What works for stubborn aches, pains, and injuries? What doesn’t? Why? SaveYourself.ca reviews your treatment options: hundreds of detailed, free self-help articles and several e-books about common pain problems, constantly updated, and readable enough for anyone but heavily referenced for professionals. (There’s also a giant bibliography.) I serve up the science with some sass — I try to have fun taking this subject seriously. The salamander? More mascot than logo, he’s a symbol for regeneration and unsolved mysteries of biology. ~ Paul Ingraham, publisher
The microblog is bite-sized news items, deep thoughts, and helpful ideas — whatever comes up while I work on making feature articles and books. Quotes and comics, study results and weird science, interesting links, and so on. Subscribe with RSS, Twitter, Facebook and Google+, or browse the microblog archives.
SaveYourself.ca is now a successful project. It’s going so well it’s almost alarming: it has gotten tough to juggle all the demands of a fast-growing publishing business. You can read more about that on my personal blog, Writerly (PaulIngraham.com). Here’s a snippet from Uh oh, success!
Many people who start small businesses want them to stay small, usually so we can (mostly) keep wearing the hat that defines us (butcher, baker, e-book maker). We’re more interested in whatever our business is about than we are in running a business. Fast growth — too many customers, too much “paper”-work, too many phones ringing — can make that vision recede in the distance like a mirage.
This blog will now fall mostly silent for a spell, while I work harder than ever on new content, avoiding the distraction of blogging about the subject matter as I go. I need to buckle down and do some serious work:
major updating and polishing of the books
finishing the audio versions (finally!)
purging some scruffy old content
major investments in publishing technology and efficiency (my favourite part, actually)
And so on, and much more. Stay tuned for a revival of this blog and a lot of good stuff in 2014. The salamander’s best is yet to come!
Sometimes when researchers sum up by saying “more study needed,” what they really mean is “the evidence hasn’t gone our way yet, so let’s keep doing shabby science until it tells us what we want to hear.” This meta-analysis of kineso taping for sports injuries in New Zealand’s Sports Medicine journal doesn’t really have much good news to report, but it manages to come off as pro-taping and cautiously optimistic anyway:
In conclusion, there was little quality evidence to support the use of KT over other types of elastic taping in the management or prevention of sports injuries. KT may have a small beneficial role in improving strength, range of motion…. The amount of case study and anecdotal support for KT warrants well designed experimental research, particularly pertaining to sporting injuries, so that practitioners can be confident that KT is beneficial for their athletes.
This formal response in the British Journal of Sports Medicine, by Drs. Steve Kamper and Nicholas Henschke, just seethes with irritation.
Despite the title of the review, the authors do not report a meta-analysis of the included studies. … The review has several flaws, the most serious of which is selective reporting of outcomes. As only positive (significant) results are reported it is not possible to assess the entirety of the evidence for effectiveness of kinesio taping. In addition, while the authors report to have followed the methodological guidelines of the Cochrane Collaboration this does not appear to be the case. … Clinicians should look to other sources of information…
More study of taping is needed, but not “so that practitioners can be confident” — it should be done because we need to find out if practitioners should be confident. And the limited evidence so far is discouraging, not encouraging, and to the extent that there are a few scraps of positive evidence, it’s a classic case of damning with faint praise.
“Kinesio taping for sports injuries”
Science-Based Medicine posts off and on for years now, often sharing a laugh or commiserating about some of the tragic subject matter (like today’s post, Faith Healing: Religious Freedom vs. Child Protection). She’s an amazing writer and person:
When Harriet Hall graduated from medical school in 1970 and entered the Air Force, she was in a distinct minority. As the second woman ever to do an Air Force internship, she had to fight for acceptance. Even a patient’s 3 year old daughter proclaimed, “Oh, Daddy! That’s not a doctor, that’s a lady.” She was refused a residency, paid less than her male counterparts, couldn’t live on base, and couldn’t claim her husband as a dependent because he wasn’t a wife. After six years as a general medical officer in Franco’s Spain, she became a family practice specialist and a flight surgeon, doing everything from delivering babies to flying a B-52. She earned her pilot’s license despite being told “Women aren’t supposed to fly,” and eventually retired from the Air Force as a full colonel. She is witness to an era when society was beginning to accept women in traditionally male jobs but didn’t entirely like the idea yet. A somewhat warped sense of humor kept her afloat, and it spices the stories she tells about her own experiences and the patients and colleagues she encountered.
