symptoms.

I was also very sad to hear that her search for a “miracle cure” is not at an end. She said:

“If I have to go over to China and do experimental procedures, I’ll find a way to get it all back,” she said. “It may take a while, but I will get everything back. I will find a way.”

No – don’t go to China. All you will find there are clinics looking to take money from desperate Westerners with resources.

It is for people like Desiree Jennings that I feel compelled to be active in exposing health fraud. I have paid close attention to this story because of the anti-vaccine angle, but there is also another story here. Desperate patients with controversial or problematic symptoms are prime targets for fraud and quackery. There are sharks in the water ready to gobble up any victims who come their way. Regulations have failed to protect them (as they have with Buttar, who was able to skirt attempts at regulatory discipline). The media largely act like accomplices. Academia is failing to adequately address these issues (with some notable exceptions – but they are exceptions).

The public is practically left to fend for themselves, at the most desperate times in their lives, against sophisticated con-games that prey upon their health. That is the real story I want the media to tell.

Anthropologist Pat Shipman has written a paper and an upcoming book hypothesizing that our relationship with animals was a key component of recent human evolution. Working with animals, she argues, evolved out of our knowledge of animals as prey and predators. Our ancestors intently learned about the animals in their environment, so that they could better hunt prey and avoid becoming prey themselves. This animal knowledge base then allowed them to exploit those same animals. Acquiring and passing on a complex knowledge base requires language, and therefore the benefits of animal knowledge became a key component of the selective pressures in favor of language itself. Those ancestors that were better able to form relationships with animals had a significant advantage over those who did not.

Let’s take dog domestication, for example. This was a long process, and what we can say at this point is that the dog genetic line split from the wolf line about 100,000 years ago. It is unclear what role, if any, humans had in this original split. One hypothesis is that some wolves began following human hunters to scavenge. Those that were less threatening to the humans were more likely to survive at the edges of human activity, until eventually you have a wolf transitioning to become a dog. At some point humans became involved in the process, feeding the proto-dogs in exchange for their service as an alarm system and protection against other predators. The oldest dog fossil dates to about 32,000 years ago, although this fossil still has some wolf-like features. The earliest example of clear human-dog cohabitation dates to about 14,000 years ago. Genetic evidence suggests that dogs are evolved from Middle Eastern wolves, although there was likely a contribution from Asian wolves which might have been an independent domestication.

Today we use dogs for companionship, as an alarm system, for protection, herding, hunting, and transportation. I use my dog to keep squirrels away from my bird feeders and deer away from my garden.

The advantage to our ancestors of using animals is clear. It is easy to imagine the extreme advantages to early tribes of humans if they had large hunting dogs at their sides, or horses to ride, or farm animals as a convenient food source, or even just cats to keep away the vermin.

But Shipman is making a further argument – the advantage of communicating knowledge about animals was significant enough to become an important factor in our own evolution. As evidence for this she writes:

“Though we cannot discover the earliest use of language itself, we can learn something from the earliest prehistoric art with unambiguous content.  Nearly all of these artworks depict animals.  Other potentially vital topics — edible plants, water, tools or weapons, or relationships among humans — are rarely if ever shown,” Shipman said.  She sees this disproportion as evidence that the evolutionary pressure to develop an external means of storing and transmitting information — symbolic language — came primarily from the animal connection.

That is an interesting argument. The fact that our ancestors focused their art almost entirely on the depiction of animals is certainly worthy of some explanation. But Shipman makes a tricky inference. It is also true that animals are often beautiful and fascinating creatures. It is easy to understand the artistic obsession with animals without invoking any other explanation. In order to interpret the implications of the disproportionate focus on animals in early art we would need to know the role of art in early human culture. Was it used to depict useful or important aspects of human life, or things that were thought to have a spiritual connection, or simply the most interesting things available in the environment?

