published 6/20/04, updated 11/16/09

The Humble Therapist

Why you need to be skeptical when your massage therapist, physiotherapist or chiropractor tells you where the pain is really coming from

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

Since I graduated from school and began private practice in 2000, I’ve learned two important lessons:

I must base my clinical choices on good scientific evidence and a plausible rationale whenever possible.
There is painfully little good scientific evidence on which to base my work, and a rationale only gets you so far.

Indeed, the simplest things are unsolved mysteries, or hotly debated — the usefulness of stretching, the nature of DOMS, the cause and effect of joint cracking, the best practices for treating back pain, even whether or not we really need “8 glasses of water per day.” The only defence for the average clinician is to muster as much scientific rigour as we can, and otherwise trust our instincts and stay humble. We often do the right thing … but not because we understand the right thing. I know that massage therapy often helps my patients, or seems to — but I rarely know why.

The necessity of humility and conservative diagnosis is the theme of everything I’ve learned since graduation. In school, I learned that it is the job of the physical therapist (massage therapist, physiotherapist, chiropractor) to see the interconnectedness of the human body — to see causal relationships between seemingly unrelated structure and function. If we don’t have some depth of understanding about the biomechanical puzzle, then we are useless to the people we serve. But it is all too easy to go too far, and begin making connections that exist only in our hopes.

The impressive therapist

It is always reassuring to both therapist and client when skilful assessment seems to yield evidence that “everything really is connected” — as though we weren’t entirely sure of it. In fact, both practitioners and patients tend to judge the quality of a treatment on the basis of how many degrees of separation the therapist can perceive between symptom and cause.

We all like diagnoses that connect the dots. The more dots we connect, the more we like it!

The therapist who claims to understand therapeutically significant connections between parts that seem particularly unrelated is more likely to impress his patients — and to think highly of himself. But it’s a trap.

Diminishing returns

Unfortunately, there is a problem of sharply diminishing returns as the number of dots (variables) increases. This results in what I will call the Law of Fancy Diagnosis:

The more clever a therapist tries to be about a diagnosis, the less likely it is to be meaningful.

A classic extreme example of the Law of Fancy Diagnosis at work is a chiropractic modality based on the reasoning that all symptoms in the body originate with only the joints of the upper cervical spine — a panacea, firmly in the “too good to be true” category. But many practitioners of this modality are so gung ho that they will not treat other spinal joints, let alone any other part of the body. I don’t think much of this, and I think such practitioners survive largely on the basis of the emotional authority of such a fancy-sounding premise for therapy.

I have treated many refugees from such therapy, who failed to get relief from their symptoms. Those who claim relief are probably enjoying a nice placebo effect, or would have healed just fine in any case.

Why does the attempt to make elaborate connections usually result in useless therapy?

Too many variables

The number of variables wedged between the symptoms and the deepest causes of even the simplest musculoskeletal conditions is simply shocking.

While it is reassuring on the one hand to validate the interconnectedness of anatomy and physiology, it is on the other hand downright alarming to recognize that everything really is connected — and paralyzingly complex, like looking at the night sky and being completely freaked out by the number of stars. Manual therapy is a bewildering and miraculous game of pick-up sticks where everything we do affects everything else, and no health care professional can seriously hope to make common sense of it. There is no certainty about anything in this business.

Therefore, elaborate attempts to connect pain with distant or subtle causes are usually doomed. They never impress.

It can be downright alarming to recognize that everything really is connected … and hopelessly complex.

I have dared to get pretty fancy with my own theories about the connections between upper body pain and respiratory dysfunction (see The Respiration Connection). I have told my clients, with unjustified confidence, that they must learn to breathe with their diaphragm to cure their headaches. I think it even worked once. This idea relies on several steps of logic, each of which depends on others — things that can be pretty hard to nail down. For instance, people almost certainly do not breathe the same way under all conditions. Someone who has significant difficulty with diaphragmatic recruitment in my office may have no problem with it at all when she is jogging — or the other way around. How would I know? So where does that leave my attempt to diagnose respiratory dysfunction as a cause of headaches?

