A review of scientific studies of reflexology finds … nothing!

The best evidence available to date does not demonstrate convincingly that reflexology is an effective treatment for any medical condition.

Assessing kneecap alignment is a reflex for most manual therapists — a staple of knee pain diagnosis, as inevitable as a doctor asking you to say “ah.” Kneecap alignment is almost universally regarded as a sign of patellofemoral pain syndrome and patellar instability and accurate assessment of kneecap position is essential for meaningful taping (a popular treatment method). Obviously you can’t use tape to align a kneecap if you don’t know how it’s misaligned to begin with.

But is assessment of patellar alignment actually reliable? Turns out probably not. As with so many other eyeballings of biomechanics, the same patient is likely to get different diagnoses from different professionals.

A 2009 paper in Manual Therapy reviewed nine reliability studies of 306 knees. (They noted that this is not much evidence, and more is needed. No kidding! We’re talking about one of the most common of all testing procedures for knee pain, and we’ve only properly studied its accuracy on 306 knees, ever? Think about how many bazillions of dollars of therapy money are spent on knee alignment issues!)

As with so many other eyeballings of biomechanics, the same patient is likely to get different diagnoses from different professionals.

What evidence there is showed that assessment of patellar position was “variable” from one therapist to the next — if you get a bunch of clinicians to all assess the same kneecap, they will come up with a variety of diagnoses.

Of course it’s possible that there is a way to accurately assess patellar alignment, and maybe someday we’ll know that and all manual therapists will be properly trained in it. Maybe. But that doesn’t matter to patients now. These scientific tests of existing methods with competent practitioners should have produced clear agreement and strong reliability — not “variable” results. That’s pretty discouraging for patients.

Despite these problems, a “wonky patella” diagnosis is commonly used to dubiously shore up a diagnosis of patellofemoral pain syndrome or iliotibial band syndrome (which is usually unnecessary, because we can diagnose those conditions just fine without even asking the patellar alignment question), and then used as a justification for a bunch of time-wasting and money-wasting therapy and therapeutic exercises. Elaborate and tedious exercises to try to “align” kneecaps are almost as common as the testing procedure itself. Take your hurtin’ knees to a manual therapist, and odds are excellent that they will not only conclude that you have an alignment problem, but that you need therapy and exercise to fix it. Imagine that. But it’s all based on a diagnosis that is proven to be unreliable.

If you’re doing a bunch of therapy based on the idea of patellar misalignment — and I mean both patients and professional — you should seriously reconsider it.

ADVANCED TUTORIAL

Save Yourself from Patellofemoral Pain Syndrome!

PFPS is a common kneecap pain problem — and yet almost universally misunderstood. Patients are often given exactly the wrong advice. There is no miracle cure for patellar pain, but this tutorial is much more detailed than anything else you can find, weighing in at 40,000 words. Both patients and pros can greatly improve their understanding of the options — and maybe that is a kind of miracle. Inspired by the work of surgeon Scott Dye and firmly grounded in readable analysis of the science. Add it to your shopping cart now ($14.95) or read the first few sections for free!

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One of the most pervasive myths in manual therapy and athletics is the belief that injuries are prevented by strength, flexibility and coordination. Unfortunately, the research simply doesn’t back this up, such as the 2008 study by The American Journal of Sports Medicine.

A thousand soldiers in basic training were studied to determine whether or not an exercise program could “reduce the incidence of overuse knee injuries and medial tibial stress syndrome [shin splints].” Half participated in an exercise program consisting of stretching, strengthening or coordination exercises, and their injury rates were compared the other half that did nothing.

There were fifty injuries among those who exercised to prevent injury, but only forty-eight among those who did nothing. The researchers reasonably concluded that classic injury prevention exercises — all standard prescriptions to athletes — “did not influence the risk” of injury.

ADVANCED TUTORIAL

Save Yourself from IT Band Syndrome!

ITBS is an infamously stubborn lateral knee pain common in runners. Therapy hasn’t been working? You’re not alone. This exhaustively researched tutorial shows that most medical “facts” about the condition are wrong — supported by 80 footnotes analyzing as much of the science as you can stand. Cures cannot be guaranteed, but this tutorial offers both patients and pros 25 detailed treatment options and more insights than you can find anywhere else, as well as a free bonus: SaveYourself.ca’s valuable trigger point tutorial. Add it to your shopping cart now ($14.95) or read the first few sections for free!