I look forward to reading Shipman’s book to see how she further develops this argument. Regardless of the true implications of this observation about early human art, and the precise role that animals played in driving human evolution (specifically with language and tool use, as Shipman argues), there is no question that animals were vitally important to the success of humans as a species. I see the formation of useful relationships with other species as just one of many skills that our ancestors developed to help them survive and thrive, but perhaps one that deserves more attention.

Incidentally, I took two courses on human evolution with Pat Shipman while I was an undergrad at Johns Hopkins. She was an excellent teacher and helped further my interest in the science of evolution. She is now an adjunct professor of biological anthropology at Penn State University.

We know that the vertebrate brain displays considerable plasticity – it learns and remembers. When you train at a task, you get better at it. For example, I can type pretty fast. I don’t have to think about where the keys are, and I don’t even have to look at the keyboard. I just think of the words I want to type and my fingers fly effortless over the keyboard. This is a product of decades of typing.

Anyone who has learned to play a musical instrument is also familiar with brain plasticity. After years of playing, the complexity and subtlety with which you can perform on an instrument becomes impressive. You don’t have to think consciously about every move – you just feel it. Further, your ear is more sensitive to subtle aspects of pitch, tone, timing, and timbre. You notice things other people don’t notice.

That much is very clear from the research and not controversial. This new paper reviews the evidence which establishes that these changes in ability that accrue with music training result in changes to the brain itself – the relevant areas of the brain that involve auditory processing and motor control are larger and more active in musicians than non-musicians, and this correlates with age of onset of training and duration of training.

In addition, the brain changes associated with musical training occur at cortical and sub-cortical levels – meaning in the parts of the brain that involve auditory processing prior to conscious awareness. And again, this applies to music and language.

But when we move beyond this basic fact of neural plasticity, we start to get into some controversy. The next question is – do increases in auditory function that directly relate to music training extend to auditory processing in general? Would they apply, for example, to the auditory processing of language?

There is also a further question beyond that – does musical training improve brain function in areas not related directly to auditory processing or motor control? Does musical training make people “smarter” by improving their memory, attention, or other generalizable mental skills?

I have gone back and forth on this question over the years, as conflicting evidence comes in. Recently I have been leaning toward a negative conclusion – that training in one area does not significantly affect other cognitive areas. Last month, for example, I reported on a Nature study that showed no such effect. “Brain training” improves the task that is being trained, but does not appear to transfer to other tasks.

What does this latest review have to say about music? They report:

Below, we describe data that support the view that the fine-grained auditory skills of musicians, which are acquired through years of training, percolate to other domains, such as speech, language, emotion and auditory processing. Thus, music training improves auditory skills that are not exclusively related to music.

They go on to discuss the fact that the processing of language involves many of the same cognitive skills as music: discriminating changes in pitch, deriving information from sound, and directing attention toward the details of sound. This makes perfect sense. In fact I would go beyond that to speculate that our appreciation for music may in fact be an evolutionary outgrowth of language itself. From an evolutionary point of view, music may be a side consequence of our adaptation for spoken language.

An excellent example presented in the paper is that of processing regularities in auditory sensory input. When trying to separate the sound of a person speaking from background noise, auditory processing in the brain looks for statistical regularities in the sound, distinct from the randomness of background noise. So the processing is there to appreciate regularities. This same processing gives us an appreciation for the regular timing in music. It is an excellent example of how evolutionary adaptation can result in “unintended consequences.”

But further it creates the potential to improve the ability to distinguish speech from background noise through musical training, since the same underlying neurological processing is involved.

But what about the final question – does music training percolate to other areas of cognition not related to auditory processing or the motor skills required to play an instrument? (This is the alleged “Mozart” effect, which has not been supported by research.) The paper does not discuss this question, or review any evidence that directly bears on it.

Conclusion

This is a very interesting review, and is an excellent overview of the research on the effects of music training on the brain and its implications for language ability. But the review does not present any evidence to suggest that music training has neurological benefits that extend beyond the brain processing involved in music (which overlaps with language). The “Mozart effect” remains dead.

