This a complete archive of 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. Recent posts are always on the home page, and this page shows the complete archive of 301 posts, about 32,000 words (so it’s a pretty big page). This is not the main content of the site: see the main table of contents for full-length articles.moreMost of the content on SaveYourself.ca is a large wiki-like collection of feature articles that get updated over time (some more than others). As I work on the main content, I blog about what I’m working on. So SaveYourself.ca is definitely not just a blog, but it has a blog. This page shows just the microblog, and there’s a separate page that lists all articles and blog posts.
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.”
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.
So I got accused of having a “pro-science” bias. Correct! As advertised. Just like it says on the tin. This is like accusing a painter of a “pro-art” bias…
However, just because we can’t seem to reliably find smoking gun causes of back pain with modern imaging technology does not mean it isn’t there. Physical therapist and researcher Tony Ingram makes this important point in a short, clear, evidence-based opinion piece, The back is still important in back pain. And I’ve added a reference to it to my back pain book, of course.
See also this academic paper from 2011: What happened to the ‘bio’ in the bio-psycho-social model of low back pain?
Many people have complained that my article about the sketchiness of trigger point science undermines the integrity and value of my book about trigger points. I’ve had people tell me they refuse to buy my book because “apparently you can’t make up your mind” or because they feel “betrayed” by my doubts. One reader pointed out that the only negative “review” he could find of my book was written by…me!
There’s no doubt it’s unusual, but I think questioning key points in my own book increases its value and integrity. Regardless, it’s clear that many people are disoriented by my “doubts” article, so I’ve (reluctantly) added this disclaimer to the introduction:
We know something is going on, and it is ofen labelled “trigger point” pain, wisely or unwisely. No one doubts that: not me, not the harshest skeptics, not anyone. What is in doubt is the explanation, the nature of the beast. Although this might seem to contradict the purpose of my book, it does not: armchair speculation about the biology of trigger points should not discourage anyone from rational exploration of their treatment options. The purpose of this article is to address the reasonable and fair questions of skeptics about the science of trigger points. In any case, I do not conclude or condemn anything at this time — I just question and consider. I hope readers will respect the fact that I’m willing to ask the tough questions, even if they aren’t superficially good for my bottom line.
P.S. I updated this article substantially in January. If you haven’t looked at it recently, it’s changed. There’s also a freshly updated audio version of it.
Marshall et al is a decent and recent example of evidence that stretching can improve flexibility. When subjects were stretched with the same force (torque) applied, pushed to the same level of discomfort, they could go 20% farther. So we know something changed! But was is it a “plastic” deformation in the tissue? Or a neurological change in tolerance for stretch? Despite plenty of contrary evidence, Team Plasticity remains large and devout.
Marshall et al followed their data into an overinterpretation in favour of plasticity. Because range increased, but pain at the end of the range did not, they unwisely concluded that a change in tolerance was probably not a factor. But stretching farther without hurting more could certainly mean an increase in tolerance! Although it wasn’t measured, it’s safe to assume the subjects’ pain would have been less if stretched only to the end of their original range.
The experiment was simply agnostic on the “how” question. It demonstrated only an increase in extensibility, not whether it was due to neural or structural adaptations. The pro-plastic opinion was just an opinion, and a good example of confirmation bias at work.
For many people, a diligent effort over a period of weeks might well increase your range of motion. In 2011, a nicely done experiment by Marshall et al showed that regular hamstring stretching substantially increased range of motion in normal university kids. Specifically, after “a 4-week stretching program consisting of 4 hamstring and hip stretches performed 5 times per week,” their range increased about 16˚ or 20%. That’s a real result. For whatever it’s worth. Regardless of what it does for flexibility, stretching remains amazingly useless for nearly any other popular or clinical goal. See Quite a Stretch. And see the next post for more discussion about the implications of this study: Plasticity versus tolerance.
“A randomized controlled trial for the effect of passive stretching on measures of hamstring extensibility, passive stiffness, strength, and stretch tolerance”
Just published! When I’ve read it, I’ll review it, but I predict good news: this is likely to be a fine book, and a great reading recommendation in countless places around SaveYourself.ca. Todd Hargrove is a clear thinker and terrific writer. For years now, I’ve been reading his blog — www.BetterMovement.org, similar to this one in so many ways — and routinely kicking myself for not writing about a topic as craftily as he did, or as diplomatically, or as insightfully. He’s one of those writers that keeps me striving to refine my own skills. Buy the book from Amazon (paperback for now, Kindle coming soon).
A study published Monday by the National Institutes of Health found that the typical American now requires three distinct attempts to raise themselves from a seated position… The report also found that once standing, Americans could resume a seated position in a single fluid motion.
This is so plausible it barely qualifies as satire.
I recently added a classic satirical citation to my bibliography, and then worked it into a revision of my article about the difference between evidence-based and science-based medicine:
Evidence-based medicine was mocked in a classic article for the British Medical Journal, which pointed out that “the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.” EBM isn’t actually that foolish in theory. Good testing is extremely important, but only one part of a complex puzzle, and good doctors and scientists know this perfectly well. But they aren’t the problem. In practice, EBM richly deserved the satire, because it has often been applied overzealously, as though all that matters is study results. And that, bizarrely, created a wonderful opportunity for quacks…
I recently joined the new Society for Science-Based Medicine (SFSBM.org), a society advocating for more and better science in medicine: “People should not suffer, die and lose hope, time and money due to pseudo-medicine.”
Edzard Ernst on the “integrated medicine” straw-man:
The notion that only those who preach the gospel of integrated medicine are able to perform the art of medicine is as ridiculous as it is insulting to everyone in healthcare who does his/her best to meet the needs of their patients. The assumption that unproven or disproven treatments become acceptable simply because they are often administered in a kind and caring fashion is quite simply not true.
How’s this for a counter-intuitive research result? Alex Hutchinson:
When physiologists at the University of Wisconsin used spinal injections of a powerful painkiller to block lower-body pain in a group of cyclists, the cyclists actually got slower. They initially felt great and started out faster than normal, but then faded. Without the feedback of pain, they couldn’t pace themselves properly.
In 2001, the infamous Philadelphia Panel on rehabilitation interventions showed that many popular treatments cannot beat a placebo, an evidence-based bummer of epic proportions. Physical therapist Carol Davis found this “shocking in many ways” and wrote a letter to the editors of Physical Therapy. Like so many others, before and since, her reaction was to blunt the bad science news by putting placebo on a pedestal and moving the goalposts of science, suggesting that controlled trials aren’t so great. The editors’ reply was excellent:
If Dr. Davis believes that our future as a profession lies in our ability to produce placebo effects, perhaps she misses the point. Her view taken to its logical conclusion would not mean that we could, as she said, “reduce the musculoskeletal curriculum by two thirds,” but rather that we could possibly eliminate this aspect of the curriculum in its entirety as we become not physical therapists but rather practitioners of “placebo enhancement.” As a curriculum coordinator, Dr Davis should know that this role is not what sets us apart from other practitioners and is not seen as our raison d’être in any practice act or in any document that describes our practice. I believe Dr Davis’ views to be unwise and reckless and, most importantly, potentially injurious to those patients who expect us to have some basis in science for our practice.
Bartonella quintana (or trench fever, or five-day fever), is a disease carried by body lice that causes, weirdly, hyperaesthesia of the shins — that is, generally heightened shin sensation, though mostly just heightened pain. However, this is unlikely to cause any diagnostic confusion with shin splints, since trench fever also causes a nasty fever and many other unpleasant symptoms, like fierce headaches and eyeball pain. Nevertheless, perfect sidebar fodder for my shin pain tutorial.
settles a class-action lawsuit about its FiveFingers “shoes,” pays $3.75 million to customers, and agrees to remove all claims that the product “strengthens” or “reduces injury” until they can be proved. I have been pointing out for years that such claims for the powers of minimalist shoes and barefoot running were premature. Interestingly, Vibram’s claims are still online for now — I wonder how much longer? — and they are just as bold and unsubstantiated as I remember.
It’s good news, but companies will keep making premature health claims as long as the potential profits trump the risk of getting spanked for it (so, forever). Lots of discussion of this item on Facebook, and I’ve updated my barefoot/minimalist article: Does barefoot running prevent injuries?
Since its publication, “the Cassidy paper” has been the defensive citation used by chiropractors to respond to accusations that neck adjustments involve a risk of stroke, and therefore should not be conducted without proven benefit and informed consent. The abstract seems to strongly exonerate chiropractors: “We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.”
“But abstracts are like movie trailers,” as Dr. Mark Crislip wrote. “They give a flavor of the movie, but often leave out many important plot devices and characters. … If you were to read this article in its entirety, you would not be so sanguine about the safety of chiropractic.” He goes on to explain exactly why in one of the earliest popular posts on ScienceBasedMedicine.org, Chiropractic and Stroke: Evaluation of One Paper.
“Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study”
I met an elderly leg amputee. I asked him, “Do you have phantom pain?”
(I’m never shy about asking people about their pain — it’s particularly interesting to me, of course, but I’ve also learned over the years that people like being asked about their pain. Pain is almost everyone’s favourite subject! Which is why you’re not supposed to talk about it (see 3rd item), along with talking about how you slept, your dreams, money, your diet, and so on. But it’s my job to be interested, and it’s my job because I am.)
He laughed merrily as though this were an especially clever question, and said, “You know, I suffered from phantom pain for my whole life, but only found out that there was a name for it just a few years ago!” And he described intermittent nighttime episodes of horrible burning, stabbing pain that he’d had in his “foot” since he was a boy, before a prosthetist finally explained the phenomenon to him.
Decades of health care professionals had never talked to him about it, even though they must have known — phantom limb pain is extraordinarily well-documented, and one of the most fascinating areas in pain research.
This is an excerpt, a new-ish ancedote in my muscle pain book.
Too often people smugly dismiss a study just because of small sample size, ignoring all other considerations, like effect size … a rookie move. For instance, you really do not need to test lots of showers to prove that they are an effective moistening procedure.
Placebo is full of paradoxes. For example, the original was: if placebo is so ding dang “powerful,” why isn’t everyone cured? And here’s a sequel, via researcher Steve Kamper:
…there exists a logical paradox at the very heart of the way placebo effects are conceptualised. We have an intervention that is, by definition, inert (a placebo intervention) which produces an effect which is real (a placebo effect). Now maybe this reflects my own lack of imagination, but I just can’t get my head around an effect that has no mechanism. Surely there must either be no effect (i.e. there is no placebo effect), or the intervention must have a mechanism (i.e. placebos are not inert, but real treatments).
