My co-bloggers and I have spent considerable time and effort over the last four years writing posts for this blog (and I for my not-so-super-secret other blog) bemoaning the infiltration of quackademic medicine into what once were bastions of evidence- and science-based medicine. We’ve discussed at considerable length reasons for why this steady infiltration of pseudoscience into medical academia has been occurring. Among other potential explanations, these reasons range from the ascendence of postmodernism in areas where it really doesn’t belong; to a change in our medical culture to a more “consumer”-oriented, “keep the customer satisfied”-sort of model in which patients are often referred to as “clients” or “customers”; to the corrosive influences of moneyed groups (such as the Bravewell Collaborative) and government agencies (such as the ); to the equally corrosive influences of powerful woo-friendly legislators who use their position and influence to create such agencies (such as Senator Tom Harkin and Representative Dan Burton) and otherwise champion “complementary and alternative medicine” (CAM) and “integrative medicine” because they are true believers in quackery; to cynical legislators, like Senator Orrin Hatch, who champions such government programs supporting pseudoscience because he represents a state that is home to the largest concentration of supplement manufacturers in the United States and is consequently a master at bringing any initiative to regulate the supplement industry more tightly to a screeching halt.
As a result of our efforts and the need for a counterweight to the quackery that has infiltrated so much of academia, SBM has become fairly prominent in the medical blogosphere. Our traffic is good, and we have a number of “thought leaders” who regularly read what we write. We’ve even caught the attention of Dr. Josephine Briggs, director of NCCAM, and our founder Steve Novella was even invited to appear on The Dr. Oz Show for “balance.” All of this is something that we are justly proud of. On the other hand, I can’t help but keep things in perspective. While our traffic as a blog is quite respectable and we have become prominent in the skeptical and medical blogosphere and even, to some extent, in academia—we’re particularly gratified at the number of medical students who are regular readers—compared to the forces arrayed against SBM in academia and the media, we have to face facts: We are truly a tiny voice in the wilderness. For instance, we average around 9,000 to 16,000 visits a day. Compare that traffic to the many millions who used to watch Oprah Winfrey and still watch her protégé Dr. Oz or to health media and product empires of people like Andrew Weil and Deepak Chopra, and you get the idea.
All of this is why I started looking for opportunities to respond more directly to incursions of pseudoscience into medical academia. Occasional SBM contributor Peter Lipson provided me with just such an opportunity last summer when he sent me a link to a about the use of CAM in cancer that shows just how bad a study can be and still be published in what I used to consider a reasonably good cancer journal. I say “used to consider,” because the fact that this journal accepted a study this ludicrous indicates to me that its peer review is so broken that I now wonder about what else I’ve read in that journal that I should now discount as being too unreliable to take seriously. Maybe everything. I don’t know. What I do know is that seldom have I seen such a bad study in such a good cancer journal. Studies like the one about Tai Chi in fibromyalgia or placebo acupuncture applied to asthma don’t even come close.
Soon after this study appeared online ahead of print, ed me and asked me if I wanted to be co-author on a letter to the editor of the journal. Honored by Dr. Coyne’s request, I immediately said yes (of course), and together with at the Survivorship Unit of the Danish Cancer Society, we submitted our letter to the editor. To my surprise, given the utter failure of past efforts to publish letters to the editor about studies of this sort, our letter was accepted for publication. Last week, the study in question saw print, and our letter was published online ahead of print, along with the response of the authors. All are instructive and, to me, show just what we are up against in trying to prevent pseudoscience from creeping into academia.
The study: “Energy chelation”? I kid you not!
No doubt at this point, some of you are thinking that perhaps I’m being way too harsh when I called this study “brain-meltingly bad.” That is why, even though Peter has already discussed this paper, I feel obligated to describe the study and my objections to it at some length. So let’s dig in, shall we? The journal is , which is the official journal of the and has an . That is, as we say in the biomedical research biz, not too shabby. The investigators are from the (which, as you might recall, published a recent survey on CAM adoption by hospitals), the University of California San Diego, the RAND Corporation, and Healing Light Center Church, and the paper is entitled .