This review also does not alter my opinion regarding brain training in general – mental training improves the tasks that are trained, and the underlying neurological processing, but not cognitive areas that are not directly related to the tasks that are being trained.

At the end of the article the authors advocate for increased music training as part of basic education. I think they make a reasonable argument for this. Language function is a core cognitive skill, and music training does seem to enhance the auditory processing of language. But I caution against extrapolating beyond the limited implications of the research.

Mr. Nicklison says that he wants to die, and is raising the issue of assisted suicide in the UK. Legally he can refuse food and water and would die of dehydration, but he and his wife do not want to use that option. He would rather die quickly at a time of his choosing. But he fears that his wife would face prosecution for murder if she gave him a lethal injection.

Mr. Nicklison says of his own condition:

“I have no privacy or dignity left. I am washed, dressed and put to bed by carers who are, after all, still strangers.

“I am fed up with my life and don’t want to spend the next 20 years or so like this. Am I grateful that the Athens doctors saved my life?

“No, I am not. If I had my time again, and knew then what I know now, I would have not called the ambulance but let nature take its course.”

It is easy for most people to sympathize with the horrible state of being locked-in. If we try to imagine ourselves in such a condition (even though we probably cannot fully imagine how it would be) we can understand why someone might rather die than continue in such a state. Put another way – it is difficult to imagine any quality of life in such a state.

However, a survey conducted by the Association du Locked-in Syndrome (ALIS) in France:

based on a survey of 70 to 78 individuals with LIS by ALIS in France: 71% never thought of suicide, 26% thought of it occasionally and only 3% often; 53% had never considered euthanasia, 39% had considered it at some stage but not anymore and 8% would demand it now.

That only 8% of those in a locked-in syndrome would demand euthanasia if offered is surprisingly low. Some researchers believe this is partly due to modern technology which allows locked-in patients to communicate and to use computers and the internet. It is often surprising how resilient people can be and that  some people can find value in life even in terrible conditions.

This brings us back to the issue of assisted suicide or euthanasia. While we might admire people who can persevere even in a locked-in syndrome, we are in no position to judge those who find such a life unacceptable. I face this decision with patients frequently – in ALS patients who are slowly losing their muscles and are essentially progressing toward a locked-in syndrome. Without heroic measures, they will die before they get to this state, but patients need to decide for themselves if they wish such measures to be taken (mainly tracheostomy and being connected to a respirator) or if they wish to die comfortably. Here there is no question of euthanasia because such patients will die without an intervention that they have the right to refuse.

What we have found over the years is that this is a very personal decision. Some people can find value in a purely intellectual existence, even if they have no physical quality of life. Others cannot imagine such an existence.

With those who become locked-in suddenly, and who do not require a ventilator, like Mr. Nicklison, the choice is between starvation/dehydration, euthanasia, or continued life locked-in. This is tricky from an ethical point of view, and very controversial. There are those who assert an individual’s right to take their own life, or request another to assist them in taking their life as a fundamental right to privacy. This is a perfectly legitimate argument.

But it also has to be weighed against some very practical concerns – concerns which have caused most countries to make euthanasia illegal. One concern is that the person requesting euthanasia is certain about their choice, and that their choice is settled after long deliberation. As the survey indicates above, while 39% of those locked-in have contemplated euthanasia, only 8% would accept it now. This suggests that there are many individuals who change their mind. How long does it take, therefore, for such a decision to be considered settled.

There are also concerns about the caretakers decision-making. How much is the burden being placed on caretakers affecting the decision to accept euthanasia? Does the option of euthanasia compromise the dedication toward doing everything possible to maximize quality of life of the affected person? Maybe, for example, if they were treated for depression (a common complication of stroke) they would no longer request euthanasia.

It seems we are heading towards more nuanced laws regarding the right to die and balancing it with protection for the therapeutic and caregiver relationships and the rights of individuals to proper care and treatment. The Nicklison case is sparking this debate anew in the UK and will test their existing laws.