Indeed. The whole short article is excellent.
Rational chiropractor, Preston H. Long, author of a new book, Chiropractic Abuse—A Chiropractor’s Lament, knows Twenty Things Most Chiropractors Won’t Tell You. Number 16 is particularly well-phrased:
16. The fact that patients swear by us does not mean we are actually helping them.
Satisfaction is not the same thing as effectiveness. Many people who believe they have been helped had conditions that would have resolved without treatment. Some have had treatment for dangers that did not exist but were said by the chiropractor to be imminent. Many chiropractors actually take courses on how to trick patients to believe in them.
Repeat after me:
Satisfaction is not the same thing as effectiveness.
Then read the other 19. Then read the book.
There is an annoying trend in alternative medicine: the aggrandization of “the power of placebo” as a justification for therapy that can’t beat a placebo. Therapies that perform no better than placebo are now predictably spun as being “as good as placebo,” as though placebo is the new gold standard to meet. The absurdity of this inflation of the placebo currency becomes clear with a simple comparison: would you take a drug that had been proven to be “as good as a placebo”? Not a chance!
Fun fact: the spine is tough and strong and difficult to stabilize without surgically installing screws and rods, and even then it’s tricky: spinal fixations occasionally fall apart (my wife’s did). In fact, it’s so hard to control spinal movement that the value of external bracing in spinal fracture rehab remains controversial. Worse, one fascinating experiment (Rohlmann et al) showed that bracing may actually cause some some, dysfunctional spinal function — resulting in less support, rather than more!
I don’t want to talk anyone out of a lovely sensation-boosted placebo: a firm, wide belt might just help your nagging back pain. But what you believe about what it’s doing for you is critical! Your belief has more power than the treatment itself, and spinal stabilization contraptions usually do more to reinforce self-defeating beliefs about spinal fragility than spines.
Readers asked, and I’ve finally delivered: there’s now a whole new section about these products in my low back pain book.
Sting operations have been proving that it’s alarmingly easy to publish bogus science. Ergo, it’s more important than ever to consider the source. Ars Technica:
None of this is to say that there is a complete crisis in peer review. At the higher-profile journals with reputations to protect, most of the research is likely to be reliable (with interdisciplinary work being a potential exception). But it should certainly raise an added level of caution about some of the work that is published in the more obscure or overly specialized journals that have popped up in recent years.
This is a video of a two-legged dog, having great fun at the beach.
As summarized by distractify.com:
Duncan Lou is a young boxer discovering the beach for the first time. He happened to be born with two deformed legs, which were removed as a puppy. He has a wheelchair, but he hates it. So instead, he runs full speed unassisted with his two unstoppable fore-legs. When you see him gallivant across the beach, you'll understand. Duncan is pure courage.
So, tell me again how a slight leg length difference or an barely perceptible spinal joint “misalignment” is the cause of someone’s terrible back pain? Biology is fantastically flexible. Minor biomechanical variation is never at the heart of any common, serious pain. In fact, even major ones are often handled gracefully: in dogs or people. Which is not to say that a pup like Duncan Lou won’t grow up to have some pain (he probably will), but it puts minor biomechanical glitches in perspective.
The sketchiest methods will always be promoted the most aggressively.
In spite of my strong general skepticism about stretching, I wouldn’t hesitate to do some for a strained muscle. It’s hardly a big commitment to stretch one muscle a little. If you are gentle, it won’t do any harm. And, as with gentle contraction of the muscle, stretching may help cue healing mechanisms in your muscle to lay down new connective tissue in an tidier way. And this idea is supported by a little shred of evidence from 2004 Malliaropoulos et al that showed that about 40 strained Greek athletes who stretched recovered faster than those who didn’t. How much faster? They regained their range of motion about 22% sooner, and their “rehabilitation period” was about 12% shorter. The researchers reported that this was of “great importance in treating muscle strain injuries.”
I’m not quite that thrilled by those numbers — they’re good, not great. It’s also probably the only study of its kind, and I don’t particularly trust it. But it is promising data that provides a solid reason to experiment with rehab stretching. I do hope it’s true, even it’s not of “great importance”!
“The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow-up”
I’m telling my story: the rather dramatic fate of my massage career, how SaveYourself.ca became profitable, and the nail-biting transition between the two. The introduction is now available on my sleepy little personal blog, Writerly, and the first dozen chapters are queued up — they’ll be freely available while I finish writing the book.
It all began innocently enough, when I got excited by the potential of selling e-books to supplement my massage therapy income, and I started moonlighting and pulling 12-hour days. That’s when the money started to flow. And the trouble…
I keep hearing the claim that taping can increase circulation, and this is one of the main ways that it enhances performance. I’ve made fun of that claim. When I first looked at the results of a 2013 study, I was ready to eat some humble pie and issue a mea culpa: the results of Aguilar-Ferrándiz et al seemed more encouraging than I expected.
Mixed Kinesio taping-compression therapy improves symptoms, peripheral venous flow and severity and slightly increases overall health status in females with mild chronic venous insufficiency.
But @exuberantdoc brought me back to my senses by quipping “compression socks with tape.” I don’t mind being wrong and admitting it, but I don’t think I need to do it today, about this. Circulation is driven pretty much exclusively by metabolic demand — not by minor stimulation of the skin and superficial connective tissues. The idea that tape can increase circulation anywhere near enough to fight fatigue while exercising is extremely wishful thinking. Blood doping, cocaine, and better fitness can fight fatigue — not tape. In someone with venous insufficiency — basically, blood pooling in the legs — you can bind up their calves with tape like compression socks, and that will be … about as helpful as compression socks, of course. There’s not really any reason to use tape for that. If tape (or compression socks) had a measurable circulatory effect on healthy people, now that would be mildly interesting. But it would be downright shocking if it was a robust enough effect to affect athletic performance (let alone elite performance). I’ve updated my taping article with a citation to Aguilar-Ferrándiz et al, plus this perspective:
I’m pleased to announce the first complete professional editing of two of my books — about plantar fasciitis and iliotibial band syndrome. Although the difference will not be obvious to most readers, several hundred improvements and corrections were made to each, and the reading is definitely smoother.
What took me so long? Logistics and cash. Like any truly professional writer, I always knew I needed good editorial help, but that can be hard to find and pay for. Editing a book is a Big Deal. But SaveYourself.ca has grown to the point where it finally got important and affordable, and I was lucky enough to find a skilled, reliable editor: JoAnne Dyer of Seven Madronas Communications. After working with JoAnne on many smaller projects over the last couple years, I asked her to start working on my books. Two down, six to go!
I am often criticized for failing to suggest alternatives when criticizing bad ideas in therapy, especially in my article about “structuralism” (overemphasizing biomechanical factors in therapy). It’s a bogus gripe: failing to suggest a wardrobe for the emperor to wear tomorrow doesn’t make him any less naked today. Structuralism is a deeply flawed basis for therapy regardless of whether anything can readily replace it. But I’ve gone ahead and made some simple suggestions anyway, in a short new conclusion to the article (link takes you directly to the conclusion).
There will be much more on this so-what-does-work theme over the next couple years. I’m just getting started on it.
I enjoy it when extremely different interests overlap. I am a nut for Roman history, and I recently found a reference to massage in a charmingly oddball context: “massage instead of exercise” as an explanation for the corruption and weakness of the Vandals, and how they lost their North African kingdom to the last great Roman General, Belisarius, in the 6th Century.
Almost everything about this historical situation was a little odd. It was odd that a Germanic tribe had migrated all the way to North Africa and taken Carthage from the Romans in the first place. It was odd that Rome had lost Italy as well, yet continued to thrive in the east. Belisarius himself was a remarkable character, almost freakishly competent. And rarely in history has any hostile takeover been as rewarding as the Vandal occupation of Carthage: they got about as rich from it as anyone has ever been, and it should have been easy for them to keep their kingdom.
But perhaps the wealth did make them soft. In Robert Graves’ as-true-as-possible novel about the life of Belisaurius, Count Belisarius, he describes the condition of the Vandals like so:
As for their fighting qualities: these fair-skinned, fair-haired Northerners had now, by the third generation, become acclimatized to Africa. They had intermarried with the natives, changed their diet and yielded to the African sun (which makes for ill-temper rather than endurance) — and to such luxuries as silk clothes, frequent bathing, spiced foods, orchestral music, and massage instead of exercise. This enervating life had brought out strongly a trait common to all Germanic tribes, namely an insecure hold on the emotions.
And so Belisarius beat them. Outrageously outnumbered, far from home, without even the element of surprise, and thanks only to a little good luck, he beat them fair and square and reclaimed Carthage for Rome, before moving on to take Italy back as well. I bet the Vandals really regretted all that enervating massage!
My barefoot running content has been revised and compiled. It’s approaching the point where it’s a fairly in-depth feature article — as opposed to a mere blog “post.” That’s what I do here: I just keep updating and improving articles until you can’t resist sharing them on Facebook!
My main stretching article now includes a section on the failure to treat contracture (a scar-like shortening of soft tissues). Stretching always gets the benefit of the doubt, whether it deserves it or not. Most people and most professionals probably assume that long, intense stretches are an effective prevention/treatment for contracture. It is not an assumption held with much conviction, I imagine — it’s just that stretching always gets the benefit of the doubt, whether it deserves it or not, and it seems to “make sense” that stretching would be a cure for contracture.
Common sense fails again, I’m afraid. Continue reading (link goes directly the new section).
I needed a shrewd disclaimer to use wherever I choose to feature an anecdote on SaveYourself.ca — because smart folks (correctly) get annoyed with me if I rely too much on mere anecdote to make my points here. From now on I will use this text when making my excuses for stooping so low…
I use anecdotes on SaveYourself.ca only with great caution, because they are inherently unreliable. It’s historical fact that there has never been a snake oil so outlandish or even harmful that it lacked for happy customers who swore it worked for them. While people may well “know” what they felt, that does not necessarily mean they understand it. Anecdotes are not even the lowest level of “evidence” — they don’t constitute evidence at all. At best, they are an inspiration to seek the truth of things rigorously. But at the same time, experience is where all investigation must begin. Experience is problematic, but not useless. And so I will cite anecdotes! But only if the source seems unusually bright and articulate; if it doesn’t blatantly confirm a bias; if it echoes something I myself have experienced, or heard often from others (which gives me a higher level of confidence in it); and if it is balanced in general by the best available evidence.