Fatigue is a huge problem in cancer patients, and this study was designed to test the effect of what the authors call “biofield” therapies on fatigue in 76 breast cancer patients with significant fatigue during chemotherapy. For purposes of this study, “biofield” therapies were defined to be more or less the same thing as energy healing, which encompasses reiki, therapeutic touch (TT), healing touch (HT), and others. In actuality, from a strictly scientific standpoint, the experimental design of this study wasn’t half-bad. The problem comes from how this study examines a therapeutic modality for which there is no evidence, namely something the authors call “energy chelation.” (I kid you not. That’s actually what they call it! In an actual scientific paper!) To sum up the study in a nutshell, this was a phase 2 randomized, intention-to-treat clinical trial that compared biofield healing (“energy chelation”) with a “mock healing” control and a waitlist control.
Never having heard of “energy chelation” before and having written a lot about chelation therapy as a form of quackery claimed to be useful as a treatment for autism caused by “vaccine injury” and for cardiovascular disease, I was very curious. So I read with interest how the authors described this modality:
The specific technique used in the biofield healing group is termed energy chelation, and was selected by 1 of the authors (R.L.B.), whose healing techniques have been incorporated in modalities such as Healing Touch and Therapeutic Touch.26,27 During energy chelation, the practitioner practices hands-on healing with standard hand positions, beginning with hands on the feet, then to the knees, hips, bladder area, stomach, hands, elbows, shoulders, heart, throat, head, and back to the heart. The practice of energy chelation is 45 to 60 minutes, with a practitioner generally focusing for 5 to 7 minutes on each position.
Naturally, my next question was: Who is “R.L.B.”? R.L.B., it turns out, is Reverend Rosalyn L. Bruyere from the Healing Light Center Church. I did some Googling and enough. On Bruyere’s website, she is thusly:
Founder and director of the Healing Light Center Church, Reverend Bruyere has committed her life to the teaching of these sacred and ancient disciplines, thereby providing her students with practical tools for living the spiritual life, while introducing them to the venerable traditions from which those tools are derived. Her goal is to encourage the compassionate healing and empowerment of the individual, believing that as we each heal, we can be of greater assistance in the healing of the world.
She is the originator of the whole-body technique known as Chelation which has become a classic, taught in many modern healing schools, as well as Brain Balancing and a pain-reducing skill which some have called Pain Drain.
Her book, , is an invaluable text for the bridging of ancient and modern healing arts. Rev. Bruyere has studied extensively in areas of Egyptian temple symbology, Sacred geometry, ancient Mystery School rites, international shamanic practices, the pre-Buddhist Tibetan Bon-Po Ways, and various Native American Medicine traditions.
Rosalyn’s knowledge of ancient traditions and practices has led to requests for her technical assistance on several films and documentaries. Among the more notable features on which she has served as technical consultant are “Resurrection” and “The Last Temptation of Christ”.
Although I don’t recall having blogged about “Brain Balance” before, fortunately Harriet Hall already has and quite correctly concluded that it is “based on speculation, not on credible evidence.” Pain Drain is an HT technique in which the “practitioner” holds one hand above an area of complaint until the pain recedes and then places the other hand near the area of relief. In other words, it’s yet another variant of “energy healing” modalities like TT and reiki. As for energy chelation, I Googled that as well and found quite a few links describing it. For instance, here is a , who charges $65 an hour for her energy chelation ( for waving your hands around people) and ensures us that it “works by moving heavy or stagnated energy, once this movement takes on a transformation then your whole body system reacts similar to downloading, accepting the changes in your energy field into your physical being” and that there is indeed detoxification with energy chelation (much like real chelation, I would imagine). She even gives a helpful primer on the :
Reiki is best use for general consistent work to maintain your energy whole field balance. Energy Chelation is best applied to detailed energy needs in defined areas of one energy field. Energy Chelation also has different vibrations associated with it, such as sound energy. Sound Energy is described as a deep vibration and is very effectively use on areas of old stagnate energy, such as childhood issues. These old issues are stubborn dense often times large energy blocks that require that extra boost of vibration to initiate movement.
Well, that’s useful. Reiki is faith healing in which the person being healed is usually not touched but the practitioner believes that he’s channeling healing energy into the patient from a “universal source,” while energy chelation “hands on” energy healing. They’re totally different! Really!