Local news reporters brought us the Desiree Jennings story, and now they bring us the story of digital drugs, or i-dosing. From Oklahoma News 9 we learn that parents need to be very concerned (maybe they should even panic) – their kids are downloading digital drugs and listening to them on their i-pods, and this may be a gateway drug to the hard stuff.

Read and watch the report. I love the picture of the teenager with a towel on his face listening to headphones – real trippy. I wonder how staged that photo was. If you have ever dealt with a local news reporter you would wonder the same thing.

According to the report, teenagers are listening to tracks containing binuaral beats, which alter brain waves and can create a high. There is one piece of information that is conspicuously missing from the report, however. Binaural beats are complete pseudoscience – they don’t work, they don’t affect brain function. You cannot get high from listening to noise. I discussed binaural beats four years ago on the SGU – but here is a quick overview and update.

The concept is that by combining different frequencies of sound in different ears, and illusory additional beat is heard by the listener. This beat is not present in the sound, but is an auditory illusion created by the brain’s processing of the auditory information. This much is probably true – but that is where the truth of claims made for binaural beats end. Proponents argue that binaural beats alter brain waves. This may be true in the trivial sense that brain activity – experiencing sensory input – alters brain waves, but only as part of the normal functioning of the brain. I can alter your brain waves by shining a strobe light in your eyes, but this will not alter your brain function (unless you have epilepsy, in which case in might induce a seizure).

A 2010 study of the effects of binaural beats on brain processing found:

The perceptions of binaural beats involve cortical activity that is not different than acoustic beats in distribution and in the effects of beat- and base frequency, indicating similar cortical processing.

In other words – this is just normal brain processing and perception, nothing magical or special.

There are also a few pilot studies or small controlled studies (i.e. preliminary data only) showing possible reduction in mild anxiety, but no effect on attention in ADHD. Subjective anxiety is a tricky outcome to measure, especially in uncontrolled or unblinded studies. It’s possible there is a small non-specific effect just from the distraction of the experimental process, and no reason at this point to think there is a specific physiological effect from the binaural beats themselves.

There is also no published evidence at all concerning binaural beats and getting high.

The News 9 report included no skepticism at all about binaural beats. The reporters did not even ask the question of whether or not these digital drugs actually work, let alone consult an expert. Instead they presented the most sensational opinions and the immediate knee-jerk panicked reactions of schools and officials. National news outlets then repeated the story without adding any skepticism or useful information. At least Wired had the sense to make fun of the story a bit (although the humor is a bit subtle, and they also did not add any skepticism). They wrote:

Will future presidential candidates defend their i-dosing past by saying, “But I had it on mute”? Are we supposed to declare a war on cyberdrugs or a cyberwar on cyberdrugs? How will police know if a teen is with headphones on is i-dosing or just listening to Justin Bieber? Is the iPod the bong of the future? What would happen if some ne’er-do-well took over the console of the Super Bowl and dosed the entire country? What if kids smoked dried banana peels and listened to these trippy tunes at the same time — could they OD? What happens if someone sells a tainted MP3?

My advice to parents is not to worry. Binaural beats are benign – in fact, they do nothing. There is no evidence to suggest that they lead to actual pharmacological drugs, and kids may be “experimenting” with them partly because they know the whole thing is silly. Next we’ll probably hear that kids are trying to get high on homeopathic drugs. That would also be completely ineffective and nothing to worry about (as long as they were truly homeopathic).

In addition to mediocre science journalism we also face dedicated ideological groups who go out of their way to spin, distort, and mutilate the scientific literature all in one direction. The anti-vaccine community is a shining example of this – they can dismiss any study whose conclusions they do not like, while promoting any horrible worthless study as long as it casts suspicion on vaccines.

Yesterday on Age of Autism (the propaganda blog for Generation Rescue) Mark Blaxill gave us another example of this, presenting a terrible pilot study as if we could draw any conclusions from it. The study is yet another publication apparently squeezed out of the same data set that Laura Hewitson has been milking for several years now - a study involving macaque infants and vaccinations. In this study Hewitson claims a significant difference in brain maturation between vaccinated and unvaccinated macaque infants, by MRI and PET analysis. Blaxill presents the study without noting any of its crippling limitations, and the commenters predictably gush.