Jason Silvernail, PT, regarding a plea to help defeat legislation to make dry needling of trigger points the exclusive domain of acupuncturists:
This is the kind of pointless turf war foolishness that the licensure system encourages. Remember it has nothing to do with evidence and everything to do with lobbying and economic protectionism.
Definitely. It’s important context that acupuncturists are struggling to preserve their reputation as the evidence piles up and overflows: acupuncture can’t beat a placebo. This is a blatant attempt to lay exclusive claim to a superficially similar treatment method that has the appearance of being more evidence based, because it is currently practiced by many physical therapists and doctors. Unfortunately and ironically, it isn’t based on much evidence — at best, it’s only more plausible. Acupuncture isn’t even worth testing any more — it’s all over — whereas dry needling still needs to be properly tested. Nowhere in this legal battle can you find anything of clear value to fight over: it’s a tug-of-war over scraps.
Nevertheless, I have no trouble picking a side …
Do our bones influence our minds? “Who thinks of the bone as being an endocrine organ? You think of the adrenal gland, you think of the pituitary, you don’t think of bone.” But apparently you should.
The data is now overwhelmingly negative. DoctorDoubter:
I will say what surgeons seem reluctant to say: “I am sorry, but for this condition, surgery is unlikely to provide any benefit over the non-operative alternatives.”
And that’s why I link to him.
Mea culpa: that knee ligament “discovery” I linked to yesterday? Not so much discovered as “looked at more careful like.” Studied, classified. Perfectly worthwhile research, but over-hyped by the media reporting about it. It was definitely hyperbole to describe it as a discovery. It’s been known of for at least a century, and a paper last year reported finding it in every knee they looked at. I didn’t look more carefully at the story because it was just a minor interesting thing (and anatomy really is never done), but it’s amazing what even a tiny little bit of hype will do. Hat tip to Tony Ingram of BBoy Science for raising my awareness.
Two knee surgeons at University Hospitals Leuven have discovered a previously unknown ligament in the human knee. This ligament appears to play an important role in patients with anterior cruciate ligament (ACL) tears.”
And perhaps iliotibial band syndrome? I don’t see any obvious relevance to ITBS — this new ligament is a little low for that — but I’ll be mulling it over. Regardless, it’s a fun discovery. Contrary to what people assume, “basic” anatomy is still a work in progress.
If you’re trying to build muscle size, how many weight-lifting sets should you do? One set? Two sets? (Red set, blue set?) More? James Krieger’s 2010 paper in Journal of Strength & Conditioning Research is the best review of the evidence to date. While it can’t conclusively settle the issue until there’s more data, it does strongly suggest that “more is better,” and yet at the same time it reaffirms that “less is fine.” Single sets will get the job done, which is ideal if your goal is bang-for-buck. (If you want to be “hyooge,” though, definitely go with more sets. It’s all about goals.)
Alas, there wasn’t that much data to review, just 8 studies, and only 2 of those included higher numbers of sets. That’s not a lot to work with. But the results are consistent with the more complete data about strength (see Krieger’s 2009 review), and strength and muscle size do tend to go together. Both citations are now included in my article about strength training bang-for-buck, see:
The SaveYourself.ca “microblog” was introduced in March of 2013, a minimalistic format optimized for bite-sized posts and announcements. This week it got its first big upgrade: small as they are, posts now have their own dedicated pages (instead of just living in a big list). For instance, see the last post, “Dissing dyskinesis.” Or — random example — the very popular “Good news about running.”
There could be a little strangeness with the RSS feed at first, probably duplicates of recents posts, but it will be fine going forward.