I’ve lost sleep over that one.

Lions, tigers and bias, oh my!

People are ridiculously complex, and a diagnosis that relies on any more than a couple steps of logic is problematic even for a therapist with machine-like objectivity — which, of course, no therapist has. But it gets worse when the therapist is a real person with emotional biases and vested interests.

If any of the many variables that a diagnostic theory depends on is subject to biased perception — if the practitioner must guess about anything, if she must feel for a joint position as subtle as a grain of sand in a towel, if her reputation is at stake, and if this procedure is in itself is two degrees of causal separation from the symptoms in another region of the body (admittedly related but by no means related significantly) — then forgive me if I am quite skeptical about the whole thing.

And I am more skeptical still when treatment will supposedly require weeks or months of expensive therapy and diligent therapeutic exercises … all of which is based on the assumption that the original diagnosis was accurate!

Another example: the leg-length debacle

Even seemingly simply connections defy easy understanding. Most therapists believe, for instance, that there is an important connection between leg length difference and back pain. This is one of the sacred cows of physical therapy.

I could retire if I had a buck for every client who has ever told me that they’ve been diagnosed with a leg-length difference that accounts for their symptoms. Therapists and clients alike love this diagnosis for its seemingly savvy grasp of biomechanics. The more subtle the leg-length difference, the higher the regard for the diagnosis, which says a lot.

I could retire if I had a buck for every client who has ever told me that they’ve been diagnosed with a leg-length difference.

Unfortunately, it’s wrong. A 1984 study in the British medical journal, Lancet, concluded that there “no association was found” between leg-length differences and chronic back pain.1 It seems obvious that these dots would be connected, but then again people once thought it was obvious that a heavier object falls faster than a slow one. It doesn’t, of course. You have to check these things!

The necessity of conservative diagnosis

For all of these reasons, I increasingly try to avoid clever evaluations of biomechanics and posture. I do not make much of leg length differences, or torsions of the pelvis, or any other alignment bogeymen. Even if these things are important, I do not pretend to be able to understand them well enough to justify exhaustive assessment and elaborate treatment. It’s just not good bang for my clients’ buck.

I prefer instead to believe that people are not particularly fragile, and that therapy can be used to encourage normalization of function regardless of whatever biomechanical dysfunction may be present. I prefer to believe that it is not always realistic to diagnose the deepest cause of every problem, and that treating “just the symptoms” may actually be a perfectly reasonable thing to do when the root causes are a needle in a haystack … especially when searching through the hay costs $95/hour!

Appendix: “I have been humble for 2 decades now” — a classic case of therapist arrogance

I received a note from a reader — allegedly a colleague and kindred spirit. He briefly expressed his appreciation for my writing, and then asked:

Would you like to know what actually causes trigger points? I have been at this for twenty years and have the answers that we all search for.

Uh oh.

Clearly, this is someone who fancies himself a “healer” with special knowledge. His delusions of grandeur are betrayed not only by his belief that he has “the answers that we all search for,” but by his teasing lack of detail. If he really has special knowledge, why would he ask me if I want to know? Why wouldn’t I? Why be guarded or vague? Just share! Can you imagine a scientist writing to another scientist and saying, “Would you like to know how things really work?”

I decided to bite, just to see what he would say, and his reply was vain and vague, with hand-waving references to an “amazing” therapeutic protocol that can work marvels with pain patients, and all of it depending on something — he doesn’t say what — in the feet. This is classic wind up for a doozy of a structural theory to explain all pain. For structuralists, “it all” always hinges on one critical biomechanical factor.

Can you imagine a scientist writing to another scientist and saying, “Would you like to know how things really work?”