The first (and really only) thing you need to know about this study is that it involves 9 vaccinated monkeys and 2 controls. That’s right – just 2 controls. The fact that Hewitson bothers to do statistical analysis on such a small set of subjects is laughable. Let’s keep in mind that most pilot studies turn out to be wrong – they are called pilot studies because they are intended to point the way to further research, not as a basis for any conclusions. Serious researches recognize that pilot studies are shots in the dark – and that counts even for good pilot studies, which this is not.

If the outcome were something hard and dramatic – like survival vs death, then 2 subjects would be a reasonable pilot study. But in this case Hewitson is doing a somewhat tricky measurement of brain volume changes over time and binding of opioid ligands in the amygdala. It is also worth noting that there were originally 4 controls, but one was eliminated due to improper protocol. We never learn what happened to the third monkey, we are just told there is data on two controls. This kind of missing data, especially when the overall numbers are so pathetically low, is very concerning.

She is also making multiple analyses (another red flag by itself), which means she can compare multiple variables looking for any difference. Then she invokes the sharpshooter fallacy and declares any change she does find to be clinically meaningful. So while there is no difference in brain volume or amygdala volume between exposed and unexposed monkeys, she finds differences in the change over time. We don’t know if still other variables were looked at and not reported – this is another weakness of pilot studies and why follow up studies replicating the specific effects reported are necessary before any conclusions can be drawn.

As further evidence of looking for any difference then declaring that the outcome of interest, we can look back to Hewitson’s 2008 reporting of her monkey data, in which she wrote:

“Compared with unexposed animals, exposed animals showed attenuation of amygdala growth and differences in the amygdala binding of [11C]diprenorphine.”

But in the current study she finds increased amygdala growth in exposed monkeys:

Not surprisingly, given the different maturational trajectories in exposed vs. unexposed animals, (unexposed decreasing and exposed increasing) there was a statistically significant interaction between exposure and time on total amygdala volume (Wald χ2=10.93; P=0.001). However, there were no significant main effects on total amygdala volume of either exposure (Wald χ2=0.75; P=0.39) or time (Wald χ2=1.14; P=0.29).

So which is it? Reading the results of the current study, especially in light of previous publications, gives the overall impression of a random scatter of data with incredible cherry picking in order to make the argument that there are any meaningful results at all.

Taken by itself, this is a worthless study. The numbers of subjects is too small to do any meaningful analysis. The results are all over the place, and not even consistent with prior publications by the same authors. The analysis is also far-fetched. Hewitson argues that both thimerosal-containing vaccine and MMR (which does not contain thimerosal) contribute to the alleged brain changes she is reporting. While the word “autism” does not appear in her report, Blaxill is concluding in his reporting that these brain changes are the same as those found in autism (an absurd conclusion given how non-specific these changes are, even if real, which cannot be concluded from this study). The anti-vaccine agenda is now clear – they get to have their cake and eat it too. They can now argue that an interaction between thimerosal and MMR cause or contribute to autism, through completely independent mechanisms, apparently.

To put this study further into context, this research is being conducted by the Thoughtful House Center for Children – Andrew Wakefield’s home after he was essentially kicked out of the UK and subsequently struck off. Wakefield’s name, however, does not appear anywhere on the current study, although he was listed as final author on previous publications from the same research. Apparently his name has become too toxic for the Thoughtful House.

The current study also appears in a obscure journal, Acta Neurobiologiae Experimentalis – which dedicated an entire issue to publishing dubious research on autism. The same issue includes two articles by the father and son Geier team – other vaccine and autism researchers who are off in their own world and whose research cannot be replicated.

Conclusion

This current study, as well as the entire macaque research program by Hewitson, is a good example of terrible research. The subject numbers are far too small for any meaningful statistics, and the outcomes being followed are numerous and tricky with a random scatter of results not even consistent between different publications of the same research.