Another website helpfully proclaims the “” as:
Human Energy Chelation Therapy (HECT), a process of transmitting or channelling energy, is based on the electromagnetic nature of the human body. The body’s electromagnetic or auric field is generated by the spinning of the chakras. As it spins, each chakra produces its own electromagnetic field. This field then combines with fields generated by other chakras in the body to produce the auric field. An individual’s auric field is manifested via a combination of energies from three chakras. Generally these are the first, third and fifth chakras, which empower the person’s physical, intellectual, and etheric bodies. It is a combination of these three chakras that produces the primary auric field (the inner shell of the aura), which can be physically felt by the therapist’s hand as it is passed over the client’s body in the process of scanning.
And where does energy chelation get its name? :
Heavy metals are toxic to the human body. Chelation has been a tried and true method in removing them from the body. The toxins must be removed before the body can benefit from any health promoting actions.
Stuck emotions are very similar to heavy metals in that they too are toxic to the body, mind and spirit. Healthy emotions are energy in motion. However when emotions are stuck, not acknowledged, stuffed and ignored they become like heavy metals and are toxic to the human system. They need to be removed before health-promoting actions can produce beneficial results. Just like chelation removes heavy metals from the body, energy chelation is a method which removes sticky, heavy dark energy from the human energy field.
Is “sticky, heavy dark energy” anything like the ? It rather sounds that way to me. In actuality, it might as well be, because energy chelation is every bit as much a work of fiction as anything ever written by Douglas Adams, except that Douglas Adams had far more imagination. In any case, it amuses me to no end when CAM advocates start using metaphors as names for their nonesense. Be that as it may, the next question I had, after learning that energy chelation is “hands-on energy healing” was what the control group would be. In other words, what, exactly, was “mock healing”? Here is a description of the mock healing control group taken straight from the Methods section of the paper (yes, this is verbatim):
Mock healing practitioners were skeptical scientists who were trained to use the identical hand placements as biofield healing practitioners. Mock healing practitioners were asked not to intend to heal the patient when touching, but rather to disengage into “planning mind” by contemplating current and upcoming research-oriented studies and grants they were currently involved in. Given that biofield healing practitioners would have more familiarity with working with patients than mock healing practitioners, to preserve participant blinding mock healing practitioners practiced procedures with study personnel until the mock healing practitioner demonstrated mastery of the hand placements and confidence interacting with and fielding potential questions that a patient might ask the mock healing practitioner before or after the session.
It never ceases to amaze me how science drives out magic; even practitioners of energy chelation seem to accept that. After all, if they didn’t, then why would they have chosen the control group that they did and gone to all the trouble to train scientists to put their hands on people in the same positions that Rev. Bruyere uses while thinking extra super hard about how they don’t believe any of this nonsense? In actuality, it’s not a bad control group–if you accept the premise of the study. What is that premise? It’s that there is a human energy “biofield” that healers using “energy chelation” can manipulate to therapeutic intent and that there has to be a degree of belief for that to work. I do like how that evil “planning mind” (as opposed, I suppose, to a “believing mind”) can destroy the magical rays that supposedly heal by chelating all that bad energy. In any case, this is exactly what Harriet Hall meant by “tooth fairy science” when she wrote:
We can study the amount of money left by the Tooth Fairy in different settings, but since we haven’t determined that there is really a Tooth Fairy, any conclusions we reach will be falsely attributed to an imaginary being rather than to the real cause (parental behavior). In acupuncture studies, the acupuncture points/meridians/qi may be imaginary and we may be studying an elaborate placebo rather than a real physiologic phenomenon.
It has not been established that such a thing as a “human energy field” (at least not what “energy healers” mean by the term) exists, that humans can perceive and manipulate it, or that that perception and manipulation of energy fields allows them to heal. In fact, it’s about as clear as clear can be that humans can’t, as a 12-year-old girl named Emily Rosa .
So, after all that introduction, what were the results? What do you think they were? I’ll give you a hint. These results were entirely consistent with placebo responses. Basically, there was no difference in total fatigue levels between biofield healing and mock healing. Both produced a decrease in fatigue that patients on the waitlist control did not. In other words, for the primary outcomes measured in the study “biofield” therapy didn’t work compared to the “mock healing” placebo control. So, given this completely negative result, what did the authors do next? They did what any good CAM believer does (and, for that matter, all too many scientists do) and started mining the data for associations, delving into the Multidimensional Fatigue Symptom Inventory short form subscales. Not surprisingly, they found barely statistically significant differences between biofield healing and mock healing in a couple of measures, as is frequent whenever researchers start making a bunch of pairwise comparisons. They also measured salivary cortisol levels and found a significant decrease in cortisol slope over time for the biofield healing versus both mock healing and control. What this means, I have no idea, given that salivary cortisol “variability” (which they calculated) hasn’t been validated as a reliable diagnostic tool for much of anything that I’m aware of or correlated with fatigue.
