May 16 2016

Review of Probiotics

probioticsThe idea behind probiotics superficially sounds reasonable – friendly bacteria are important to the functioning of our gastrointestinal (GI) system and immune system. Probiotic products are supposed to supplement those friendly bacteria with live bacteria from certain foods, such as yogurt, or even in capsules.

A recent paper, however, reviews studies looking at probiotics in healthy subjects, finding no evidence for benefit. Let’s take a close look at this study and the science of probiotics.

The systematic review focused on studies looking at the change in the composition of bacteria in feces in healthy adults taking probiotics compared to placebo. They found:

Seven RCTs investigating the effect of probiotic supplementation on fecal microbiota in healthy adults were identified and included in the present systematic review. The quality of the studies was assessed as medium to high. Still, no effects were observed on the fecal microbiota composition in terms of α-diversity, richness, or evenness in any of the included studies when compared to placebo. Only one study found that probiotic supplementation significantly modified the overall structure of the fecal bacterial community in terms of β-diversity when compared to placebo.

The definition of α-diversity is the mean difference in species in a specific location, while β-diversity is the difference in species between two different locations.

The bottom line is that there was no consistent effect among these seven studies. The studies were all relatively small, from 21-81 subjects, and were rated medium to high in terms of overall quality. It is fair to say that there is probably no clinically significant effect, given these negative studies, however an effect too small to be seen in studies of this size cannot be ruled out without larger studies.

There are also other ways to track the alleged benefits of probiotics, such as looking at specific health outcomes like weight control, diabetes, and the risk of autoimmune disease. A 2015 systematic review of probiotics for weight loss showed no benefit. However another 2016 review concluded there was evidence for a small benefit, although it seems they used a lower bar for including studies.

A 2014 review found some evidence for benefit in lowering blood pressure. There may also be benefit for glucose metabolism.

However, this research is generally preliminary and effect sizes are small. Further, the fact that probiotics do not seem to change the intestinal microbiotia does call into question any clinical benefits (although does not rule them out).

The best evidence exists for probiotics for antibiotic-associated diarrhea. This makes sense, because the problem is too little friendly bacteria in the GI system. A recent review found:

Based on this systematic review and meta-analysis of 23 randomized controlled trials including 4213 patients, moderate quality evidence suggests that probiotics are both safe and effective for preventing Clostridium difficile-associated diarrhea.

Plausibility of Claims for Benefit

Here is a typical list of claimed benefits from probiotic products:

Support immune system, improve digestive function and mineral absorption and aid in healing leaky gut*

Improve skin health, acne and dry red flaking skin, Kills candida and bad bacteria,*

Enhanced synthesis of vitamin B12, calcium and vitamin K2, Support digestion of difficult substances like gluten and lactose.*

These are classic “structure function” claims that are not reviewed by the FDA. They are not supported by good evidence or any evidence at all in some cases.

Does it really make sense that eating live bacteria can affect your health? The plausibility of this claim may be more complicated that originally thought. It seems that the microbiome exists as a stable ecosystem of about 100 species of bacteria. Eating extra bacteria does not seem to impact this stable ecosystem.

This does not mean it’s impossible to do so, but it likely takes more than eating yogurt. We may need to use something more radical, like a fecal transplant. Essentially we need to transplant another stable ecosystem. Or we may need to consume dozens of species in high colony counts over an extended period of time.

Even if we could make permanent changes to the microbiome, it is not clear if this is an effective health intervention. Right now we have data that correlated certain types of bacterial environments with certain health states, like diabetes or obesity, but the cause and effect is not clear.

Conclusion

The current state of probiotic science is best described as preliminary. Clearly the gut microbiome is important, and is integrated into the whole organism. There are interesting correlations with various microbiome ecosystems and various states of health and disease. There are plausible mechanisms by which the microbiome might affect health.

However, the research has not yet advanced to the point that we know how to significantly or reliably affect that microbiome. The most recent review suggests that current probiotic products are not having any significant effect on the microbiome, at least in healthy individuals.

This is an area, like stem cells, that is likely very promising, and there is some preliminary suggestion of possible benefit. However, preliminary evidence has a very poor track record overall of panning out to actual benefits. It is too early to tell how the science of probiotics will play out. I suspect that any real health benefits will only come once we have fairly sophisticated and aggressive methods for making specific changes to the long term ecosystem of the microbiome. Real benefits may also only come once we incorporate genetically modified bacteria into the mix, with specific properties designed to affect health.

We also appear to be at or near the point of maximal hype. This is a pattern often repeated. Right now there is lots of hope and speculation that manipulating the microbiome will have potential benefits. The research is largely preliminary, which tends to be false positive. This situation is ripe for exploitation by companies to sell supplements with claimed or suggested benefit, before the research definitively shows that such products have little or no benefit, or that the situation is more complex than we thought.

We were here 20 years ago with antioxidants, for example, and 10 years ago with stem cells. Now it’s probiotics’ turn. There will always be something.

Still, altering the microbiome as a health intervention has promise, but it may be 10-20 years before we have real science-based interventions.

Further, it may not be necessary or helpful to alter the microbiome in a healthy individual. They may already have an optimal microbiome. More is not necessarily better.

241 responses so far

241 Responses to “Review of Probiotics”

  1. hardnoseon 16 May 2016 at 10:50 am

    “The most recent review suggests that current probiotic products are not having any significant effect on the microbiome, at least in healthy individuals.”

    Why would probiotics have an effect on a healthy individual? That study doesn’t make a lot of sense.

    “altering the microbiome as a health intervention has promise, but it may be 10-20 years before we have real science-based interventions.”

    And that is one of the big problems with your “science-based medicine.” If something is probably harmless, not very expensive, and might be helpful, there is no reason a suffering person should not try it. Even if the big drug companies have not yet decided to spend billions of dollars studying it.

    Not using probiotic interventions for someone on high doses of antibiotics, just because there is no “convincing” evidence, would be just stupid.

  2. Steven Novellaon 16 May 2016 at 12:09 pm

    HN predictably misses the actual points.

    A person taking high dose antibiotics is not a “healthy person,” meaning someone without any specific health issue. So that situation does not apply to my statement, and I specifically said that

    “The best evidence exists for probiotics for antibiotic-associated diarrhea. This makes sense, because the problem is too little friendly bacteria in the GI system.”

    There is no evidence to support taking probiotics routinely while healthy without any specific indication on the basis that it will do anything beneficial, like support the immune system. I reject that notion that they cannot be harmful – if they can help, they can harm, and statistically the latter is more common.

    You also have to consider the time and expense of a routine intervention that is probably of no benefit, and the countless number of such interventions out there.

    Finally, you have to consider whether or not the specific claims made for probiotic products are justified.

  3. DS1000on 16 May 2016 at 12:55 pm

    @Hardnose – I make an excellent tea made from local grass clippings that supports digestive function. Perhaps you’d like to buy the ingredients from me for only $5 a bag? At the very least you could take it prophalactically until it gets proven ineffective by big pharma.

  4. DS1000on 16 May 2016 at 12:56 pm

    @Hardnose – Oops, forgot to mention that it’s probably harmless.

  5. hardnoseon 16 May 2016 at 1:20 pm

    “you have to consider whether or not the specific claims made for probiotic products are justified.”

    Of course you have to consider that, but my point is there is more than one way to answer that question. You can wait for Big Drug to get around to spending billions on it, or you can resort to “inferior” methods.

    You don’t value any of these “inferior” methods, but I do. The experiences of practitioners and patients can be very valuable, in my opinion. And very often that is all we have. Or would have, if MDs were allowed to use their own knowledge and reasoning ability.

    Medical doctors are not supposed to recommend anything to their patients if it has not been shown in huge studies to benefit the average patient. Well … that is just insane. This is exactly what is being done all the time everywhere, because of the tyranny of “science-based medicine.”

    If medical practitioners are not allowed to try things based on their own scientific knowledge, and the scientific knowledge of others, and the experiences of their patients, that is VERY sad. But that is the reality we are stuck with now.

    I just wish MDs would keep complete records of everything they try on their patients, what works and what doesn’t. If all these records could be integrated, we would have a valuable resource.

    But it will not happen — because it is “unscientific” and not placebo-controlled.

    Damn.

  6. Cherylon 16 May 2016 at 2:27 pm

    Who says probiotics are harmless? We finally got to the root of my spouse’s gastro issues when I challenged her to take her probiotic supplement by itself, on a day she could afford to deal with any negative ramifications. I had begun to notice that it was the one thing that was the same when she’d have a sudden onset of nausea — not all the time, mind you, but enough to make me begin to wonder. Guess what? Her “meal replacement” morning shake was heavy on the probiotics. A product review noted that it was great for most people, but a few experienced an upset stomach. More like projectile vomiting, chills, dizziness and a lost day from work/life. Solved that problem once and for all.

  7. daedalus2uon 16 May 2016 at 2:32 pm

    This is a subject near and dear to my heart. I have been working on specific bacteria as part of the human skin microbiome for many years. None of our products have been included in any of these meta-analyses, primarily because we have not published any clinical trials (yet). These are the ammonia oxidizing bacteria which I am commercializing at AOBiome LLC.

    The only things that we are currently selling are “cosmetics”, and we only make cosmetic claims for them. We do have an FDA approved IND for acne, and we are doing blinded clinical trials for acne and other medical conditions. When they are ready, we will publish them.

    I completely agree that there is more hype than substance in many microbiome claims (not in ours because we are not making any claims). Also, we are working on the skin microbiome, most everyone else is working on the gut.

    The gut microbiome is exceedingly complicated. Usually there are a thousand or so species, and they are different between individuals and they change over time. What this means is that essentially every human gut microbiome is unique, and so is an anecdote. The number of possible permutations between different bacterial strains is astronomically high.

    Fortunately (for humans), there is physiology of the gut that auto-tunes itself to select for the “right” bacteria (or the “right enough” bacteria). How this happens remains mostly unknown. Essentially the only time that people get C. diff infections, their gut microbiome has been disrupted by antibiotics. One of the most important things that prevents adverse gut bacteria is having a “healthy” gut microbiome. Unfortunately, what that is remains unknown.

    For the most part, bacteria that are considered “probiotic” are not anything “special”, other than that they have been used for preparation of traditional fermented foods, yogurt, cheese, pickles. Essentially all “pickling” was traditionally done via generation of lactic acid by lactic acid bacteria. The low pH from fermenting sugars into lactic acid preserved everything else from decay, putrefaction, and fungal attack. This is how silage is made; to preserve forage for later consumption by cattle.

    Low pH is a pretty good anti-microbial treatment, and that is part of what the stomach does normally with HCl (to a pH less than 1).

  8. Steven Novellaon 16 May 2016 at 2:34 pm

    HN – Nice false dichotomy. There is a vast universe between large pharmaceutical trials and anecdotal evidence.

    It is not insane to not rely on anecdotal evidence, which has been proven to be massively unreliable because it is overwhelmed with bias.

    Further, there are many studies, including those on probiotics, which are not funded by drug companies but are investigator initiated. These are the studies we mainly have now. It is not just that these studies are not adequate to support clinical claims, some of those studies are also negative.

    There is no “tyranny” of science-based medicine. That is a fictional narrative you have worked up in your own mind. Rather, SBM simply means looking at all the evidence in its proper context to make the best judgement possible about whether or not a treatment is likely to be safe and effective. Then we make a risk vs benefit decision for individual patients, and will use treatments that are below the level of “proven with massive trials” if an SBM risk vs benefit approach says it is reasonable, and with proper informed consent.

    Contrast that with your silly cartoon. None of this, also, is new if you actually read what I actually write.

  9. hardnoseon 16 May 2016 at 3:49 pm

    Steve N, I am glad to hear that you are willing to use your own judgement when necessary. But I reallt think we need a compromise between “scientific” and anecdotal evidence. If you have seen many patients over many years, you may have observed things that no other doctor has. These “anecdotes” could become an extremely valuable database, if large numbers of medical practitioners contributed their records.

  10. Steven Novellaon 16 May 2016 at 4:12 pm

    They are valuable – for generating medical hypotheses, documenting natural history, and raising red flags. They just are not valuable for confirming hypotheses. Many doctors do record interesting cases, as case reports and case series.

  11. daedalus2uon 16 May 2016 at 4:47 pm

    I am in complete agreement with Dr Novella, and I am employed by a company doing probiotic research, development and sales.

    Anecdotes are data with low and indeterminate statistical significance. If the anecdote is positive, then the evidence is not negative. That is about all that can be said of anecdotes.

    Anecdotes are good for hypothesis development, that is about it.

  12. ccbowerson 16 May 2016 at 5:19 pm

    “For the most part, bacteria that are considered ‘probiotic’ are not anything ‘special,’ other than that they have been used for preparation of traditional fermented foods, yogurt, cheese, pickles. Essentially all ‘pickling’ was traditionally done via generation of lactic acid by lactic acid bacteria. ”

    I was going to bring up this before I hopped on a plane back home from NECSS =). One problem here is that we are talking about a very broad topic (Have probiotics, a heterogenous but not well defined category, been shown to do anything in healthy patients?).

    First of all, it would be quit surprising if our current attempts at significantly altering our microbiome in healthy patients actually worked. Biology doesn’t tend to work that way, especially for things that are important for organisms. If we are expecting health benefits by throwing a few bacteria at a stable ecosystem, then we are implying that our microbiome is very amenable to change, which is not what we observe in healthy individuals nor what would make for stable functioning. We observe that the microbiota are very specific to locations on our bodies, and that attempting to remove them usually results in only a transient change. We would expect that repeated persistent actions would be required to result in even small persistent changes, and significant interventions, like antibiotics, should be required for significant persistent changes. To the extent that we think that our microbiome is important to our health, we should expect it to be resistant to change, except for those situations in which the ecosystems of microbiota are significantly disrupted.

    Another issue is the heterogeneity of the probiotic category, yet the limited number of bacteria we are actually talking about. We are talking mostly of a handful of lactobacillus and bifidobacterium species. The main reason why we use these is that these genera are found in fermented food products (mostly milk, because they can metabolize sugars found in milk), not because they were determined to be the most abundant or important gut bacteria. That we are evaluating probiotics as a category shows that we are still approaching this question in a fairly crude fashion.

    The disconnect I see here is what often happens with new-ish areas of inquiry in science. There are many interesting possibilities here, but we are in the early stages of understanding. Fecal transplant is a closely related topic and one of the better examples of altering the microbiota of the gut after it being significantly altered.

    Unfortunately, the preliminary research in other areas has been over-extrapolated by many media outlets. NPR / Ira Flatow loves the topic so much that it is grating, and I’m afraid he is doing a disservice by overselling the idea too early. This does contribute to the pubic misunderstanding (or even distrust) of science, when the general public cannot distinguish between established science and interesting areas of exploration.

  13. hardnoseon 16 May 2016 at 7:02 pm

    “If the anecdote is positive, then the evidence is not negative. That is about all that can be said of anecdotes.”

    That is not true. If a doctor gets an idea and tries it, and gets consistently good results on large numbers of patients, and keeps careful records, that is information that could be extremely useful to others.

    Memory is fallible, our reasoning is fallible, but we are not all morons. That is an extremist “skeptical” view which has been promoted for decades in cognitive psychology research.

    Of course people are biased in their own favor and are going to remember their successes. But effective new therapies should not be ignored simply because no one has decided to pour money into formal research.

    Clinical experience should count. Doctors should be more scientific about how they use that experience.