I pointed out that his lack of humility, lack of detail, and lack of scientific evidence was all fairly off-putting. And this was his reply, pitch perfect for a delusional “healer.” I have reproduced it here word for word, because it is just such a gloriously irritating example of this kind of thinking, which is absolutely rampant in alternative health care:

I appreciate what you are saying, I have been humble for 2 decades now, in fact this has been my ministry for 20 years. As I have said I don’t have all the answers and I don’t have a panacea for anything, neither have I cured anything, I’ve worked with many alternative types of medicine and have used these methods to end my own bout with cancer. What makes my method work is a complimentary adjustment top to bottom. What makes the adjustment stay is the cuboid [a small foot bone] being held in place. If you have the skills needed to reduce or eliminate the scoliosis then you can appreciate that just to get proper treatments in some areas, you have to fight. I am entirely guilty of being an old warrior, who finally has won. I don’t need to argue any more, I demonstrate. I have no desire to change the way things are, only to save as many as I can. Technical explanations are good for conversing with doctors, but my mission is to communicate with the average joe who has been through the “mill” and has lost hope, these are my flock. To check out my “ extraordinary claims” You will find confirmation in Dr. Warren Hammers book entitled; Soft tissue examination and treatment by manual methods pg 425.

There are so many things about his thought process that are disturbing that I hardly know where to begin, but here are the highlights:

“I have been humble for 2 decades now” is not an expression of humility. No one gets bragging rights for being humble!
Unsurprisingly, he attributes his miracluous healing abilities to a single biomechanical factor … and a small one at that, the cuboid bone, a sugar-cube sized lump of bone in the foot which he can therapeutically “hold in place,” implying both that it could be significantly and disastrously loose before his treatment (it can’t), and that he has the magic hands to somehow ensure that it remains firmly in place after his treatment (he can’t). Man, this really is structuralism as its most outrageous!
In the attempt to seem humble, this guy claims that he doesn’t have all the answers and that he hasn’t cured anything … but then in the same paragraph he goes ahead and claims that his method depends on a single biomechanical factor, directly implies he can cure, that he’s “an old warrior who has finally won”, that he wants to “save” people, and that he can reduce or eliminate scoliosis — a condition that I have never seen successfully treated in my career, despite the efforts of many who claimed they could.
Like every intellectually lazy professional, he dismisses the importance of “technical explanations.” They are good “for conversing with doctors” … something I think we can safely bet he doesn’t actually ever do.
He cites a single reference as “confirmation” for a wildly optimistic, extravagant claim of therapeutic efficacy. Wow, that must be some reference! That brings oversimplification of a complex subject to new lows!

That brings oversimplification of a complex subject to new lows!

And a final dig I can’t resist…

He is allegedly a complementary medicine professional … but he can’t spell it. How sad. Also, he can’t punctuate. As my father always said, “Bad writing doesn’t necessarily mean you’re stupid, but it sure makes you look stupid.”2

This is why so many doctors so reasonably object to alternative medicine: because it is, so often, so disappointingly ego-driven.

“I have been humble for 2 decades now” is not an expression of humility.

Notes

Grundy et al. Lancet. 1984. From the abstract: “In a case-control study, in which a specially designed questionnaire and a ‘locating jig’ were used to investigate the association between difference in lower limb length and other disproportion at or around the sacroiliac joints and the existence of chronic low back pain, no association was found. Chronic back pain is thus unlikely to be part of the short-leg syndrome.” Return to text.
Of course, whenever I make criticasms of sloppy writing, I do open myself up to a charge of hypocrazy, because there are certainly scattered errrs on my website, probbly even on this veru page , maybe evn in this foonote. But it’s a matter of dagree. I only critisize someone’s communiation skills when their writeing problem are signicifant and revelant : when the errors are thick and nasty and thick and nasty, when they arre combimed with style problems like SHOUTING IN CAPS!!!, or abusing “quotion marks”; or just horrible spellung and grammer and sentense structure, and and whn they betray ignoranse of the subjet matter,, like a chiropracor who writes the “veterbra” three times in the same short email and declares “I’m a proffesional”.

(I’m not making that last bit up. I actually got that message.)

Not everyone’s a writer, but writing that bad is much worse than just lacking a knack — and it exposes a lack of mental rigour and maturity. There is such a thing as a minimum literacy required for one’s ideas to be taken srsly. Return to text.