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ADVANCED TUTORIAL

Save Yourself from Patellofemoral Pain Syndrome!

PFPS is a common kneecap pain problem — and yet almost universally misunderstood. Patients are often given exactly the wrong advice. There is no miracle cure for patellar pain, but this tutorial is much more detailed than anything else you can find, weighing in at 40,000 words. Both patients and pros can greatly improve their understanding of the options — and maybe that is a kind of miracle. Inspired by the work of surgeon Scott Dye and firmly grounded in readable analysis of the science. Add it to your shopping cart now ($14.95) or read the first few sections for free!

  $1495

The most familiar example of a confidence cure is when you go to your doctor frightened by a strange and unpleasant symptom, and your doctor compassionately chuckles and authoritatively explains that you have nothing to worry about: the condition is common and easily treatable. You have no doubt that he knows what he’s talking about. You walk away not only with the “real” medicine, but also feeling much better before you even take it.

There are many ways that the confidence cure works its magic, but an obvious one is the one I just described in my last post: the intensity of our pain is determined by the opinion of our brains, not by what’s going on in our tissues.

Pain problems freak people out

Many common painful conditions are characterized by strong patient fear and anxiety that does not get relieved, because few health professionals understand them well enough to offer credible reassurance. For instance, in the case of low back pain, patient fear is understandable, but usually way out of proportion to the severity of the problem — and not only do health professionals not know enough about low back pain to reassure them effectively, but often scare the patient by reinforcing any number of common, ominous myths about low back pain.

Reassuring a patient is not a “placebo,” per se — it’s not fake medicine, not a sugar pill. There’s a genuine therapeutic effect based on rational, informed confidence.

But placebo has a “genuine therapeutic effect,” too! In both cases, the patient has been led to believe that they are going to be fine, and that belief in turn may have a therapeutic effect. So what’s the difference? And why is it fine to aim for a confidence cure, but sugar pills are ethically dubious?

A placebo is not a long term solution — confidence is

The problem with placebo is that it’s ethically wrong to systematically lie to people … even for their own good. It’s acceptable in some situations, but not as a general rule. If you can get the same effect without lying, not only are you morally safer, but you also get a much more robust effect over time.

The therapeutic problem with “fooling” people with a pure placebo — or with a quack therapy — is that most people rarely stay fooled for long, and often end up more hurt and scared and bitter than ever before.

For instance, consider the example of a true snake oil, a therapy that is expensive and totally bogus. Initially, a placebo effect will be powered by the charisma of the therapist and the desperate hopes of the patient. But most patients have a little voice asking them: “Is this stuff crap? Did I just waste my money?” Rather than true confidence, most people who’ve spent a bunch of money on questionable therapy are watching anxiously for the first sign that they wasted their money. And of course those signs come quickly, because the therapy is bogus.

Confidence and hope rapidly turn to ashes — so much for a placebo effect!

The beauty of a real confidence cure is that you get an extremely robust therapeutic effect that is much less likely to be taken away from you later by the discovery that you were being ripped off. That’s the difference: a placebo is not a long term solution, but rational confidence based on good information is. That’s a huge difference.

ADVANCED TUTORIAL

Save Yourself from Low Back Pain!

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 171 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Ships with a free copy of SaveYourself.ca’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!

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Pain is not “in” tissue. In fact, the only thing that happens in the tissue is transduction — the conversion of stimuli into nerve signals that do not yet “mean” anything. They are meaningless until they get to the central nervous system. The CNS decides what they mean.

In the case of a computer, the separation of signal and interpretation is nice and obvious: a computer decides what a mouse click “means” … not the mouse.

We can’t detect this separation. As far as we can tell, there’s no practical difference between the signal and the interpretation, because the huge majority of the time the system works brilliantly well: actual tissue problems are interpreted “correctly.”

As far as we can tell, there’s no practical difference between the signal and the interpretation.