Recently in a discussion on Facebook, a chiropractor got annoyed with a physical therapist for calling shoulder dyskinesis a “dubious” clinical concept. He asked for evidence and linked to a PubMed search, suggesting that the existence of so many papers about it must mean it’s legit. This was too good a rebuttal opportunity for me to pass up: a slow pitch right across home plate. Evidence that shoulder dyskinesis is dubious? In those search results, it took me all of 10 seconds to find Wright et al on the first page, a nice fresh 2013 review in the British Journal of Sports Medicine concluding “no physical examination test of the scapula was found to be useful in differentially diagnosing pathologies of the shoulder.” Hard to treat what you can’t diagnose.
“Shoulder dyskinesis” is just fancy talk (elaborate parlance!) for “bad shoulder movement.” It’s a bogeyman for freelance therapists to chase for pay. With almost nonexistent diagnostic reliability, it’s clinically useless, a diagnosis that has more to do with sounding good than actually knowing anything helpful, so that they can stare at your shoulder for a couple minutes and wisely declare, “Well, there’s your problem,” as though it were obvious — to an expert, anyway. disclaimerThis is not to say that there is nothing ever wrong with shoulder movement. It is to say that it mostly defies useful interpretation and is much less important than supposed by some, just like most other diagnoses of dysfunctional movement and alignment.
Alert reader Michael B. sent me this example of crazy clinical arrogance about diagnosing by feel (palpation), How To Get Out Of Pain In 30 Days. There’s a million crappy miracle cure sales pitches out there, of course, but this one stands out for its emphasis on near-magical powers of palpation in particular, an entertainingly distinctive delusion of grandeur.
Now, close your eyes and comb over the paper until you find the hair; continue to drag the hair underneath your finger and around the paper until you lose it. Repeat for 15 minutes/day. Within 2-4 weeks, you’ll have an incredible sense of touch.
Yes, that’s all it takes to get “x-ray hands”: hair rubbing. And if you believe that, I’m having a bridge sale. I’ve written about this particular flavour of nonsense before…
There is no such thing as “medical acupuncture.” The term is oxymoronic propaganda, a common way to make acupuncture seem more legitimate. But it’s all just acupuncture: defeated in one rigorous clinical trial after another for many years now.
Flexing your knee can squish the blood out of your kneecap like it’s a sponge — maybe literally, or maybe just a metaphor — suggesting that poor circulation could be a cause of patellofemoral pain syndrome (anterior knee pain). In particular, it might explain the notorious “movie sign,” in which simply sitting with flexed knees makes them ache. A 2008 study (Näslund et al) of 22 patients showed that 19 of them had reduced blood flow while the knee is flexed, but no such sign could be detected in healthy people. The method used to measure blood flow (photoplethysmography!) is new and therefore not exactly a sure thing, but there’s a good chance it works as advertised. Their data was a bit all over the map, but the averages were clear enough. If the results can be believed, it raises more questions than it answers: Is it cause or a symptom? Why would blood flow be reduced in the first place? Could this be why almost any kind of exercise tends to help — normalizing blood flow? And since when can you squeeze blood out of living bones?moreBecause living bones are surprisingly rubbery. The kneecap in particular is subjected to simply astonishing compression forces even in unloaded knee flexion. The squishableness of kneecaps in itself is a fun fact, but not especially surprising. The real curiosity here is: what’s the difference between the patients with knee pain and healthy controls? Why does knee bending impair circulation in some kneecaps and not others? How does that work? Tantalizing data!
“Decreased pulsatile blood flow in the patella in patellofemoral pain syndrome”
Update: this item got my friend Dr. Rob Tarzwell of One-Minute Medical School curious about arterial supply to the patella. He writes: “It looks like normal anatomy involves a circulatory anastomosis. That's where multiple arteries plug into a ring, and the ring then has feeders going to the patella. Presumably, this is to allow for redundancy of supply in the event of flexion of the knee closing off supply. Now, if the anatomy isn't sufficiently redundant, then supply could become temporarily compromised. Variants of normal anatomy are legion.” In other words, not everyone’s arteries may be arranged optimally to cope with flexion, and some may fail to keep the blood flowing during flexion — which would explain these results, and potentially a lot of otherwise mysterious anterior knee pain. This is a fascinating, plausible hypothesis.
