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Placebo.

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No, No, No, No, No. Chiropractors are still quacks. Part 2.

Last week I wrote part 1 of “No, no, no, no, no.  Chiropractors are still quacks”.  In that article, I wrote about a paper in the Journal of the American Medical Association (JAMA) entitled “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis” by Paige et. al.” (If you can’t get a copy of the paper and want to read it, DM me).  That paper concluded, based on a meta-analysis, that spinal manipulation therapy (SMT) had some small beneficial effects on treating back pain.  Though I’m skeptical of that conclusion and you can read an in depth article about the weaknesses of the study over here at sciencebasedmedicine.org.  Basically, they have the same conclusion that I have to the question of does SMT help relieve back pain?  The answer is I don’t know.  It might or it might not.  But the evidence that is does actually help is very weak to put it kindly.  I’m not saying the SMT definitely does not work, I’m simply saying I don’t know because the evidence simply isn’t there. And if you look at the actual wording of the guidelines put forth by the American College of Physicians they also seem a bit skeptical [emphasis added]:  

RECOMMENDATION 1:

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation).

RECOMMENDATION 2:

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation).

Notice that each time they mention spinal manipulation it is followed parenthetically by the phrase “low-quality evidence”.  None of the other treatments are followed by this caveat.  That’s important to note.  But chiropractors seem to have a way of taking any non-negative mention of chiropractic and further proof that it’s true while conveniently ignoring any research that shows chiropractic is basically an elaborate placebo.  Now expect chiropractors to present evidence that their field is true (clearly they are biased), but the way the media covers this stuff really makes me cringe.

I first heard about this from my wife when NPR did a story on this piece.  Here is how NPR covered it.  They actually seem to do a fair job with the story.  They are focusing on SMT in their headline and most of the article.  They then note that this therapy is performed by a wide array of practitioners including practitioners.  This seems fair to me based on what the actual JAMA article is claiming (though I still think the claim in the JAMA article are dubious).  But then there is the way the New York Times covered the story.

Take a look at this:

No, no, no, no, no.  The JAMA article is about one specific therapy (i.e. SMT) performed by a wide variety of practitioners (including, but not limited, to chiropractors) and its effects on a specific kind of back pain.  (Between this chiro article and their pseudo-science climate change garbage, I have cancelled by subscription to the NY Times.)

Here are some excerpts from that article (emphasis added):

Physicians are traditionally wary of spinal manipulation (applying pressure on bones and joints), in part because the practitioners are often not doctors and also because a few chiropractors have claimed they can address conditions that have little to do with the spine.

Still, there is no merit to many other claims about spinal manipulation — that it has been proved to work for things like infantile colic, painful periods, asthma, gastrointestinal problems, and more. For most conditions, the therapy lacks a good evidence base.

Along these same lines, Dr. Richard Deyo says in his response to the JAMA meta-analysis [emphasis added]:

Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors. Chiropractic therapy is not widely accepted by some traditional health care practitioners. This may be, at least in part, because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.

and this:

Concerns also exist about claims of exceptional benefit from some chiropractors. For example, there is no biological evidence to support spinal manipulation as an effective therapy for diabetes, heart failure, or thyroid disease.

A “few chiropractors”?  “lacks a good evidence base”?  The author of the NY times article is talking about these things as if they are afterthoughts.  Like yeah chiropractors might claim to be able to treat 100 different conditions with absolutely no evidence to support their claims, but let’s ignore that because there is low-quality evidence that they can help with back pain.

Deyo talks about “early practitioners” rejecting some sound scientific principles including immunization.  Well, there still appears to be a sizeable portion of chiropractors that don’t believe in immunizations.  This article, published in a chiropractic journal in 1994, found that “One-third agree that there is no scientific proof that immunization prevents disease, that vaccinations cause more disease than they prevent, and that contracting an infectious disease is safer than immunization.”  This is insane.

For me these aren’t afterthoughts, they are the whole point: Chiropractors make wild claims about being able to treat a wide array of conditions through spinal manipulation and treating subluxations.  And, with the exception of some types of back pain, there is basically zero evidence that chiropractic does anything for any of these other conditions.