What we have is far worse than ideological reporting and spinning of the scientific research – apparently we have the ideological conduction of research in the first place. This is similar to the research program of Benveniste on homeopathy.

In general it is a good rule to be suspicious of research that seems to be unique to one researcher or research team and is out of step with the broader research community. Unfortunately, such research contaminates the literature and is easily exploited to confuse the media and the public who often do not distinguish crank research from legitimate science.

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Others reporting on this study:

Respectful Insolence – Orac also points out that Hewitson failed to disclose her COI – that she has a child with autism who is part of the Autism Omnibus suit.

Ibrb – Author, Sullivan, also points out that amygdala size should increase in macaques, so it is especially odd that the non-exposed monkeys’ amygdalas shrank. That makes no sense, and is likely due to the quirkiness of having only two controls. So the authors conclusions are entirely based upon a weird result in their tiny control group – i.e. this is completely bunk science.

There are occasionally extreme examples that demonstrate this latter principle – that no individual, not matter what their scientific history, should be relied upon as a sole authority of scientific truth. In science the Nobel Prize is often looked upon as the ultimate achievement, and Nobel Laureates carry what is probably an unhealthy amount of individual celebrity and authority. Don’t get me wrong – winning a Nobel Prize in science is a tremendous achievement, and only comes to those who have made significant scientific contributions. This is deserving of honor and respect.

But I would add a few caveats. First, there are many scientists who have made very significant scientific contributions who were never honored with a Nobel Prize. Second, winning a Nobel Prize involves a bit of luck. Hardly any scientist can set out to win a Nobel Prize – it is not just a matter of smarts and hard work. You also have to be in the right place at the right time – to make a discovery that turns out to have a huge impact. Impact is hard to predict, and is not always proportional to the difficulty and sophistication of the scientific research itself.

It further needs to be recognized that there are many aspects of scientific work. There is a technical side – knowing how to design and run complex experiments and how to use complex equipment. There is also fund of knowledge – keeping on the cutting edge of information in your field. There is also scientific vision – creatively thinking of new ways to potentially explain phenomena, and how to test them. And finally there is critical thinking – the ability to question even your own findings and the ability to weigh various kinds of evidence and avoid the many pitfalls that plague human thinking.

A great scientist will have some of all of these virtues, but not every scientist will have all of them in equal measure. Specifically, it is possible for a scientist to be excellent at the technical aspects of  scientific research, and also be creative in their thinking, but lack critical thinking. Scientists may also achieve mastery within their own narrow field, but fail to recognize that different cognitive skills are required to be successful in other fields of science. A physicist, for example, may fall prey to the false assumption that all science should operate like physics.

I frequently see scientists who are not physicians or any kind of clinicians make this latter type of error – failing to recognize that there is a certain logic to clinical science that they may not be prepared to deal with as bench researchers.

Linus Pauling

There are historical and recent examples to illustrate these principles. Most famous, perhaps, is Linus Pauling who won two Nobel Prizes: the Nobel prize for chemistry in 1954, and then the Nobel Peace Prize in 1963 for his activism against nuclear weapons. Pauling was a brilliant researcher, of that there is no doubt. But later in life he descended into quackery, advocating for megadoses of Vitamin C to fight off infections, including the common cold. This was part of his broader support for “orthomolecular medicine” – a term he coined. According to Pauling substances which occur naturally in the body can be used in high doses to prevent disease and promote health.

To me this is the perfect example of a brilliant scientist stepping outside his area of expertise and trying to apply the wrong principles to another discipline. The concept of orthomolecular medicine may make sense to a chemist, who is focused on the chemical activity of biological substances. But medical researchers are likely to find such ideas hopelessly naive (even accounting for the time period). Pauling failed to support his ideas with clinical research, and therefore failed to recognize the need to translate a basic science understanding of things like biochemistry to actual clinical applications. Despite our advancing understanding, the body is ridiculously complex and so net clinical effects need to be measured. We cannot simply extrapolate from our basic science knowledge to clinical claims, and Pauling did.