In chronic pain, though, the interpretation often gets increasingly out of whack with the signal. This is called “centralization” of pain — the experience of pain is now dominated by the CNS, and it matters less and less what’s really going on in the tissue. The state of the tissue may be almost irrelevant! The problem may feel dramatically worse than it really is. For the chronic pain patient, it becomes important to understand that the brain is in charge. Even for someone with a stubborn tendinitis, this can be a vital principle to understand.

This concept may explain why therapies that try to “fix the tissue” — most of them — are so generally ineffective.

Sleep-deprivation can wreak havoc in a person’s life, and it’s much more common than most of us realize. (For instance, increased muscle pain is almost certainly one of the consequences of sleep deprivation.) A new paper from the U.S. Department of Health and Human Services’s Morbidity and Mortality Weekly Report reports that about 30% of American adults are getting less than 7 hours per night (and of course many of those are getting much less), and at least 10% of people have gotten “insufficient rest or sleep on all days during the preceding 30 days.” That’s one in ten people getting inadequate rest every night for 30 days in a row! (Sounds like me and several people I know, actually.)

The importance of chronic sleep insufficiency is under-recognized as a public health problem, despite being associated with numerous physical and mental health problems, injury, loss of productivity, and mortality. Health-care providers should consider adding an assessment of chronic rest or sleep insufficiency to routine office visits so they can make needed interventions or referrals to sleep specialists.

I have long believed that this was an almost completely neglected consideration in chronic pain care. For some ideas and science about the relationship between sleep deprivation and muscle pain, see Insomnia Until it Hurts.

Facts do not cease to exist because they are ignored …

Aldous Huxley

A reader just reported to me that, after a few days of regularly massaging her masseter muscles (as per instructions here and here), she experienced “a 20 hour state of euphoria” during which time she “needed very little sleep, was completely pain free, and was giddy with joy.”

Wow!

And then the effect faded.

Self-massage rarely has such a strong effect (“giddy with joy” is really, really good). I normally associate such strong state-of-being changes with The Art of Bioenergetic Breathing. This effect is not surprising in principle — it’s like anything that feels like a refreshing change in state, from hot baths to tickle fights with your kids and other obvious examples of things that feel wonderfully different than the grind of work and chores — but the strength of the effect can be really amazing. People may feel dramatically rejuvenated for hours or days.

The trouble is, it inexorably fades: soon enough you’re back in your various human ruts and habits and you don’t feel so very refreshed any more. But this isn’t a bad thing. It’s just life!

New publishing systems and strategies mean a lot of great new content for SaveYourself.ca readers, coming soon. My goal is nothing less than to “finish” SaveYourself.ca over the next few years. This has come from the personal and entrepreneurial challenge of trying to figure out how to be a writer in the 21st Century:

• pick your turf
• write about it incessantly and charmingly
• distribute every imaginable techy way (blogs, Facebook, Twitter, podcasts, YouTube and much more)

My job is to make contacts with readers, and make every contact count. Every time I’m on someone’s radar, I want that person to think, “Oh, hey, it’s that guy who writes about pain problems and manual therapy. Again! My, but he’s persistent! And amusing!”

I am ready for this now. I am armed to the teeth with publishing technology and a savvy plan. I am ready to be a writer for the rest of my life.

Write once, publish everywhere

The biggest challenge was to create a way to “write once” but “publish everywhere.” That was hard.  <?php echo "I had to program stuff." ?>  I’ve been up to my eyeballs in technology for days now, applying elbow grease to the guts of SaveYourself.ca, scrambling to wrap my head around RSS feeds, content management systems and — worst of all — social media. Cue horror movie music!

It’s been kind of intense.

More good stuff for SaveYourself.ca readers

Another problem for the 1st Century writer is how to work on big projects (books!) while also producing a constant flow of interesting nuggets of content for the impatient internet (blogs!).

The solution? Blog the process. Publish the pieces.

From now on, basically all new content that I publish (not this) will be a chunk of some larger project. It may be as small as a beautiful phrase, or as large as a whole new chapter. This also means that you’re going to see more in this space: quite a lot more. As I polish the new systems over the next few weeks, the pace of new posts is really going to pick up, with both lots of small bite-sized items, and many more substantive chunks as well.