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.
Like most “simple” things, it’s not so simple under the hood. But after launching without fanfare, it has been working just fine for customers for the last week.
I’ve known for ages that bookmarks were possible, because modern websites can do damn near anything. The trick is getting a feature like this to work smoothly for everyone, even people who’ve never read any kind of e-book before. That was a tall order. And so SaveYourself.ca now has another feature that is surprisingly unusual in the world of publishing, and in some ways more sophisticated than Amazon’s bookmarking feature for Kindle books. As with my footnotes and bibliographic management, I’ve never seen anything else quite like it. Instead of a “furthest read” bookmark (like for Kindle), it’s a “last read” position — far better for books that encourage jumping around. Every book remembers where every customer left off. It doesn’t matter whether you load it on a phone or an iPad or your PC at work. There are no settings or preferences; users don’t have to do anything. It just remembers your last position, offers to take you there, and then scrolls to that spot. (I love the scrolling bit.)
If any treatment worked really well for any painful problem, it would be the only one to discuss. There wouldn’t be a plethora of treatments to consider. There wouldn’t be a bunch of imperfect options for me to review in my books. Which is why Chekhov wrote this:
Like most writers, I collect quotes that add colour, gravitas, or support to my own writing, and there are dozens of them around SaveYourself.ca. So, how could I have never noticed this quotation before? Funny how even the apt-est can escape a writer’s attention for years at a time!
When a lot of remedies are suggested for a disease, that means it can’t be cured.
Anton Chekhov, The Cherry Orchard
A new blurb on the weirdness of pain, from a coming-soon update to the patellofemoral pain syndrome book (and equally applicable to most chronic pain problems).
What if the red warning light on the dashboard was wrong? What if the alarm system itself was malfunctioning? What if there wasn’t much going on in your knees at all anymore, but your brain kept flashing that warning light?
This happens. The brain has immense power to tune pain severity and quality, independently of whatever’s actually going on in your knees. Fear, anxiety, and stress dial pain up. No one is surprised to hear this, but almost everyone underestimates it.
In related news, I rebranded my main pain article yet again, and I think I’ve settled on a good title for the long haul: Pain is Weird.
This is an extremely popular warm-up ritual, performed with great faith by millions of people, that not only doesn’t help but actually dings performance. That’s an impressive disconnect between belief and reality.
My huge stretching article has been duly updated.
Watch this Japanese advertisement for a core strength training machine. It just keeps getting better!
Oh, and: earworm warning.
Dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions…
I have written a lot about about how surprisingly little connection there is between pain and obvious-seeming causes like poor alignment, or even vivid arthritic degeneration. And what is true of humans is apparently true of our pets as well. Veterinarian Johnny Bat-Yonatan on canine hip dysplasia, an arthritic condition common in big breeds like Labrador retrievers, German shepherds, and rottweilers:
It’s a horrendous thing that often leads to the animal having to be euthanised, but the highly specialised grading of hip dysplasia doesn’t correlate directly with mobility and life quality. You have great x-rays of animals that can barely walk, and horrendous hips in dogs that don’t display any pain. X-rays sometimes tell a story, other times they’re a footnote. We learn early that we need to treat the animal, not the radiograph.
“Treat the animal, not the radiograph.” Nicely put, and equally apt for pets and their humans. We’re all animals! For more information, see Canine Hip Dysplasia, by Wendy Brooks, DVM, DipABVP.
Grant, Tjoumakaris, Maltenfort, and Freedman in the American Journal of Sports Medicine:
The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.
Fantastic news, if true. On the other hand, maybe I should be careful what I wish for: my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine…
“Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time?”
A few years ago I published an article about the over-hyped importance of fascia, the sheets of connective tissue that bind us together. It covers several popular, dubious theories about why massage therapists and other manual therapists should try to manipulate fascia specifically. I’ve updated the article several times, but recently it struck me that I had strangely neglected something basic:
What is the actual clinical significance of fascia in medicine? Why would it come up for a family doctor? Why would a surgeon think about fascia?
The answer is boring but critical: fascia functions as an important infection barrier. Much like skin prevents pathogens from getting into the bottom in the first place, layers of fascia limit their spread. For example, from Gray’s Anatomy for Students:
A typical example of a fascial layer would be that overlying the psoas muscle. Infection within an intervertebral body secondary to tuberculosis can pass laterally into the psoas muscle. Pus fills the psoas muscle but is limited from further spread by the psoas fascia, which surrounds the muscle and extends inferiorly into the groin pointing below the inguinal ligament.
But there’s a dark side to this vital function — one of the most unpleasant malfunctions in medicine. If fascia stops the spread of disease, what happens behind the barrier? Well, it can get grim: a blocked infection is also a trapped infection, and if it burns out of control it can destroy the contents of the compartment. Journalist Miles O’Brien lost a forearm to compartment syndrome, a raging infection that came out of nowhere and inflated his forearm like a high-pressure sausage.Journalist Miles O’Brien lost a forearm to compartment syndrome — see “Just a Flesh Wound” — a raging infection that came out of nowhere and inflated his forearm like a high-pressure sausage.5 Since fascia is so tough and will not yield, circulation gets cut off and all the flesh in the compartment begins to die. The compartment must be sliced wide open to bleed off the pressure — a huge, grisly wound and a slow, difficult recovery even if all goes well. And it didn’t all go well for O’Brien:
Things tanked even further once I was on the table. And when I lost blood pressure during the surgery due to the complications of compartment syndrome, the doctor made a real-time call and amputated my arm just above the elbow. He later told me it all boiled down to a choice…between a life and a limb.