  14. ccbowerson 16 May 2016 at 7:31 pm

    “Memory is fallible, our reasoning is fallible, but we are not all morons. That is an extremist “skeptical” view which has been promoted for decades in cognitive psychology research.”

    It is not about being a “moron,” but you knew that already. You just can’t pass up a straw man. It is your calling. The scientific method is used to limit the influence of all the biases that anecdotes are prone to.

    “Of course people are biased in their own favor and are going to remember their successes. But effective new therapies should not be ignored simply because no one has decided to pour money into formal research.”

    No one said to ignore them, but they are, at best, useful for generating hypothesis to be tested. You are OK at arguing against straw men. You are great at creating them.

    “Clinical experience should count. Doctors should be more scientific about how they use that experience.”

    That is what case reports and case series are, but they are a very limited form of evidence. Again, they are used for generating hypotheses. Then we should formally test them.

  15. Willyon 16 May 2016 at 7:58 pm

    hardnose: Congrats! You are correct. We aren’t ALL morons. Just some of us.

  16. GrahamHon 16 May 2016 at 8:38 pm

    Man moves into a new environment and changes it (e.g. slash and burn) and severely disrupts the local balanced ecology,
    Now people want to disrupt their own gut ecology.
    When will Greenpeace et al step in to protect this new ‘land’.

  17. bachfiendon 17 May 2016 at 5:13 am

    I’m extremely sceptical that if probiotics (or organic foods) have any health benefits at all, that they’re actually proportional to the high prices charged. That they’re very expensive for very little if any extra benefit over normal products.

    Personally, I consume a lot of yoghurt (and drinking yoghurt which I make for myself out of commercial yoghurt and skim milk at a reasonable cost of around $1.50 a litre). Not because I think that there’s any health benefit beyond having a balanced diet. But because I enjoy the taste.

  18. hardnoseon 17 May 2016 at 8:53 am

    “That is what case reports and case series are, but they are a very limited form of evidence. Again, they are used for generating hypotheses. Then we should formally test them.”

    And not use them until they are formally tested and replicated. Which might take years or decades, or for most things will never happen.

    Large numbers of case reports should be carefully collected and analysed. We do have computers now.

    There will be bias, but extreme biases would probably be cancelled out, given large enough amounts of data.

  19. daedalus2uon 17 May 2016 at 9:22 am

    If there are enough degrees of freedom, bias doesn’t “cancel out”.

    In the case of the gut microbiome, there are a few thousand species which have been found to be present in some microbiomes. None of those are found in all microbiomes. If you consider that maybe 500 are “important” (but we don’t know which ones are important, where, when and under what circumstances), 500! is ~10^1100. You can’t look at even a tiny fraction of the possible microbiome-space.

    If you want to do statistics, you need a statistically significant sample. Only then does the “bias” cancel out. In the case of 10^1000 different states, you need on the same order. Maybe you could get by with 0.000000000000000000001% of the possible states. You would still need to look at ~10^980 cases.

    That is simply not going to happen.

    The plural of anecdote is not data. Even if you did have state-of-the-art gene sequencing on every stool sample you looked at, standard practice is to only sequence at most a few million, out of 10^13 or so bacteria.

  20. hardnoseon 17 May 2016 at 7:44 pm

    Your comment doesn’t seem to make any sense daedalus2u. Are you saying it is not possible to study the suspected benefits of probiotics by collecting anecdotes, because there are too many possible states, but it is possible with formal experiments? That seems incoherent to me.

    Lets say an MD has 100 patients with a certain problem that probiotics are thought to be good for. He decides, of course with very imperfect knowledge, to prescribe a probiotic that others have found useful for that condition. Let’s say he finds that 70 of the patients improve greatly. Then he might try to figure out what is different about the 70 patients where probiotic therapy succeeded, vs the 30 where it didn’t.

    It is not so terribly difficult to do that, especially if you keep accurate records, and if other MDs are also keeping accurate records.

    What is the alternative? Don’t say anything about probiotics to your patients, let them find the information for themselves online? Wait until all possible states of the gut microbiome have been thoroughly researched and completely understood?

    Clinical experience is a valuable form of research, and most of the time it is all you have. Why not try to improve on it by recording everything that happens with your patients? And sharing your database with other MDs?

    We know there will sometimes be a slight placebo effect, and we know that patients often improve regardless of the treatment. No, it would not be perfect but it would be a heck of a lot better than the two extremes, which are:

    1. Wait until someone gets around to spending time and money researching the question, and their results have been replicated and confirmed. Which, in many cases, will not ever happen.

    2. Rely on your memory and intuition and just do whatever feels right, or what other doctors have dreamed up.

  21. daedalus2uon 18 May 2016 at 8:52 am

    My objection was to your naive “do enough ad hoc experiments and the bias will cancel out” idea. If there are enough degrees of freedom, the n required for bias to “cancel out” may be so large as to be completely infeasible. Usually the reduction in “noise” goes as square root (n). If the “noise” is unacceptably large in a population of 100, you might cut the noise in half if you go to a population of 10,000. Noise reduction by increased sample size only works for very simple systems. Nothing in physiology is simple enough for large numbers to cancel out noise.

    The usual way to do science is to first understand the basics. This is especially important in highly complex systems. The gut microbiome is more complicated than the rest of physiology put together. Not knowing which part (if any) of that complexity is important, to achieve useful progress, first the basics need to be understood.

    Once you understand the basics, then you can (intelligently) reduce the complexity of the system(s) you are working with. If you don’t understand the basics, you can’t.

    The most important thing in science is to not fool yourself, and you are the easiest person to fool. A naive “gather lots of data and have computers sort it out” isn’t going to work for non-linear, coupled systems with more than a few variables. Physiology has tens or hundreds of thousands of variables; per cell, most of which can’t be measured or controlled.

    In the case of the human microbiome, the basics remain not understood. What is needed is data. Data that covers “normal” human variation. The most useful data would be from humans living in “the wild”, in the natural state that humans evolved in. There are relatively few populations of humans (if any) still living as our ancestors lived while they evolved in Africa. Understanding the “normal” human microbiome and how it changes with perturbations (sickness, diet, age, stress, other perturbations).

    Until data has been collected and understood, the system remains unknown. Theory can help in understanding systems even in the absence of specific data. The gut microbiome is still a physical system, it obeys the laws of thermodynamics, physics, and general relativity. There is no “spontaneous generation” in the gut (or elsewhere). Chemicals in the gut behave the same as chemicals in the laboratory.

    Understanding that humans evolved, puts constraints on what bacteria can be in the gut and how they would likely react and how the human immune system is likely to react. The gut microbiome is pretty robust to perturbation, but it can be disrupted by known and unknown disturbances.

    Most bacteria in the gut can’t be grown in culture, and have physiology which is not understood. Fortunately for us, there is considerable auto-regulation by human physiology of the gut microbiome so as to foster and facilitate a gut microbiome that is “healthy”. Understanding how human physiology facilitates a “healthy” gut microbiome will be instrumental in understanding the properties of a healthy gut microbiome.

    For example, gut mucus has a very complex composition, with complex carbohydrates linked together with disulfide bonds. Bacteria in the gut are nourished by those carbohydrates, and that nourishment by gut mucus helps to regulate what species are where in the gut. Usually, bacteria are pretty fastidious in what they require. A particular unit of gut mucus may have a dozen different carbohydrates that require a dozen different bacteria to metabolize. Using different bacteria to metabolize the same unit of mucus, slows down the degradation of that mucus by requiring bacteria to move around. One type of bacteria metabolizes carbohydrate in one region until it is relatively depleted, then moves to another region and other bacteria move in to metabolize carbohydrate the first bacteria couldn’t. A microorganism that could metabolize all types of carbohydrate could “drill through” the protective mucus to the gut wall and cause problems.

    What is needed is basic research to understand these very complex systems. Unfortunately many science funding organizations (like the US Government) don’t appreciate how important basic research is. You need a whole lot of basic research before it makes any sense to do applied research to try and implement treatments.

  22. hardnoseon 18 May 2016 at 12:14 pm

    daedalus2u — yes we need more research on the gut microbiome! I would never disagree with that! More research, including basic research, is always better, but as you noted we have to wait until the US government, etc., finally decide this subject, or any other subject, is worth studying. Hell might freeze over several times before that happens.

    So what can we do? We can just despair and give up trying to cure ourselves or others of diseases related to problems with the gut bacteria.

    Or we can do what I said. Encourage clinicians to be more scientific (without controls, yes I know) and to keep accurate records, and to share those records.

    You can’t do controlled experiments to study climate change, and many other things. Scientists very often have to find other ways.

    You can ignore clinical experience because our memories aren’t perfect and we are good at fooling ourselves. You can refuse to do something that is good, just because it isn’t perfect.

  23. daedalus2uon 18 May 2016 at 12:31 pm

    Doing stuff at random without knowing the fundamentals is extremely unlikely to be successful.

    People have been dying of heart attacks since forever. Should they have tried to do heart transplants in the 19th century?

    The bacteria in yogurt can cause liver abscesses. Most bacteria in the gut are not as benign as the bacteria in yogurt.

    Fecal transplants (when they work), are often extremely successful. But fecal-oral transmission is a major route for things like hepatitis, cholera and worse.

    It is extremely frustrating to not have the data to be able to know and verify that certain treatments are safe and effective. Good clinicians don’t just make stuff up because they are frustrated.

  24. hardnoseon 18 May 2016 at 5:52 pm

    “People have been dying of heart attacks since forever. Should they have tried to do heart transplants in the 19th century?”

    That statement is irrational. Many things have been discovered about heart disease without controlled experiments. For example, the connection between metabolic syndrome, type 2 diabetes, and CVD was observed by alternative medicine clinicians long before mainstream medicine ever decided to study it.

  25. hardnoseon 18 May 2016 at 5:54 pm

    “It is extremely frustrating to not have the data to be able to know and verify that certain treatments are safe and effective. Good clinicians don’t just make stuff up because they are frustrated.”

    What I am trying to say is that we do have some data. It just isn’t as perfect as you would like.

    Just making stuff up is exactly what I am against. But I am also against ignoring pretty good data just because it is not great.

  26. daedalus2uon 18 May 2016 at 7:42 pm

    I am not saying to ignore data, but unreliable measurements are not “pretty good data”, they are anecdotes.

    There are hundreds of variables which might be important, and none of them are routinely measured. Even if they were routinely measured, many of them are variable and change over time.

    One of the problems is that most researchers think the idea of homeostasis is correct. It isn’t. The idea of homeostasis is a myth. The most complicated physiological state is the state of good health, at rest. All other states are more simple than the state of good health at rest.

  27. hardnoseon 19 May 2016 at 11:28 am

    “unreliable measurements are not “pretty good data”, they are anecdotes.”

    That is not an accurate or reasonable statement. Anecdotes can be great data if you have enough of them, especially if they are compiled in some kind of understandable and convenient way.

    The best way to get medical anecdotal data now is to read online patient forums. Of course they are not compiled so you have to read hundreds of them. But they tend to be honest, since they have no reason to be biased (as opposed to doctors who are selling something, and only show you their success stories).

    If you read hundreds of patient reports and 90% say seaweed enemas cured their hiccups, for example, and no one got sick or died from it, then I consider that good evidence.

    “One of the problems is that most researchers think the idea of homeostasis is correct. It isn’t. The idea of homeostasis is a myth. The most complicated physiological state is the state of good health, at rest. All other states are more simple than the state of good health at rest.”

    Whoever said homeostasis is simple? Natural systems try to maintain a relatively balanced state, that is a fact. I can’t figure out what you are saying.

  28. hardnoseon 19 May 2016 at 12:20 pm

    And how is anecdotal data different from observational data? Why do you believe what climatologists say about climate change, if you don’t believe anything medical doctors observe about their patients?

  29. daedalus2uon 19 May 2016 at 2:23 pm

    What does a “relatively balanced state” mean?

    When two things are “relatively balanced”, how can you know their relative values? Are those relative values important?

    Is the “balance” between -10,000 and +10,001? Or is it between 0 and +1?

    If you don’t know the difference between observational data and anecdotal data, then you have no business trying to infer medical effects from it.

    There is a good paper estimating the number of species of bacteria on Earth. They estimate on the order of 10^12. Of which 99.999% remain unidentified. Are any of those unidentified bacteria important? Good question, to which the answer is, “we don’t know”.

    http://www.pnas.org/content/early/2016/04/26/1521291113.abstract

  30. hardnoseon 19 May 2016 at 7:09 pm

    We don’t know most things. All of medicine is based on extremely incomplete information. I don’t know what you expect anyone to do about it.

    “If you don’t know the difference between observational data and anecdotal data, then you have no business trying to infer medical effects from it.”

    A physician observes his patients, that is observational data and it is also anecdotal.

    Whenever experimental research is impossible, scientists resort to observation. This should be acceptable in medicine, as it is in many other fields.

    “Science-based” medicine insists that medical observations are not valid data. I have read enough of this blog and the science-based medicine blog to know that they will not recommend anything that has not been studied in placebo-controlled double-blind experiments. That kind of research can only answer certain kinds of questions.

    Most things have not been studied in that way. That is why MDs should be scientists. If you spend all day every day seeing patients, you should notice some patterns. And you should test your observations. And most of all, keep accurate records.

  31. Niche Geekon 20 May 2016 at 3:48 am

    Hardnose,

    “and you should test your observations” – how? If you don’t like prospective trials or feel they add li,tied vale, then how do you propose to test? If you do feel anecdotes are enough, then why test at all?

    Re climate science vs medicine and observational data. There are quantitive and qualitative observations. If physicians are tracking purely physical observations as well as climatologists track temperatures then your scheme might work. Given how much of medicine and physician observations are qualitative and how much of what physicians treat can be self limiting or erratic, like hiccups, you’d be foolish to trust anecdotes over trials. Blood letting was popular because the physicians of the day thought it worked. They had lots of anecdotes to prove it too.

    I say this because you do recognize that EBM and SBM have a hierarchy of evidence and don’t reject anecdotes… They just don’t accept anecdotes as sufficient.

  32. Niche Geekon 20 May 2016 at 3:50 am

    Ugh… So many weird autocorrects. I was suggesting that HN felt trials added little value.

  33. The Other John Mcon 20 May 2016 at 7:52 am

    hardnose, physicians have being doing observational and anecdotal data collections for centuries upon centuries… how much progress was made? how good was the state of medicine? can’t we just call it quits on that front? Add experimental science to the mix, and look what has happened in only a few hundred years.

    Also you might be losing something by conflating observational science with anecdotal evidence. Observational science often has strict well-tested protocols, rigorous methods and data collection techniques, etc. It’s much much more complicated than a doctor saying “When I did this, I noticed that” or whatever cartoony version you seem to be advocating.

    Still, there are very often findings in observational sciences that get overturned later by experiments, happens constantly, simply because the observational pieces leaves out the experimental controls that you really need to make solid conclusions. Progress is excruciatingly slow in observational science, and often just a hits a brick wall and fails to move forward, or just spins in theoretical circles. Experiments are where it’s at! 😛

  34. hardnoseon 20 May 2016 at 11:25 am

    “If you do feel anecdotes are enough, then why test at all?”

    I DO NOT feel anecdotes are enough and I NEVER said that. Observation data is often all we have. We should use it.

  35. hardnoseon 20 May 2016 at 11:26 am

    “If physicians are tracking purely physical observations as well as climatologists track temperatures then your scheme might work.”

    That is EXACTLY what I am recommending. Track physical things that you can quantify.