A “new” article about the worst pain I’ve ever personally survived, cobbled together from old blog posts, updated and tuned a bit:
This classic quote applies to a lot of fields of human endeavour:
Now let’s translate that for this website. How does it apply to manual therapy? Well, the number one thing in the last quarter century that professionals have tended to not understand is that structural factors are surprisingly unimportant in pain and rehabilitation. And yet they are convenient, plausible scapegoats, and so it “pays” to sell therapy for them, resulting in an epidemic of expensive barking up the wrong tree. So …
It is difficult to get a man to understand something when his job depends on not understanding it.
It is difficult to get a therapist to understand that structural abnormality is rarely meaningful when his job depends on emphasizing it.
That became a popular tweet last week. I also added it to my article on this topic: Your Back Is Not “Out” and Your Leg Length is Fine.
P.S. This is good example of the kind of thing that just strikes as I’m working on other things — I have updated articles like this probably several thousand times over the years.
I have reluctantly conceded that I do not have the time or resources to make audio versions of my books. The two I have already made (for plantar fasciitis and IT band syndrome, plus several audio articles) will remain available, but there will be no more.
This is just one of several other business development projects I have recently abandoned with a sigh. The truth hurts: I can only do so much. I have recovered from the thrill of making a living online, which inspired a lot of giddy schemes from about 2010 to 2012, and now I’m getting back to my roots: I’m just a writer with a big, nice website, selling some e-books to keep the lights on. It turns out that is plenty of work for one person, forever. Ambitious product development is out of reach unless I start hiring full-time staff, which I will not do — the only kind of business I want to run is the small kind. So no audiobooks, among other things: “just” good articles, books, and a huge bibliography, passionately maintained.
The marble hand illusion study is evidence that the list of inputs the brain uses to form an image of the body is indeed endless. Apparently, the brain even considers what a hand sounds like in determining how it should feel.
Really a delightfully strange illusion.
Here is a meticulous, sensible, and readable analysis of the very best studies of back pain treatments that have ever been done: the greatest hits of back pain science.
“Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials”
There is a great deal of back pain science to review, but authors Machado, Kamper, Herbert, Maher and McCauley found that shockingly little of it was worth their while: just 34 acceptable studies out of a 1031 candidates, and even among those “trial quality was highly variable.” Their conclusions are derived from only the best sort of scientific experiments: not just the gold-standard of randomized and placebo-controlled tests, but carefully choosing only the “right” kind of placebos (several kinds of placebos were grounds for disqualification, because of their known potential to skew the results). They do a good job of explaining exactly how and why they picked the studies they did, and pre-emptively defending it from a couple common concerns.
The results were sad and predictable, robust evidence of absence: “The average effects of treatments … are not much greater those of placebos.”
SaveYourself.ca is “all about the science,” but not actually all: I am realistic about the limits of the science, much of which is clearly pretty junky. (And I don’t just mean blatant pseudo-science in fake alt-med “journals” — I’m talking about the weakness of normal, mainstream science.) This is a huge topic, but here’s one simple example of a common problem: control groups that don’t actually control. This is particularly common in back pain science.
Rather than comparing a treatment to a good, carefully selected placebo, most studies use a comparison to a treatment that is allegedly neutral, underwhelming, or placebo-ish. That makes the results hard to interpret: if they work out about the same, it could mean that the treatments are equally effective … or equally ineffective!
So much back pain science has this problem — or any one of a dozen others — that you can effectively ignore at least 80% of it, because it’s so far from the last word on anything. Data like that mostly just muddies the waters.
Good science is essential to solving these problems, but really good studies are also really difficult and rare. See the next post.
Some follow-up from a prominent news item last year: a complete summary of the kerfuffle over the alleged fracture of a baby’s neck by an Australian chiropractor. In a nutshell: we’ll never know for sure what happened, but the chiropractic profession’s response to the allegation was predictably poor and damning, and — as always — chiropractors simply have no business treating children in the first place. See also Dr. Harriet Hall’s summary post on ScienceBasedMedicine.org, Chiropractic Reform: Myth or Reality?
Can a custom shoe prevent injuries by compensating for individual differences in running mechanics?
“Injury reduction effectiveness of assigning running shoes based on plantar shape in Marine Corps basic training”
Knapick et al. gave several hundred Marine Corps recruits motion control, stability, or cushioned shoes for their “low, medium, or high arches.” Those recruits got injured just as much as hundreds of other recruits who were given stability shoes, regardless of their arch shape. It’s a large, good quality experiment that clearly establishes that prescribing special shoes “based on the shape of the plantar foot surface had little influence on injuries.” What “Big Ortho” doesn’t want you to know!
I get hate mail from quacks… but love letters from librarians, for the bibliography-friendly foundations of SaveYourself.ca. New short article about the design and odd technology of this website. Because people are always asking.
I have stopped offering PDF versions of my books. Instead, I’m now offering lifetime access to my web versions. Previously, web versions expired after six months, with the option to buy future editions at a steep discount. Now, every customer can always read the most current version of any book they have ever bought, forever — until the end of the internet, I hope. (I have plans in place to preserve SaveYourself.ca well after my demise, timely or otherwise.)
Customers certainly want PDFs, but that doesn’t mean you should. What a horrible technology! Ugh! I sold them for about 15 months, really nice ones (for PDFs) … and hated every minute of it. They were a bit of a nightmare. It was fingernails on chalkboard for five quarters of business. I’m extremely happy to be done with them, even though it meant abandoning one of the largest programming project I have ever done.
I am a connoisseur of reading technologies. I have been using every imaginable digital publishing and reading technology since the early 1980s, and they are all seriously flawed. I am an expert about this, maybe the only thing I am truly expert about, and I choose to publish exclusively on the web for a long list of good reasons — perhaps it’s foolish and idealistic and stubborn, but I am what I am, and this is just how I do things here, and it makes me happy to show up for work again. So goodbye, PDFs! And hello, lifetime access.
When my customers request refunds, which is unusual, by far the most common reason given is that the book didn’t solve their problem. About half of them add some kind of complaint about my legendary negativity. Here is a typical recent example:
This eBook didn’t decrease my shin pain. Apparently you think nothing works.
Not many self-help books go to great lengths to stifle false hope and unrealistic expectations…but mine do. My shin splints book is not intended to “decrease shin pain,” and I warn readers about that, in several ways, in both the free introduction and in the main text. In fact, I would say it’s impossible to actually read and understand my book and still think that it should have “fixed” anything. It’s an unreasonable expectation of any book… but particularly one that goes well out of its way to caution readers against that expectation!
My friend Dr. Rob Tarzwell is celebrating the publication of this here scientific paper with his name on it. It’s about brain injury, so it’s well off-topic for the salamander … but I’m very interested on a personal level, because my wife’s brain was so badly hurt in an accident in Laos back in 2010. Plus, the tech of it is bloody fascinating (and arcane). My congratulations to Rob on a meaningful and novel contribution to medical science: hats off and high fives!
For some folks, this visual joke probably needs some splainin’. If you don’t know Pulp Fiction, there’s a legendary scene in which Samuel L. Jackson scares the hell out of a punk who keeps answering his questions with a stunned “what?” Jackson dares him (and then double-dares him) to say it again, and then shoots him. The phrase “say ____ again” has become a catchphrase: fill in the blank with anything you’re sick of hearing about. It implies that you’re so fed up you might just shoot the next person who says it.
The other part of the joke: “release” is an exasperatingly meaningless and misleading term in massage and manual therapy. In particular, the term has reached annoying buzzword status when paired with therapy aimed at fascia (connective tissue), another faddish notion polluted with a great deal of nonsense. There is some serious backlash against it; many professionals are pretty fed up hearing about fascia in general, and release in particular, so hence the joke. I don’t know who first created this image, but I love them.
I dissect the idea of release thoroughly in my article, Does Fascia Matter? A detailed critical analysis of the clinical relevance of fascia science and fascia properties.
Heel spurs are outcroppings of calcification on the heel, about the texture of a potato chip. Despite their ominous appearance on x-rays have never seemed to be all that medically important. As the authors of a new paper (“The Conundrum of Calcaneal Spurs: Do They Matter?”) point out, “spurs were originally considered the cause of plantar fasciitis but are now regarded as an incidental finding by most authors.” But surely they aren’t entirely meaningless? No, probably not.
Moroney et al. looked at about a thousand heel x-rays, found spurs in about 12%, and then compared them to some spurless patients. Spurred patients were heavier and had more diabetes, arthritis, and (non-plantar-fasciitis) pain, leading the authors to a rather grand-sounding conclusion: “We have demonstrated the relevance of a radiographic finding once considered irrelevant.” In other, humbler words: smoking gun evidence that heel spurs are, shocker, not entirely innocuous and are more common in people whose lower limb tissues are under seige from age and weight. It’s mildly interesting data, but I’m not sure it matters much, and we can probably do without the grandiosity and just file this one under No Shit, Sherlock.
For what it’s worth — a little data-based context — I have added this reference to my plantar fasciitis tutorial.
“The Conundrum of Calcaneal Spurs: Do They Matter?”
So there’s a new review of massage for fibromyalgia out.
“Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials”
This is going to seem negative to a lot of folks (because, hey, it’s me), but let me be extremely clear right at the start here: I don’t think this paper shows anything one way or the other. I think it’s straightforwardly inconclusive. It has a positive sounding conclusion that isn’t really justified and has major caveats. But that doesn’t mean that I wouldn’t go get me some massage if I had fibromyalgia. I would! But that’s another story. This is about the paper, so here goes:
This paper epitomizes the “garbage in, garbage out” problem with meta-analysis. There was virtually no research on this topic worth analyzing to begin with. Trying to pool the results of several weak studies is basically meaningless. To the extent that the study results are generally inconclusive and ambiguous, the conclusions of any review are going to have more to do with the authors’ opinions than hard data.
This review is somewhat novel in that it includes some Chinese research, but it doesn’t really help. The introduction curiously boasts that “traditional Chinese massage is one of the most ancient massage therapies,” but there is not enough distinctive about Chinese massage that makes it worthy of any focus, and massage is ancient in every culture. This weird, prominently placed statement is a red flag: biased interpretation ahead! (And only one study of traditional Chinese massage made it passed the selection criteria anyway.)