And it’s not just a “few chiropractors” or “early practitioners” who are making the crazy claims.  Take ChiroOne for instance (you may have seen them trying to sign you up for chiropractic care on a street corner, art festival, or a whole foods if you lie in Chicago).  They have over 40 locations in the Chicago area.  Here is a list of conditions that they claim to be able to treat with chiropractic care: Screen Shot 2017-05-10 at 11.06.21 AM.png

Some of these are in the realm of possibility like sciatica and scoliosis.  Others are absolutely ridiculous like ADD/ADHD, high blood pressure, cold, flu, and virus symptoms, Crohns disease, and diabetes.  Though I think the most absolutely appalling thing listed here is “Newborns and Chiropractic care”.  For F*$&%^ sake, do not take your newborn in for a spinal manipulation!

So what I’m saying is, this isn’t the fringes of the chiropractic community.  This is mainstream stuff in their world.  Finally, I’ll end this post with a quote from a different JAMA article by David J. Fugazzotto, MD from 1970:

It continues to amaze me that, with all the evidence against the value of chiropractic, it still exists in our society today.

That was 47 years ago.  And somehow the quackery still persists.  My goal is that in another 47 years as a society we can look back on the scam that was chiropractic and just shake out heads in disbelief.

Cheers.

 

No, No, No, No, No. Chiropractors are still quacks. Part 1.

So I was in Whole Foods the other day and they often have vendors in there giving out free samples of their products.  Everyone loves a free snack.  But this time I came across Chiro One, a chiropractic group in the Chicago area.  They were excited to talk to me until I started talking to them and the conversation quickly ended.  I finished my shopping (I was getting a ton of soup because it was cold and rainy and that’s what you do when it’s cold and rainy) and went to complain to a manager.  I asked is she knew what they were claiming they could treat and she was really nice and said she would go take a look at their display.  I’m really interested to see what they do (I’m going to follow-up of course) because Whole Foods seems to be pretty big into selling “supplements” and “natural cures”.  So maybe chiropractic fits in with their vision for their company.

So, I’ve had chiropractic on the brain for the last few days and I was talking to my wife about it last night.  She mentioned that she had recently heard a piece on NPR where they talked about how chiropractic is now actually recommended as a treatment for lower back pain based on a recent study.  So naturally I wanted to look into this more and I found the manuscript that the NPR piece was based on.  It’s a research article in the Journal of the American Medical Association (JAMA) entitled “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis” by Paige et. al.  From the abstract the authors conclusions are as follows: 

Conclusions and Relevance  Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

Basically, there conclusion is that there is a small benefit to spinal manipulative therapy (SMT), which is very specific and NOT the same thing as chiropractic as a whole.  Though SMT is most often administered by chiropractors.  They also note that “heterogeneity in study results was large”.  Basically, the study results are all over the place.  This article was published along with an editorial entitled “The Role of Spinal Manipulation in the Treatment of Low Back Pain” by Richard Deyo, which is also worth reading.

So what did Paige et al do in their systematic review?  They did something called a meta-analysis.  The idea of a meta-analysis is to collect study that are similar in concept and combine these results to get a better overall estimate of the effect.  You can think of a meta-analysis as being a “study of studies” (i know.  So meta.) Now meta-analysis is a legitimate statistical procedure, but as with all statistical procedures when you ask yourself the question “Can I apply this technique here?” the answer is always “it depends”.  And with meta-analysis it’s easy to go astray.  You have to make assumptions that the studies are similar enough to even be combined together, there is the potential for publication bias to be amplified by meta-analysis (i.e. The File Drawer Problem) (they do mention in the article “There was no evidence of publication bias in the overall pooled result, with a Begg rank correlation of 0.92 and an Eggar test P value of .58.”), and you have to assume that the individual studies themselves are done well.

Well….I have a few issues with this meta-analysis.  For instance, of the 26 studies included in the effectiveness analysis, the authors state:

None of the studies met the criterion for blinding of providers. Only 4 studies met the criterion for blinding of patients.

The gold standard for randomized clinical trials in double-blind placebo controlled studies.  Most of these studies didn’t bline the provider OR the patient.

The authors also say:

Two studies of SMT vs sham SMT reported non-statistically significant results.