  36. hardnoseon 20 May 2016 at 11:28 am

    “Blood letting was popular because the physicians of the day thought it worked. They had lots of anecdotes to prove it too.”

    Why does everyone always use that example?? There are no other examples. And by the way, blood letting does work for certain things, and medical leeches are still being used. The problem was that they used it for things it does not work for, maybe because they had no better ideas at the time.

  37. hardnoseon 20 May 2016 at 11:28 am

    I meant “There are no other examples?” question mark.

  38. hardnoseon 20 May 2016 at 11:30 am

    “Add experimental science to the mix, and look what has happened in only a few hundred years.”

    You are making unwarranted assumptions. Were antibiotics discovered by formal research? No of course not. One scientist alone making observations.

  39. hardnoseon 20 May 2016 at 11:32 am

    “the observational pieces leaves out the experimental controls that you really need to make solid conclusions. Progress is excruciatingly slow in observational science, and often just a hits a brick wall and fails to move forward”

    You missed my entire point. I never said we don’t need experimental controls, but that is not always possible or practical.

    And progress is excruciatingly slow in formal experimental research. And excruciatingly expensive.

  40. leoneton 20 May 2016 at 1:29 pm

    I just have to say that #hardnose here appears to have an understanding of medical research analogous to a creationist’s understanding of evolution. The fact is that ‘formal’ researchers are very much aware of all of his alleged problems, including the greater expense of the the best (Placebo-Controlled RCT) data and already work hard to integrate as much clinical observation and health-record data as possible into their knowledge base.

    In fact, researchers even have statistics on how big an effect size a treatment must have for its benefits to be clearly visible in routine clinical observations and that effect size is actually quite big. One of the benefits of science-based controlled trials (that #hardnose seems to hate) is that they allow treatments with smaller, more subtle effects to be recognized as valuable.

  41. hardnoseon 20 May 2016 at 4:31 pm

    I said over and over I don’t hate controlled trials. I said they are not always possible or practical.

    “they allow treatments with smaller, more subtle effects to be recognized as valuable.”

    Oh yes, you can give 100 patients statins and maybe one will benefit. That is extremely valuable, for the drug companies.

  42. hardnoseon 20 May 2016 at 4:33 pm

    “already work hard to integrate as much clinical observation and health-record data as possible into their knowledge base.”

    Oh really? I guess you have not read the SBM blog, where they will not recommend anything unless it has already been verified by RCTs. In other words, some big company or organization decided it is worth testing, for reasons we can only guess.

  43. mumadaddon 20 May 2016 at 5:09 pm

    hn,

    This thing about aggregating GPs’ (physicians’) observations seemed familiar to me when you brought it up. Having thought about it for a bit, I’m ~70% sure I heard it in Ben Goldacre’s Bad Pharma.

    I think I might actually agree with you. This would be epidemiological data, which is often self-reported. You have to hope that any placebo effects cancel out with large enough datasets. You could even try to introduce some rigour in the form of inclusion/exclusion criteria, and it could all be just part of an automated software system used by GPs.

    Easy win I think.

  44. mumadaddon 20 May 2016 at 5:09 pm

    “This would be epidemiological data, which is often self-reported”

    Fact check time. Shit…

  45. mumadaddon 20 May 2016 at 5:25 pm

    If the Chinese had had such a system, who knows where their herbal remedies would have been by now. Obviously it’s not a large scale RCT, but it still has value, right?

  46. mumadaddon 20 May 2016 at 6:06 pm

    (PS: I know China also has lots of ‘sane’ (allopathic) practitioners too, so don’t go calling me bigoted)

  47. hardnoseon 20 May 2016 at 8:25 pm

    mumadadd I am glad you agree. I think this is an idea that could be extremely helpful. I don’t know if anyone is already doing it but I suspect they are not.

    It might be a very difficult and expensive thing to do, but maybe it could be done in evolving phases.

    One problem is that MDs might “forget” to record and share all of their failures. This happens in formal research also — the “file drawer” effect, where failed experiments get shoved in the file drawer and forgotten.

    But hopefully the fact that different doctors have different agendas would even things out somewhat.

    I know that when I am researching a medical problem the only resources I find are:

    – The official medical websites which are usually only slightly helpful, if at all.

    – PubMed abstracts — usually can’t find much if anything on the subject I am searching for.

    – Patient health forums. These are the most helpful, but since they are not compiled you have to read one post after another to get a sense of what works or not. Also there is no hard quantitative data or statistics.

    – My doctor. Well I get 15 minutes to ask him everything. And he has never once said anything like “80% of my patients who have a similar problem to yours got better when they took vitamin F.” That makes me think he does not keep good records, and that his doctor friends don’t either.

  48. mumadaddon 21 May 2016 at 1:41 am

    http://www.phc.ox.ac.uk/news/nhs-gp-level-prescribing-data-open-for-all

    Ah, I was trying to remember the specifics of what BG was saying. This is to do with prescription trends rather than self reported outcomes.

  49. mumadaddon 21 May 2016 at 2:17 am

    hn,

    I have to row back on what I said. I conflated what you said with BG’s five to pool data on GP prescribing behaviour.

    I can sympathise with your experience of trying to do your own research, but I can’t see how you can separate real effects from placebo when ring on self reported subjective outcomes.

    I think maybe the place for this is looking for extreme but rare side effects from drugs.

  50. mumadaddon 21 May 2016 at 2:17 am

    Five = drive.

  51. mumadaddon 21 May 2016 at 2:18 am

    Ring = relying. Jebus.

  52. hardnoseon 21 May 2016 at 2:32 pm

    “I can’t see how you can separate real effects from placebo when ring on self reported subjective outcomes.”

    The concept of placebo effects has been extremely exaggerated. Slight and subtle differences may sometimes be explained by placebo, but dramatic and obvious results are not.

    We all know this, but somehow the Skeptical ideology prevents you from admitting it.

    Let’s say you have some kind of bothersome symptom and you try something you heard about, and the symptom quickly vanishes. You think this may be a coincidence, but then you find it happens every time. You try a different thing you heard about, and there is no difference, the symptom is still there. Try again, same thing, no effect. Go back and try the first thing — dramatic improvement.

    We have all been through this kind of thing. Have you been so brainwashed that you can’t remember?

    Then you try a third thing, and you really can’t tell if it worked or not. Maybe you feel slightly better, but it’s hard to say. That one could be placebo. But it doesn’t really matter if it is or not, since the benefit is so slight. It is not something you are likely to waste time or money on again.

    Yes experiments are great for certain things, and sometimes they can be done. But never trusting our own experiences, no matter how dramatic and obvious, is just plain dumb and stupid.

    And we need to have a little trust in the experiences of others as well. If I read a hundred patient reports saying something works great, and only a few saying it’s worthless, then I have to consider the possibility that those hundred people are not all delusional.

    I am skeptical of any claims made by someone who is trying to make money.

  53. mumadaddon 22 May 2016 at 10:16 am

    hn,

    The thing is, I can’t see how something like you’re describing wouldn’t lead you to the conclusion that, say, acupuncture works for various things.

    “Slight and subtle differences may sometimes be explained by placebo, but dramatic and obvious results are not.”

    “We have all been through this kind of thing. Have you been so brainwashed that you can’t remember?”

    I haven’t been through this kind of thing, no. The only times I’ve taken some treatment (generally pharmaceuticals), and had a “dramatic and obvious” result, they were prescribed by a physician. And I do have an experience of trying to find my own treatments — I periodically suffer with pretty crippling insomnia, and while CNS suppressants such as zopiclone are really effective at knocking you out, doctors are highly reluctant to prescribe anything but a short course. Everybody, and I mean everybody has their own sure fire cure for insomnia, and I’ve tried them all, from hot baths to melatonin to milk and honey (plus more desperate measures I won’t go into), and none of them worked. But the CNS suppressants absolutely did, with no room for doubt or interpretation.

    The kinds of interventions that have sudden and obvious effects tend to have already been studied properly, with controls in place for placebo effects, so you don’t need to rely on testimonials to find out how effective they are, and doctors don’t need to rely on anecdotes from their patients as the primary guide to prescription criteria.

  54. daedalus2uon 22 May 2016 at 10:36 am

    HN, you don’t know what you are talking about with regard to the placebo effect. You are exhibiting the Dunning-Kruger effect.

  55. BillyJoe7on 22 May 2016 at 6:12 pm

    Ditto d2u, and that applies to pretty well every topic he comments on.
    It has been a painful experience reading this thread over the past few days.
    It is beyond me how someone who has been reading this blog as long as he has could still know almost nothing about science or scepticism.
    You’d think at least some of it would get past his blood brain barrier.

  56. ccbowerson 22 May 2016 at 10:07 pm

    “But never trusting our own experiences, no matter how dramatic and obvious, is just plain dumb and stupid.”

    If the cause and effect is obvious – like getting punched in the face or a severe allergic reaction to a single ingredient, then sure trust your perception, but if we are talking about the treatment of an illness that comes and goes as you are describing then you are fooling yourself. You are clearly overconfident in your ability to determine that a treatment works and you have little insight into the problems with that.

    There is the natural course of a condition, motivated placebo effects, confirmation bias, etc. Come on, that is why we even need a scientific process in the first place. If you think ‘just winging it’ is a reasonable approach then you haven’t been paying attention. That is how we have billions $ spent per year for OTC supplements. Even products that have been studied and failed can sell very well. How do you think that happens?

  57. hardnoseon 23 May 2016 at 9:14 am

    Most things have never been studied by big agencies and corporations. And even if something has been formally researched, it probably doesn’t work for everyone. The only way to find out if it works for you is to try it.

    The placebo effect is subtle, even the Skeptics here will tell you that.

    The kinds of treatments that must be individualized are hard to study in RCTs.

    I know for an absolute fact that chiropractic can work for allergies. I am sure no big agency or drug company has ever studied this. No, not every chiropractic technique works for every allergy patient. You can only find this out by trial end error. It is a fact I have experienced repeatedly.

  58. hardnoseon 23 May 2016 at 9:19 am

    And mumadadd, unfortunately you won’t believe me but I’ll tell you anyway. I know the cause and cure for insomnia. You have some vertebrae slightly out of place. It causes restless muscles, especially in the legs. I get that once in a while, and fix it the same way I fix allergy symptoms. The reason you don’t always have insomnia is that those vertebrae are not always out of place.

  59. daedalus2uon 23 May 2016 at 9:26 am

    The mechanism by which chiropractic works for allergies is via the placebo effect.

    So much for the placebo effect being “slight and subtle”.

  60. arnieon 23 May 2016 at 10:10 am

    d2u, you’re correct, and ditto for insomnia, of course.

  61. mumadaddon 23 May 2016 at 10:23 am

    I really don’t know what to say to that. I really wasn’t expecting that. Jebus.

  62. hardnoseon 23 May 2016 at 10:50 am

    mumadadd you could analyze what you experience during insomnia, if you were at all curious. Is there any experience of restless muscles? Do the curves or your spine seem any different than usual?

    I found this out about allergies from years of trail and error. It has nothing to do with the placebo effect. I tried everything else imaginable, including drugs from the doctor, and didn’t get any placebo effect at all. I would have been glad to get a placebo effect, but never got one.

  63. mumadaddon 23 May 2016 at 11:16 am

    No and no. It’s primary insomnia.

  64. hardnoseon 23 May 2016 at 11:54 am

    Ok mumadadd sorry I couldn’t help. But this is yet another example of a disorder modern medicine has little or nothing for.

    My experience is with allergies, which there isn’t much for aside from drugs, which don’t work for everyone. But I know people with all kinds of other things that modern medicine doesn’t help. So either they believe their doctor — that nothing can be done — or they do their own “research” and “experiments,” and hopefully find something.

    In my experience, there is no placebo effect whatsoever. Maybe some people get a placebo effect, but I never have. If something works I know it right away. If it doesn’t work, I can’t fool myself into thinking it works.

    And I have read articles here or at SBM saying that the placebo effect, when it does occur, is weak.

  65. The Other John Mcon 23 May 2016 at 12:55 pm

    “If something works I know it right away.” That’s what someone with a placebo effect would say. You really don’t get it? Both placebo and real treatment cause many people to claim “it’s working on me for sure”…but you need the stats to tell them apart.

    You sound like you would buy and try a bottle of prominently labeled Placebo Pills if they sold them.

  66. hardnoseon 23 May 2016 at 2:28 pm

    As I already explained, I tried many things for allergies and they did not work. If the placebo effect was such a big deal, then everything we try would seem to work. I found one thing that causes dramatic immediate improvement.

    If you have ever tried anything that did not work, even if it works for many others, then you know the placebo effect is weak at best.

    The placebo effect actually has been studied, and found to be weak at most.

  67. hardnoseon 23 May 2016 at 2:30 pm

    It makes sense to be skeptical and question your perceptions and those of others. It is bordering on insane to never trust your own experiences no matter how obvious they are.

  68. RickKon 23 May 2016 at 6:55 pm

    Did that just happen? With zero information at all hardnose, with no hesitation, claimed to diagnose mumadadd’s insomnia.

    Where are Dunning-Kruger medals when you need one?

  69. The Other John Mcon 23 May 2016 at 7:04 pm

    Allergies and insomnia have the same cause and cure? And it has to do with spine? Color me confused

  70. SteveAon 24 May 2016 at 6:59 am

    I think HN must be allergic to restless legs.

  71. BillyJoe7on 24 May 2016 at 7:31 am

    Just when I thought my estimation of hn couldn’t sink any lower…

    And the hubris:

    “In my experience, there is no placebo effect whatsoever. Maybe some people get a placebo effect, but I never have. If something works I know it right away. If it doesn’t work, I can’t fool myself into thinking it works”

    I swear he hasn’t he even heard of Richard Feynman.
    Let alone David Dunning and Justin Kruger.

  72. mumadaddon 24 May 2016 at 8:07 am

    hn,

    “As I already explained, I tried many things for allergies and they did not work. If the placebo effect was such a big deal, then everything we try would seem to work. I found one thing that causes dramatic immediate improvement.”

    Yes, and many of the people recommending various folk remedies for insomnia had tried all sorts of things before landing on the thing that “worked, dramatically and immediately” for them. One of my colleagues tried all sorts of smoking cessation interventions before a quack pierced her ear with a thread, which she would then pull on when a craving struck, and she insisted that it was the treatment that worked, dramatically and obviously, so I should try it (I used to smoke*).

    What you are implying is that people are so physiologically variant that while some treatment can be demonstrated to be ineffective on a large sample under controlled conditions, it can still work for you, or my colleague, or my well meaning friends and family.

    * I no longer smoke. Obviously I did not go and get a thread put in my ear.

  73. hardnoseon 24 May 2016 at 8:43 am

    “What you are implying is that people are so physiologically variant that while some treatment can be demonstrated to be ineffective on a large sample under controlled conditions, it can still work for you, or my colleague, or my well meaning friends and family.”

    Most things have not been tested much, if at all, especially if they are “alternative.”

    Chiropractic has not failed extensive high quality research. It can’t be blinded, for one thing. And the drug companies have no interest in it, and the Skeptics fight it relentlessly.

    Not that I am an advocate for chiropractic. I just make use of some of the ideas.

    But yes, people are not all the same. We are all similar, but there are sub types, sub sub types, etc. It is very possible that an effect would wash out completely on a large heterogeneous population, even if it works very well for certain types of people.

  74. hardnoseon 24 May 2016 at 8:54 am

    If someone has tried many different things and none of them work, and then something works immediately and dramatically, you can’t explain that away as delusion. Especially if you know the person and they are not generally delusional.