This paper epitomizes the “garbage in, garbage out” problem with meta-analysis. There was virtually no research on this topic worth analyzing to begin with.
Unsurprisingly, the conclusions here are superficially positive: massage “significantly improved pain, anxiety, and depression in patients with FM.” But that’s statistical significance only, not a clinically significant degree of improvement: the size of the effect is trivial (much smaller than amplitude of the noise in the data). As usual, using the word “significantly” this way is technically correct and defensible, but otherwise misleading to all but the most alert readers.
Also, the conclusion is based in large part on the data about depression and anxiety, which are likely to improve with massage regardless of any effect on fibromyalgia. (This is the one truly evidence-based effect of massage.)
And more bad news: despite the seemingly strong positive conclusion, the data is silent on longer term effects. Only two studies had any follow-up data at all. Without promising data about long-term effects, it would be hard to say massage “works” even if the short term data were much more clearly positive.
Both sides of this research question are highly problematic: fibromyalgia is hard to diagnose or define, and massage is hard to study. Even using official diagnostic criteria, which changed significantly in 2010, there’s a lot of wiggle room. (As Fred Wolfe has put it, “One doesn’t either have fibromyalgia or not have it. There is a gradual transition from the mild to the severe. The point at which we classify an individual as having fibromyalgia is arbitrary, but reasonable.”) The types of massage reviewed here were generally vague and all over the map, from the straightforward (Swedish massage) to trendy-but-meaningless “connective tissue massage” (the idea of isolating or even emphasizing connective tissue in massage is a biological absurdity, like trying to eat the gristle out of a steak without masticating anything else) to rank quackery like “therapeutic touch” (which is literally not massage at all and roughly on par with believing in magic). What a mess.
So here’s my conclusion: whoopty-do. There’s really nothing here, except maybe massage for fibromyalgia being damned by faint, ambiguous praise. Sigh.
Thought I’d get the blogging rebooted with something easy and fun. More substance tomorrow!
I’m back at my desk, working and blogging again. That was my longest break from blogging ever, almost four months. I worked crazy hard on big picture SaveYourself.ca projects for all of December and January while my wife was travelling in India, and then took six weeks off when she returned (my first serious holiday in years).
Business has been great while I was gone, running well on semi-automatic, as it was always designed to do. But it’s not like nothing was happening: several contractors and collaborators were working while I was slacking, and I’ll be making some neat announcements about their work soon. It will probably take me a couple weeks to get back up to full blogging speed — I have a ginormous backlog of email, bookkeeping, and other “paper”-work — but scads of posts have been waiting in the wings since December and January.
As always, you can follow along and comment on Twitter, Facebook and Google, or subscribe via RSS feed. (Twitter is where I’m liveliest these days.) I’ve also been working on my personal blog lately, Writerly, and I will be very active there as well — more than ever, in fact.
My weird nine-week sabbatical-ish thing is done, and I’ve begun a proper holiday of a few more weeks. It was such a peculiar experience that I blogged a bit of a post-mortem: what’s it like tyring to “finish your career” in a couple months?
I have a huge backlog of posts and announcements prepared for this blog, but I’ll hang onto them until I’ve had the holiday. It would be easy enough to post something every day, just a couple minutes — it’s all mostly ready to go — but then you all would want to comment, and correct, and debate, and discuss (on Facebook especially) and I would end up either getting into it, or feeling guilty for not getting into it, and before you know it my brain is full of work again! So the blog will remain mostly idle for another few weeks, and will finally resume “sometime in March” (some comfortable latitude there).
Meanwhile, if you browse around, there are lots of updates and upgrades to be discovered. In particular, try the new, “smart” index to the site (and there’s one announcement taken care of early).
I’m a little more than half way through my eerily quiet, intense sabbatical: day 36, and just 27 to go. My wife is happily tromping around India, first the north, now the warmer south. While she looks at cave paintings and pornographic ancient temples, my circumstances at home are ideal for the hardest and most focussed work I’ve ever done (plus a lot of exercise). Many whole days have passed without even a phone ringing: long meditative stretches of precise, relentless productivity, something most writers never get to try.
I’m churning out dozens of painfully overdue updates and upgrades to SaveYourself.ca, untangling a mind-melting knot of loose ends — papers I’ve been meaning to cite since 2012, factual errors pointed out to me in 2011, clarifications I promised a customer in 2010, a glitch I noticed in 2009 that I’ve seen every few months ever since and thought, “Is that still there? I should really fix that.” Now I finally am!
So it’s going well, and it’s also exhausting and humbling. I’ve been forced to admit my limits and officially kill off some major projects I truly thought were non-negotiable (as recently as Thanksgiving). Now they’ve been wedged into my bulging Never Gonna Happen file, between “learn Español” and “get my black belt.” Apparently writing and maintaining several books and a bunch of articles is enough for one career! If I plan to knock off the 80-hour weeks for the second half of my life, that is. Starting in 27 days.
SaveYourself.ca is now a successful project. It’s going so well it’s almost alarming: it has gotten tough to juggle all the demands of a fast-growing publishing business. You can read more about that on my personal blog, Writerly (PaulIngraham.com). Here’s a snippet from Uh oh, success!
Many people who start small businesses want them to stay small, usually so we can (mostly) keep wearing the hat that defines us (butcher, baker, e-book maker). We’re more interested in whatever our business is about than we are in running a business. Fast growth — too many customers, too much “paper”-work, too many phones ringing — can make that vision recede in the distance like a mirage.
This blog will now fall mostly silent for a spell, while I work harder than ever on new content, avoiding the distraction of blogging about the subject matter as I go. I need to buckle down and do some serious work:
major updating and polishing of the books
finishing the audio versions (finally!)
purging some scruffy old content
major investments in publishing technology and efficiency (my favourite part, actually)
And so on, and much more. Stay tuned for a revival of this blog and a lot of good stuff in 2014. The salamander’s best is yet to come!
Sometimes when researchers sum up by saying “more study needed,” what they really mean is “the evidence hasn’t gone our way yet, so let’s keep doing shabby science until it tells us what we want to hear.” This meta-analysis of kineso taping for sports injuries in New Zealand’s Sports Medicine journal doesn’t really have much good news to report, but it manages to come off as pro-taping and cautiously optimistic anyway:
In conclusion, there was little quality evidence to support the use of KT over other types of elastic taping in the management or prevention of sports injuries. KT may have a small beneficial role in improving strength, range of motion…. The amount of case study and anecdotal support for KT warrants well designed experimental research, particularly pertaining to sporting injuries, so that practitioners can be confident that KT is beneficial for their athletes.
This formal response in the British Journal of Sports Medicine, by Drs. Steve Kamper and Nicholas Henschke, just seethes with irritation.
Despite the title of the review, the authors do not report a meta-analysis of the included studies. … The review has several flaws, the most serious of which is selective reporting of outcomes. As only positive (significant) results are reported it is not possible to assess the entirety of the evidence for effectiveness of kinesio taping. In addition, while the authors report to have followed the methodological guidelines of the Cochrane Collaboration this does not appear to be the case. … Clinicians should look to other sources of information…
More study of taping is needed, but not “so that practitioners can be confident” — it should be done because we need to find out if practitioners should be confident. And the limited evidence so far is discouraging, not encouraging, and to the extent that there are a few scraps of positive evidence, it’s a classic case of damning with faint praise.
“Kinesio taping for sports injuries”
Science-Based Medicine posts off and on for years now, often sharing a laugh or commiserating about some of the tragic subject matter (like today’s post, Faith Healing: Religious Freedom vs. Child Protection). She’s an amazing writer and person:
When Harriet Hall graduated from medical school in 1970 and entered the Air Force, she was in a distinct minority. As the second woman ever to do an Air Force internship, she had to fight for acceptance. Even a patient’s 3 year old daughter proclaimed, “Oh, Daddy! That’s not a doctor, that’s a lady.” She was refused a residency, paid less than her male counterparts, couldn’t live on base, and couldn’t claim her husband as a dependent because he wasn’t a wife. After six years as a general medical officer in Franco’s Spain, she became a family practice specialist and a flight surgeon, doing everything from delivering babies to flying a B-52. She earned her pilot’s license despite being told “Women aren’t supposed to fly,” and eventually retired from the Air Force as a full colonel. She is witness to an era when society was beginning to accept women in traditionally male jobs but didn’t entirely like the idea yet. A somewhat warped sense of humor kept her afloat, and it spices the stories she tells about her own experiences and the patients and colleagues she encountered.
Jason Silvernail, PT, regarding a plea to help defeat legislation to make dry needling of trigger points the exclusive domain of acupuncturists:
This is the kind of pointless turf war foolishness that the licensure system encourages. Remember it has nothing to do with evidence and everything to do with lobbying and economic protectionism.
Definitely. It’s important context that acupuncturists are struggling to preserve their reputation as the evidence piles up and overflows: acupuncture can’t beat a placebo. This is a blatant attempt to lay exclusive claim to a superficially similar treatment method that has the appearance of being more evidence based, because it is currently practiced by many physical therapists and doctors. Unfortunately and ironically, it isn’t based on much evidence — at best, it’s only more plausible. Acupuncture isn’t even worth testing any more — it’s all over — whereas dry needling still needs to be properly tested. Nowhere in this legal battle can you find anything of clear value to fight over: it’s a tug-of-war over scraps.
Nevertheless, I have no trouble picking a side …
Do our bones influence our minds? “Who thinks of the bone as being an endocrine organ? You think of the adrenal gland, you think of the pituitary, you don’t think of bone.” But apparently you should.
The data is now overwhelmingly negative. DoctorDoubter:
I will say what surgeons seem reluctant to say: “I am sorry, but for this condition, surgery is unlikely to provide any benefit over the non-operative alternatives.”
And that’s why I link to him.
Mea culpa: that knee ligament “discovery” I linked to yesterday? Not so much discovered as “looked at more careful like.” Studied, classified. Perfectly worthwhile research, but over-hyped by the media reporting about it. It was definitely hyperbole to describe it as a discovery. It’s been known of for at least a century, and a paper last year reported finding it in every knee they looked at. I didn’t look more carefully at the story because it was just a minor interesting thing (and anatomy really is never done), but it’s amazing what even a tiny little bit of hype will do. Hat tip to Tony Ingram of BBoy Science for raising my awareness.