I’m not impressed. Here’s why. First, I can’t help but note that none of these differences were mentioned in the abstract, which implies to me that even the authors didn’t consider them particularly significant. More importantly, we have multiple comparisons among small groups of patients. (Remember, there were only 76 patients in this study.) Finally, fatigue is a variable symptom that waxes and wanes frequently. it’s very prone to regression to the mean, placebo responses, and reporting bias. It’s very hard to say a lot about whether these barely detectable differences in a couple of subscale measures are in any way clinically significant. Probably not. Not that that stops the authors from laboring mightily in the discussion section to make it sound as though their biofield therapy is the greatest thing since sliced bread. Let me ask you a question whose answers regular readers of SBM should know: What do we normally call it when there is no difference between the real treatment and a sham treatment in a clinical trial testing a drug or device? That’s right. We say there’s no effect greater than that of a placebo and that the trial is negative; i.e., the tested experimental intervention doesn’t work.
Not this study:
This RCT examined whether biofield healing, compared with both active (mock healing) and waitlist control groups, positively affected fatigue as well as cortisol slope, depression, and QOL in breast cancer survivors with persistent fatigue. In addition, this study explored the role of belief in receiving healing as a potential predictor of responses. Findings indicate that both touch-based interventions reduce fatigue in fatigued breast cancer survivors, with considerable effect sizes. Previous research by our group on a separate sample of breast cancer patients indicated that the mean Multidimensional Fatigue Symptom Inventory-short form total scores was 5.99 immediately before the start of anthracycline-based chemotherapy, and rose to 19.9 immediately before the fourth cycle.38 Our fatigued survivors in the mock healing group (mean postintervention score ¼ 10.9) dropped to fatigue scores lower than those found for breast cancer patients toward the end of chemotherapy, and the biofield healing group (mean postintervention score ¼ 4.2) fell to fatigue scores that were below prechemotherapy scores, as well as below previously published means noted for breast cancer patients overall.28 This drop in fatigue appears to have clinical as well as statistical significance.
In other words, according to the authors, because both the “real” biofield healing and the “mock” biofield healing resulted in a decrease in fatigue scores and a barely statistically significant difference in a chosen surrogate marker, biofield healing “works.” This is the to claim that acupuncture “works” when they find that sham acupuncture results in the same apparent measured effects as “real” acupuncture. The correct interpretation of this study is that it’s a negative study, and “energy chelation’ does not work. It is placebo. Stick a fork in it; it’s done. Or, as Drs. Coyne, Johansen, and I wrote in our :
The registered primary outcomes of the trial were self-reported fatigue, depressive symptoms, and quality of life. No significant differences were obtained between TT and the mock treatment, whereas both conditions were superior to waitlist control. Essentially, the authors examined 3 primary outcomes, with secondary analyses of 5 subscales of the fatigue measure, and a secondary outcome, cortisol, with all pairwise differences explored between the TT, mock treatment, and waitlist control conditions. With any control for multiple comparisons, the modest difference between TT and mock treatment in cortisol is no longer significant.
There is no known therapeutic benefit to changed cortisol slopes. To justify cortisol as a secondary outcome, the authors selectively cite findings that flatter cortisol slopes are modestly related to metastatic disease and predict mortality in breast cancer patients. These limited correlational data alone do nothing to establish that cortisol is a suitable surrogate endpoint.
We concluded that this trial is negative, something I believe to be even more true when one takes into account prior probability and the lack of correcting for multiple comparisons, which led us to wind up our letter thusly:
We believe that publication of this TT trial encourages more pseudoscientific studies of energy fields or auras and gives the wrong message to clinicians and patients.
The authors respond
Not surprisingly, the authors were not too happy about our letter. Even less surprisingly, in they retreated to common tropes used by apologists for reiki and “energy healing.” Their response to our letter is a veritable template for defending tooth fairy science. First, the authors tried to disabuse us of our “misconceptions” about the study by pointing out how very wrong we were to lump “energy chelation” in with HT, TT, and reiki as an “energy healing” modality:
We wish to clarify some misconceptions put forth by Coyne, Johansen, and Gorski regarding our reported randomized controlled trial.1 First, the intervention used was not therapeutic touch but a specific hands-on technique commonly used in many types of biofield therapies for ameliorating fatigue.