    The idea that people can fool themselves so deeply is part of the Skeptic mythology. There is no other way to explain the fact that some alternative things can work for some people.

  75. mumadaddon 24 May 2016 at 8:57 am

    “If someone has tried many different things and none of them work, and then something works immediately and dramatically, you can’t explain that away as delusion.”

    No, you can explain it as placebo effects.

  76. hardnoseon 24 May 2016 at 9:12 am

    No you can’t, since many other things did not work.

  77. hardnoseon 24 May 2016 at 9:14 am

    And the placebo effect is a delusion. Usually just a slight delusion. But some people might be extremely suggestive and anything they try works for them. Others are not suggestive at all.

  78. mumadaddon 24 May 2016 at 9:30 am

    “Chiropractic has not failed extensive high quality research. It can’t be blinded, for one thing. And the drug companies have no interest in it, and the Skeptics fight it relentlessly.”

    It would be simple enough to blind this I think. Take two groups of people, teach one the chiropractic intervention for condition a, teach the other a sham version of the chiropractic intervention for condition a. Not sure that would be very ethical though….

    Anyway, chucking ethics out the window for this hypothetical — if such a test were conducted and the results showed the “real” treatment to be no more effective than the “sham”, would you agree that chiropractic doesn’t work for condition a?

  79. hardnoseon 24 May 2016 at 10:13 am

    No I would not agree, that would be just one test. And chiropractic is extremely complicated and not well understood, even by chiropractors. It is not something you can test simply in an experiment.

    I really don’t know how or if you can test chiropractic, or acupuncture or homeopathy, since are are individualized, complex and poorly understood (even by the practitioners).

    What is needed is what I suggested before — high quality case study research, with large numbers of accurately recorded cases, with quantitative measures.

    I am not a believer in any of those things, by the way. I happened to find out that chiropractic ideas can be applied to get rid of allergy symptoms, for me anyway.

  80. daedalus2uon 24 May 2016 at 10:46 am

    Chiropractic, acupuncture and homeopathy are all placebos. They understood, but not by “believers” and “practitioners” because they don’t want to understand that they are placebos.

    hn, I think your problem in understanding the placebo effect is that you don’t have a coherent definition of it. You are lumping multiple things into it, and excluding others based on inconsistent and arbitrary ad hoc criteria.

    Write down your definition of the placebo effect and then it might be able to be understood.

  81. mumadaddon 24 May 2016 at 10:56 am

    hn,

    Seriously? You don’t see the value in isolating the variable in question? This is what’s achieved by randomising/blinding/placebo control. As far as it’s possible to do so, you want to make sure any effect you’re seeing is from the specific intervention and not something more general to the interaction between the care giver and patient. You can still use subjective outcome measures here, but so much the better if you can use hard outcomes.

    And the aim of this test is not to establish whether chiropractic works/doesn’t at all, but how effective it is for condition a.

    “I really don’t know how or if you can test chiropractic, or acupuncture or homeopathy, since are are individualized, complex and poorly understood (even by the practitioners).”

    So you also want to ignore scientific plausibility. Righto. And again you’re implying (well, outright asserting here) that through quirks of individual physiology, no treatment effect can be generalised beyond the individual.

    What you said about not being able to test interventions because they are “individualized, complex and poorly understood” is rubbish; us skeptical ideologues would call it special pleading. Look at the specific claims that are made for each of these, and test those. You could use proponents of any of these treatments to design inclusion criteria or screening process. There is no reason that a real effect can’t be picked up just because you add rigour to the testing procedure.

    “What is needed is what I suggested before — high quality case study research, with large numbers of accurately recorded cases, with quantitative measures.”

    You’re basically saying, to test things you think work for you, remove all the constraints that would be able to distinguish placebo effects from real effects.

  82. mumadaddon 24 May 2016 at 10:58 am

    D2U has it right — “They understood, but not by “believers” and “practitioners” because they don’t want to understand that they are placebos. “

  83. steve12on 24 May 2016 at 11:01 am

    Your instincts about research are very good Mumaddad. Of course you can use a sham control for chiro:

    https://scholar.google.com/scholar?hl=en&q=sham+control+chiropractic&btnG=&as_sdt=1%2C22&as_sdtp=

  84. hardnoseon 24 May 2016 at 11:02 am

    mumadadd, I am not opposed to controlled experiments for chiropractic, etc. I just thing it would be expensive and impractical. Chiropractors have their own journals with lots of research, but I don’t know how much of it is blinded.

  85. mumadaddon 24 May 2016 at 11:24 am

    hn,

    Funny that top of the list in s12’s link is a study referencing massage along with chiropractic as manual therapies.

    I can believe you when you say cp worked for insomnia; it’s quite plausible (to me anyway) that manipulation could have a similar relaxing effect to massage, making that crucial bit of difference that allows you to get to sleep that night. A lot of the time with insomnia, breaking the cycle can put an end to that particular bout, and you would be reasonable (though quite probably incorrect) to attribute the positive result with whatever you did preceding it.

    You can see why blinded placebo controlled testing would be useful in this case, right? You could test cp vs massage/cp vs sham/sham vs massage. This would weed out placebo effects and help you better understand specifically what it is about cp that causes the effect — is it a relaxing effect similar to massage? is it more to do with the ritual aspects of the treatment? This is all useful information, and I don’t see how, if done properly, you’re going to lose anything.

    Btw I’m not trying to assert that my above explanation as to why cp worked for you is correct; it may be that there is something specific to your cp intervention, and only that, that caused the effect. But my point is, without proper testing, how are we going to know? What use is the fact that it worked for you in advancing medicine or physical therapy?

  86. mumadaddon 24 May 2016 at 11:30 am

    s12,

    I guess it’s pretty easy to single blind, but tricky to double blind.

  87. steve12on 24 May 2016 at 11:42 am

    Trivial to single blind.

    But double not possible. At least I can’t think of any way it could be possible.

    Considering the small effect sizes and DVs (pain) we’re talking about here , to not at least sham for single blinding makes the experiment pointless IMO.

  88. mumadaddon 24 May 2016 at 11:48 am

    “DVs” what does that stand for?

  89. hardnoseon 24 May 2016 at 11:54 am

    “Write down your definition of the placebo effect and then it might be able to be understood.”

    In controlled experiments a placebo condition uses a treatment that is known to be ineffective. So that subjects and experimenters believe the placebo group is getting an effective treatment.

    The reason for the placebo group is to factor out psychological effects.

  90. hardnoseon 24 May 2016 at 12:02 pm

    mumadadd,

    I personally believe in the subluxation concept. If I touch my back I can feel when vertebrae are out of place. And this corresponds directly with how I feel, allergies, etc.

    The curves of the spine are normally smooth. If you feel areas that are flat or bumpy, that indicates what chiropractors call subluxations.

    This is something I know with absolute certainty, but proving it to others would not be easy.

    I definitely can’t go along with the “chiropractors are all quacks” idea, because of what I know about subluxations. But I am NOT saying chiropractic is generally effective, or that most chiropractors are good. Just that I know this aspect of their philosophy is correct.

    Sometimes we just know something from direct repeated obvious experiences. No, it does not count as scientific data. But it does make me open-minded about what chiropractors claim.

  91. mumadaddon 24 May 2016 at 12:03 pm

    hn,

    You described a placebo rather than placebo effects. Placebo effects can be anything not directly attributable to the clinical intervention in question.

    e.g. You test real vs sham (cocktail sticks instead of needles – no penetration and don’t use actual ‘meridians’ acupuncture for migraine, both groups experience a statistically significant pain reduction effect, but both are around the same. So the effect of the ‘real’ treatment is not directly attributable to the acupuncture itself, unless you use a vague definition of acupuncture that captures the sham treatment also.

    The (real) effects of both the sham and real treatment could be caused by regression to the mean, attention from the practitioner, belief that the treatment could work. These are all placebo effects.

  92. mumadaddon 24 May 2016 at 12:13 pm

    hn,

    “Sometimes we just know something from direct repeated obvious experiences.”

    No — without proper testing you will never know whether the effect a placebo effect or not.

    That’s the point. If cp works every time for your insomnia, how are going to know whether that’s because the physical manipulation relaxes you, or something else altogether?

  93. mumadaddon 24 May 2016 at 12:19 pm

    Please, somebody correct me if I got something wrong about placebo effects. Don’t want to continue being wrong if so.

  94. hardnoseon 24 May 2016 at 12:45 pm

    “The (real) effects of both the sham and real treatment could be caused by regression to the mean, attention from the practitioner, belief that the treatment could work. These are all placebo effects.”

    No, regression to the mean is not part of the placebo effect. A placebo effect is just when people say they feel better, although they did not get any treatment.

    You don’t get any placebo effect with objective measurements.

  95. hardnoseon 24 May 2016 at 12:47 pm

    “If cp works every time for your insomnia, how are going to know whether that’s because the physical manipulation relaxes you, or something else altogether?”

    How do you know that when you are thirsty and drink water, you are not thirsty any more? No one says you’re just imagining it, because this is an experience everyone shares. If I have an experience that you don’t share, you can’t possibly understand.

  96. hardnoseon 24 May 2016 at 12:49 pm

    And mumadadd, insomnia would be something that might be cured by relaxation. What I said I repeatedly cure with cp is allergy symptoms. Insomnia can be at least partly psychological, but allergies are generally considered physical.

  97. hardnoseon 24 May 2016 at 12:52 pm

    “No — without proper testing you will never know whether the effect a placebo effect or not.”

    I will know, other people I tell about it might not believe it. My allergy doctor doesn’t seem to know if he believes it or not.

    I tried extremely expensive things that were supposed to work but didn’t. You would think that if I spent thousands of dollars on something I would at least get a slight placebo effect.

  98. hardnoseon 24 May 2016 at 12:56 pm

    Also, cp for allergies was not something I had heard about or believed in previously. I just happened to notice subluxations when I had the symptoms, and no subluxations when I didn’t have symptoms. Always, every single time.

    Now, do you think I should go raise millions of dollars to fund formal research before using this cp technique on myself?

  99. steve12on 24 May 2016 at 1:09 pm

    Mumaddad:

    I don’t do RCTs, but you essentially have it re: placebo effects.

    DV – dependent variable.

    I’m loathe to engage The Troll, but I will tell you this Mumadadd. The notion that some Special People can consciously tell you what the proportions are of the source of the effect that they are experiencing (manipulated:placebo) is such grandiose BS that it defies all description.

    No one can do this. The notion that it’s possible doesn’t even make sense.

  100. hardnoseon 24 May 2016 at 1:13 pm

    The notion that people can never have any idea of what they are experiencing or why is such authoritarian nonsense it is beyond description.

  101. steve12on 24 May 2016 at 1:17 pm

    Re: insomnia,

    I had it fairly bad – but it would come and go. Not sure if this is your experience. One of the standard pieces of advice is to keep a regular sleep schedule, and I avoided doing that. I would regularly sleep late for a few days, then not at all for 2 days, etc.

    But if I HAD to get up early, I could count on 0-little sleep.

    Being forced into a regular schedule by a new job has completely “cured” me. It’s not even super-regular (varies by ~2 hours / night), but it was enough.

    I have to admit, though, that I miss my binge reading until the sun comes up nights! Overall, though, worth it.

  102. steve12on 24 May 2016 at 1:20 pm

    Mumaddad:

    “No one can do this. The notion that it’s possible doesn’t even make sense.”

    I forgot to add stupid to this.

    It’s stupid to think that it’s possible to tell what percentage of your pain relief came from the placebo effect, and what percentage came form the intervention.

    So a person who presents making this claim is an idiot, crazy (delusions of grandeur), or a little of both.

  103. BillyJoe7on 24 May 2016 at 1:56 pm

    “No, regression to the mean is not part of the placebo effect”
    “I personally believe in the subluxation concept”
    “If I touch my back I can feel when vertebrae are out of place”

    Reading this thread has been like watching someone walking into a public place unaware that he is completely naked.

  104. mumadaddon 24 May 2016 at 1:58 pm

    S12,

    Yeah, mine comes and goes, but less frequently and severely now than in the past. I’ve gotten way better at coping with it psychologically (and not letting it turn into a self-perpetuating crisis) and applying some discipline to keeping a routine, and it’s improved drastically.

  105. BillyJoe7on 24 May 2016 at 2:00 pm

    Put it this way…
    Up until now our little friend has been walking around with at least his underpants on, but now he has discarded them as well.

  106. mumadaddon 24 May 2016 at 2:03 pm

    BJ7,

    You owe me a new keyboard. This one is covered in spittle and phlegm…

  107. mumadaddon 24 May 2016 at 2:05 pm

    hn,

    “No, regression to the mean is not part of the placebo effect. A placebo effect is just when people say they feel better, although they did not get any treatment.

    You don’t get any placebo effect with objective measurements.”

    How can you have been kicking around this blog for so long and believe that? So if you widen your definition to match the one I gave, can you see why proper testing is needed to distinguish intervention-specific results from placebo?

  108. mumadaddon 24 May 2016 at 2:34 pm

    hn,

    “Also, cp for allergies was not something I had heard about or believed in previously. I just happened to notice subluxations when I had the symptoms, and no subluxations when I didn’t have symptoms. Always, every single time.”

    This is really just a rephrase of what’s already been said, but here goes. All you have is a correlation: you get cp, and you get x result. Honestly, I would question the validity of even the correlation though. How tight are you being with your definitions of how bad the problem is/how successful the treatment? You’re going to be vulnerable to some bias here if you’re just going on memory and ill-defined problem/treatment.

    And even if the correlation stacks up perfectly, you still haven’t isolated whatever variable it is that produces the effect. To think that you can just tell is, as s12 said, ridiculous.

    “Now, do you think I should go raise millions of dollars to fund formal research before using this cp technique on myself?”

    No hn, sincerely, if you’ve found something improves your quality of life, then providing it doesn’t cost you too much money and you aren’t out there peddling it to the public, then I wish you every success with it. But it’s no use to anyone else, and you don’t get to assert that this is a valuable datapoint, or that lots and lots of such datapoints are valuable.

    Insomnia is a good example of a condition for which there’s little in the way of long term pharmaceutical treatments (that don’t come with a substantial trade-off); the causes and effects are also highly subjective. Finding something that works for you is pretty reasonable in this case. If it were me though, I’d be bothered about plausibility. And we’re talking generally about standards of evidence here — you have said that science can’t test cp, ap etc. I don’t begrudge you your placebo, I just wondered if I could get you to understand why standards of evidence matter in general.

    “I tried extremely expensive things that were supposed to work but didn’t. You would think that if I spent thousands of dollars on something I would at least get a slight placebo effect.”

    So, you’re immune to placebo effects, therefore this can’t be placebo. Okay then.

  109. hardnoseon 24 May 2016 at 2:36 pm

    “I’ve gotten way better at coping with it psychologically (and not letting it turn into a self-perpetuating crisis) and applying some discipline to keeping a routine, and it’s improved drastically.”

    Wait a minute. How do you KNOW it improved drastically for those reasons? And how do you even know it improved at all? You might be imagining the whole thing.

    Without placebo-controlled trials, I simply can’t take your word for it.

  110. hardnoseon 24 May 2016 at 2:44 pm

    “I just wondered if I could get you to understand why standards of evidence matter in general.”

    I keep having to repeat this, well here it is again. I am not against controlled experiments AT ALL. However they are not always possible. There are other kinds of evidence, and scientists use them when controlled experiments are not practical.

