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
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One of the top five questions I am asked by email, about any condition, is simply Is there hope? The answer is nearly always the same…
Yes, there’s hope. There’s never a guarantee, but there’s always hope, and recovery from most kinds of severe chronic pain is not only possible but fairly common. Unless you have a known serious aggravating factor — a major trauma, for instance — there is almost never any reason to fear that recovery from any chronic pain problem is impossible. For the same reason that pain can be absurdly persistent and out of proportion to any clear cause — because it is so brain-tuned — it also never loses the potential to finally shift and evaporate.
This thought was added to my Pain is Weird article, and probably should be in several other articles as well.
The 2nd edition of the patellofemoral pain syndrome e-book is now available, after many months of collaboration with a new co-author, Tony Ingram of BBoy Science (the similarity in our surnames is just a fun coincidence). The book has been updated many times over the years, but the new edition thing had to wait for this. It’s longer by about 5000 words and a few dozen footnotes, and there are scads of other improvements. Mostly it’s just better, but there is one important thing that’s different…
I must be doing something right, because a guy like Tony is a catch of a co-author: he’s a physical therapist and a researcher in hot pursuit of his PhD. We’ve been working on the new edition since late last year, and most of the work went into a strong new (and overdue) emphasis on the evidence-based value of exercise — reversing my grumpy anti-exercise position. That’s the biggest change to the book.
Practically the first thing Tony said to me when we got down to work was, “I have to turn you around on exercise.” And he did. Getting my mind changed on a key point or two was the whole point of teaming up with him — more about that below.
Tony also did his masters thesis on anterior knee pain, and has the credibility of someone who has pushed his body to new limits as a dancer. Few people can combine serious academic credentials with that kind of athletic experience.
It has been an interesting and successful collaboration. Although Tony was a fan of many aspects of the previous edition, he did challenge me on several points. I think he sent some of his early criticisms with great trepidation! Although our preliminary conversations had all been promising, you just don’t know how someone is going to cope with criticism until it’s happening. But I’m an old hand at this, and I couldn’t possibly be any kind of a success as a writer if I didn’t know how to shut up and listen attentively and humbly when a real expert is talking. Time and again, I think Tony was relieved when my responses to his emails came back calm and appreciative. I like being corrected. The alternative is to be wrong and not know it.
The tables were turned near the end when I had to ask Tony, “Where’s the beef?” about one of his new sections — a matter of editorial expertise more than knee knowledge. I like being corrected. The alternative is to be wrong and not know it.Tony looked a little startled at first, but he took it like a scientist, and proceeded with a significant upgrade to that section. It was my turn to be relieved!
Effective writing and publishing partnerships are rare, and I’ve had many of them fall through or just fail to thrive. But Tony and I had a great time on this first project, and we’re like to expand our collaboration. Stay tuned!
Making the 2nd edition more positive about exercise has been a great example of responding to new evidence — and a good example of a treatment that works, but probably doesn’t work how most people think it works. I was anti-exercise before because the evidence just wasn’t there for it yet, and too many professionals fancied that they were prescribing exercise to change biomechanical parameters (e.g. patellar tracking) that correlated poorly with the condition. Such prescriptions tended to be overzealous: too much exercise, too soon for patients suffering from what is fundamentally an overuse condition. And this kind of prescribing is still common.
Now there is good evidence that exercise is effective — Hallelujah, some much-needed good news! — but dosage and timing are key, and the biomechanical rationale still needs to be taken out with the trash.
The new edition explains it all in the signature style of SaveYourself.ca: it’s detailed but sassy and whimsical, a pleasure to read if you’re remotely interested in the subject.
The previous version of the book had a significant weakness, a major idea about the nature of the beast (basically the whole “it’s the homeostasis, stupid” theme). My idea was plausible and elegant, but lacked adequate scientific support for an important basic point of the book. One advanced reader complained:
I didn’t buy your book so I could get one guy’s theory about how patellofemoral pain syndrome works. Not even if it’s a good theory.