Reflexology will probably get a big PR boost from this pseudoscience, already “highly accessed,” because it creates the appearance of validity where there is none. The paper has a shiny, hard protective shell of superficial legitimacy. It’s difficult to criticize specifically, because there’s nothing obviously wrong with the mechanics of the fairly complicated and technical experiment. The problems here are more basic and general: fancy brain studies purporting to show the existence of a mechanism for reflexology are more propaganda than interesting or useful science. fMRI scans are notoriously uninterpretable and prone to producing research artifacts, and the results just happen — coincidence, I’m sure! — to give a lot of comfort and aid to one of the most implausible and scientifically bankrupt treatment claims in all of alternative medicine. Dr. Christopher Moyer:
There is no good theory for reflexology. In the absence of a good theory, a single study that connects a twitch of the toe to the blink of an eye, or their neural correlates, is of very little value.
Without good replication, this one gets no more than a Spock eyebrow raise from me: it’s just another case of tooth fairy science.
In a 2011 paper, “The Modernisation of Manipulative Therapy,” Australian physiotherapist Max Zusman writes:
Research indicates that, despite physiotherapists’ comprehensive training in the basic sciences, manipulative therapy is still dominated in the clinical setting by its original, now obsolete, structure-based “bio-medical” model. more“This is further inexplicable in the light of evidence that not only the underlying “philosophy” but also several of the fundamental requirements of the clinical process itself which has the structural-mechanical model as its basis, have been shown to be flawed or at least irrelevant. The apparent inability of the profession to fully abandon outmoded “concepts” (and embrace the acknowledged science-based “best practice” biopsychosocial model) may have potentially undesirable consequences for both patients and therapists engaged in the management of (chronic) musculoskeletal pain and disability.”
Extreme examples are educational. For instance, we know from the experience of ultra runners that it is possible to run in a way that is less hard on your body. Once again, consider the case of Philippe Fuchs, who ran from Paris to Beijing, covering ~5,100 miles in 161 days. His primary concern was his “ability to keep absorbing muscular and skeletal punishment day after week after month,” of course. By the time Fuchs finished, he had developed an endurance stride that was clearly shorter and lower: he padded along with about 6% more steps per mile, a whopping 30% less time in the air, and 11% less landing force. I’m betting he wouldn’t have made it without those adjustments. Fascinating!
20 hours per day faster. Sorta. The slowest part of downloading most web pages is the images. Although SaveYourself.ca pages are already fast (under one second for most visitors), a good chunk of that time is images.
From the Dept. of Long Overdue Chores: hundreds of images on SaveYourself.ca have now been replaced with lighter, aggressively web-optimized versions that download about 20% faster on average. It doesn’t sound like a lot, but with about 18,000 page visitors per day, it definitely adds up. In fact, it will save (very roughly, lots of variables) about twenty hours of data downloading time for my visitors every single day. With more and more people on cellular data plans, that actually matters!
So that’s how it is. But why and what does it mean? That’s much trickier, of course. Apparently hamstring flexibility is a trivial factor in how the back moves, and it gets trumped when people develop back pain. Which probably means that tight hamstrings aren’t a risk factor for back pain. Which probably also means stretching — even if you could stretch hamstrings — also won’t have much effect on how back pain patients use their backs. For whatever that’s worth.
Oh, and the lack of correlation persisted even after recovery, which is particularly interesting. And also mostly uninterpretable without more information (like how long that effect lasts).
“Effect of hamstring flexibility on hip and lumbar spine joint excursions during forward-reaching tasks in participants with and without low back pain”
“It’s all coming from the ____, I know it!” The temptation to boil the cause of chronic pain down to a single culprit can be almost overwhelming, but you must resist. Single causes of long term pain are almost unheard of. Nearly all chronic pain is a witch’s brew of different factors, complex by nature (not just coincidence or bad luck). This makes it harder to beat overall, but some factors are more treatable or manageable than others. Find and work with those.