But further, the notion that if a little is good then more is better runs contrary to basic medical knowledge. For most biological functions that we care to measure there appears to be an optimal range of values, and having either too much or too little becomes progressively unhealthy. Also, evolutionary forces have conspired to put into place feedback mechanisms that keep a long list of biological parameters within an optimal range. We mess with this delicate balance at our own peril.

So while Pauling was a brilliant chemist, he was not aware of the risk vs benefit approach central to medical decision making, displayed a lack of humility in extrapolating basic science knowledge to clinical claims, and went against certain hard-won bits of biological wisdom. The result was pure crankery, but backed by the authority of a Nobel Laureate.

Eli Mechnikov

Perhaps a less well-known example is that of Eli Mechnikov – the originator of the concept of probiotics. He won the Nobel Prize in medicine in 1908 for his work on phagocytosis – that certain cells in the immune system will essentially eat invading or dying cells. He did excellent basic science work on the functioning of the immune system.

Mechnikov ventured a bit afield, however, when he started speculating about the role of gut bacteria in health. He hypothesized that the metabolic products of harmful bacteria in the gut were largely responsible for aging. Therefore, by replacing those bacteria with more benign bacteria the aging process itself could be slowed. He extrapolated wildly from flimsy evidence to support this notion. For example, he believed that people living in Bulgaria or the Russian steppes lived long lives because of their diet, which included a large amount of dairy products fermented by lactic-acid bacteria. He never tested this hypothesis, but instead drank sour milk every day for the later part of his life.

His advocacy for the notion of probiotics is partly responsible for their continued popularity a century later. I am not suggesting there is no science behind probiotics. There is (to give a quick summary) some evidence for a mild benefit for specific gastrointestinal indications. As our probiotic knowledge and technology improve we may be able to optimize the use of probiotics for certain indications. Although there is no evidence or theoretical justification for routine use of probiotics, and no reason to suspect they can be used to increase life span.

Luc Montagnier

This all brings me to the contemporary example that triggered this article – the story of Luc Montagnier. He was the 2008 Nobel Prize in Medicine along with Harald zur Hausen and Francoise Barre-Sinoussi – Hausen for his discover of the human papilloma virus, and the other two jointly for their discovery of HIV. Montagnier’s work on HIV is impressive and he deserved the Nobel Prize for his work. But his later work makes me wonder if he is more of a gifted and lucky technician than a true scientific thinker.

Recently Montagnier has published a paper in which he claims that diluting the DNA of pathogenic (and only pathogenic) bacteria results in the creation of nanostructures in the solvent that retain the radiowave emitted by DNA. These radiowave memories can then result in the reconstitution of the originating bacteria or virus.

Here is the abstract from his paper, Electromagnetic signals are produced by aqueous nanostructures derived from bacterial DNA sequences:

A novel property of DNA is described: the capacity of some bacterial DNA sequences to induce electromagnetic waves at high aqueous dilutions. It appears to be a resonance phenomenon triggered by the ambient electromagnetic background of very low frequency waves. The genomic DNA of most pathogenic bacteria contains sequences which are able to generate such signals. This opens the way to the development of highly sensitive detection system for chronic bacterial infections in human and animal diseases.

Wow – DNA producing electromagnetic waves, which can be remembered by water interacting with background EM noise. He then adds the rather incredible notion that these signals can result in the formation of the bacteria or virus from which the DNA derives (by interacting with other cells). Montagnier is not making one incredible leap here, he is making several all at once. That is usually a sign that a researcher is getting erroneous results, and rather than consider a flaw in their experiment protocol they start jumping through logical hoops in order to explain their impossible results.

This article sums up the pathological science well:

The reasoning Montagnier used to reach his conclusions seemed identical to that used by those who study homeopathy. Obvious and simple explanations have to be skipped in order to pursue obscure ones, things that haven’t been demonstrated have to be assumed, and findings that have been subjected to repeated testing have to be ignored. It’s hard to describe the work as anything other than crackpot.