Which matters not at all. It was the authors, after all, not we, who said that energy chelation was a biofield therapy, which is another name for “energy healing.” In any case, their complaint reminds me of arguing that reiki is different from TT because reiki masters use different hand motions to channel the “healing energy” or that in reiki the energy comes from the “universal source” while energy chelation removes “energy blocks” in the patient. Until you can convincingly demonstrate that the “universal source” exists and can be manipulated by reiki masters and/or that there are “energy blockages” that “energy chelation” practitioners can remove, all you’re doing is comparing two different forms of magic. Alternatively, you can demonstrate with overwhelming indisputable evidence so powerful as to make us question previously understood laws of physics indicating that these techniques cause objective responses, but unfortunately for the authors of this paper this study does nothing of the sort. We’re looking at effects no greater than placebo on primary endpoints in the study, all of which are subjective responses, and an unvalidated surrogate endpoint that demonstrates a barely statistically significant effect (p=0.04), after no correction for multiple comparisons. In other words, the authors’ criticism completely misses the point.
Here’s their next objection:
Second, there is an evidence base for biofield therapies.2,3
The authors cite this and one of their own reviews. The problem with this argument, of course, is at the very core of the reason why we call this blog “science-based medicine” rather than “evidence-based medicine.” There is no consideration of prior plausibility in the studies examined, where were all over the place as far as quality goes. Add to what the Cochrane Review characterizes as poor quality, equivocal data the fact that the clinical trials involved testing a class of healing modalities whose explanation if effective would require, like homeopathy, that huge swaths of well-established physics, chemistry, and biology (particularly neurobiology) to be overthrown, and the reasonable conclusion is that “biofield therapies” do not work. In particular, this is a case where “statistically significant” doesn’t mean “clinically significant,” given that the decrease in pain reported in the Cochrane review was less than 1 unit on a typical pain scale that goes from 1 to 10. One unit has commonly been viewed as the smallest decrease in pain that a patient can perceive.
Objection number three follows:
Third, the study was designed to examine nonspecific and placebo elements that may drive responses: This is why we used the mock healing group as a comparison along with the waitlist control group. We also examined patient expectancy, belief, and patient ratings of practitioner attributesall elements of placeboas potential predictors.
So what? It was the authors who concluded against the evidence in their very own study that, in essence, their “energy chelation therapy” works to relieve symptoms of chemotherapy-induced fatigue even though the “real” energy chelation and the “mock” energy chelation were indistinguishable. The correct conclusion should have been that energy chelation performed no better than placebo and therefore did not work. Again, if energy chelation were a drug therapy, would the authors conclude from a result in which the drug does no better than placebo for the primary outcome measures that the drug worked? Why the double standard?
Up next, is this objection:
Fourth, despite Coyne et al.’s seemingly contradictory statements (stating that the study is underpowered while also suggesting cortisol slope results should have been Bonferroni corrected), the power analysis and statistics are correct and clearly described.
“Contradictory”? I fail to see what’s “contradictory” in pointing out that the study was underpowered and that the cortisol slope results should have been Bonferroni-corrected; i.e., corrected for multiple comparisons. They are separate criticisms. Even if the study were adequately powered, it would still be flawed because of the lack of correction for multiple comparisons. At least if the authors had properly corrected for multiple comparisons then they could have blamed their negative result on the inadequate statistical power of the study!
Finally, the authors write something that both amused and depressed me at the same time:
The larger issue is what constitutes “pseudoscience” and what information is worthy of dissemination to the public. Should the data from our well conducted, rigorous, randomized controlled trial be dismissed because the mechanisms are unknown or because some scientists do not believe in the specific therapy? We make no claims surrounding mechanisms. We do note that this intervention has significant promise for reducing fatigue, which is the most common complaint among cancer patients, and the therapy produces no harm. Therefore, it merits further investigation. Premature rejection of findings from rigorous randomized controlled trials are as big a threat to science as the continuation of falsehoods based on belief. Thus, as clinicians and scientists, our highest duty to patients should be to investigate promising solutions with high benefit/risk ratios, not to act as gatekeepers of information based on personal opinion.