    And I certainly never expected you or anyone here to believe me about subluxations. But you could do yourself a favor and check your spine. I only mentioned it to you because I think it’s wonderful to be able to get rid of symptoms without drugs. Allergy drugs don’t work on me anyway. And you don’t want the insomnia drugs.

    But if you want to be loved and respected at this blog you better disagree with me 100% about everything.

  111. mumadaddon 24 May 2016 at 3:31 pm

    Hn,

    “Wait a minute. How do you KNOW it improved drastically for those reasons? And how do you even know it improved at all? You might be imagining the whole thing.”

    I don’t, I have to go with what works for me as a practical necessity. I’m not saying that individuals should apply the same standards of evidence in their self-treatment of conditions such as insomnia as do the medical/pharma industries in determining the effectiveness of treatment.

    But you were advocating a different standard for testing interventions whose effects are understood scientifically to be placebos; testing of a kind that would fail to distinguish placebo effects fromantic treatment specific ones.

    I would simply accept that I’m susceptible to placebo effects, and if the evidence comes in that what I’m doing had no effect over placebo, I’ll make a call as to whether I continue to do it or not. If the evidence said that it’s just getting up at the same time every day, then maybe I’d relax on going to bed at the same time every night. But maybe I wouldn’t.

    What you are talking about — cp for insomnia AND for allergies… — is FAR better explained by placebo effects than cp being effective.

  112. hardnoseon 24 May 2016 at 3:46 pm

    You got confused. I mentioned cp for insomnia just in case you personally wanted to try it. That was a different point than the other thing I was saying about considering case studies when formal research is not practical. Or in addition to formal research.

    My personal experience with cp and allergies, etc., has really nothing to do with that.

  113. hardnoseon 24 May 2016 at 3:51 pm

    I can KNOW something with absolute certainty, and yet realize it does not count as scientific evidence.

    The cp thing is something that I know, because I tested it many hundreds of times for years. I have definitely wanted to share it with others because I think it could help everyone I know who has any kind of symptoms. However, I don’t have any good way to explain or demonstrate it.

    There are all kinds of physical therapy techniques, similar to cp. Mine is just sort of a combination of several, plus things I discovered.

  114. ccbowerson 24 May 2016 at 3:55 pm

    Wow. I’m not surpised that HN has absolutely no self awareness, but I’m slightly surprised at how he has doubled-down so hard on defending it.

    He is basically advocating that skepticism should only be applied outwardly, and describes the internalization of a skeptical approach as “bordering on insane.” This fits too well with his argument style.

    Despite all of the time he spends on this blog he still epitomizes “Mistakes were made (but not by me).”

  115. hardnoseon 24 May 2016 at 4:15 pm

    There is a difference between having a skeptical approach and taking it to an insane extreme. Never trusting anything you experience, always deferring to experts, is authoritarian and extreme and nearly insane.

  116. mumadaddon 24 May 2016 at 4:20 pm

    “That was a different point than the other thing I was saying about considering case studies when formal research is not practical. Or in addition to formal research.”

    Blinded, placebo controlled studies ARE practical for cp, apparently, homeopathy. You said you don’t know how it would be possible to test them, but they ARE being tested in well designed studies and coming back negative. It’s trivially easy to think of ways to blind and control for placebo effects.

    You also said you DO know how to test them, and proposed a testing method that is unable to distinguish placebo effects from real.

    And you say that placebo effects are a myth, but YOU can definitely tell between placebo effects and real ones.

    I do agree that case studies have some value (on a spectrum, depending on multiple factors). But this is not what you were saying… What you proposed, and your reasons for doing so — I can’t see how it wouldn’t be a placebo riddled mess.

  117. mumadaddon 24 May 2016 at 4:21 pm

    My phone corrected ap to apparently…

  118. steve12on 24 May 2016 at 4:22 pm

    “Despite all of the time he spends on this blog…”

    Can you imagine spending all that time trolling a blog to perpetrate some personal psychodrama?

    Kinda sad actually…

  119. daedalus2uon 24 May 2016 at 4:25 pm

    Here is an example where sham treatment for Parkinson’s disease (aka a placebo) produced clinically significant improvement coupled with clinically significant instrumental measures of brain metabolism.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4109544/

  120. mumadaddon 24 May 2016 at 4:28 pm

    “:Never trusting anything you experience, always deferring to experts, is authoritarian and extreme and nearly insane.”

    …and you are a great advertisement for that philosophy.

  121. hardnoseon 24 May 2016 at 4:31 pm

    It is absolutely obvious that no one constantly doubts all their experiences.

  122. hardnoseon 24 May 2016 at 4:35 pm

    Ok mumadadd, don’t try anything until it has been verified by the drug companies. Of course, their research is always unbiased and perfect.

  123. mumadaddon 24 May 2016 at 4:45 pm

    You are really mischaracterising what I’ve said. I know there are some big problems with pharma. But, to quote Ben Goldacre:

    ” FLAWS IN AIRCRAFT DESIGN DO NOT PROVE THE EXISTENCE OF MAGIC CARPETS.”

  124. hardnoseon 24 May 2016 at 4:56 pm

    Since no one understood my idea in the first place I will say it one more time:

    There are reasonable compromises. It is not a choice between either big drug RCTs or biased unreliable anecdotes. It would be extremely helpful if MDs kept accurate records and shared them.

    Evidence can be great or lousy or anything in between. We should use what is available. Waiting for the big drug companies to tell you what you need is just not rational.

  125. mumadaddon 24 May 2016 at 5:16 pm

    Okay, I’ll agree with most of the above. We should use all available evidence but it should be properly weighted. I’d also add the proviso that physicians not recommend treatments that are confirmed ineffective, or nit demonstrated at least to be safe, based on this data. Or ideally, not even recommend treatments that have not yet been demonstrated effective. You could use this info as preliminary guide for areas of study though.

  126. steve12on 24 May 2016 at 5:41 pm

    Perfect concern Troll.

    Says outrageous things to get your goat:

    I can tell what portion of pain reduction is due to placebo in myslef! I know better than clinical researchers how clinical research is done! I know can feel by loose vertabrae!

    Then comes back with the “reasonable” routine to reel you back in:

    Science is great, but shouldn’t we use all evidence? Isn’t our self report worth something? We shouldn’t ignore what people say altogether!

    All part of The Troll.

  127. BillyJoe7on 24 May 2016 at 5:50 pm

    hn just disproved his own point.

    Relying on his own experience, hn knows ABSOLUTELY that chiropractic subluxations are real.
    But chiropractic subluxations have been shown not to exist.
    Which only proves that “in my experience” is a flawed method of finding things out.

    Richard Feynman: “The easiest person to fool is yourself”

    This is why we do science.

  128. hardnoseon 24 May 2016 at 6:09 pm

    “But chiropractic subluxations have been shown not to exist.”

    If that research was done you are the only one who knows about it.

  129. hardnoseon 24 May 2016 at 6:20 pm

    “ideally, not even recommend treatments that have not yet been demonstrated effective.”

    That is the central problem mumadadd. As I said before, it takes an awful lot of time and money to do the formal RCT research that would confirm something beyond doubt. And even after you think it was confirmed beyond doubt, more research can come along and unconfirm it.

    I certainly can understand why the health insurance companies won’t pay for things that are still in doubt. And I can understand why MDs would not prescribe things that could be harmful.

    But there is a vast grey area in between the two absolutes. And there is not much to help us with that. I think there is a great need for careful and accurate research based on case studies. I think Skeptics exaggerate the impact of the placebo effect. Yes it probably happens but it probably does not usually cause dramatic and consistent results.

    And it would make sense to check the conclusions of research done by big corporations and government agencies.

  130. daedalus2uon 24 May 2016 at 7:10 pm

    Research on subluxations is not difficult to find.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238291/

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1208927/

  131. Steve Crosson 24 May 2016 at 7:48 pm

    Fun Story:

    Years ago, I lived in Davenport, Iowa, home of the (in)famous Palmer College of Chiropractic. My wife was BFF with the fiancee of a Palmer grad. As a result, we were occasionally invited to parties with a high number of Palmer students/grads.

    On more than one occasion, I heard budding chiropracters complain that their patients would never believe them when the “doctor” tried to convince the patient that they had already fixed an “inaudible subluxation”. The students all learned to crack their own knuckles while “performing an adjustment” so that the patients would believe that something was actually done.

    For some reason, they didn’t take kindly to my suggestions that CP was all BS and any “relief” was purely due to placebo effect. At least, we stopped getting invitations.

  132. BillyJoe7on 25 May 2016 at 12:25 am

    hn: “If that research was done you are the only one who knows about it”

    Well, at least you don’t know about it, which is yet another thing to add to your list of what you don’t know.

  133. hardnoseon 25 May 2016 at 8:52 am

    There is no placebo effect when the outcome measure is objective and quantifiable. Patient reports are subjective and unreliable. Can you tell if your symptoms have improved slightly?

  134. daedalus2uon 25 May 2016 at 9:11 am

    What caused the improvement in the patients with Parkinson’s Disease that were treated with sham treatments in the report I linked to above?

  135. hardnoseon 25 May 2016 at 10:46 am

    Yes the mind has some influence over the body. If you have positive thoughts about a treatment it could be more likely to have an effect.

    But dramatic improvements seldom occur simply because the patient expects something to work.

    That article also found that some patients are more likely to experience a placebo effect. As I said, I never get them, even though I spent thousands of dollars on things that were supposed to work, and I had every reason to expect they would.

    Objective measures are better and less vulnerable to placebo effects. It is of course better to have a placebo control when feasible, but always better to avoid subjective patient reports as your only outcome measure.

  136. daedalus2uon 25 May 2016 at 11:04 am

    It was objective, instrumental metabolic measures that improved. Something that you assert that placebos cannot do.

    “There is no placebo effect when the outcome measure is objective and quantifiable. Patient reports are subjective and unreliable. Can you tell if your symptoms have improved slightly?”

    Here is an example of something that you assert that placebos cannot do. This conclusively demonstrates that your assertions about the placebo effect are false.

    Your assertions of reduced allergies and improved sleep are “subjective patient reports”. You acknowledge that “Patient reports are subjective and unreliable.”

    Why are your “subjective patient reports” suddenly reliable?

  137. hardnoseon 25 May 2016 at 11:31 am

    “Why are your “subjective patient reports” suddenly reliable?”

    I keep having to explain the same things over and over and over.

    I NEVER said my subjective experiences are scientific evidence. I can KNOW that something works without expecting anyone to believe it, unless they try it and it also works for them.

  138. daedalus2uon 25 May 2016 at 11:41 am

    So when you say that you “know” something, what you really mean is that you “believe” something.

    Ok, just calibrating your use of language.

  139. hardnoseon 25 May 2016 at 11:51 am

    If you let your skepticism run wild, you will doubt all your experiences, no matter how obvious and real, and drive yourself crazy.

    I don’t need an official stamp of approval from the big drug companies to tell me if something worked or not.

    If an improvement is only slight, it is hard to know if it’s real or not. But when symptoms get completely and immediately turned off, that can’t just be placebo. Except I guess for things that were psychogenic to begin with.

    I know my allergy symptoms are not psychogenic, having been tested repeatedly with the same results.

  140. daedalus2uon 25 May 2016 at 12:11 pm

    I don’t let my skepticism run wild. I keep it under very good control. I keep my beliefs under even more rigorous control.

    I tend to use subjective personal experience only to answer subjective questions, or for hypothesis generation.

    When symptoms turn off very quickly, that makes it more likely that what ever “turned them off” is a placebo. Symptom resolution that requires “healing” can’t be any faster than the “healing process”.

  141. steve12on 25 May 2016 at 12:37 pm

    daedalus2u:

    “What caused the improvement in the patients with Parkinson’s Disease that were treated with sham treatments in the report I linked to above?”

    Ha! The Troll doesn’t answer direct questions like this! That would be engaging in an honest and straightforward manner.

    The Trolls dodges. He would NEVER answer a question like that straight up. Maybe Big Pharma conspiracy. Maybe.

    This is why I maintain that this is not merely someone we disagree with. He’s a dick who’s is purposefully trolling us.

  142. hardnoseon 25 May 2016 at 1:11 pm

    “When symptoms turn off very quickly, that makes it more likely that what ever “turned them off” is a placebo.”

    Is that just your belief, or is there evidence for it? If the mind can turn off extreme physical symptoms that quickly and easily, then maybe we should give up drugs altogether and learn to use this amazing mental power.

  143. daedalus2uon 25 May 2016 at 2:40 pm

    hn, you don’t have a coherent idea of what a “placebo” even is.

    According to you, if something “turns off” symptoms, then it can’t be a placebo.

    There is no point in further discussions because you are not interested in using shared, common terms, and you keep changing the meaning(s) of the terms you are using.

  144. hardnoseon 25 May 2016 at 5:08 pm

    “According to you, if something “turns off” symptoms, then it can’t be a placebo.”

    It would be unlikely to be just a placebo. If we could turn off severe symptoms with our minds, there would not be much need for drugs. If our minds really had such great power over our bodies, why does medical science mostly ignore it?

    The placebo effect is usually slight, and could be at least partly because patients might say they are better even if they aren’t.

  145. BillyJoe7on 26 May 2016 at 7:26 am

    The magnitude of the placebo effect.

    I think there has been a bit of a misunderstanding regarding the magnitude ot the placebo effect.
    The placebo effect can be quite significant if looked at from the point of view of the subjective changes, but pretty insignificant if assessed by objective tests.

    Have a look at this study:

    http://www.nejm.org/doi/full/10.1056/NEJMoa1103319#t=articleTop

    It is a report of a clinical trial comparing an “active inhaler” for the treatment for asthma with two placebos (“placebo inhaler” and “sham acupuncture”), and “no treatment”. If you don’t have time to read the whole paper, then just click on the following links which pretty well summarise the whole thing in graphic from:

    fig 4: http://www.nejm.org/doi/full/10.1056/NEJMoa1103319#t=articleTop

    This graph illustrates that the percentage change in SUBJECTIVE improvement is 50% for the “active inhaler”, 45% for “placebo inhaler”, 46% for “sham acupuncture”, and 21% for “no treatment”.
    In other words, the SUBJECTIVE improvements for “active inhaler” and the two placebos are almost identical! You might be tempted to say, “why not then use a “placebo inhaler” and get the same beneficial effects as the “active inhaler” without its side-effects?”
    Well, here is why….

    fig 3: http://www.nejm.org/doi/full/10.1056/NEJMoa1103319#t=articleTop

    The percentage change in OBJECTIVE improvement using the commonly used respiratory function test for asthma is 20% for the “active inhaler”, 7.5% for “placebo inhaler”, 7.3% for “sham acupuncture”, and 7.1% for “no treatment”.
    In other words, the OBJECTIVE improvement for the “active inhaler” is almost 3X greater than for the two placebos; and the two placebos are really no better than “no treatment”.

    What this tells us is that the SUBJECTIVE placebo effect is quite significant – the patient feels a lot better – but the OBJECTIVE placebo effect is more or less indistinguishable from zero. As you might imagine, this could be quite dangerous.

    Of course, you could look also for objective tests of the subjective placebo effect, but you would have to look in the brain instead. It is the brain that generates the subjective experience of feeling better and this is where we would look to do objective tests. Maybe an fMRI, maybe chemical tests, maybe actual neurons firing. If the subjective experience was real, these objective tests would also show quite a significant effect . If not, that would indicate the patients only reported that they felt better wthout actually feeling better (trying to please the experimenter who seems to be going out of his way to help).