That’s right – this is homeopathic nonsense applied to DNA.

Le Canard Noir of Quackometer fame also points out that Montagnier assumes that only pathogenic (to humans) bacteria possess this property. But there is no theoretical reason that only some bacteria would have such a property, and that they would somehow know if they were pathogenic or not to humans. I would add, that this can only make sense if this property is what determined that the bacteria were pathogenic in the first place. But this flies in the face of a great deal of research which tells us why some bacteria are pathogenic and others are not – it has to do with their specific biological properties. I would further add that some bacteria are friendly at some times, but then can turn pathogenic at others.

Conclusion

Scientific achievement, while admirable, is no guarantee that one’s later work will be valid. This phenomenon is not limited to Nobel Prize winners – many scientists, after a mainstream and successful career in science, have turned to crankery in their later years. History has not been kind to such scientists.

The lessons here are many. The first is never to trust the authority of a single individual. A broad consensus of opinion should be compelling, and it is progressively less likely that may scientists (especially if they are coming from different perspectives) would all make the same mistakes. But individuals are quirky.

Past performance is also no guarantee. There has been speculation, in fact, as to why it is observed that older scientists sometimes jump off the deep end. Are they losing some of their faculties? Are they afraid that their legacy is inadequate and they are looking to punctuate their career with a dramatic discovery? Or perhaps they feel they have paid their dues with mainstream science and now wish to pursue their true passion? Then there are those who have been so successful that perhaps they feel they can turn their scientific eye to any question, even one far outside their specialty, and outperform the experts in that field.

From one perspective it is always a bit sad to see a respected scientist squander their legacy by delving into nonsense. In many cases they become more infamous for their crankery than famous for their legitimate contributions. But on the other hand, such episodes are constant reminders of the human condition and the need for a little humility (even among the best of us) in light of the awesome complexity of the universe we hope to understand.

The HCCC accuses the AVN of providing inaccurate and misleading information and selectively quoting research out of context to argue against vaccination.

The report has also noted accusations that the AVN harassed the parents of a child who died of whooping cough last year, after the parents advocated the importance of childhood vaccination.

This is the result of a long investigation – but also the result of a campaign by my friends and colleagues “down undah,” specifically Rachael Dunlop (Dr. Rachie) who spearheads the anti-antivax efforts of the Australian Skeptics. They have done an excellent job of keeping the pressure on the AVN and have been scoring huge victories in the media.

The complaint that sparked the HCCC investigation was made by Ken McLeod, who is quoted as saying:

“I mean reason and science just does not break through [to them],” he said.

“They’re not interested in reality, they’re interested in conspiracy theories and junk science.”

Of course, Meryl Dorey who runs the AVN is denying the accusations.

The HCCC is requiring that the AVN put a disclaimer on their website stating that they are anti-vaccination and also that they are not dispensing medical advice. In essence all they are asking for is transparency, and it is not clear anywhere on the AVN site that they are editorially anti-vaccine.  Unfortunately, there are probably no teeth to their report and it is probable that they will not have the legal basis to force the AVN to comply. But at least the media coverage has been good.

Not surprisingly the AVN’s American counterparts are coming to their defense. Orac does a nice takedown of a hilarious piece of paranoid nonsense over at the Age of Autism. Their made-up story is that skeptical groups are sinister fascist organizations heavily funded (I find that particularly funny) by industry to silence dissenting opinions. Seriously, they think they can just make up any bull they want. Unfortunately, their readers seem to swallow it wholesale.

Keep in mind, the HCCC is not trying to silence anyone. They are just asking for a little editorial transparency – fascists!

Optimistically these events may serve to further marginalize the anti-vaccination movement. The more paranoid and absurd their arguments, the more reasonable people will see them for what they are. But even a marginalized subculture can be very vocal and can do a great deal of damage. So our vigilance against their dangerous nonsense must continue.