More links collected and presented for you, while I am on a “holiday.” (No, really, I am on holiday. Getting these ready was the only work I did yesterday. Honest!)

Kaiser Rejects Neck Manipulation. A major American medical insurer, Kaiser Permanente, cut neck manipulation from their chiropractic coverage, and Dr. Harriet Hall reported on the decision in detail for ScienceBasedMedicine.org. This is a fairly big deal, possibly even a major turning point in the story of the chiropractic profession. Kaiser Permanente’s revised policy states:

“Given the paucity of data related to beneficial effects of chiropractic manipulation of the cervical spine and the real potential for catastrophic adverse events, it was decided to exclude chiropractic manipulation of the cervical spine from coverage.”

Sports injuries and illnesses during the Winter Olympic Games 2010. The nugget: 1 in 10 athletes were injured. Youch. That’s quite a few! Speaking of injury rates …

Risk of injury on third-generation artificial turf. I run on stuff like this all the time playing Ultimate, and it’s really weird stuff. I hear a constant stream of wild speculation from other players about its safety versus grass: many firm assertions in the absence of data, invariably leaning towards the sensational extremes, either “way safer” or “definitely more dangerous.” Click the link to find out the actual, factual answer! Go empiricism.

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Pop quiz! Modern artificial turf is: a) safer? b) less dangerous? c) same as grass? The British Journal of Sports Medicine has the answer for you …

Medical reporting in the lay press does the public a disservice, “because it distorts more than it informs.” This is a worthwhile short article by Dr. RW Donnell about the internet’s medical “misinformation explosion,” which I have watched unfold in slow motion over the last decade. He proposes several “basic” knowledge challenges that any medical science journalist should be able to pass, such as “define and distinguish: DNA, RNA” or “Define and distinguish: axiom, postulate, hypothesis, theory, fact.” Yes, I can (easily) pass his test. And he gets bonus points from me for included this item

“Explain why consideration of biologic plausibility is important in the evaluation of health claims and why evidence based medicine often fails when biologic plausibility is not taken into account.”

Hallelujah. (And here’s the answer.)

Dilbert does placebo. Just barely relevant to SaveYourself.ca, but I love the placebo-centric punchline. And a new article about placebo is brewing.

I’m on holiday for a couple weeks at the moment, so updates will be slow for a couple weeks. But of course I never truly stop working entirely …

A recent email exchange with a reader inspired this small piece, which is really more about critical thinking and cognitive distortion than Epsom salts. In this case, the reader was well aware that the apparent benefits of Epsom salts baths might well be explained by the baths not the salts. Most mail I get on the topic is just the opposite: Epsom salts routinely get credit they probably don’t deserve. Here’s how it goes:

1. Patient has a problem and tries non-salty hot baths or soaking. However, because it’s just a bath and expectations are low, this effort is never particular diligent. This is key to the setup: the patient has never actually given non-salty soaking a good try, at least not compared to what they will do when …
2. Patient gets the idea to try Epsom salts! This seems much more promising.
3. Thus inspired, the patient proceeds to soak quite diligently — much more diligently than ever before.
4. When some benefit is then observed, patient attributes this to the salt — of course. Maybe it is, but maybe it’s just the unusual regularity of the nice soaking. The point is that we obviously can’t know … but the patient is now officially biased.
5. If the benefits are at all notable, this person will usually start proclaiming to anyone who will listen that they "know" that Epsom salts work.
6. When challenged (“It might be just the hot bath, eh?”), they will almost certainly object and claim (correctly!) that they have tried simple hot soaking without results. They have indeed. But it was never actually tried well enough to really know.

Tricksy, the human mind is.

• A Scientific American article about do-it-yourself clinical trials: “The Information Age has patients tuned in and geared up to try alternative and off-label therapies on their own terms, forcing doctors and scientists to change the game.” I don’t know if I’m thrilled or horrified by this idea. Both, I guess.
• A homeopath cites his 21 favourite, crappy scientific studies of homeopathy. Isn’t it cute when homeopaths attack science in one breath, but then use the next breath to try to get shelter from science by citing the most pathetic crop of cherry-picked, biased, exaggerated, under-powered, and mis-represented studies you could possibly cook up?
• Inkling: A gorgeous new iPad app for the textbooks of the future. OMG, I want my ebooks presented like this! Not only is this a fascinating and amazing product, look at the product presentation: absolutely first rate graphic design and copywriting. Love that headline: “Textbooks. Now featuring features.”
• Mostly for professionals (fairly heavy reading), the superbly erudite Lorimer Mosely on pain biology. He opens with the wonderful understatement, “This paper argues that the biology of pain is never really straightforward, even when it appears to be.” (For patients who find this article a little too thick with neurology for comfort, I have a simpler version of this article, with some practical implications: Pain Is an Opinion.)
• Token off-topic link: All of Chewbacca’s Dialogue From ‘Star Wars.’

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Five stars! This book reads like one of my own: interesting science translated into plain English, and translated into practice. I learned more from this book than I have from any other source in quite a while. It’s not necessarily my favourite or the very best writing, but the mind-blow factor is high.

Many myths are well-busted.