    If the lesson here can be generalised, it is that you are not going to cure anything with a placebo, but you might feel a great deal better without actually being better (which could be quite dangerous), or you might merely report that you feel better without actually feeling better.

  146. BillyJoe7on 26 May 2016 at 7:28 am

    Okay, those second two links are to the paper – you will need to click down to fig 4 and fig 3 and click to enlargen.

  147. BillyJoe7on 26 May 2016 at 7:28 am

    I meant “scroll” down to fig 4 and fig 3

  148. hardnoseon 26 May 2016 at 9:03 am

    That is why, as I said, subjective outcome measures are not very useful.

  149. Steve Crosson 26 May 2016 at 10:56 am

    Ummm … You do realize that your own observations are entirely subjective, right ???

    So, by your own observations and logic, you have thoroughly refuted your own point.

    As BJ7 showed, many can EASILY fool themselves into thinking that fake treatments are almost as good as real ones.

    You aren’t the special snowflake you think you are.

  150. hardnoseon 26 May 2016 at 2:04 pm

    My own observations are useful to ME. I was talking about in research, obviously.

  151. hardnoseon 26 May 2016 at 2:05 pm

    “You aren’t the special snowflake you think you are.”

    Ok, you finally convinced me. Instead of trusting my own experiences, no matter how obvious they are, I should always check with experts and authorities. Without the official approval of Big Brother, I should assume that everything I observe or experience is a delusion or hallucination.

  152. hardnoseon 26 May 2016 at 2:09 pm

    “many can EASILY fool themselves into thinking that fake treatments are almost as good as real ones.”

    Maybe, if their problem was psychosomatic to begin with. Or if they said they felt better even if they didn’t, just to make the researchers happy. Or if the improvement they subjectively experienced was slight.

    I am sure you will NOT find many examples of people getting a dramatic, meaningful, repeatable, lasting improvement from a placebo, if they had a real physical problem.

  153. mumadaddon 26 May 2016 at 2:50 pm

    hn,

    Trust your own experience that something worked for you, sure. But don’t trust a chiropractor to tell you why it worked. Leave that bit to science. That’s all we’re asking.

  154. steve12on 26 May 2016 at 2:53 pm

    Referring to:

    A. The assertion that one cannot distinguish placebo & non-placebo effects

    as…

    B. An assertion that one needs to consult experts to in assessing their own pain state.

    THIS is the king of purposeful lying that The Troll brings to the table, just to needle people he doesn’t know for cyberattention.

    What a psycho.

  155. hardnoseon 26 May 2016 at 3:32 pm

    No I am not trying to torment you steve12. I am genuinely extremely concerned about the Skeptic movement. I honestly think it is just another form of authoritarianism, disguised as enlightened free thinking.

    A central message is “trust the experts, you are too ignorant to understand it yourself.”

  156. mumadaddon 26 May 2016 at 4:58 pm

    hn,

    “A central message is “trust the experts, you are too ignorant to understand it yourself.””

    So, give me an example of something non-subjective for which it would be more reasonable to trust your own subjective experience than that of a consensus of experts’ derived from rigourous testing and peer review. (?)

  157. steve12on 26 May 2016 at 5:08 pm

    Actually, I’m kind of trying to torment you, The Troll.

    You’re a liar who wastes everyone’s time and energy with this Waterhead F*around routine that you run instead of engaging and discussing.

    I no like.

  158. hardnoseon 26 May 2016 at 5:10 pm

    There are countless things where I disagree with the “expert consensus” mumadadd. One example is statin drugs. Another, as I have already said in comments, is the supposed safety of GMOs. Lots and lots of things.

    And no, I don’t agree with the nutty conspiracy websites either.

  159. hardnoseon 26 May 2016 at 5:11 pm

    steve12, no one is forcing you to read my comments, if it gives you so much agony.

  160. steve12on 26 May 2016 at 5:11 pm

    Of course, if others get something out of this “discussions” with The Troll, I mean them no disrespect to them. Sometimes going over the basics cements your own thinking. Or whatever else one may get out of it.

    I just don’t like the whole disingenuous routine. I may have pointed that out.

  161. steve12on 26 May 2016 at 5:12 pm

    No agony. You’re a lying dick and I like to point it out.

  162. steve12on 26 May 2016 at 5:12 pm

    Oh, I’m sorry:

    Dr. The Troll.

  163. hardnoseon 26 May 2016 at 5:13 pm

    My experience of chiropractic agrees with chiropractic theory, and disagrees with the Skeptic consensus on that subject. I also think the chiropractic theory makes sense, based on everything else I know and have read.

    For one example.

  164. hardnoseon 26 May 2016 at 5:14 pm

    If you get so upset about someone writing comments you disagree with steve12, maybe a psychiatrist could help you.

  165. steve12on 26 May 2016 at 5:21 pm

    Is it Dr. The Troll M.D. or Dr. The Troll, Ph.D. ?

  166. BillyJoe7on 27 May 2016 at 9:13 am

    Hardnose on skeptics and the placebo effect.

    “The concept of placebo effects has been extremely exaggerated. Slight and subtle differences may sometimes be explained by placebo, but dramatic and obvious results are not.We all know this, but somehow the Skeptical ideology prevents you from admitting it”
    Here he says that skeptics exaggerate placebo effects and claim that placebo effects can be dramatic.

    “The placebo effect is subtle, even the Skeptics here will tell you that”
    Now he says that skeptics claim that placebo effects are subtle.

    “I think Skeptics exaggerate the impact of the placebo effect. Yes it probably happens but it probably does not usually cause dramatic and consistent results”
    And now he says that skeptics exaggerate placebo effects and claim that they can be dramatic.

    “And I have read articles here or at SBM saying that the placebo effect, when it does occur, is weak”
    And now he’s back to saying that skeptics claim that placebo effects are weak or subtle.

    So which is it hn?
    Here, let me help you: “What this tells us is that the SUBJECTIVE placebo effect is quite significant – the patient feels a lot better – but the OBJECTIVE placebo effect is more or less indistinguishable from zero”

    That was the purpose of my last post – patients will often report dramatic placebo effects (fig 4 in that paper), but objectively they hardly any better (fig 3). The placebo effect can produce dramatic subjective effects but it does not produce any significant objective change.

    “There is no placebo effect when the outcome measure is objective and quantifiable”

    Unless you look in the brain. If the patient feels better, then objective evidence of this could be found in the brain because it’s the brain that produces this feeling. The brain can then produce secondary physiological effects on the rest of the body. These can also be objectively measured. The problem is that the effect is weak, variable and transient.

    “But when symptoms get completely and immediately turned off, that can’t just be placebo. Except I guess for things that were psychogenic to begin with”

    Hmmm…I guess he just contradicted himself!
    It can’t be placebo except that it can!

    “In controlled experiments…the placebo group is to factor out psychological effects…placebo effect is just when people say they feel better….regression to the mean is not part of the placebo effect”

    No, the placebo group is not just to factor out psychological effects. And, yes, regression to the mean IS part of the placebo effect. In clinical trials, the placebo accounts for everything except the effect of the active treatment. This includes psychological effects, regression to the mean, reporting bias, expectation bias, researcher bias, conditioning etc etc etc.

    “You don’t get any placebo effect with objective measurements”

    False. But you need to look primarily in the brain where these subjective feelings are produced. For example, PET scan studies demonstrate that placebo analgesia induces dopamine release by basal ganglia which is related to an expectation of analgesia*. The brain then produces secondary effects on the rest of the body – for example changes in muscle tone, vascular perfusion, respiratory rate, blood pressure, and heart rate.

    Finally he gets something right:

    “I am sure you will NOT find many examples of people getting a dramatic, meaningful, repeatable, lasting improvement from a placebo, if they had a real physical problem”

    *reference: http://www.ncbi.nlm.nih.gov/pubmed/19784082

  167. BillyJoe7on 27 May 2016 at 9:22 am

    “I really don’t know how or if you can test chiropractic, or acupuncture or homeopathy”

    Chiropractic: only single blinding is possible and not ideal, but sufficient to demonstrate that Chiropractic helps only back pain for which it is no better than a good massage.

    Acupuncture: Double blinding is possible using sham acupuncture needles, or single blinding using fake acupuncture points, and demonstrates that acupuncture is not useful for anything.

    Homoeopathy: Let the homoeopath do whatever he wants to do with the patient. Have the dispenser dispense randomly either the presribed treatment or a placebo.

  168. BillyJoe7on 27 May 2016 at 9:39 am

    Finally a Gish Gallop of pseudoscientific nonsense:

    “I know for an absolute fact that chiropractic can work for allergies. I am sure no big agency or drug company has ever studied this. No, not every chiropractic technique works for every allergy patient. You can only find this out by trial end error. It is a fact I have experienced repeatedly…I know the cause and cure for insomnia. You have some vertebrae slightly out of place. It causes restless muscles, especially in the legs. I get that once in a while, and fix it the same way I fix allergy symptoms. The reason you don’t always have insomnia is that those vertebrae are not always out of place…I found this out about allergies from years of trail and error. It has nothing to do with the placebo effect. I tried everything else imaginable, including drugs from the doctor, and didn’t get any placebo effect at all. I would have been glad to get a placebo effect, but never got one…In my experience, there is no placebo effect whatsoever. Maybe some people get a placebo effect, but I never have. If something works I know it right away. If it doesn’t work, I can’t fool myself into thinking it works…I personally believe in the subluxation concept. If I touch my back I can feel when vertebrae are out of place. And this corresponds directly with how I feel, allergies, etc.The curves of the spine are normally smooth. If you feel areas that are flat or bumpy, that indicates what chiropractors call subluxations.This is something I know with absolute certainty, but proving it to others would not be easy.Sometimes we just know something from direct repeated obvious experiences. No, it does not count as scientific data. But it does make me open-minded about what chiropractors claim…Also, chiropractic for allergies was not something I had heard about or believed in previously. I just happened to notice subluxations when I had the symptoms, and no subluxations when I didn’t have symptoms. Always, every single time…I certainly never expected you or anyone here to believe me about subluxations. But you could do yourself a favor and check your spine. I only mentioned it to you because I think it’s wonderful to be able to get rid of symptoms without drugs. Allergy drugs don’t work on me anyway…I can KNOW something with absolute certainty, and yet realize it does not count as scientific evidence.The chiropractic thing is something that I know, because I tested it many hundreds of times for years. I have definitely wanted to share it with others because I think it could help everyone I know who has any kind of symptoms. However, I don’t have any good way to explain or demonstrate it. There are all kinds of physical therapy techniques, similar to chiropractic. Mine is just sort of a combination of several, plus things I discovered…If an improvement is only slight, it is hard to know if it’s real or not. But when symptoms get completely and immediately turned off, that can’t just be placebo. Except I guess for things that were psychogenic to begin with. I know my allergy symptoms are not psychogenic, having been tested repeatedly with the same results”

    Well, no comment.

    😀

  169. hardnoseon 27 May 2016 at 11:48 am

    You worked hard on that BillyJoe7, you must find it interesting that chiropractic ideas can actually work.

  170. Steve Crosson 27 May 2016 at 1:39 pm

    “You worked hard on that BillyJoe7, you must find it interesting that chiropractic ideas can actually work.”

    Actually, we’ve only established that you BELIEVE that they work based on your own subjective observations.

    And, as we all agree (even you), subjective observations are not very good evidence for anything.

    However, I think you have provided some strong, objective evidence for the rest of us to conclude that the more someone is convinced of their own infallibility, the more likely they will be to fool themselves with the placebo effect.

  171. hardnoseon 27 May 2016 at 3:22 pm

    It is possible to know if something works or not without feeling infallible. If that were not possible no one could survive. We constantly have to determine good vs bad, just to stay alive.

    But you want us to surrender our common sense and everyday judgements to Big Drug and the Scientific Authorities.

  172. BillyJoe7on 27 May 2016 at 3:45 pm

    Perhaps one day hardnose will provide us with a video showing his allergy (probably something you can’t actually observe!), suddenly and completely disappear as soon as he pushes his finger into one of those flat or bumpy bits on his spine (also probably something you can’t actually observe!) which will then also suddenly and completely be magically restored to its normal curve.

    Until then, I think we can safely assume the whole thing is a figment of his imagination.

  173. Steve Crosson 27 May 2016 at 3:55 pm

    “We constantly have to determine good vs bad, just to stay alive.”

    True, but people that can tell the difference between coincidence and actual cause and effect are more likely to stay alive longer.

  174. ccbowerson 27 May 2016 at 4:49 pm

    HN thinks that he is impervious to placebo effects and motivated reasoning, and that his personal experiences trump rigorous scientific evidence. He also thinks that being a skeptic means to be contrarian to what others say, but thinks that applying doubt to ones own beliefs and motivations is “borderline insane.”

    Over the years HN has shown us a valuable lesson of how NOT to be a skeptic.

  175. Steve Crosson 27 May 2016 at 5:42 pm

    HN won’t admit it (even to himself), but he really does view his own “logic” as infallible — thus epitomizing Feynman’s famous dictum:

    “The first principle is that you must not fool yourself – and you are the easiest person to fool.”

  176. BillyJoe7on 27 May 2016 at 6:17 pm

    “But you want us to surrender our common sense and everyday judgements to…the Scientific Authorities”

    Your common sense tells you that Heliocentrism, Relativity, Quantum physics are wrong, right?
    So, are you going to hold out against the scientific consensus on these subjects?

    You’re just a little boy, hardnose, and when you grow up you are going to realise that there are many people around who have far more understanding than you do about subjects in which they have expertise and you have none, and that the consensus of these experts in their area of expertise far outweighs any of your peurile cogitations on the matter.

    The question is: when you grow up, will you be man enough to accept your limitations?

    https://www.youtube.com/watch?v=_VrFV5r8cs0

    In the mean time please work on that video, because, personally, I don’t believe a word of what you have said about your allergies and your personalised form of chiropractic treatment.
    That’s right, I’m calling you on it. Prove me wrong.

  177. hardnoseon 27 May 2016 at 7:22 pm

    There are millions of people who feel that chiropractic helps them. It isn’t just me. The chiropractic journals are full of positive research.

    So there are millions of idiots who are fooling themselves, vs the all-knowing Skeptics whose mythology says that chiropractic theory must be wrong.

  178. tmac57on 27 May 2016 at 8:27 pm

    There are millions of people who work in ERs, in law enforcement, and other professions that deal with the vagaries of human interaction, who would swear to you that on full moon nights, that crime, and other out of control human behavior, rises. That is their sense and ‘feeling’ about those events.
    Statistics proves them wrong, but they will ignore that evidence, and rely on their own ‘experience’ instead.
    Confirmation bias is the bane of truth. Until you are ready to shed that compelling and most misleading of all human flaws, then you will forever be lying to yourself.
    We have all been there. But some of us, at least, try to acknowledge the trap, and try to escape rather than to persist in defending our self imposed ‘territory’.
    You have absolutely nothing to gain in life by believing in that which is not true, self esteem and pride be damned.

  179. mumadaddon 27 May 2016 at 11:12 pm

    “It is possible to know if something works or not without feeling infallible. If that were not possible no one could survive. We constantly have to determine good vs bad, just to stay alive.”

    Trying shit out and seeing if it works is absolutely a valid way of seeing if shit works. It’s just really bad way to get to an explanation of why and how it works. Or in fact, if it actually works because reasons or just because psychology.

    I know a few basic card tricks. If I execute them properly and spin a story that I predicted what card you would pick because I mixed a load of poseidon’s angry jizz with some chicken bones and read the pattern of constellations from a certain latitude on the equator, you should absolutely believe me.