There’s so much wrong in this paragraph that I could spend an entire blog post deconstructing it line by line. Note the wounded cry about “dismissing” results based on dogma rather than science. Note the straw man argument that we reject the results of this study because we “do not believe in the specific therapy” or because the “mechanisms are unknown.” The first trope is a massive misstatement of our objections. What we argue is that the results of this trial do not mean what the authors think they mean. The authors conclude that the trial indicates that energy chelation shows “significant promise.” (They even repeated that assertion in their response!) We conclude that the study’s own results indicate that energy chelation functions no better than placebo and therefore does not work. It would have been nice if the authors had addressed our actual criticism than such an easily revealed straw man version of it. The second trope is commonly used in defense of pseudoscience because it is difficult for many to understand that there’s a huge difference between a mechanism that is “unknown” and a mechanism that is physically impossible based on current scientific understanding. An example of the former is a drug whose mechanism of action is as yet unknown but whose effects are easily documented. We know that the drug must function through some sort of biochemical interaction with a receptor, enzyme, or other macromolecule within the cell that we can discover and that we do not need to invoke mechanisms that break the laws of physics and chemistry to explain the drug’s effects. Again, to illustrate the difference between such a drug and impossible mechanisms, I like to use the example of homeopathy, which, if it worked would necessitate the overthrow of huge amounts of exceedingly well-established science in multiple disciplines, including physics, chemistry, and biology. Let’s just put it this way. Energy chelation is the same. For it to “work,” the same sorts of vast quantities of well-established science would need to be overthrown.
As a skeptic, I have to admit that it’s certainly possible, albeit infinitessimally so, that so much of what we understand about science is not just wrong and/or incomplete, but so incredibly wrong and/or incomplete that there might be an as yet undiscovered physical mechanism by which energy chelation and “biofield therapies” could work. However, if you’re going to convince me that something like energy chelation can truly work as a treatment modality, you’d better have evidence far more compelling than a small, equivocal clinical trial like this in which the effect on primary outcomes was no greater than placebo and whose analysis of secondary outcomes didn’t even bother to correct for multiple comparisons. Heck, even Dr. Pasche’s data that I discussed last week was far more compelling than this study, and his results are still not particularly convincing. Bringing a study like this “energy chelation” study to argue that “biofield therapies” work (or even that they might work) is akin not just to bringing a knife to a gun fight. It’s akin to bringing fists to an and grenade fight.
And that’s not just our “personal opinion,” either. Of course, it’s far easier to dismiss criticisms that one can somehow label “personal opinion” than it is to address our actual criticisms. That’s probably why the authors try to characterize our objections to their study as nothing more than a disagreement of opinion, before floating off into the ether of a self-righteous and condescending lecture to us about our “highest duty” as clinicians and scientists. I retort that, as clinicians and scientists, it is our highest duty not to engage in magical thinking that subverts science-based medicine. It’s our highest duty not to waste precious resources investigating therapies so utterly implausible that their efficacy requires that the laws of physics be overturned in favor of magic. It’s our highest duty to base our treatments in science, not in prescientific vitalism and religion, which is all that most “biofield” therapies are: faith healing, the laying on of hands. I would also retort that our tax dollars should not be funding magic like this. Yes, you guessed it; this study was funded in part by NCCAM.
As I conclude, I’m left wondering, jaw agape: What were the editors of Cancer thinking? I know what I’m thinking now: From now on, I’m going to be extra skeptical of any articles I see in Cancer, and you should too. I’m also depressed. If such a study and such a trope-laden response to criticism of that study can find its way into Cancer, the official journal of the American Cancer Society, what other cancer journals are publishing pseudoscience?
- Jain S, D Pavlik, J Distefan, RR Bruyere, J Acer, R Garcia, I Coulter, J Ives, SC Roesch, W Jonas, and PJ Mills (2012). Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A randomized controlled trial. Cancer 118: 777-787. DOI:
- Coyne JC, C Johansen, and DH Gorski (2012). Letter re: Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A randomized controlled trial. Cancer, E-pub ahead of print. .
- Jain S, D Pavlik, J Distefan, RR Bruyere, J Acer, R Garcia, I Coulter, J Ives, SC Roesch, W Jonas, and PJ Mills (2012). Response re: Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A randomized controlled trial. Cancer. E-pub ahead of print. DOI: .
- So PS, Y Jiang, and Y Qin (2008). Touch therapies for pain relief in adults. Cochrane Database Syst Rev CD006535. DOI: