Ladies and gentlemen: Your new NCCIH director, acupuncture true believer Dr. Helene Langevin.
You might or might not be aware that the National Center for Complementary and Integrative Health (NCCIH) is currently without a permanent director and has been since last year, when its latest director, Dr. Josephine Briggs, retired. Late last week I learned that Dr. Briggs’ successor had been named, and Dr. Helene Langevin will be the new director of the NCCIH. Regular readers know that we here at SBM don’t much like the NCCIH, formerly known as the National Center for Complementary and Alternative Medicine (NCCAM). The reason is simple. Basically, “integrative medicine” or “integrative health” or whatever you want to call it is nothing more than a strategy for mainstreaming quackery by combining it with science-based medicine. When this happens in academic medical centers, I like to call it quackademic medicine. Of course, the vast majority of the “alternative medicine” that “integrative medicine” purports to integrate with real medicine and that quackademic medicine investigates has either not been proven scientifically to be efficacious and safe, has proven not to be efficacious, or is based on physical principles that violate well-established laws of physics (such as homeopathy or “energy healing”). Indeed, if the term “integrative medicine” were not thus, it would be a completely unnecessary moniker.
To paraphrase Tim Minchin, Richard Dawkins, John Diamond, Dara Ó Briain, and any number of skeptics, there is no such thing as “alternative” medicine because “alternative” medicine that is shown through science to work becomes simply medicine. Thus, newly validated medical treatments have no need to be called “integrative” because medicine will “integrate” them just fine on its own. That’s what medicine does, although admittedly the process is often messier and takes longer than we would like. Integrative medicine, like alternative medicine before it, is a marketing term that is based on a false dichotomy. Only unproven or disproven medicine needs the crutch of being “integrative”, a double standard that asks us to “integrate” unproven treatments as co-equal with science-based medicine even though they have not earned that status. So when I see that a new NCCIH director has been named, my question is: Will this director make NCCIH more or less scientific than it already is. Given that this new director is Dr. Helene Langevin, my prediction is that we’re going to be heading back to the salad days of quackery that NCCAM used to engage in back in the 1990s.
A brief recent history of NCCIH: Dr. Josephine Briggs
To understand why, let’s step back a few years to the director before Helene Langevin was named. I’m referring, of course, to Josephine Briggs. Dr. Briggs was a nephrologist with impeccable scientific credentials, which is probably why CAM advocates like our old friend John Weeks were appalled by her appointment. At the time of her appointment, her history was described thusly in an announcement:
Dr. Briggs received her A.B. cum laude in biology from Harvard-Radcliffe College and her M.D. from Harvard Medical School. She completed her residency training in internal medicine and nephrology at the Mount Sinai School of Medicine, followed by a research fellowship in physiology at Yale School of Medicine. She was a professor of internal medicine and physiology at the University of Michigan from 1993 to 1997. From 1997 to 2006 she was director of the Division of Kidney, Urologic, and Hematologic Diseases in the National Institute of Diabetes and Digestive and Kidney Diseases. For the last year and a half she has been senior scientific officer at the Howard Hughes Medical Institute.
Dr. Briggs has published more than 125 research articles and is on the editorial boards of numerous journals. She is an elected member of the American Association of Physicians and a fellow of the American Association for the Advancement of Science. She is also a recipient of the Volhard Prize of the German Nephrological Society. Her research interests include the renin-angiotensin system, diabetic nephropathy and the effect of antioxidants in kidney disease.
As you can see, when she was appointed as director of then-NCCAM, Dr. Briggs was an interesting and odd choice. She had no background in complementary and alternative medicine (CAM) or “integrative medicine” (which is what Mr. Weeks was so unhappy about) and, as far as I can tell, had not used CAM in her practice or done any research into it. I suspect that, at the time, she was intended as a director to impose scientific rigor to NCCAM, although I also wondered how she could have met with the approval of the National Advisory Council for NCCAM, the committee that oversaw it and to whom any NCCAM director had to report. The reason is that the Council by charter has to include as half of its voting members, practitioners “licensed in one or more of the major systems with which the Center is involved”; i.e., they must be acupuncturists, naturopaths, and other practitioners of alternative medicine. Two-thirds must be “selected from among the leading representatives of the health and scientific disciplines (including not less than 2 individuals who are leaders in the fields of public health and the behavioral or social sciences) relevant to the activities of the NCCIH.” In other words, the Council is overwhelmingly made up of true believers. This was by design when Senator Tom Harkin was crafting the legislation that guided the creation of NCCAM, in order to prevent too much scientific rigor. Remember, the original purpose of NCCAM was to prove that quackery worked, not to produce negative studies. Indeed, nine years ago, when that’s pretty much all that NCCAM had produced, Sen. Harkin admonished Dr. Briggs by saying:
One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.
Note what Harkin said first here. He didn’t say that the purpose of NCCAM was to investigate alternative approaches and determine if they work or not. Rather, he said that the purpose of NCCAM was to investigate and validate alternative approaches.
I had my disagreements with Dr. Briggs over the years. Mainly, these derived from my view that what NCCAM was trying to research consisted of pseudoscience and quackery and that the interventions that it was studying that weren’t pseudoscience and quackery were well within the realm of science-based medicine. It’s what I refer to as the “rebranding” of modalities like diet, exercise, and lifestyle as being somehow “alternative”. Even so, I gave Dr. Briggs some credit because I thought she was in an impossible situation. She was a real scientist trying to impose scientific rigor on an enterprise that was inherently resistant to such an imposition.
You could see her efforts to try to impose scientific in the two five-year strategic plans she produced. For example, the 2011-2015 plan basically proposed doing just that. And that was basically accurate. It didn’t work, which is why I referred to the second strategic plan (2016-2021) as, “Let’s try to do some real science for a change“. On the other hand, that plan made explicit one of the most harmful tactics of quacks to legitimize their quackery under the banner of “integrative medicine,” the co-opting of the opioid crisis as an excuse to claim all nonpharmacological treatments for pain as being “integrative”. The results are threatening great harm to chronic pain patients by misguided governments wanting to force them to undergo quack treatments like acupuncture as a means of getting them off opioids.
Which brings us to Helene Langevin.
Helene Langevin: True quackademic believer
Helene Langevin has been mentioned in the digital pages of this very blog on a number of occasions. Why? Simple. She’s all-in when it comes to “integrative medicine” and totally believes in the theatrical placebo known as acupuncture. Most of her career has been in integrative medicine, and she’s done some howlingly bad studies. First, let’s see what the NCCIH says about her:
Dr. Langevin comes to NIH from the Osher Center for Integrative Medicine, jointly based at Brigham and Women’s Hospital and Harvard Medical School, Boston. She has served as director of the Osher Center and professor-in-residence of medicine at Harvard Medical School since 2012. She has also served as a visiting professor of neurological sciences at the University of Vermont Larner College of Medicine, Burlington.
As the principal investigator of several NIH-funded studies, Dr. Langevin’s research interests have centered around the role of connective tissue in low back pain and the mechanisms of acupuncture, manual, and movement-based therapies. Her more recent work has focused on the effects of stretching on inflammation resolution mechanisms within connective tissue.
Basically, Langevin’s whole thing is connective tissue. She believes that the stretching of connective tissue is how a number of CAM modalities “work”, such as chiropractic, massage, and, of course, acupuncture. Of course, it’s not entirely unreasonable to think that connective tissue has something to do with massage therapy and even chiropractic. Of course, the problem with chiropractic is not so much the manual manipulation of the spine (with the exception of cervical manipulation, which is potentially dangerous) and muscles, along with connective tissue. It’s that the whole rationale for chiropractic is vitalistic at its core and based on pseudoscience. It’s also that chiropractors claim to be able to do far more than you could reasonably expect manipulation to do, such as treat allergies and all manner of diseases, as well as even prevent diseases like the flu. (No, really. I kid you not.) That’s why I like to say that chiropractors are middling to incompetent physical therapists with delusions of grandeur.
One time when I took note of Dr. Langevin was when she wrote a truly horrendous defense of acupuncture for the Harvard Health Blog, specifically a defense of acupuncture for headache. It basically bought into every trope about acupuncture, including buying into acupuncture as a potential solution to the opioid crisis and characterizing acupuncture as an “ancient practice with a theoretical foundation incompletely understood by modern science”.
For a taste of what she’s about, when we take a look at Dr. Langevin’s website at the Osher Center, we see this:
Imagine a body that is totally coordinated, strong and flexible, healing quickly when injured and able to fight off infections and cancer cells. This would be a body with healthy connective tissue. The goal of the Osher Center Connective Tissue Lab is to learn how to keep connective tissue flexible and free from pain, slow down aging and increase the health of the whole body.
We believe that many of the seemingly unsolvable riddles of medicine (why do some injuries heal while others result in chronic pain? how does the body defend itself against cancer?) are due to the fact that their answers involve connective tissue, which medicine so far has mostly neglected.
One of the limitations of conventional medicine is its fragmentation of the body into separate systems and body parts. Connective tissue is a body-wide network that connects all the systems and parts of the body together, and therefore is important for the integrated functioning the whole body.
I can’t help but think this reminds me of the whole “discovery” of the “interstitium” based on a dubious study that made the news a while back. Let’s just put it this way: Deepak Chopra liked that study, thinking the interstitium validated a whole lot of woo. I get the same vibe from Langevin’s work.
It gets worse than that, though. To see what I mean, take a look at her work on acupuncture by checking out this interview in which she talks about her research:
Notice that Langevin has been studying acupuncture ever since at least the 1990s, when she came up with the idea that somehow the needle interacting with the connective tissue is how acupuncture “works”. Of course, nowhere in her “research” have I been able to see anything resembling a coherent or even suggestive mechanism as to how connective tissue could modulate the “activity” of acupuncture. Also, to her it’s not just the needles, but the twirling of the needles that is so important to do…something. Somehow this minute stretching of the tissue is enough to explain acupuncture’s miraculous “effects.” It’s not quite clear. She also seems unduly impressed by ultrasound findings in patients with chronic low back pain suggesting more thickened tissue, as though chronic inflammation might be going on. Ya think? What could sticking little needles into the body do for this? It doesn’t even make sense.
She also regurgitates her previous work in cadavers and human subjects in which she claims that acupuncture meridians correspond to areas where two muscles come together. And guess what? That’s where connective tissue is and the likelihood of getting deeper into connective tissue is higher. As a surgeon, I laughed out loud when I heard that part. Let’s just put it this way. I can jam a needle as deep into a body as I want pretty much anywhere other than where it hits bone, no need to go into grooves between muscles, and there’s a lot of connective tissue within muscles as well, for instance, around the fascicles. (Seriously, Dr. Langevin, look up epimysium, perimysium, and endomysium.) I can’t help but mention at this point that a lot of acupuncture meridians run pretty close to the courses of major nerves as well. Why isn’t she studying that?
I think it’s worth taking a look at what is perhaps Dr. Langevin’s most famous study in a bit more depth in order to get an idea of just what we as advocates of science-based medicine will be dealing with
Seeking an anatomic basis for acupuncture?
In 2010, Dr. Langevin published a paper entitled “Electrical Impedance of Acupuncture Meridians: The Relevance of Subcutaneous Collagenous Bands” in PLoS One. Acupuncturists like it because it claimed to have found a possible basis for acupuncture, but did it? I think you know the answer. So let’s take a look. I knew right away that there was a serious problem right from the very first sentence of the abstract:
The scientific basis for acupuncture meridians is unknown.
Well, I suppose that’s true enough in a very trivial fashion, you know, the same sort of fashion that the scientific basis for homeopathy is “unknown”.
And then there’s first paragraph of the introduction to the paper:
To this day, the fundamental tenets of acupuncture, the acupuncture point and meridian, remain a mystery. What are they anatomically and how do they function physiologically? Past studies have anatomically linked these Traditional Chinese anatomical structures to neurovascular bundles [1], [2], [3], trigger points [4], [5], [6], and connective tissue fascial planes [7]. Other studies have identified functional correlates including reduced electrical impedance [8], [9], [10] and enhanced migration of nuclear tracers [11], [12], [13], [14], [15], [16]. However, due to multiple study design limitations – including inadequate descriptions of acupuncture point/meridian localization, small sample size, and unexplained statistical analysis – a definitive conclusion regarding the scientific basis of these structures is difficult to establish.