Studies have shown that runners probably do not get more knee osteoarthritis than anyone else, which is a bit surprising: surely regular pounding wears out joints? Researchers took a bunch of fancy pictures of the insides of knees before and after a marathon, using a new MRI technique that can detect early cartilage degeneration: “Runners showed elevated T1rho and T2 values after a marathon, suggesting biochemical changes in articular cartilage” and “the patellofemoral joint and medial compartment of the knee show the highest signal changes, suggesting they are at higher risk for degeneration.” Sounds bad, doesn’t it? Also, perhaps some biomarkers of trouble “remain elevated after 3 months of reduced activity” — but it’s arguable that those results were not actually statistically significant.
So, bad biomarkers in the knee after running, oh noes! But I actually see good news for knees here. It’s not surprising that a lot of running has an effect on joints in the first place, of course, and this data confirms that. But this data also shows that the effect is surprisingly minor, and that most knees recover, either mostly or completely, within three months. Which is very important information. Stressfully loading a joint in itself is probably not a problem per se, and could even be healthy, stimulating, toughening — as long as you allow time to recover. It’s excessive loading without adequate recovery, AKA “overdoing it,” that is likely to be the real hazard for runners. I see this as (more) evidence that the average sane runner is not wearing out his or her knees (and also that runners who do get into trouble really, really need to rest and let their biomarkers simmer down).
“High-Field Magnetic Resonance Imaging Assessment of Articular Cartilage Before and After Marathon Running: Does Long-Distance Running Lead to Cartilage Damage?”
Here’s a short, fascinating ultra-running case study with a counter-intuitive outcome: Philippe Fuchs ran from Paris to Beijing, covering ~5,100 miles in 161 days. He “lost five pounds during the run, and his percent body fat dropped from 21.5% to 16.5%. You’d think this would make him more oxygen efficient. It didn’t.” Damn! Biology is wacky.
new article about Kinesio Tape® and similar products, which explains that therapeutic taping is mainly just a sensation tweaker, and that’s fine as far as it goes. We humans are neurological input-output machines. We constantly, systematically, creatively tinker with how we feel … touch-testing the world. This is why I have no strong objection to therapeutic taping, but also why I will probably never be impressed by it: it’s just another method of playing with how our bodies feel, one of many. But it will never trump functional challenges as the main drivers of recovery and performance. The bottom line is always going to be that we have to push ourselves a little to get better than we are — and being taped just isn’t much of a challenge.
“Performance enhancement” is usually a problematic claim, because it’s commonly based on sloppy extrapolation from recovery effects (which are themselves often a bit sketchy). Even what genuinely helps people who are sick or broke is not necessarily going to do anything for fit, healthy people. Or vice versa. (Simple example: compression bandaging for swelling. Unambiguously handy in recovery … but useless if you’re not swollen!) Rehabilitation and performance enhancement are just different things. On the one hand, they are the same process with different starting points. On the other hand, how much value the body can extract from an input is generally proportionate to need. A glass of water is more important to a man dying of thirst, and novel sensation is more neurologically useful to an injured person than a healthy Olympian.
Pretty regularly I report evidence that Brand X therapy or exercise doesn’t work very well, if it all. And, almost always, I get protests that it works if done properly — as opposed to the presumably typical version that was tested. This is problematic, even if it’s true. There’s probably not much point in branding a method of therapy or exercise if its benefits are inaccessible to most people. This is the “prodigy problem” for modalities: if it requires exceptional intelligence and skill to implement, then it’s a hollow victory that is excluding everyone else. How good can it be if the average professional cannot deliver it, and/or the average patient cannot learn it? And can anyone actually tell who the prodigies are? Treatments that aren’t reasonably replicable are not worth much in practice. I can’t really recommend a treatment that is useless in the hands of 85% of practitioners. And yet the world of therapy is quite preoccupied with the idea of the special therapist who can deliver results that others cannot…