“sham SMT” here is acting as the placebo, so only TWO of the studies considered here actually used a placebo.  These two quotes alone are enough to render this meta-analysis basically meaningless.  But I could go on and on about the weaknesses of this meta-analysis and the individual studies comprising it, but that blog post had already been written in much greater detail by Dr. Mark Crislip.  Dr. Crislip concludes:

Does SMT help for low back pain? Who knows. I have zero idea. Not that I could tell from the primary literature. Any effect of SMT is impossible to dissect out from all the other interventions in the studies. What little beneficial effect that is reported is small and likely from placebo and/or bias. And with a hodgepodge of interventions, it would appear to be a nonspecific effect, like one ape grooming another.

I’d like to point out one more thing about the meta-analysis before moving on to how this was reported by the media.  Several of the works cited in this meta analysis are from a journal called the Journal of Manipulative and Physiological Therapeutics.  This is a journal published by Mosby on behalf of the American Chiropractic Association (ACA).  I, for one, do not trust a journal published by the ACA.  Just to give you a taste of the kind of articles they have published in that journal over the years there is this:

Manner, Harold: Amygdalin, vitamin A and enzyme induced regression of murine mammary adenocarcinomas. Journal of Manipulative and Physiological Therapeutics, Dec. 1978.

That article, according to quackwatch.org, which is run by Stephen Barrett, M.D.:

Manner entered the public spotlight in 1977 by announcing at a National Health Federation seminar that he had cured cancer in mice with injections of laetrile, enzymes and vitamin A. The experiment was published in 1978 in a chiropractic journal [7]. What Manner actually did was digest the tumors by injecting digestive enzymes into them, which cannot cure metastatic cancer.

There is also this article from 2004 where a chiropractor treated a child with Attention Deficit / Hyperactivity Disorder (ADHD) in an article entitled “Cervical Kyphosis Is a Possible Link to Attention-Deficit/Hyperactivity Disorder” written by three chiropractors.  The conclusion of that manuscript is as follows:

This case study shows that spinal correction using the CBP approach may have effects much greater than relief of musculoskeletal conditions. Altered spinal biomechanics associated with abnormal posture clearly relate to significant neurological stress and malfunction. This is particularly evident when considering the effects on the brainstem and the autonomic nervous system. Thus, even in obscure cases with systemic, organic, or chemical dysfunction like ADHD, we suggest optimal spine equals optimal health.

This conclusion is based on ONE patient with no comparison to a placebo.  That’s not science, that an anecdote.

tl;dr: Chiropractors are still quacks.  Save your money and go get a back massage.

Cheers.

 

Nuts and bolts, the Metro Division got (a little bit) screwed

I want to be Mike Lopez when I grow up.

StatsbyLopez

Here’s a look at the NHL’s final regular standings in the Eastern Conference from 2016-17. As a reminder, eight teams in each conference make the playoffs

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Tiebreakers and divisional qualification rules not withstanding, both the Islanders and Lightning finished a point out of the playoffs. That’s a difference between what would likely be at least a 1 in 25 chance at a Stanley Cup and at least two games of home playoff revenue, or an early start to golf season. That point difference was immense.

But there’s a problem with using the standings above – the points aren’t equivalent. Specifically, I’ll argue in this post that the 94 points from the Islanders is, all else equal, likely more impressive than the 95 points for the Leafs, given the caliber of each team’s schedule.

The NHL’s unbalanced schedule.

First, some background. NHL teams play intra-division opponents either four or five times, inter-division/intra-conference opponents three times, and all inter-conference opponents two…

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Towards an understanding of the NHL’s final standings

This is interesting.

StatsbyLopez

In a recent paper, Gregory Matthews, Ben Baumer, and I looked at the role of randomness in professional sports outcomes. Perhaps unsurprisingly, we identified that NHL and MLB games tend to be closest to a coin flip, with the worst teams capable of beating the best. Meanwhile, there are larger gaps in talent between franchises in each of the NBA and NFL. Although our focus was on individual game outcomes, we laid a bit of groundwork for related work with respect to between-league and between-team comparisons.

In particular, I left curious as to the end impact of the NHL’s randomness. If most game outcomes are near coin flips, what impact does that have on season outcomes? In this post, I’ll reflect back on the NHL’s final standings, with the goal of better understanding the underlying differences in team strengths, and what that means about where teams finish.

Why final standings?

Sports leagues use final regular season standings to both determine playoff…

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Color Survey Results

xkcd

Who in the rainbow can draw the line where the violet tint ends and the orange tint begins? Distinctly we see the difference of the colors, but where exactly does the one first blendingly enter into the other? So with sanity and insanity.
—Herman Melville, Billy Budd

Orange, red? I don’t know what to believe anymore!
—Anonymous, Color Survey

I WILL EAT YOUR HEART WITH A FUCKING SPOON IF YOU AKS ANY MORE QUESTIONS ABOUT COLORS
—Anonymous, Color Survey

Thank you so much for all the help on the color survey.  Over five million colors were named across 222,500 user sessions.  If you never got around to taking it, it’s too late to contribute any data, but if you want you can see how it worked and take it for fun here.

First, a few basic discoveries:

  • If you ask people to name colors long enough, they go totally…

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Cinderella Plots 2017 #ncaa #marchmadness

I originally made this plot for the 2012 Stat Geek Idol contest run by Team Rankings, and they are still cool.  The original article describing them can be found here. Below I’ve updated the plots for games through March 19th.  (For games that haven’t been played yet this year, I’ve assumed the higher seed wins for the sake of the plot.)

Cheers.

Cinderella2017

 

CinderellaPlot2001-2017

Cheers.

$10.8 Billion. But none for the players. #ncaa

In 2010 CBS signed a deal with the NCAA for the rights to broadcast the NCAA tournament for 14 seasons from 2011-2024.  According to the NCAA, the deal is worth 10.8 BILLION dollars.

Let’s do some fun quick math, shall we:

There are 347 NCAA division 1 NCAA basketball teams and they each offer 13 scholarships.  That’s a total of 4,511 spots.  If you paid every single one of these players $50,000 per year, that would cost about 225 million dollars ($225,550,000).  Let’s assume salaries go up 3 percent a year for inflations, which would mean that in 2024 you are paying players around $73K per year.  The grand total over 14 years for this plan would cost about 3.8 BILLION dollars ($3,853,820,415).  That’s a ton of money.  BUT it’s dwarfed by how much money this deal is worth.  If you took this money out of this deal to pay the players, you’d still have almost $7 BILLION left over  ($6,946,179,585).  And keep in mind, this is just for the tournament.  That’s 67 games over three weeks in march.  There is more money than this for regular season TV contracts not to mention the money schools make for selling tickets and merchandise.  Merchandise, some of which, has players’ names on it!!!! The school can make money off of a player’s name, but the player can’t! (Well the player can, he just then can’t play in the NCAA).  Think about that.  Screw you NCAA.  Screw you.

The NCAA is a cartel that makes billions of dollars off of the back of labor that has absolutely no representation.  I don’t know why as a society we put up with this.  In literally every other area of life, if you are good enough at something to get paid for it, someone can pay you for it.  The exception is sports.  Why do we value amateurism in sports?  I have no idea.  But I’ll continue to call out the hypocrisy of the NCAA until they pay the players who actually make this stuff worth watching.  Coaches get to negotiate a salary and can come and go as they please.  Hell, some coaches get huge contract buy out to NOT COACH.  But players have basically no rights.  So until the NCAA changes it’s ways, I hope they get sued from every direction until they have no choice but to pay the players.

Cheers.

 

 

Not our year #kaggle

After 48 games we are in 97th place in this year’s March Machine Learning Madness.  I’m going to guess that we finish in 45th.  Screen Shot 2017-03-19 at 10.52.55 PM

Cheers.

Sunday’s NCAA game predictions with probabilities #kaggle

In 82nd after 32 games.  In 101st after 40 games.  Not a great day for us.  Need something big tomorrow to get within striking distance.  I’m guessing we will finish in the top 50, but it looks like our lucky run of three top 4 finishes in a row is pretty much over.

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Here are our predicted probabilities for Sunday’s games (with ridiculous precision):

  • Louisville over Michigan: 0.7051029
  • Kansas over Michigan St: 0.8346071
  • UCLA over CIncinnati: 0.6074323
  • Oregon over Rhode Island: 0.7488454
  • Duke over South Carolina: 0.7873011
  • Kentucky over Wichita State: 0.6272257
  • North Carolina over Arkansas: 0.8434368
  • Baylor over USC: 0.8055379

Cheers.