A better way to put it would be that there is no known physiological or anatomic structure that corresponds to acupuncture meridians, which brings up the issue of how it was supposedly possible for practitioners of traditional Chinese medicine to have identified these meridians in the first place. Science can’t tell any difference; they don’t really correspond to any nerves; and there’s no criteria by which a meridian can be distinguished from a non-meridian other than drawings on mannequins. It’s magic. It’s fairy dust. In fact, as I’ve described many times before, meridians are irrelevant to acupuncture. It doesn’t matter if you stick the needles in a meridian or not, which meridian, or even if you stick the needles in. Virtually any old place will do. Given that, one wonders why Dr. Langevin even bothered to try to undertake a study. But undertake it she did, trying to use a combination of ultrasound and impedance measurements. It’s a tour de force of what our very own Harriet Hall once so famously dubbed Tooth Fairy science and Dr. RW termed quackademic medicine using the following rationale:
Given these two reported associations [allegedly between acupuncture meridians and decreased electrical impedance and between decreased impedance and increased intramuscular connective tissue], we hypothesized in a previous study that intermuscular connective tissue was the anatomical basis for the reduced electrical impedance reportedly observed at acupuncture meridians. We tested this hypothesis and found that electrical impedance at Pericardium meridian-associated connective tissue was significantly reduced compared to an adjacent muscle control [22]. The Spleen channel segment, on the other hand, showed no statistical difference. This lack of difference was attributed to unintended placement of Spleen-control needles in an adjacent intermuscular plane.
So, did Dr. Langevin actually find a physiological basis for acupuncture points, or was she measuring how much money the Tooth Fairy leaves behind? Did she find an objective way to demonstrate that there is an anatomic difference between the tissue under meridians and the tissue elsewhere that could produce a plausible biological mechanism by which acupuncture “works”? Or did she simply measure which sorts of teeth bring a larger haul of cash from the Tooth Fairy?
Let Harriet apply the general beat down to Tooth Fairy Science:
You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists.
In other words, carefully applied scientific methodology used to study fairy dust produces results that are still fairy dust. Prove the phenomenon exists and that acupuncture works, before you go to all these contortions to try to relate it to subcutaneous connective tissue and changes in impedance.
Let’s see what Langevin and her team did:
To avoid confounding by an adjacent connective tissue plane and to see whether the findings from the Pericardium (PC) channel were generalizable to other body sites, we assessed the electrical impedance of skin and underlying subcutaneous connective tissue at the Large Intestine (upper arm), Liver (thigh), and Bladder meridians (calf). These sites were originally chosen because they represented a good balance of anatomical locations and meridian types (2 Yang and 1 Yin channel), and the meridians were not located close to another meridian or intermuscular tissue plane. Acupuncturists determined the location of meridian sites, and ultrasound images were obtained at each test site to record any potential structural associations with electrical impedance. There were two primary aims for this study: (1) to determine whether the electrical impedances at acupuncture meridians were significantly lower than impedances at adjacent controls, and (2) to assess whether echogenic collagen was significantly associated with electrical impedance obtained at the test sites.
So very science-y.
Basically, Langevin’s team signed up 28 subjects (19 female, 9 male). Exclusion criteria included: age under 18 years old; pregnancy; anticoagulant usage; history of a bleeding disorder; implanted ventricular defibrillator; chronic skin conditions; chronic skin inflammation (eczema or psoriasis, for example), or a collagen disorder. They also excluded obese people with a BMI greater than 30. Meridians were identified by two different acupuncturists and in the case of any disagreements the two came to a consensus. According to the methods section, the acupuncturists had an average of seven years of experience, and each represented a different acupuncture style, one Chinese, one Japanese.
Now here’s where it gets odd. The acupuncturists originally intended to insert the needles into the intermuscular connective tissue but had a hard time getting the needles in there. That’s some pretty deep insertion, which makes me wonder what relevance this even had for acupuncture. Neither did the acupuncturists, either, it would appear, because there’s a most telling passage in the methods:
Furthermore, the intermuscular trajectory mapped out by imaging did not consistently match the trajectory mapped out by the acupuncturists. This was particularly true for the intermuscular plane near the LV meridian where the Sartorius muscle runs obliquely along the leg and across the LV meridian path. For these reasons, we decided to focus on the skin and underlying subcutaneous connective tissue in all our subjects. In other words, impedance measurements were limited to the subcutaneous fat region above muscle.