    That’s almost as absurd as magic life-force energy that goes into the top of your skull; interruptions in which cause every known malady.

    People in general just need to Google the word ‘epistemology’.

  180. mumadaddon 27 May 2016 at 11:24 pm

    What I’m saying is: hn, you’s a wilfully ingnint mofo. Also highly inconsistent. You have a system of coming up with ‘knowledge’. Over the last two and a half centuries, people have developed a better one. And it works quite well. We have paracetamol, aspirin, antibiotics, heart transplants, brain surgery, fecal transplants, fMRIs, keyhole surgery, proton pump inhibitors, anaesthetic, titanium plates, brain machine interfaces…

    You have some magic that worked for you. And you just swallowed the explanation you were given by the quack who administered the magic.

  181. BillyJoe7on 28 May 2016 at 1:41 am

    “There are millions of people who feel that chiropractic helps them”

    The operative word here is “feel”.
    Yeah, there are millions of people who “feel” that chiropractic helps them.
    There are also millions of people who “feel” homoeopathy helps them.
    Ditto for all the other alternative treatments.
    But, short of a systematic review of well controlled clinical studies of chiropractic, they will not, and cannot, “know” if it helps.

    “The chiropractic journals are full of positive research”

    How do you know that?
    Do you know how to go about evaluating a clinical trial?
    Have you looked at this “positive” research with a critical eye backed up with this knowledge?
    If so, give us the best example you have of positive research from a chiropractic journal.

    “So there are millions of idiots who are fooling themselves”

    You know this is a strawman right?
    I mean you’d have to, wouldn’t you, after spending all these years reading this blog.
    So why are you lying about what sceptics say?
    The truth is that we are all prone to fooling ourselves.
    But the best way to guard against this is to have a sceptical outlook.
    Even then it’s difficult – even for someone with a PhD.

    “the all-knowing Skeptics whose mythology says that chiropractic theory must be wrong”

    Again, why are you lying?
    You know this is not true.
    The evidence is in and chiropractic has failed the test for all conditions except back pain for which a good massage works just as well.
    You know this is not mythology but a reasonable conclusion based on all the available evidence.

  182. hardnoseon 28 May 2016 at 10:10 am

    ‘You have a system of coming up with ‘knowledge’. Over the last two and a half centuries, people have developed a better one. And it works quite well. We have paracetamol, aspirin, antibiotics, heart transplants, brain surgery, fecal transplants, fMRIs, keyhole surgery, proton pump inhibitors, anaesthetic, titanium plates, brain machine interfaces…’

    You are confused, but so are lots of other people. The increasingly rapid evolution of technology has provided all those things. The scientific method is something else, it did not provide those things.

    The scientific method is a formalized, conscious, implementation of what people have always done.

    I do not have a “system” of my own, I use the same methods that have been used for eons. Hear about something, try it, see if it works.

    The RCTs of modern medicine cannot be credited with any of those things on your list. I am NOT opposed to RCTs. I am just trying to explain how you are confounding things.

    You should think more carefully about this.

  183. hardnoseon 28 May 2016 at 10:11 am

    “The evidence is in and chiropractic has failed the test for all conditions except back pain for which a good massage works just as well.”

    If only medical science were that easy.

  184. mumadaddon 28 May 2016 at 12:37 pm

    hn,

    Ignore last two comments, it was 4am at the end of a long and debauched night. Always seems like a good idea to comment at the time…

    I’ll just reiterate what I said before, and what’s been expounded in more detail by others: I have no problem accepting that cp “worked for you”, but are wrong about how and why.

  185. hardnoseon 28 May 2016 at 1:11 pm

    Steve N. has a recent post at SBM about chiropractic. This is what he said about the chiropractic subluxation theory:

    “None of their basic premises have been demonstrated scientifically, and in fact their claims are incompatible with modern medical science.”

    “Modern medical science” in that sentence refers to a faction of modern medicine, sometimes called “mainstream” or “conventional.” As opposed to holistic, alternative, etc. The two factions have been at war for centuries. Each has its own journals and organizations.

    Steve N., and others like him, do not understand subluxation theory. Their tribal mythology says it is wrong. There is nothing in modern medical science showing that it is wrong.

    All non-mainstream current medical practices include a belief in “life energy.” That is also true of all ancient medical systems. Only mainstream western medicine does not believe in it.

    Of course you “know” the reason. Modern western medicine is superior because it uses the scientific method, and it has proven there is no life energy.

    No, that actually did not ever happen. Modern western medicine decided that there is no life energy, it was an arbitrary and dogmatic decision.

  186. daedalus2uon 28 May 2016 at 2:03 pm

    No, modern physics shows that there is absolute conservation of mass/energy, momentum, charge, weak isospin and a few other things. Relativity showed that their was no “action at a distance”.

    The idea of some kind of “life energy” is completely incompatible with modern physics. Completely incompatible with the Standard Model, and with General Relativity.

    That is why Medicine abandoned the idea of some sort of “life energy”. It is completely incompatible with everything that physics has learned in the past 100 years.

  187. hardnoseon 28 May 2016 at 2:04 pm

    wrong

  188. hardnoseon 28 May 2016 at 2:29 pm

    https://en.wikipedia.org/wiki/Vitalism#Criticism

    Wikipedia is dominated by Skeptical mythology, so if there were definite objective evidence against vitalism you would expect to find it in that wikipedia article. However, it shows that rejection of vitalism was primarily a philosophical decision.

    Modern science has a long history of trying to separate itself from “primitive superstition,” although not all scientists have taken that path. Many, including all alternative medicine practioners, do not consider vitalism unscientific, do not feel a need to separate themselves from the ancient belief in vital energy.

    The current Skeptical movement continues the vitalism-rejecting branch of modern science. Rejecting vitalism is central and essential in the Skeptics’ mythology.

    The existence of vital “energy” has not be proven or disproven in any scientific way. Rejecting an idea just because you don’t like it, just because you somehow think it is at odds with modern science, is NOT scientific at all.

  189. hardnoseon 28 May 2016 at 2:30 pm

    Most people who reject vital energy say it’s because modern science can explain life very well without it. No, you cannot explain life, that is a complete fallacy.

  190. mumadaddon 28 May 2016 at 3:04 pm

    Troll vs science. That’s a one line e pitch for a documentary.

  191. ccbowerson 28 May 2016 at 5:40 pm

    “Most people who reject vital energy say it’s because modern science can explain life very well without it. No, you cannot explain life, that is a complete fallacy.”

    No that is not the reason. Vital energy is rejected because of a lack of evidence that it exists. It is not much of decision at all. Put forth evidence for vital energy and it will be considered. But you aren’t going to do that, because it doesn’t exist. The amount of evidence would have to be huge, as it would have to overcome many of the reasons why it is thought not to exist as d2u mentioned above.

    You believe in things without evidence because you want to, and dismiss things for which there is ample evidence because you want to. And you don’t think you need to challenge these beliefs, because you trust your own judgement despite being shown that your judgement is poor. The person who needs to turn skepticism inwards the most, thinks doing so is borderline insane. But it is exactly the opposite.

  192. The Other John Mcon 28 May 2016 at 6:41 pm

    I rejected vitalism because when i signed up as a member of The Skeptics they told me to, said it was part of their mythology. I just said ok, fine I’ll sign anything you want me to, just let me be in your special club and teach me the handshake

  193. hardnoseon 28 May 2016 at 7:04 pm

    Denying life energy causes a lot of things to not make sense. It is a worthwhile hypothesis. It was rejected by “mainstream science” as part of the effort to separate from ancient belief systems.

  194. daedalus2uon 28 May 2016 at 7:50 pm

    So what properties does “life energy” have?

    Is it conserved? Does it have mass/energy (like everything else that has any effects that can be measured)?

    If it doesn’t have mass/energy, how does it interact with things which do have mass/energy? Electrons, ions, proteins, electric fields, photons, and so on?

  195. hardnoseon 28 May 2016 at 8:13 pm

    As you probably know daedalus2u, not everything in the universe has been explained by modern science. Actually, most things have not. The fact that something has not been explained does not mean it can’t exist.

    Alternative scientists hypothesize that life fields and life energies represent a higher level of organization than physics. Higher levels would presumably interact in some ways with lower levels.

  196. BillyJoe7on 28 May 2016 at 8:32 pm

    d2u,

    I have raised all these problems about “life force” with him before. I even went to the trouble of providing multiple references, which he simply dismissed with an ad hominem about my source. He doesn’t want to hear that there is no “life force” because he really wants there to be. You can only guess at the underlying motivation.

    Essentially, the argument is as follows:

    The most successfull theory of particle physics is QFT.
    There is no room in QFT for a “life force”.
    To accept “life force” you would have to disprove QFT.

    That is a tall order.

    Of course, our little hero is not up to it, never has been, never will be.
    He doesn’t even understand basic concepts, but, with Dunning-Kruger hubris, he contradicts, with cheap self-styled “common sense” arguments, what all the experts in every field of scientific endeavour are telling us.

  197. hardnoseon 28 May 2016 at 8:53 pm

    And why, exactly, is there “no room?”

  198. daedalus2uon 28 May 2016 at 9:03 pm

    Where does the “life force” get added to the Schrodinger equation?

    Which term does the “life force” have effects on?

    If the “life force” does not have its own term, or does not have effects on other terms, then the Schrodinger equation wouldn’t “work” to describe anything because it would be incomplete.

    https://en.wikipedia.org/wiki/Schr%C3%B6dinger_equation

  199. BillyJoe7on 28 May 2016 at 9:20 pm

    More pseudoscientific nonsense from our little friend:

    “not everything in the universe has been explained by modern science”

    He uses “modern science” as a pejoritive, like homoeopaths use the word “allopath” for real doctors.

    Yeah, not everything in the universe has been explained by science, but, if you accept QFT, there are no “unknown unknowns” in science as far as our everyday experiences are concerned (and black holes and dark matter and energy are NOT part of our everyday experiences!). In the realm of our everyday lives, all the forces have been accounted for, and there is no room for any more “undiscovered forces”. Physicists know that any “undiscovered forces” are either too weak (one billionth the size of gravity) or too short range (less than a millimeter) to have any effect on our everyday lives.
    In other words, physicists know there is no “life force”.
    If our pseudosientific friend believes otherwise then let him provide evidence (and no physicists has ever found any) that most successfull theory of particle physics, QFT, is wrong.

    “Actually, most things have not”

    Correct. But irrelevant.

    “The fact that something [life force] has not been explained does not mean it can’t exist”

    False. Physicists “know” that any “unknown” force cannot influence our everyday lives.
    The “life force” does not, and cannot, exist.
    Otherwise provide evidence that refutes QFT.

    “Alternative scientists hypothesize that life fields and life energies represent a higher level of organization than physics.”

    Do you even understand the meaning of the word “hypothesis”?
    Are you basing your whole life on a mere “hypothesis?
    Yeah, it is a “hypothesis” – a “failed hypothesis”.

    “life fields and life energies represent a higher level of organization than physics”

    This is a meaningless statement.
    It explains nothing. It predicts nothing. It means nothing.

    “Higher levels would presumably interact in some ways with lower levels”

    “Higher levels” (arm waving at it’s best!) would “presumably” (presumably???) interact in “some way” (arm waving at its worst!) with lower levels.
    And this cheap non evidence based armchair pseudoscientific nonsense is supposed to replace hard earned scientific knowledge?

  200. BillyJoe7on 28 May 2016 at 9:23 pm

    “And why, exactly, is there “no room?””

    See above.

  201. hardnoseon 28 May 2016 at 9:48 pm

    “if you accept QFT, there are no “unknown unknowns” in science as far as our everyday experiences are concerned (and black holes and dark matter and energy are NOT part of our everyday experiences!). In the realm of our everyday lives, all the forces have been accounted for, and there is no room for any more “undiscovered forces”. Physicists know that any “undiscovered forces” are either too weak (one billionth the size of gravity) or too short range (less than a millimeter) to have any effect on our everyday lives.”

    Are all your thoughts just echos of Sean Carroll’s thoughts? Or do you have some of your own?

  202. BillyJoe7on 28 May 2016 at 10:02 pm

    See what I mean.

    He thinks he – a not particularly intelligent non-expert – can have ARMCHAIR-BASED THOUGHTS about quantum physics that rival the EVIDENCE-BASED CONCLUSIONS of actual quantum physicists!
    The hubris of Mr. Dunning Kruger.

    Will he answer any of the questions rainsed above?
    Well, here’s a hint…

    He doesn’t even understand the questions.

  203. BillyJoe7on 28 May 2016 at 10:03 pm

    raised

  204. jsterritton 29 May 2016 at 12:44 am

    @hn

    “The existence of vital “energy” has not be proven or disproven in any scientific way. Rejecting an idea just because you don’t like it, just because you somehow think it is at odds with modern science, is NOT scientific at all.”

    Wow, the cards are on the table.

    HN, you know perfectly well that science cannot “disprove” anything to a certainty. And you also know the burden to “prove” the various “energies” you speak of fall to their proponents, who have failed to generate a whisper of a hint of a ghost of a chance that such “energies” exist at all. Ditto for real scientists who have generously investigated such claims in the name of curiosity and sportsmanship.

    The only person here dismissing claims b/c they don’t “like it” is YOU. The rest of us reasonably dismiss nonsense as nonsense when there isn’t any plausible reason to believe nonsense: there’s no evidence, no lines of inquiry to follow, and no basic science supporting such mush-brained hooey. In fact, much of the knowledge we have hard won by methodical, unbiased, rigorous science would have to be jettisoned b/c it cannot co-exist with your magical nonsense (e.g., laws of the universe, basic chemistry, anatomy, etc).

    Unlike other commenters here, I see no reason to disabuse you of fantastical notions, because — ultimately — I cannot. I can only demonstrate a system of knowledge that is sound, satisfactory, predictive, testable, “dual,” and evidence-based such that it that dwarfs your unsupported “energies” claims as the sun does a wet candle.

    Your disdain for “medical science” (aka “mainstream science”) is the laziest argument a person can make against it. You merely assert that science is scientism and then use that weak-ass proof by assertion as a foundation that you think can support your contrarian beliefs in any- and everything science rebuffs. This time around it’s life energy and vital forces and inherent intelligence. Next time, it will be something equally unlikely and speculative. You’ll keep bringing q-tips to gun fights, insisting that the difference in firepower is “arbitrary” and “dogmatic.” You’ll trivialize real, complicated science that you don’t understand and mock Dr Novella and commenters for being in thrall to their Big Science paymasters. You’ll insist that arguments better than yours are “authoritarianism” — as if that’s any kind of rebuttal to an argument!

    Why not simply cherish your beliefs — whatever they are — and stop pretending that ideas you pull out of your ass somehow leapfrog scientific muster on your say-so, your conspiracy theories, and your false narrative that science is incurious, rigged, exclusive, and dogmatic. Why not save yourself the embarrassment of making false claims with such arrogance:

    “All non-mainstream current medical practices include a belief in “life energy.” That is also true of all ancient medical systems. Only mainstream western medicine does not believe in it.”

    Not only is this an appeal to antiquity and an appeal to science-refusal — it’s also just false. Most (not all or some) “non-mainstream current medical practices” have no “life energy” component: Alexander technique, Bach flower remedies, chelation therapy, non-TCM cupping, dry needling, dietary supplementation, exclusion diets, magnet therapy, ear candling, functional medicine, herbalism, iridology, phrenology, homeopathy, Rolfing, Gerson and other quack cancer therapies (detoxification, antineoplastons, Zoetron Therapy, psychic surgery, etc).