“Just a Flesh Wound”, O'Brien (milesobrien.com)
Now that is clinical relevance. That’s how the properties of fascia medically matter — its toughness as a wrapping, primarily.
Audio articles are exclusively available as a perk for my boxed set customers (plus any visually impaired reader). I also extended the one about my trigger point doubts, keeping up with major recent updates to the written version.
Those Germans have a word for everything! “Hexenschuss” is a German word for back spasm or lumbago, but translated literally it means shot by the witch (hexe = witch and Schuss = shot). Hat tip to reader Richard Moison for teaching me this excellent word, now added to the introduction of my low back pain tutorial.
Seems like I picked a pretty good project to help out with, back in 2009. I’m sure glad I chatted up Dr. Steven Novella at that party in Vegas!
Not my acromioclavicular joint dislocation, not the aftermath of it for the next six months (as bad as that got), but two years later re-injuring the vulnerable area working out at the gym. Weeks of consciousness were consumed by waves of agony from ear to elbow. What a grind.
It’s impossible to say exactly how I beat it — there were a bunch of variables, I tried everything I know — but basically it seemed like a good massage was finally what did the trick.
Surprisingly, Frobell et al found that it’s not clear if a torn anterior cruciate ligament should be surgically repaired. In a randomized, controlled study of 121 young adults with acute ACL injury, there was little difference between getting reconstructive surgery right away and just doing normal rehabilitation. Given the structural importance of the ACL ligament, it’s amazing that it can recover from major trauma without surgery approximately as well as it can without. This study did not show that ACL repair is never or rarely necessary, but it certainly strongly suggests that it’s less crucial than most people would expect.
“A randomized trial of treatment for acute anterior cruciate ligament tears”
The Oatmeal: “Remember, marathon success does not come from training or perseverance, it comes from waterboarding yourself at aid stations.”
I’ve been doing this workout regularly for months now: the “Scientific 7-Minute Workout.” I think it’s a great idea, and I’m endorsing the heck out of it today. The more I study pain, and the longer I live with my own litany of musculoskeletal complaints, the more convinced I get that fitness is great medicine for most kinds of chronic pain. And yet, awkwardly, exercise is also a very bitter pill for the people who need it the most. Chronic pain and getting out of shape feed on each other, a downward spiral with a fierce grip. Reversing that vicious cycle is one the hardest things there is; the slightest advantage is precious. And the surprising efficiency of exercise is one of the only things working in our favour.
The workout is based on the good-news principle that small, intense exercise doses are much more effective than most people realize — not just better than nothing, but greatly so. The workout is well-rounded and requires only a chair and a few minutes of oomph: a dozen simple exercises, each performed for 30 seconds, with a brief break between each of them. It was designed by exercise scientists Brett Klika and Chris Jordan, and published in ACSM's Health & Fitness Journal (see Klika et al), and nicely explained and summarized by Gretchen Reynolds for the New York Times, which became the 6th most popular article the Times published in 2013. People love the idea of exercising efficiently!
It also adapts nicely to injury rehab. For instance, if you are recovering from a stubborn knee problem like patellofemoral syndrome, you can skip the exercises that stress the knee — exercising everything else as efficiently as possible.
The order of the exercises matters, and so does the oomph (it’s brief and simple, not easy). Read more about it and then try it: there are also dozens of apps, websites, and videos to guide you (though an egg-timer and a picture of the exercises works fine); the best I’ve seen (so far) is www.7-min.com.
My experience with the workout
I’m in peak condition currently, my best in years, and I initially found the workout to be almost laughably easy. I actually didn’t break a sweat. But I quickly found ways to dial-up the intensity! I don’t take breaks between the exercise, and I do them for longer (it’s now the 8-minute workout for me). Even just an extra ten seconds for each exercise makes it quite a bit harder (and a few seconds less would be really helpful for someone struggling to get started). The efficiciency is addictive! I still do all kinds of other exercise, but I love knowing that I’m getting as much bang for my buck as possible. I expect to keep doing this workout routinely, indefinitely.
The foot strikes, paired next to each athlete’s place and time in the trials, vary widely. But they all belong to elite athletes who, whether they made it to the Olympics or not, are amongst the world’s most talented runners. And yet, some clearly drive their heels into the ground, some land squarely on their forefoot, and others seem to practically land on their pinkie toes.
So that clears that up.
Is it hate mail? Or fan mail? It’s hard to tell:
Are you a narcissist? The way your web page is written make [sic] you seem like an ego maniac. I did appreciate the information you had on trigger points.
I’m getting mixed messages here, buddy. Facebook posts and tweets about my weird mail are really popular, but this one inspired so many funny suggested replies that I just have to publish some highlights:
And my personal favourite:
I get a lot of poignant emails asking for help and advice about some really tough painful condition, but some of the most heart-wrenching are from soldiers on active duty — a situation that usually makes the best rehab options impossible or close to it. Same with single moms. I hate trying to answer those emails, because there’s almost nothing I can do. I offer them a free book. It’s not much, but it’s something.
I officially stopped trying to answer all my e-mail a good three years ago, because the volume was already overwhelming even then, but of course I still choose to answer some, and certain kinds of message are just about impossible to ignore, no matter how busy I am. When I ignore the hate mail, it’s largely to reserve time and energy for mail like this.
Does stretching increase range of motion by changing the physical characteristics of soft tissues (“plasticity”)… or our neurological tolerance for elongating it? It’s one of those surprisingly basic body mysteries. Here’s a fresh new data point in the plasticity vs. tolerance debate, from Konrad et al:
The increased range of motion could not be explained by the structural changes in the muscle-tendon unit, and was likely due to increased stretch tolerance possibly due to adaptations of nociceptive nerve endings.