So basically, our intrepid team of researchers decided to give up on trying to measure impedance in intramuscular collagen bands and stick to the skin and subcutaneous tissue. They even showed in Figure 2 ultrasound images showing muscles with thin bands of connective tissue between them. Of course, any orthopedic surgeon could have told them that they’d have a hell of a time hitting those bands of intramuscular connective tissue. Heck, if they had asked me, I could have told them that they’d have a lot of trouble hitting those bands, even with ultrasound guidance, which, by the way, acupuncturists don’t normally have or use in deciding where to place the needles.
So, having failed at their first objective, our intrepid band of acupuncturists decided to look at impedance measurements in the superficial perimuscular fascia; i.e., the band of connective tissue that surrounds each skeletal muscle, comparing impedance measurements for meridian versus control. Then, they in essence went anomaly hunting. What do I mean by that? Basically, the investigators used all sorts of statistical models looking for associations between differences in impedance and meridians and correlations between differences in impedance and ultrasound-measured tissue density. Of course one thing that must be noted is that it would be completely unremarkable to find correlations between ultrasound-measured echogenicity (the ability to reflect sound) and differences in impedance. After all, if there’s one thing ultrasound is good at, it’s measuring differences in water content, which, along with various other mechanical properties of the tissue, determine differences in echogenicity between tissues. Consequently it would be utterly trivial to find correlations between tissue impedance and echogenicity, and not at all surprising. It would also not be particularly surprising if differences were not found, because there could well be too much variation in tissue impedances to produce a statistically significant results. Either finding would not be “evidence” for acupuncture meridians.
It’s also rather remarkable that the investigators felt the need to use such sophisticated statistical methodology to look for differences in impedance between meridian and non-meridian segments and for correlations between ultrasound-measured echogenicity and differences in impedance. Let’s put it this way: if there were a clear-cut difference in impedance between the meridian and non-meridian segments tested, the investigators wouldn’t need to do all the analyses they did. Doing something as simple as a t-test or one-way ANOVA will usually suffice to show the difference. Even if the statistics were appropriate for the data, again, what we appear to have in Dr. Langevin’s study is an example of the Texas sharpshooter fallacy. Basically, all those mixed model statistical methods were modeling was how fast the Tooth Fairy can complete her rounds of harvesting teeth and leaving goodies under the pillows of little boys and girls.
So what did the authors find? Let’s take a look. First, they claimed to have found a small difference in impedance between the Large Intestine meridian impedance and the control (345±15 Ω versus 355±15 Ω, p=0.021, at 10 kHz; 432±23 Ω versus 449±23 Ω, p=0.017 at 1 kHz). Everything else was negative. Does this mean anything? Who knows? Does it validate the existence of the Large Intestine meridian? No, but nice try. All it says is that there might be a difference in impedance between one area on the upper arm and another area. Worse, the observers aren’t blinded at all. Without blinding, there’s the possibility of subtle bias creeping into the measurements and sampling. Would it have been so hard to have the acupuncturists place the needles and then leave the room, after which the technicians doing the measurements come into the room to do the impedance and ultrasound measurements?
Finally, the investigators undertook a multivariate analysis to see if they could identify any factors that explained the differences in impedance other than meridians. They looked at subcutaneous tissue thickness, dermal zone echogenicity, subcutaneous zone echogenicity, and perimuscular zone echogenicity. The result are the graphs in Figure 4, which are what I call star charts. About the best that all these multiple comparisons could come up with was the earth-shattering observation that percent echogenicity in the subcutaneous zone correlated with differences in impedance. Personally, I’m surprised that more measurements didn’t correlate with changes in impedance.