    …add to these the faith-based “non-mainstream” practices and the list is almost complete! Christian Science, faith healing, prayer, voodoo, intercessory prayer, and good ol’ blame-the-victim for “not doing it right” or “not being a good enough person.”

    HN, no one here gets it wrong as often as you do. No one takes such strange satisfaction from doing it. You’re a cranky contrarian who gets attention here exclusively because total and complete surrender of your dignity and any claim to intelligence is always your opening gambit. In a way, you can’t lose. But in another, more accurate way, you’re just a loser.

    Talk soon!

  205. daedalus2uon 29 May 2016 at 9:40 am

    An analogy to physicists missing some as yet undiscovered “life force” would be like cartographers and map makers missing an as yet undiscovered island the size of Australia, in the Atlantic Ocean.

    Ancient documents talked about such an island, called Atlantis. Modern map makers looked around for such an island, didn’t find one, decided there was no such island, and now have stopped looking. Of course they aren’t going to find any island, they aren’t looking for one.

    Could there have been such an island before people looked for it and didn’t find it? Yes, presumably there could have been such an island, but the Atlantic Ocean has been carefully examined. The ocean floor of the Atlantic Ocean has been mapped. There isn’t enough area in the Atlantic Ocean that has not been explored for an island the size of Australia to fit.

  206. hardnoseon 29 May 2016 at 10:05 am

    “You merely assert that science is scientism”

    NO. What you Skeptics call science is scientism. The belief that science has it all (almost) figured out, well at least it has all the basics that explain our “everyday” reality. The belief that human intelligence can potentially understand everything, given enough research funding. That all human knowledge that preceded the “enlightenment” era was garbage. Etc.

  207. hardnoseon 29 May 2016 at 10:06 am

    NO daedalus2u, vitalism has NOT been explored by mainstream science. Only alternative scientists consider it.

  208. hardnoseon 29 May 2016 at 10:09 am

    jsterritt,

    All I do here is express views from a different “tribe.” Tribes don’t like having to consider alternate views, so you go into fighting mode. I don’t care. I know that it’s just tribalism, and I also know that some of what I say could make some of you actually think.

  209. BillyJoe7on 29 May 2016 at 11:03 am

    Well, at least we all got a good laugh at the end there. 😀

  210. The Other John Mcon 29 May 2016 at 12:26 pm

    Contrarianism just for the sake of being contrary, should not be confused for cleverness or enlightenment. It’s easy to be contrary, but hard to invest time and mental energy understanding a complex topic. HN, why do you always take the easy route? Sheer laziness?

  211. hardnoseon 29 May 2016 at 12:30 pm

    I spent decades working on trying to understand the things I mention here.

  212. Steve Crosson 29 May 2016 at 1:16 pm

    “I spent decades working on trying to understand the things I mention here.”

    What a shame that you didn’t start your quest by trying to understand “HOW TO UNDERSTAND”.

    Instead, you’ve followed the same, lazy path that most people throughout history have followed — wishful thinking and confirmation bias. Instead of admitting to yourself that you’ve wasted a good portion of your life, you simply double down on your own ignorance. Very sad.

    There is a reason that the scientific method has been spectacularly more successful than ANY alternative. It works — reliably and repeatably. We only know that any particular phenomenon is well understood when multiple, independent observers can reproduce the same results.

  213. daedalus2uon 29 May 2016 at 1:31 pm

    And those main-stream cartographers practicing “mapism”, only looking at their main-stream maps. They have even stopped looking for Atlantis. Of course they are never going to find it.

    We need a brave, maverick alternative map-maker to go beyond the current mapism paradigm; stuck with its 20th century view of the world.

    Has anyone looked for Atlantis today? In the last 30 minutes? Then how does anyone prove it isn’t there?

  214. hardnoseon 29 May 2016 at 1:57 pm

    Worldviews come into and go out of style. Vitalism is sneaking back into mainstream science, in emergentism, complex systems science, etc. You can give it new names, but it will always be back, because it makes sense and agrees with observations.

  215. hardnoseon 29 May 2016 at 1:58 pm

    “There is a reason that the scientific method has been spectacularly more successful than ANY alternative.”

    I have NEVER EVER EVER criticized the scientific method. I lost count of how many times I had to say this.

  216. jsterritton 29 May 2016 at 2:49 pm

    “Vitalism is sneaking back into mainstream science, in emergentism, complex systems science, etc. You can give it new names, but it will always be back, because it makes sense and agrees with observations.”

    This assertion is riddled with shameful falsehoods. Vitalism is not “sneaking back into mainstream science,” and emergentism is not vitalism any more than complex systems science is. You are willfully pretending that complex systems study and the soft-boiled, metaphysical cop-out of emergentism support your wholly unsupported dualist ideology. THEY DON’T!

    “I have NEVER EVER EVER criticized the scientific method. I lost count of how many times I had to say this.”

    You endlessly criticize conclusions of scientific investigation. What’s more, the scientific method cannot be used to support your ghostly claims. You ramble and “argue” based on assertion alone. You’ll have to forgive those of us who have mistaken your disdain for proper, rigorous, scientific methods — not to mention your diatribes against science — as criticism of the scientific method.

    Duh.

  217. Steve Crosson 29 May 2016 at 3:11 pm

    HN,

    Every single time you assert that your own subjective observations are equal to or superior to the consensus opinion of experts, you are implicitly criticizing the scientific method.

    You either have literally no idea what the scientific method entails or you are lying or you are a fool — probably all three.

  218. hardnoseon 29 May 2016 at 5:10 pm

    “you assert that your own subjective observations are equal to or superior to the consensus opinion of experts”

    There are plenty of experts who have the same opinion I do about chiropractic subluxations. The theory was rejected by materialist medical science simply because it is vitalist, NOT because any research demonstrated it to be wrong.

    Vitalism is despised by certain factions, such as the organized Skeptics, because it implies that life is ultimately a mystery, and infinitely beyond human intelligence. That is the “mystical” worldview.

    It is understandable that people who value human intelligence above everything would hate vitalism. But this hatred has no foundation in scientific evidence.

    It is very possible to be a scientist, to use the scientific method, to value technology, to develop technology, while believing in vitalism. (And having the belief that vitalism makes sense does not mean believing in every kind of silly nonsense that someone is trying to sell.)

    My subjective experience of chiropractic subluxations is just another reason why I think the theory makes sense.

  219. hardnoseon 29 May 2016 at 5:10 pm

    “wholly unsupported dualist ideology”

    I don’t have any dualist ideology, and never said I did.

  220. The Other John Mcon 29 May 2016 at 5:57 pm

    Vitalism is essentially dualism, but I’m sure you know that after decades of careful study

  221. hardnoseon 29 May 2016 at 6:04 pm

    Vitalism and dualism are unrelated. You have been misinformed.

  222. Steve Crosson 29 May 2016 at 6:10 pm

    “There are plenty of experts who have the same opinion I do about chiropractic subluxations. ”

    Simply believing in something does NOT make someone an expert. True experts understand the importance of independently verified, reproducible evidence.

    Just because you desperately WANT to believe in vitalism does NOT mean that the rest of us suffer from the same character flaw. You are assuming that we don’t want to believe in something, when in fact the whole point of skepticism is NOT allowing emotions to influence belief. The ONLY reason most of us feel that vitalism is extremely unlikely is simply because there is no good evidence for it, plus a significant amount of counter evidence indicating implausibility or even impossibility.

  223. Steve Crosson 29 May 2016 at 6:15 pm

    “Vitalism and dualism are unrelated.”

    BS — they’re simply different names for the same “special sauce” that you desperately want to exist so you can continue your magical thinking.

  224. hardnoseon 29 May 2016 at 6:54 pm

    I am not “desperately” trying to believe in subluxations. I happen to notice how my health is affected by them.

  225. Steve Crosson 29 May 2016 at 9:19 pm

    Actually, you’ve “noticed” the power of the placebo effect.

    You sound like my grandmother. She was absolutely convinced that her daily newspaper horoscope accurately predicted her day to day life events — even after I repeatedly showed her that horoscopes from different sources were often dramatically different and even contradictory.

  226. ccbowerson 29 May 2016 at 9:28 pm

    In a sentence or two, what do you mean by vitalism and what evidence is there that it exists?

    In a sentence or two, what do you mean by subluxation and how do you know it exists?

    I would like to hear your answers. I am not holding my breath.

  227. jsterritton 29 May 2016 at 10:19 pm

    “I don’t have any dualist ideology, and never said I did.”

    hahahahahahahahahaha!

  228. BillyJoe7on 30 May 2016 at 12:15 am

    😀

  229. BillyJoe7on 30 May 2016 at 12:17 am

    hn posts have decended into farce.

  230. hardnoseon 30 May 2016 at 8:34 am

    Explain everything you know in a sentence or two. Don’t leave anything out.

  231. hardnoseon 30 May 2016 at 8:36 am

    Steve Cross,

    So, because your grandmother believed in the newspaper horoscope, anything that anyone notices about anything is a delusion.

  232. Steve Crosson 30 May 2016 at 9:55 am

    HN,

    Straw man.

    People notice correlations all the time. Obviously, sometimes it is legitimate causation — but sometimes it is merely coincidence. Being able to tell the difference is an important life skill.

    Lazy, careless people simply accept the correlation and remember the hits and discard the misses (confirmation bias) without bothering to carefully assess all of the evidence, contributing factors, prior plausibility or expert opinions.

    People like my grandmother (and you) prefer the false sense of security and illusion of control that an unquestioned world view provides.

  233. ccbowerson 30 May 2016 at 11:07 am

    “Explain everything you know in a sentence or two. Don’t leave anything out.”

    Ridiculous. I just asked for you to be precise about what you are talking about. You’ve made some pretty vague arguments, as usual. Others may want to engage the details around the periphery, but frankly it is a waste of time given your history of dodging the substantive arguments.

    What do you mean by vitalism and what are examples of affirmative evidence that it exists (not just ‘science can’t explain everything pleading’).

    What do you mean by subluxation and what is the evidence that they exist and cause disease?

    So far you’ve stated that you know because you’ve felt better when treated. That is not evidence of their existence, but evidence that you’ve felt better. You are quick to say that treating subluxations work before you’ve established their existence. There is a term called subluxations, which is a partial dislocation, but that is different than what chiropracters use.

    You state “The curves of the spine are normally smooth. If you feel areas that are flat or bumpy, that indicates what chiropractors call subluxations.”
    Umm. No. The vertebrae of the spine are not normally smooth throughout. You are mistaken. So you think something with “absolute certainty” based upon a complete falsehood.

    AND you fail to answer basic foundational questions about your argument. Like just defining what the hell you are talking about. But this is not surprising. Par for the course

  234. BillyJoe7on 31 May 2016 at 7:47 am

    ccbowers,

    I actually don’t believe what hn as said about his allergies, especially the following:

    “…chiropractic for allergies was not something I had heard about or believed in previously. I just happened to notice subluxations when I had the symptoms, and no subluxations when I didn’t have symptoms. Always, every single time…”

    He just “happened to notice” that his spine was out whenever he had allergies and never when he didn’t have allergies and he’d never heard that chiropractic could (allegedly) treat allergies. I’m sorry, but I just can’t believe this is a factual statement. At the very least, he’s grossly over-exaggerating.

    “symptoms get completely and immediately turned off.”

    Nope, I can’t believe this either. He presses on his spine and his allergy symptoms are completely AND immediately turned off. He is talking about magic here.
    But there may be a hint as to what is going on in his very next sentence:

    “Except I guess for things that were psychogenic to begin with. I know my allergy symptoms are not psychogenic, having been tested repeatedly with the same results”

    Yeah, maybe psychogenic.
    And, as if turning them off immediately and completely and repeatedly precludes a psychogenic cause for his symptoms.
    Waiting for that video…

  235. ccbowerson 31 May 2016 at 9:44 pm

    BJ7- Notice he has disappeared when pressed for substantive statements. Perhaps with his next adjustment, all trolling desires will immediately get turned off.

  236. mumadaddon 04 Jun 2016 at 6:01 am

    This is well worth a listen. Brain Science Podcast, interview with Dr. Fabrizio Benedetti, one of the world’s leading researchers of the neurobiology of placebos:

    http://hwcdn.libsyn.com/p/5/2/6/5266e57b58689dad/127-BSP-Benedetti-JK.mp3?c_id=11064813&expiration=1465038501&hwt=27fd7b66875496c78b6f6cee86ead0e1

  237. BillyJoe7on 04 Jun 2016 at 8:58 am

    Jesus…I mean…mumadadd, is there a transcript?
    That tape is unlistenable to.

  238. mumadaddon 04 Jun 2016 at 10:43 am

    Really?? I thought it was fine, and I’m properly bothered about audio quality. I know it’s not great, but it’s certainly possible to hear what’s being said.

    Anyway, you could download the podcast episode through iTunes or some other media application and see if it’s higher bit-rate.

    You can buy transcript for $1 (US): http://brainsciencepodcast.com/more-new-products/pdf127

  239. mumadaddon 04 Jun 2016 at 11:52 am

    BJ7,

    Give the audio another go, it’s pretty fascinating stuff. E.g. he elucidated something that was on the tip of my brain in my comments to hn but couldn’t find the right words to express — for pain, the larger the psychological component, the more effect a placebo can have. He defines a placebo as ‘the entire therapeutic ritual’. He also has a nuanced stance on the ethics of placebo research, stating that ‘quacks’ will use placebo effects as evidence that their magic treatments work (and he does call them quacks, which I loved).

    This was the kicker for me: give a patient an opioide on Mon, Tue, Wed, then on Thur substitute a placebo, and the ‘opioide system’ will be activated; give a patient a cannabinoid on Mon, Tue, Wed, then on Thur substitute a placebo, and the ‘cannabinoid system’ will be activated (though he points out that the effect is much stronger with the actual drug).

  240. mumadaddon 04 Jun 2016 at 11:56 am

    BJ7,

    Sorry – mistake…

    Give the audio another go, it’s pretty fascinating stuff. E.g. he elucidated something that was on the tip of my brain in my comments to hn but couldn’t find the right words to express — for pain, the larger the psychological component (e.g. pain), the more effect a placebo can have. He defines a placebo as ‘the entire therapeutic ritual’. He also has a nuanced stance on the ethics of placebo research, stating that ‘quacks’ will use placebo effects as evidence that their magic treatments work (and he does call them quacks, which I loved).

    This was the kicker for me: give a patient an opioide on Mon, Tue, Wed, then on Thur substitute a placebo, and the ‘opioide system’ will be activated; give a patient a cannabinoid on Mon, Tue, Wed, then on Thur substitute a placebo, and the ‘cannabinoid system’ will be activated (though he points out that the effect is much stronger with the actual drug).

  241. grayrabbit2017on 06 Mar 2017 at 11:53 am

    Hey I was wondering what do you all think of these two articles? Or moreso what you think about the subject matter, basically probiotics and the role of gut health in the body. I know some quacks like to make claims to fix “leaky gut” and link it to autism which AFAIK has no credible base but more legit research is coming out that suggest gut permeability is a real thing and may play a role in multiple autoimmune and chronic diseases. Also do any of you have any knowledge on these two studies? These and the Time magazine write-up were the two most seemingly credible sources of unbiased gut permeability info I found (I only did a quick google search) (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4253991/)(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856434/)
    https://www.drlam.com/blog/microbiome-gut-flora/23823/
    https://www.drlam.com/blog/benefits-from-probiotics/5702/

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