Good point. She went on to say that it probably was a pretty good theory, just cringe-inducingly unsupported. Simple as it is, that’s one of the best constructive criticisms I’ve ever received. And it’s one of the major repairs in the 2nd edition: Tony and I agreed early that my basic point was sound, but badly needed some scientific and expert support — and now it has that. And much more.
Several recent updates to my neck pain e-book: digital motion x-ray section, new spinal manipulative therapy evidence, comparison of “minor intervertebral derangement” to “subluxation,” and diclaimers about the weakness of trigger points science.
The benefits of many manual therapy treatments, like spinal manipulation or massage, are notoriously inconsistent and ephemeral as a general rule, and yet sometimes seem to produce amazing results. It’s difficult to explain this pattern in the world of therapy.
Most people assume that those success stories indicate that the treatment just happens to work unusually well for a certain kind of patient. And maybe that explains a few cases, thanks to a combination of luck and knowledge and skill — and that is certainly what therapists and their customers would like to believe.
And we can explain a few more treatment success stories as coincidence: recovering at the same time as a new treatment. This is not as rare as one might suppose given that people often seek care at the darkest-before-dawn point preceding natural recovery, and yet it can’t possibly explain them all, or how quickly and clearly change can follow treatment.
There’s a more likely and prosaic explanation for most success stories…
All those unreliable treatments in manual therapy are getting most of their success stories the same way: rogue waves of non-specific effects adding up to something more than the sum of their ho-hum parts. Sometimes therapy just makes a bigger impression, because everything went just so: no socially sour notes, a good belly laugh, a reassuring touch at exactly the right moment, a piece of office artwork that reminds the patient of home, a comforting story about what’s wrong that the patient could particularly relate to (but which may well be a little lost on the next patient). There are countless ways it can go well, and sometimes they really pile up. If the therapeutic interaction is the active ingredient of treatment — and there’s an extremely strong case for that — then it follows that some interactions are better than others, and some are so good that they explain most of the success stories that patients tell for years.
Well-known anti-quackery activist Dr. Steven Novella is being sued for criticizing Dr. Edward Tobinick, who runs a medical clinic selling expensive experimental drug therapy to people with serious neurological diseases. Dr. Tobinick is not a neurologist. Dr. Novella is a neurologist and the founder of ScienceBasedMedicine.org, where his original criticism of Tobinick was published. The post soon appeared in Google web searches along with Tobinick’s clinic.
“In my opinion he is using legal thuggery,” Novella says, “in an attempt to intimidate me and silence my free speech because he finds its content inconvenient.”
I got the actual complaint in my own mailbox several weeks ago (CCed because, full disclosure, I’m on the editors’ masthead at SBM). I have a keen interest in legal bullying because of my own experience with it. Although I’ve endured legalistic threats myself, and followed many other cases, I’ve never had ringside seats for one like this! How does a heavyweight like Dr. Novella respond to a legal threat? With class and toughness, of course:
Of course, we have no intention of removing the post as we feel it is critical to the public’s interest. This is what we do at SBM — provide an objective analysis of questionable or controversial medical claims so that consumers can make more informed decisions, and to advance the state of science in medicine. We also feel it is critical not to cave to this type of intimidation. If we do, we might as well close up shop (which I suspect the Tobinicks of the world would find agreeable). Defending against even a frivolous lawsuit can be quite expensive, but we feel it is necessary for us to fight as hard as we can to defend our rights and the work that we do here at SBM.
This clear, bold decision to fight for the right to criticize is a perfect demonstration of why I’m proud (and humbled) to be involved with ScienceBasedMedicine.org. You can donate to support Dr. Novella’s case at Science-Based Medicine. Use the yellow Donate button in the sidebar, and tag donations “legal defense fund.”
Like most “simple” things, it’s not so simple under the hood. But after launching without fanfare yesterday, it has been working just fine for customers so far.
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.”