If there’s one thing about complementary and alternative medicine (CAM), it’s that its adherents do more stretching and twisting to try to contort data into proving that there’s something to fairy dust. This is a perfect example. It’s in essence a fishing expedition to find any differences, no matter how small or irrelevant, between acupuncture meridian points and tissue somewhere nearby. Investigators find one difference and use the sharpshooter fallacy to declare it evidence supporting the existence of acupuncture meridians. One thing I always ask myself when I see a study like this is: Why these three acupuncture meridians? Why not others? No real explanation is given. Or maybe the investigators tried other acupuncture meridians and they didn’t work. That certainly wouldn’t surprise me.
Of late, Dr. Langevin has been looking at connective tissue in cancer. To me, this is about the only area where she is doing research that might be of value for anything other than as a justification and to produce a made up “mechanism” for woo. For instance, this year she published a study suggesting that gentle stretching could decrease the rate of breast cancer xenograft growth in a mouse model, but it’s just one study and one has to wonder if there’s a confounder she’s missing. For one thing, other than for the caliper measurements of the tumors, none of the scientists doing the experiments were blinded to experimental group, and I’m not entirely sure that the treatment of the two groups was adequately matched other than the gentle stretching. Whatever the case, such a finding could be consistent with findings that exercise is associated with improved cancer survival, but it says pretty much nothing about acupuncture.
Is the tide shifting towards more quackery at NCCIH?
Delving back into the history of NCCAM/NCCIH, I note that there have been a few constants. The scientific community never wanted this Center, nor did the scientific leadership of the NIH ever ask for it. It was foisted upon NIH by a woo-loving senator who thought that bee pollen cured his allergies, along with his allies and a bunch of quacks who supported him. As a result, from its very formation, NCCAM/NCCIH has been riven by constant war between those who are true believers and, like Sen. Harkin, want to “validate” quackery, and those who wanted to impose serious scientific rigor. It’s a battle that goes back to before NCCIH was NCCIH or even NCCAM was NCCAM, all the way back to when all that existed was a precursor organization known as the Office of Alternative Medicine (OAM). Indeed, the very first director of OAM, Joseph M. Jacobs (who, by the way, was very open to the concept of alternative medicine) almost immediately ran afoul of Sen. Harkin by insisting on rigorous methodology to study alternative medicine. Ultimately Jacobs resigned under pressure from Harkin and the “Harkinites” on the OAM advisory panel.
Oddly enough, since the late 1990s, the side of science has more or less been at least able to hold its own. Dr. Stephen Strauss was the director of NCCAM from 1999 until 2006, and he fought the same battles. Then Dr. Briggs was director from 2008 until last year, when she retired, and she actually went quite far in eliminating the worst quackery from NCCAM. Gone were studies of homeopathy, and she pledged to fight the antivaccine nonsense promoted by so much CAM. Her two strategic plans tried to lay the groundwork for real science. Of course, as a result, the modalities that the real supporters of NCCAM/NCCIH like, the actual quackery, were deemphasized to the point where most NCCIH studies were of nutrition, exercise, pharmacognosy (natural products pharmacology, but in this case primarily of things like herbs used in traditional Chinese medicine) and other modalities that are within the realm of science-based medicine. Sure, there was mindfulness, which might or might not end up being science-based, and acupuncture never really went away, but a lot of the worst quackery (like energy healing) was relegated to the fringes, if not eliminated. That’s because Drs. Strauss and Briggs, whatever their faults (such as ambition leading them to accept the assignment of running an inherently pseudoscientific and unnecessary Center) had backgrounds as real scientists. Also, aside from their efforts to be more scientific, they failed badly in not stopping NCCIH’s cheerleading for pseudoscience through funding credulous “education” about CAM. Even worse, Dr. Briggs glommed onto the whole propaganda effort by CAM practitioners to claim nonpharmacologic treatments for pain as “CAM” or “integrative” and to include acupuncture and other quackery with that. This campaign is starting to lead to horrible policy.
Helene Langevin, on the other hand, is clearly a true believer in acupuncture and any treatment modality involving with manual manipulation of muscle and tissue. Whatever her background as a real scientist might have been it’s now distant, with her having been steeped in acupuncture woo for at least 25 years if not longer. She is a quackademic in every sense of the word. That’s why I think the balance of power at NCCIH is about to shift back more towards pseudoscience and quackery than it’s been since the late 1990s. Worse, Dr. Langevin will have the largest budget ever at NCCIH to fund that shift.