Two knee surgeons at University Hospitals Leuven have discovered a previously unknown ligament in the human knee. This ligament appears to play an important role in patients with anterior cruciate ligament (ACL) tears.”
And perhaps iliotibial band syndrome? I don’t see any obvious relevance to ITBS — this new ligament is a little low for that — but I’ll be mulling it over. Regardless, it’s a fun discovery. Contrary to what people assume, “basic” anatomy is still a work in progress.
If you’re trying to build muscle size, how many weight-lifting sets should you do? One set? Two sets? (Red set, blue set?) More? James Krieger’s 2010 paper in Journal of Strength & Conditioning Research is the best review of the evidence to date. While it can’t conclusively settle the issue until there’s more data, it does strongly suggest that “more is better,” and yet at the same time it reaffirms that “less is fine.” Single sets will get the job done, which is ideal if your goal is bang-for-buck. (If you want to be “hyooge,” though, definitely go with more sets. It’s all about goals.)
Alas, there wasn’t that much data to review, just 8 studies, and only 2 of those included higher numbers of sets. That’s not a lot to work with. But the results are consistent with the more complete data about strength (see Krieger’s 2009 review), and strength and muscle size do tend to go together. Both citations are now included in my article about strength training bang-for-buck, see:
The SaveYourself.ca “microblog” was introduced in March of 2013, a minimalistic format optimized for bite-sized posts and announcements. This week it got its first big upgrade: small as they are, posts now have their own dedicated pages (instead of just living in a big list). For instance, see the last post, “Dissing dyskinesis.” Or — random example — the very popular “Good news about running.”
There could be a little strangeness with the RSS feed at first, probably duplicates of recents posts, but it will be fine going forward.
Recently in a discussion on Facebook, a chiropractor got annoyed with a physical therapist for calling shoulder dyskinesis a “dubious” clinical concept. He asked for evidence and linked to a PubMed search, suggesting that the existence of so many papers about it must mean it’s legit. This was too good a rebuttal opportunity for me to pass up: a slow pitch right across home plate. Evidence that shoulder dyskinesis is dubious? In those search results, it took me all of 10 seconds to find Wright et al on the first page, a nice fresh 2013 review in the British Journal of Sports Medicine concluding “no physical examination test of the scapula was found to be useful in differentially diagnosing pathologies of the shoulder.” Hard to treat what you can’t diagnose.
“Shoulder dyskinesis” is just fancy talk (elaborate parlance!) for “bad shoulder movement.” It’s a bogeyman for freelance therapists to chase for pay. With almost nonexistent diagnostic reliability, it’s clinically useless, a diagnosis that has more to do with sounding good than actually knowing anything helpful, so that they can stare at your shoulder for a couple minutes and wisely declare, “Well, there’s your problem,” as though it were obvious — to an expert, anyway. disclaimerThis is not to say that there is nothing ever wrong with shoulder movement. It is to say that it mostly defies useful interpretation and is much less important than supposed by some, just like most other diagnoses of dysfunctional movement and alignment.
Alert reader Michael B. sent me this example of crazy clinical arrogance about diagnosing by feel (palpation), How To Get Out Of Pain In 30 Days. There’s a million crappy miracle cure sales pitches out there, of course, but this one stands out for its emphasis on near-magical powers of palpation in particular, an entertainingly distinctive delusion of grandeur.
Now, close your eyes and comb over the paper until you find the hair; continue to drag the hair underneath your finger and around the paper until you lose it. Repeat for 15 minutes/day. Within 2-4 weeks, you’ll have an incredible sense of touch.
Yes, that’s all it takes to get “x-ray hands”: hair rubbing. And if you believe that, I’m having a bridge sale. I’ve written about this particular flavour of nonsense before…
There is no such thing as “medical acupuncture.” The term is oxymoronic propaganda, a common way to make acupuncture seem more legitimate. But it’s all just acupuncture: defeated in one rigorous clinical trial after another for many years now.
Flexing your knee can squish the blood out of your kneecap like it’s a sponge — maybe literally, or maybe just a metaphor — suggesting that poor circulation could be a cause of patellofemoral pain syndrome (anterior knee pain). In particular, it might explain the notorious “movie sign,” in which simply sitting with flexed knees makes them ache. A 2008 study (Näslund et al) of 22 patients showed that 19 of them had reduced blood flow while the knee is flexed, but no such sign could be detected in healthy people. The method used to measure blood flow (photoplethysmography!) is new and therefore not exactly a sure thing, but there’s a good chance it works as advertised. Their data was a bit all over the map, but the averages were clear enough. If the results can be believed, it raises more questions than it answers: Is it cause or a symptom? Why would blood flow be reduced in the first place? Could this be why almost any kind of exercise tends to help — normalizing blood flow? And since when can you squeeze blood out of living bones?moreBecause living bones are surprisingly rubbery. The kneecap in particular is subjected to simply astonishing compression forces even in unloaded knee flexion. The squishableness of kneecaps in itself is a fun fact, but not especially surprising. The real curiosity here is: what’s the difference between the patients with knee pain and healthy controls? Why does knee bending impair circulation in some kneecaps and not others? How does that work? Tantalizing data!
“Decreased pulsatile blood flow in the patella in patellofemoral pain syndrome”
Update: this item got my friend Dr. Rob Tarzwell of One-Minute Medical School curious about arterial supply to the patella. He writes: “It looks like normal anatomy involves a circulatory anastomosis. That's where multiple arteries plug into a ring, and the ring then has feeders going to the patella. Presumably, this is to allow for redundancy of supply in the event of flexion of the knee closing off supply. Now, if the anatomy isn't sufficiently redundant, then supply could become temporarily compromised. Variants of normal anatomy are legion.” In other words, not everyone’s arteries may be arranged optimally to cope with flexion, and some may fail to keep the blood flowing during flexion — which would explain these results, and potentially a lot of otherwise mysterious anterior knee pain. This is a fascinating, plausible hypothesis.
Reflexology will probably get a big PR boost from this pseudoscience, already “highly accessed,” because it creates the appearance of validity where there is none. The paper has a shiny, hard protective shell of superficial legitimacy. It’s difficult to criticize specifically, because there’s nothing obviously wrong with the mechanics of the fairly complicated and technical experiment. The problems here are more basic and general: fancy brain studies purporting to show the existence of a mechanism for reflexology are more propaganda than interesting or useful science. fMRI scans are notoriously uninterpretable and prone to producing research artifacts, and the results just happen — coincidence, I’m sure! — to give a lot of comfort and aid to one of the most implausible and scientifically bankrupt treatment claims in all of alternative medicine. Dr. Christopher Moyer:
There is no good theory for reflexology. In the absence of a good theory, a single study that connects a twitch of the toe to the blink of an eye, or their neural correlates, is of very little value.
Without good replication, this one gets no more than a Spock eyebrow raise from me: it’s just another case of tooth fairy science.
In a 2011 paper, “The Modernisation of Manipulative Therapy,” Australian physiotherapist Max Zusman writes:
Research indicates that, despite physiotherapists’ comprehensive training in the basic sciences, manipulative therapy is still dominated in the clinical setting by its original, now obsolete, structure-based “bio-medical” model. more“This is further inexplicable in the light of evidence that not only the underlying “philosophy” but also several of the fundamental requirements of the clinical process itself which has the structural-mechanical model as its basis, have been shown to be flawed or at least irrelevant. The apparent inability of the profession to fully abandon outmoded “concepts” (and embrace the acknowledged science-based “best practice” biopsychosocial model) may have potentially undesirable consequences for both patients and therapists engaged in the management of (chronic) musculoskeletal pain and disability.”
Extreme examples are educational. For instance, we know from the experience of ultra runners that it is possible to run in a way that is less hard on your body. Once again, consider the case of Philippe Fuchs, who ran from Paris to Beijing, covering ~5,100 miles in 161 days. His primary concern was his “ability to keep absorbing muscular and skeletal punishment day after week after month,” of course. By the time Fuchs finished, he had developed an endurance stride that was clearly shorter and lower: he padded along with about 6% more steps per mile, a whopping 30% less time in the air, and 11% less landing force. I’m betting he wouldn’t have made it without those adjustments. Fascinating!
20 hours per day faster. Sorta. The slowest part of downloading most web pages is the images. Although SaveYourself.ca pages are already fast (under one second for most visitors), a good chunk of that time is images.
From the Dept. of Long Overdue Chores: hundreds of images on SaveYourself.ca have now been replaced with lighter, aggressively web-optimized versions that download about 20% faster on average. It doesn’t sound like a lot, but with about 18,000 page visitors per day, it definitely adds up. In fact, it will save (very roughly, lots of variables) about twenty hours of data downloading time for my visitors every single day. With more and more people on cellular data plans, that actually matters!
So that’s how it is. But why and what does it mean? That’s much trickier, of course. Apparently hamstring flexibility is a trivial factor in how the back moves, and it gets trumped when people develop back pain. Which probably means that tight hamstrings aren’t a risk factor for back pain. Which probably also means stretching — even if you could stretch hamstrings — also won’t have much effect on how back pain patients use their backs. For whatever that’s worth.
Oh, and the lack of correlation persisted even after recovery, which is particularly interesting. And also mostly uninterpretable without more information (like how long that effect lasts).
“Effect of hamstring flexibility on hip and lumbar spine joint excursions during forward-reaching tasks in participants with and without low back pain”
“It’s all coming from the ____, I know it!” The temptation to boil the cause of chronic pain down to a single culprit can be almost overwhelming, but you must resist. Single causes of long term pain are almost unheard of. Nearly all chronic pain is a witch’s brew of different factors, complex by nature (not just coincidence or bad luck). This makes it harder to beat overall, but some factors are more treatable or manageable than others. Find and work with those.
Studies have shown that runners probably do not get more knee osteoarthritis than anyone else, which is a bit surprising: surely regular pounding wears out joints? Researchers took a bunch of fancy pictures of the insides of knees before and after a marathon, using a new MRI technique that can detect early cartilage degeneration: “Runners showed elevated T1rho and T2 values after a marathon, suggesting biochemical changes in articular cartilage” and “the patellofemoral joint and medial compartment of the knee show the highest signal changes, suggesting they are at higher risk for degeneration.” Sounds bad, doesn’t it? Also, perhaps some biomarkers of trouble “remain elevated after 3 months of reduced activity” — but it’s arguable that those results were not actually statistically significant.