There is a particularly fascinating and solidly evidence-based theme in this book that, when it comes to exercise, less is more. This will inspire many updates to my own articles and books on SaveYourself.ca. It will provide several delicious opportunities to admit that I was wrong about something, and I always like those. For instance, stay tuned for a post about training frequency and how the evidence (overwhelmingly) shows that strength training once or twice per week is just as effective as twice or three times per week.

Thanks to reader Bill C, who did not just recommend the book but actually sent me a copy. This is a practice I strongly encourage. I get a lot of book recommendations, far more than I will ever be able to actually honour. Sending me a copy greatly increases the likelihood that I will actually read it!

McGuff et al. Body by Science. 2009.

The authors also have a website, Body by Science.

David Moorcroft was about as flexible as a 2x4, but it didn’t keep him from winning a lot of races.

Reader Jennifer M. found this great passage from an excellent 1983 Sports Illustrated article about David Moorcroft, a British middle and long distance runner and 5,000 metres world record holder. It’s a splendid addition to my stretching article:

Stacked in a corner of Anderson’s [Moorcroft’s coach] office are bundles of scientific papers. “I’ve tried to interpret the findings of the best physiologists and translate them into sound practices,” says Anderson. “That’s made me a radical. We’ve turned some coaching sacred cows on their ear.”

For one, Anderson dismisses the stretching that most runners do. “It’s rubbish,” he says. “The received idea that by touching your toes you lengthen the fibers in your hamstrings is wrong. Soft tissue stretching like that is a learned skill and doesn’t carry over into running. Dave requires a flexibility, a joint mobility, but running fast is the right kind of stretching for him.”

The world-record holder mutely demonstrates his suppleness by reaching toward his toes. His fingertips get down to about midshin.

'What Made Him Go So Wonderfully Mad?' So Inquired a friend of David Moorcroft after the Briton broke the world 5,000 record in an amazing performance, Moore (sportsillustrated.cnn.com)

This was 1983, mind you: those “bundles of scientific papers” that led Anderson to his “radical” stretching beliefs were 27+ years old.

Jennifer added that this reminded her of her father, “who remained competitive at the 800m until into his 60s, but could never come close to touching his toes.”

Tech/publishing note: interesting that Sports Illustrated has so much back catalog content online. Also, Apple’s Safari web browser did a groovy job of stitching all the separate pages of that article into one highly readable presentation, using their nifty reader feature.

Speaking of beating dead horses (like core strength in a recent post), another topic in this category is acupuncture.

Recently The New England Journal of Medicine published a paper, already infamous, whose authors reported — yet again — that acupuncture for low back pain definitely does not work, no sir: “the most recent well-powered clinical trials of acupuncture for chronic low back pain showed that sham acupuncture was as effective as real acupuncture.”

Of course, the statement “sham acupuncture was as effective as real acupuncture” is logically equivalent with “acupuncture does not work.” But note the disingenuous reversal of the phrasing to make acupuncture sound a little better. Furthermore, the authors then went right ahead and daftly and paradoxically recommended it anyway … you know, for the sake of a good placebo effect. Not only did they recommend it, they advised doctors to send patients to a “properly trained” acupuncturist.

Properly trained how, exactly? In placebo delivery? At the point of a needle.

Bear in mind that we live in an age of such vigorously defended patient rights and robust anti-paternalism that it’s ethically verboten for doctors to prescribe so much as a sugar pill. And that’s (mostly) a good thing. But these pro-acupuncture doctors think it’s okay to send you to a “properly trained” acupuncturist for $1000 worth of placebo-inducing ritualistic needling?

The New England Journal of Medicine does not actually have a great reputation for editorial rigour. (The Last Psychiatrist recently snarked at it, “NEJM: where peer review= spell check”!) This bizarre article, in such a prominent journal, attracted the attention of critics at Science-Based Medicine, of course: both Drs. Crislip and Novella wrote about it this quite brilliantly. (Dr. Crislip’s post is funny.)

What’s the harm? Oh, there’s harm!

My knickers are really getting into a twist over this trend of defending a placebo effect as though it is just pure goodness.

(And I’m not talking about the harm to the wallet, though goodness knows that’s enough of problem right there. One of the classic perks of placebo is that sugar pills are cheap — in a world full of impoverished patients, an expensive placebo is a bad idea right out of the gate).

When I was a massage therapist, I routinely saw significant harm done by acupuncture and other ineffective therapies. Far from enjoying a robust mind-over-matter placebo effect, most patients seemed to believe all the more in their back pain as an unassailable affliction that “even acupuncture” couldn’t help.

More tragic than simply wasting time and money on a treatment that doesn’t work is that so many patients conclude not that the treatment was ineffective but that acupuncture was defeated … defeated by an unusually serious case of back pain.

Patients are strongly predisposed to anxious assumptions that their problem is “really bad,” and the failure of acupuncture confirms it. The acupuncturist is given the benefit of the doubt, while their back pain is elevated to the status of a fiercer enemy. A nice trap.

How’s that for a “placebo”? “What’s the harm,” indeed!

The scientific evidence is overwhelming that emotional and psychological factors are of major importance in low back pain (and many other kinds of chronic pain). The pain is not “all in your head,” but it is powerfully affected by what’s in your head. The despair that sets in when a minor placebo effect wears off is really problematic, significantly exacerbating people’s fear that they are “screwed.” Thanks, acupuncture! Thanks a bunch.

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