So, bad biomarkers in the knee after running, oh noes! But I actually see good news for knees here. It’s not surprising that a lot of running has an effect on joints in the first place, of course, and this data confirms that. But this data also shows that the effect is surprisingly minor, and that most knees recover, either mostly or completely, within three months. Which is very important information. Stressfully loading a joint in itself is probably not a problem per se, and could even be healthy, stimulating, toughening — as long as you allow time to recover. It’s excessive loading without adequate recovery, AKA “overdoing it,” that is likely to be the real hazard for runners. I see this as (more) evidence that the average sane runner is not wearing out his or her knees (and also that runners who do get into trouble really, really need to rest and let their biomarkers simmer down).
“High-Field Magnetic Resonance Imaging Assessment of Articular Cartilage Before and After Marathon Running: Does Long-Distance Running Lead to Cartilage Damage?”
Here’s a short, fascinating ultra-running case study with a counter-intuitive outcome: Philippe Fuchs ran from Paris to Beijing, covering ~5,100 miles in 161 days. He “lost five pounds during the run, and his percent body fat dropped from 21.5% to 16.5%. You’d think this would make him more oxygen efficient. It didn’t.” Damn! Biology is wacky.
new article about Kinesio Tape® and similar products, which explains that therapeutic taping is mainly just a sensation tweaker, and that’s fine as far as it goes. We humans are neurological input-output machines. We constantly, systematically, creatively tinker with how we feel … touch-testing the world. This is why I have no strong objection to therapeutic taping, but also why I will probably never be impressed by it: it’s just another method of playing with how our bodies feel, one of many. But it will never trump functional challenges as the main drivers of recovery and performance. The bottom line is always going to be that we have to push ourselves a little to get better than we are — and being taped just isn’t much of a challenge.
“Performance enhancement” is usually a problematic claim, because it’s commonly based on sloppy extrapolation from recovery effects (which are themselves often a bit sketchy). Even what genuinely helps people who are sick or broke is not necessarily going to do anything for fit, healthy people. Or vice versa. (Simple example: compression bandaging for swelling. Unambiguously handy in recovery … but useless if you’re not swollen!) Rehabilitation and performance enhancement are just different things. On the one hand, they are the same process with different starting points. On the other hand, how much value the body can extract from an input is generally proportionate to need. A glass of water is more important to a man dying of thirst, and novel sensation is more neurologically useful to an injured person than a healthy Olympian.
Pretty regularly I report evidence that Brand X therapy or exercise doesn’t work very well, if it all. And, almost always, I get protests that it works if done properly — as opposed to the presumably typical version that was tested. This is problematic, even if it’s true. There’s probably not much point in branding a method of therapy or exercise if its benefits are inaccessible to most people. This is the “prodigy problem” for modalities: if it requires exceptional intelligence and skill to implement, then it’s a hollow victory that is excluding everyone else. How good can it be if the average professional cannot deliver it, and/or the average patient cannot learn it? And can anyone actually tell who the prodigies are? Treatments that aren’t reasonably replicable are not worth much in practice. I can’t really recommend a treatment that is useless in the hands of 85% of practitioners. And yet the world of therapy is quite preoccupied with the idea of the special therapist who can deliver results that others cannot…
There’s always a way! This is both deep and funny — nice work by Dylan Matthews at Wonkblog. It seems like a bit of a credibility disaster for science analysis, but don’t be too cynical: most scientific papers legitimately do not deserve an A-grade. Like any good science writer, I try hard to dismiss only the evidence that actually deserves it.
It is a widely and passionately held belief that back and abdominal strengthening will help back pain, and Pilates is the branded exercise system dedicated to core strengthening, so Pilates must be good for back pain, right? But in a recent test by Miyamoto et al, patients who did Pilates had “small benefits” compared to those who did not. And the test had a serious flaw: it neglected to compare Pilates to other any other kind of activity (shamefully sloppy design, fairly junky science). These results only add to the pile of evidence that exercise and therapeutic attention of any kind are probably good for low back pain. It’s only worth reporting these results insofar as they damn Pilates with the faintest possible praise — evidence that Pilates has no special power over back pain. I am not even a tiny bit surprised by this.
“Efficacy of the Addition of Modified Pilates Exercises to a Minimal Intervention in Patients With Chronic Low Back Pain: A Randomized Controlled Trial”
Ideas based only on educated guessing about biology, however reasonable and plausible they may sound, have a nasty habit of falling apart when more directly tested. This is one of the strongest patterns in the history of medicine. A classic modern example is autologous blood injections for tendonitis: an idea that sounds promising if you just talk about the biology, but fails when tested on actual patients.
Let's start here with what nobody looks like: nobody looks like the people in magazines or movies. Not even models. Nobody.
Because, of course, what we see in magazines and movies aren’t really people anymore, but skilfully lit and pixel-manipulated artwork — beautiful in their own way, of course, or why bother? But they are only distant, abstract cousins to homo sapiens. In all my years massaging, I never experienced a client as “ugly.” It just isn’t possible when you’re actually paying attention to the person.
Yesterday I linked to Byron Selorme’s story of roofing his house with surprisingly little pain disturbance to his chronic pain. But that was a year ago, and while Byron got no worse, he also hasn’t gotten any better. I’ll try to extract an insight or two…
It was brave and wise to attempt the roofing as he did, and he got away with it, which is quite interesting and inspiring, and it strongly suggests that — in his case at least, but many others too — his pain has never been caused by anything “fragile” or “degenerating,” or the roofing would likely have been a disaster. And yet he’s also still in pain! This exasperating duality is common: one the one hand, pain is often less disabling and prone to exacerbation than people expect, particularly for those who are able to maintain confidence that they are not made of glass. If chronic pain was “just” a psychological puzzle, then thoughtful, positive people like Byron would usually solve it.And yet all the positive mental attitude in the world often doesn’t put a dent in the problem either. In a case like Byron’s, there could be a source of tissue irritation, which the brain simply refuses to ignore and doggedly, perpetually interprets as a mild threat (at least, but probably partially controlled by careful conscious management of fears, as Byron did). But there could also be some more exotic, invincible sensitization — disturbed interpretation of tissue signals — which is a real neurological issue, as opposed to the psychological problem chronic pain patients are so often accused of (sometimes carelessly, sometimes almost maliciously, sometimes even by themselves).
But you can be sure of this: if chronic pain was “just” a psychological puzzle, then thoughtful, positive people like Byron would usually solve it.
What if it was just as good for your aerobic fitness to lift weights as to run? Here’s a paper that says it probably is. The authors have a bias favouring this theory, and there’s no real evidence about it yet, but it’s plausible and they make several perfectly reasonable points about the basic exercise biology. At the very least, it does firmly support the idea that building strength is better for general fitness than most people realize (which is all I’m really after). More detail in the bibliography:
“Resistance Training to Momentary Muscular Failure Improves Cardiovascular Fitness in Humans: A Review of Acute Physiological Responses and Chronic Physiological Adaptations”
Yoga teacher Byron Selorme has a history of chronic shoulder, neck and hip pain. Then he decided to re-roof his house by himself. What happened after hauling 1,600 lbs of shingles? Which was, I gather, roughly “way” more physical strain than he was used to? Well … he was just fine: “I did not have any increase in pain. In fact it had actually lessened a bit.” How can this be? If there was something “really wrong” with is shoulder and neck to begin with, how could he possibly get away that? Maybe some conditioning helped. In his own words, “Understanding pain and why we hurt can actually make a huge difference.” I’ve heard a lot of stories like this over the years: almost freakish shifts in what people feel and what they’re capable of. “If I had listened to the sensations in my Neck, Shoulder, and Hip I would never have planned to do this project. But I have learned that how they feel does not necessarily tell me whether they are capable or not.” Indeed!
A “half hour run” sounds so innocent. I’ll just go for a half-hour run. See? No big deal, right? But I can really kick my own ass in thirty minutes.
This study (Couto et al) found “significantly” better results from dry needling of trigger points. (That’s a method of lancing painful spots in muscle with acupuncture needles. To make them feel better. No, seriously, it’s actually a thing.) But that “significant” was the statistical sense of the term. The abstract actually neglects to mention how much better the results were, which usually means that the number wasn’t worth showing off. Sure enough, looking at the data, the decrease is just 2 points on a 10-point scale. That’s not nothing, but for someone who starts at a 6 or an 8, it’s not exactly a cure, is it? If it actually does work that “well” — assuming that these pro-IMS researchers (I’m speculating, but it’s very likely) didn’t make any mistakes or do anything that might have skewed the data towards their bias a little — is a 2-point drop actually worth the high cost and discomfort of this treatment? An open question.
“Paraspinal Stimulation Combined With Trigger Point Needling and Needle Rotation for the Treatment of Myofascial Pain: A Randomized Sham-controlled Clinical Trial”
This popular article about how acupuncture works “because fascia” is riddled with problems. Alt-med celebrity Helene Langevin makes a mountain out of a biology molehill: the mildly interesting fact that tissue is a bit “grabby” and hangs onto acupuncture needles. This may or may not have anything to do with fascia, but so what if it does? Does it matter? Can such tiny fascial stretches relieve pain? In fact, we know that they don’t, because we know that acupuncture proper doesn’t relieve pain, and therefore doesn’t need any explaining in terms of fascia or anything else. Nevertheless, this is the purpose of the article, and Langevin lobs out a major bonus, bogus premise to clinch her case that acupuncture is probably all about fascia: according to her own research, acupuncture meridians correspond to fascial structures. But the “mysterious” meridians are “nothing more than a rudimentary and prescientific model of blood vessels and nerves” (Kavoussi), because until about a hundred years ago, acupuncture was pretty much the Eastern version of bloodletting, and its needles were more like little knives. There is no meaningful connection between fascia and acupuncture meridians. This article is a classic example — one of the best — of trying to make fascia (and acupuncture) sound much more medically important than the evidence can possibly justify.
This time Todd Hargrove is writing about The Complexity of Biomechanics, a favourite topic of mine. Todd’s gist is the same as my own detailed rant about “structuralism,” but Todd is pithier than I am (as usual). If you want to get the same ideas much more quickly, read his:
I think this kind of detective work is very cool and I always look forward to applying it to help one of my clients. But that is where things get frustrating, because with biomechanics, as with so many other subjects, the more you learn, the more you realize you don’t know as much as you would like to know. And sometimes you don’t know enough for your treatment protocols to make any sense.
However, I am Todd’s more cynical evil twin, and I (invariably) come to bleaker conclusions, more persuaded by his own arguments than he is. For instance, he makes a great case that even the most rudimentary biomechanical equations are fraught with unsafe assumptions and capricious variables. And if that’s true — and I really think it is — then, well, yikes! In my opinion, biomechanics are effectively impossible to apply, for the average clinician, most of the time.
Perfect little animation to whimsically “demonstrate” mobilizations (dynamic joint mobility drills). Gifs are big files, so this is a tiny version, but zoom for the full size (1.7MB!).
Also, not that it really matters, but this cat looks exactly like my cat (no longer with us, RIP) and that couch looks exactly like my couch. See?
Q Is there any scientific evidence that my favourite minor massage method really works?
A The massage world is fragmented into dozens (even hundreds) of branded methods touted to be better than Swedish massage. People ask often ask me if one these methods “really works.” Unfortunately, we can’t judge any of the lesser massage techniques based on the results of good tests (that is, careful comparisons with other treatments, and fake treatments). Such data is thin even for the most prominent massage modalities. The rest have not been studied at all, or so poorly that it barely counts (eg: “tensegrity-based massage”). For now, and maybe forever, we can only judge these methods on the basis of the strength of their defining idea.
If they even have one. What’s different about it from other common massage methods? Anything? What can it do that supposedly other techniques cannot? You’d be surprised how many barely count as more than a slight variation on Swedish massage. Even if it is distinctive, is the big idea any better than a pet theory? Most are not. The history of medicine is littered with pet theory corpses. Most treatment ideas do not work out (null hypothesis), even really good ones. And almost everything that is worthwhile about massage is probably thanks to being artfully touched, which you’ll get from most methods. A slightly more detailed version of this answer is now in my article Does Massage Therapy Work?
If a placebo treatment can do good, how much good will it do when combined with a little real medicine? That’s what I call an enhanced placebo: a treatment that seems much better than it is, because a small but real medical benefit makes it easier to believe in. Empty promises can and do reassure patients all the time, but even just a little genuine relief is more reassuring — it may prove that relief is possible to a patient that has lost hope, which can be just about as good as actually fixing anything.
One lesson to take from this is that snake oil is always much more marketable and pernicious when a little real medicine is included, exaggerating its effectiveness and generating more passionate testimonials. But enhanced placebos will make any partially effective medicine look better — which helps us to make sense of the huge, murky gray area between outright quackery and rare true cures, where real biological effects and the hopes and fears of patients are hopelessly entangled.
Never give up, because you can recover from damn near anything … if you are patient and methodical. Gene Lawrence, a 74-year-old record-setting powerlifter, tore his quadriceps. Eight months later he’s on the verge of beating his personal bests: total recovery. Bret “The Glute Guy” Contreras tells his story, and some other tales of extreme recovery, and extracts some lessons.
Hint: no (certainly not when properly defined). Todd Hargrove has “noticed that some of my colleagues in the bodywork community are somewhat disapproving of using a scientific approach to understanding how the body responds to manual therapy.” Indeed! But he’s also noticed a positive trend, and I agree: it is getting better, and it has a lot to do with blogging and social media. Nice post, with a nice mention for yours truly and several more I know well. Thanks, Todd.
SaveYourself.ca traffic hasn’t dipped under 10,000 visitors/per day in several months now, and is usually over 12,000, which is pushing half a million a year. That’s quite good for an independently run website, and only a bit less than Science-Based Medicine, an important medical blog with many distinguished contributors. I know their stats because I’m SBM’s assistant editor. SBM has more and bigger spikes of traffic, but is otherwise the same as “little” ol’ SaveYourself.ca. I can often check Google Analytics and see, in real-time, more people reading SaveYourself.ca than ScienceBasedMedicine.org — which blows my mind. What I’m trying to do here certainly matters, but it doesn’t remotely have the gravitas and range of SBM’s subject matter. SBM should have ten times my traffic, and probably will someday. We’ve been doing a lot more to promote it this year. For instance, ScienceBasedMedicine.org has had an active and well-tended Twitter account for a few months now, and just recently we added an official ScienceBasedMedicine.org Facebook page as well.
I’m quite proud of what little credit I can take for these projects. Late in 2012, I volunteered to find someone to manage social media for SBM. I was sorely tempted to take on the job myself, but I came to my senses: I’m overwhelmed already, and it was going to be a big enough job just finding someone good to do the job for us. Sure enough, that chore was stuck in my inbox like a burr for months. My own initial recruitment effort was an abject failure. I was defeated by an exasperating series of delegatory hassles and disappointments with early candidates. (Try to get anyone do any major volunteer job, and you’ll soon find yourself muttering furiously, “What is wrong with people?”)
Eventually a volunteer came out of nowhere, no thanks to me: New York medical student, Bobby Hannum, just turned up one day offering to help. But I did work with him to get him up to speed, by golly, and I still get a kick out of how he treats me with earnest deference, as though I’m actually important or something. Someday-Doctor Hannum is really doing it well on his own. A warm public thanks to Bobby for his great work and generosity. Now, please go like the fine Facebook page he created:
Pal et al. found that one kind of wonkiness (high kneecaps) was fairly strongly associated with another kind (bad tracking), and that this kind of thing was more common in people with knee pain. This contradicts my bias and I’m a bit skeptical. The researchers were probably biased in the other direction, and expected to find abnormalities correlating with pain. They didn’t measure all that many knees, just 37 people with pain, and it’s easy to find what you expect in small batches of data. They don’t report just how much higher kneecaps were in the abstract, which would be natural to do if it were an impressive number, so I suspect it’s not an impressive number. Even if the correlation is real, it doesn’t tell us anything about cause (maybe misbehaving kneecaps cause pain, or maybe knee pain causes kneecaps to misbehave). Almost half their subjects had no abnormalities at all, which is consistent with other studies (Herrington et al) showing that you can find a roughly even mix of abnormalities in everyone, whether they have pain or not.
So this data does not change my basic position: biomechanical oddities may be a causal factor in some cases of knee pain, but probably not a major factor, or a majority of cases.
“Patellar maltracking is prevalent among patellofemoral pain subjects with patella alta: An upright, weightbearing MRI study”
Here’s a study that compares two kinds of massage for shoulder pain: regular Swedish versus “tensegrity-based” massage, which I have literally never heard of in 15 years of studying massage (although I can easily guess what they think they mean.) I smell a pet theory. “Tensegrity-based” massage is not actually a thing. There is no TBM® or standard definition. It means about as much as “anatomy-based.” Tensegrity refers to a principle of biomechanical organization (see Ten Trillion Cells Walked Into a Bar). Massage “based on the tensegrity principle” is wide open to interpretation to the point of absurdity. “Tensegrity-based” massage means about as much as “anatomy-based.” And yet the defining characteristic of tensegrity-based treatment offered in the abstract of this paper is merely where massage was applied (not how): “directing treatment to the painful area and the tissues … that structurally support the painful area.” As opposed to foot massage, perhaps? Meanwhile, the control group massaged “tissues surrounding the glenohumeral joint.” So, shoulder massage compared to … other shoulder massage. This comparison may be about as meaningful as a taste-test of tomaytoes and tomahtoes.
Giving these researchers a little benefit of the doubt, perhaps the difference was just size of the area of treatment, also known as “less thorough” and “more thorough.” That would be a somewhat interesting comparison, though not really useful for validating a treatment idea as vague as “tensegrity-based massage.” I can think of a few (about 17) non-tensegrity-based reasons why more thorough massage might work well. Be thorough is pretty much the first lesson in massage school. The shocking conclusion? They found that “more thorough” worked much better.
I have frowned at this issue off and on for a long time, and finally looked into it more carefully. I didn’t like what I found: customers that pay for my e-books in anything but US dollars get a price that’s quite a lot higher than the exchange rate. For instance, right now, even though the Canadian price should be a bit better than the US price — about 2% cheaper — instead it will be shown as 10% more expensive! If that seems like a bad deal, you’re right (and congratulations on your math skills). My payment processor, eSellerate, is charging a steep fee for payment in your own non-US currency. Credit card companies don’t exactly give you the most favourable exchange rate when you buy in a foreign currency, but many do not gouge this deeply. My own card charges very little: it’s not exactly the exchange rate, but it’s nowhere near what eSellerate takes. eSellerate spins their policy as offering a “gauranteed” price in your currency, so there are no nasty surprises on your credit card bill. In other words: “Give me $10 and I’ll make sure no one mugs you in the next block — you’re safe with me!”
Bottom line: buy my e-books in US dollars and let your credit card do the exchange, unless you know that their fee is even worse than eSellerate’s.
p>Whitfield was the star of the hit TV show Spartacus. The first sign of the cancer that killed him in 2011 was steadily worsening back pain. It’s always hard to diagnose a cancer that starts this way, but Whitfield was in the middle of intense physical training to look the part of history’s most famous gladiator. Back pain didn’t seem unusual at first, and some other symptoms may have been obscured. (For instance, some weight loss could have even seemed like a training victory at first.) It was many long months before he was diagnosed — not until the back pain was much too severe and constant. A scan revealed a large tumour pressing against his spine.
A film about Andy Whitfield, Be Here Now, is nearing completion as of mid-2013. It will probably be inspiring and heart-wrenching. Spartactus is worthwhile, by the way (although rated very, very R). See my personal blog for a short Spartacus review. For more about how to know when to worry about back pain, and when not to, see The Bark and the Bite of Low Back Pain.
Here’s some positive evidence for the power of the Functional Movement Screen (FMS) screen to predict injury, maybe. Or … maybe it was that other test? Importantly, the study was also a test of another screen (Y-balance). But it’s generally good news for screening, either one or both of the tests used. Nevertheless, my money is still on the null hypothesis — that ultimately nothing will come of this — and I don’t think any of the other evidence to date is all that persuasive yet. But if, in the end, good evidence says FMS (or any other screening) can predict injury, then bully for FMS! Most of my gripes with FMS concern egregious over-reaching its stated purpose as a screen, and using it as a diagnostic/prescriptive tool. If it does actually work as a screen, I will be the first in line to say, “Congratulations, FMS!” Truly. But I’m going to need some (more, better) hard data.
“Field-expedient screening and injury risk algorithm categories as predictors of noncontact lower extremity injury”
Real question from a runner:
“I don’t have time to sit about not training. Is it safe to just stuff myself with pain killers & carry on?”
Um, no … in (at least) 2 important ways:
First, of course, there’s just a real risk of making any injury much worse that way. Duh! There are exceptions, but you need to know what those are — you need a clear and specific rationale for breaking a generally excellent rule.
And second, “stuffing” with pain-killers is seriously risky and useless to boot. Pain-killers are bandaids at best, possibly not even that, and definitely not a good long term solution, because there isn't a single one that doesn't have truly serious hazards with chronic use (not the least of which is their effectiveness wanes).
Critical what? Hardly a day goes by I don’t read something smart online about critical thinking: how important it is, how to do it. It’s everywhere. So … why is still so much not-so-critical thinking floating around out there?! It seems odd.
The answers are obvious of course: above all, good quality thinking is a skill, because it requires working around obstacles that are truly unknown to us without training (obscure logical fallacies and sneaky cognitive distortions). It’s a hard skill to learn even for people who are super motivated. There’s almost no chance if it threatens comforting beliefs… or, worse, the basis for making a living!
But it still seems mighty peculiar and ironic that there’s so much good information available about critical thinking that isn’t being used.
A small experiment (Cramer et al) optimistically concluded that Iyengar yoga helped neck pain more than a generic exercise program. But this research was too flawed to trust. Dr. Edzard Ernst was not impressed, and I entirely agree with him: “One does not need to be an expert in critical thinking to realise that… the positive outcome might be unrelated to yoga.”
How refreshing! A perspective on placebo that doesn’t worship the “power” of placebo, but looks instead at the paradox of placebo: if placebo is so ding dang powerful, why isn’t everyone cured? Perhaps because the placebo effect is basically a dysfunctional mistake. Here’s a video, Why does the placebo effect work? 6:01, and here’s the scientific paper it’s based on, Humphrey & Skoyles, Current Biology, 2012 — and here’s some excellent some extra reading from Seattle Rolfer Tod Hargrove, who did a nice job interpreting and explaining the scientific paper. The additional perspective is most welcome.
The endlessly quotable Lorimer Moseley summarizes the role of the mind in chronic pain for TheConversation.com:
This is where our understanding of pain itself becomes part of a vicious cycle. We know that as pain persists the nociception [danger signalling] system becomes more sensitive. [Indeed we do. See Woolf.] What this means is that the spinal cord sends danger messages to the brain at a rate that overestimates the true danger level. This is a normal adaption to persistent firing of spinal nociceptors. Because pain is (wrongly) interpreted to be a measure of tissue damage, the brain has no option but to presume that the tissues are becoming more damaged. So when pain persists, we automatically assume that tissue damage persists.
I think it goes like this: “more pain = more damage = more danger = more pain” and so on and so forth.
And so, “Pain really is in the mind, but not in the way you think” — a good phrase. Partly inspired by this, I’ve written a new section for my low back pain book, which means that Dr. Moseley’s very valuable perspective is now quite well represented there.
Rob Heaton, How chronic pain has made me happier:
Chronic pain has forced me into the same good habits that everyone else is after. I make sure I sleep and eat well. I don’t work too hard. I don’t drink much. I prioritize balance. For most people, an imbalanced life means burnout in a few years time, but with chronic pain this can happen almost immediately. … I am in many ways stronger, whether I like it or not.
Whilst the problem is superficially a physical one, the real challenges faced by someone with chronic pain are mental. Mental state is the biggest modulator of physical pain. Things hurt more when you’re stressed or sad, and the increased pain makes you both stressed and sad. The way out of this vicious circle is a wholesale change to how you perceive fear, suffering and setbacks.
This sentiment was perfect for my article about healing by growing up.
Animal studies don’t come up all that often in my work days, and I find them rather macabre. In a Chinese bunny study by Hou et al, rabbits were injured, and then some of them received a lot of daily automated massage during recovery, from — I love this bit — an “intelligent massage device.” Their tissues were put under a microscope before and after, and apparently “histomorphology and cytoskeletal structure can be significantly improved after massage, which may help to repair muscle injury by up-regulation of Desmin and alpha-Actin expressions.” Hmm. Okay. Any study of tissue involves substantial complexities of observation and interpretation, and so it’s basically impossible to know whether the experiment was actually conducted competently and its results are trustworthy, unless other researchers do the same thing and get similar results. But it’s interesting, and promising, and consistent with the fairly sensible notion that moderate stimulation helps tissues recover from damage.
“[Promoting effect of massage on quadriceps femoris repair of rabbit in vivo]”
I deal with a lot of controversial subject matter. I debunk and criticize many products, services and ideas, which many perceive as “negative” … while I perceived it as “ethical” and generally have a lot of fun taking my subject matter seriously.
I’ve been writing about my so-called negativity off and on for years. I’ve prepared a compilation of tales of outrageous hate mail, quotes and comics and quite a bit of whimsy and eye-rolling, the ethics and tactics of debunking, what’s it like to be an “enemy of massage,” and — my favourite — “advanced negativity,” a discussion of how cynicism is baked into science in the form of the null hypothesis.
Noise, noise, noise! I am often asked about the meaning of knee noise (“crepitus”), which can often be quite spectacular — surely the loudest joint in the body. But knee noise in the absence of any other clear signs (like pain) is usually uninterpretable. It does not correlate well with problems. So you can be in trouble ... silently. And you can be fine... noisily. Rule of thumb: crepitus is only of concern if you’re also in pain, and not necessarily even then.
Louis CK satirizing the pain-killer dilemma: “Oh, it’ll do some intestinal damage after a while! But you’ve just got to weigh that against how much you like your ankle not hurting.” Yep, that’s about right. Some other very funny stuff in this excerpt too. See also the whole segment.
In this 2003 study of 31 Olympic athletes with back pain/sciatica, only about half had signs of disc degeneration or bulging. These are elite athletes, not malingerers. If they say they hurt, they hurt! Yet MRI failed to identify a disc problem in half of them. Just one of many studies of this sort cited in my low back pain tutorial.
AllTrials.net is trying make sure all pharmaceutical research results are reported — not just results that make drugs look good. The project is going better than I dared to hope. From an encouraging update on the project website: “Major organisations around the world are now taking this problem more seriously than ever before… The problem of trial results being withheld has been well documented for three decades, with poorly implemented fixes along the way, but now there is clear policy movement.” Excellent!
Odds that I would share this? 100%! Some things are just unavoidable. When one of my favourite comic artists ever (Matthew Inman of The Oatmeal) creates something detailed (six parts!) about long distance running — The Terrible & Wonderful Reasons Why I Run Long Distances — yeah, I’m definitely gonna share that. Because I’ve written three whole books about the consequences of long distance running.
“Effects of running and walking on osteoarthritis and hip replacement risk”
Egads, worst case scenario here. Eyebrow-raising pictures. Canadian Olympian’s ‘nightmare’ after acupuncture needle collapses her lung.
Intriguing: this test of 90 patients (half with neck pain, half without) showed that neck pain correlates pretty clearly with weak breathing. But is the weakness a cause? An effect? A bit of both, perhaps — if I had to guess (and I do have to guess), I’d guess “all of the above.” Both pain and weakness are probably both a cause of AND an effect of the other.
I have an article that explains that you probably don’t have to go to the gym as much as you think to build strength. I originally called it “Less Is More,” which got me in a bit of trouble, because it’s too hyperbolic: less training doesn’t really produce more benefit, but it’s just not much less benefit. So I changed the title to “Less Is Not Less,” and it stayed that way for some time, tragically missing a terrific play on words, which was finally suggested to me yesterday by reader Bill C: “Maybe a more apt title would be ‘Less is More Than Enough’?” That’s perfect! I do not know why I didn’t think of that. I’m sure glad Bill did. In particular, it captures the key concept: that doing less than lots at the gym is better than most people realize, and indeed more than enough for most people’s fitness goals.
I recently got a sort of a promotion: I am now the “Assistant Editor” of ScienceBasedMedicine.org, which is a Very Important Website (far more important than mine). It’s not a lofty title, but it’s accurate and good: I assist with a lot. I have considerable responsibility and authority, and it’s a great honour to be a trusted member of that impressive team (of which I am by far the least credentialled member). Constant association with them is basically like getting a free, high-quality, perpetual education.
I started out as a “copyeditor” in 2009, and for the last four years I’ve been rather humbly listed on the SBM contact page as the guy to contact about typos and formatting problems. Meanwhile, behind the scenes, I exceeded mere copyediting long ago. In particular, I’ve been a full editor to some of the SBM authors — real discussion and feedback about the substance of their posts — and the main contact for many guest contributors. I knew that I was a true and trusted member of the team when I composed About Science-Based Medicine, and they accepted my careful wording without so much as a tweak. The ideas were all theirs, but I busted a gut to create a really tight, effective summary (that might sound a bit lame, but good summaries of complex ideas are hard).
Then in late 2012 we had a staff meeting and I ambitiously volunteered to bite off more than I could chew, as one does. Suddenly I was up to my eyebrows in SBM projects, and spin-off projects, and various and sundry unintended consequences. My SBM-related email spiked alarmingly. And then, slowly but surely, some good things happened because I made sure they did. Now we have an amazing new volunteer keeping our Twitter account lively, medical student Bobby Hannum; an incredibly diligent true copyeditor, who chooses to be anonymous; a great new website design, thanks to Joe Fulgham of Holy Cow Design (and Caustic Soda: The Podcast); and major under-the-hood performance and security enhancements, thanks to server guru Steve Allen.
Funny thing: Drs. Novella and Gorski literally don’t know the half of what I’ve done — shh! our little secret — because I try to protect them from inbox clutter. Big part of the job. So while I am really content with the “Assistant Editor,” a more accurate descriptive would be “Super Duper Valuable Deputy Editor in Charge of Lots.”
Why is back pain still a huge problem? Here’s an articulate explanation from a new paper by Max Zusman:
It is extremely difficult to alter the potentially disabling belief among the lay public that low back pain has a structural mechanical cause. An important reason for this is that this belief continues to be regularly reinforced by the conditions of care of a range of ‘hands-on’ providers, for whom idiosyncratic variations of that view are fundamental to their professional existence.
Nicely said. More simply: patients believe back pain is caused by structural fragility, and therapy careers are often built on catering to that belief.
If only I could edit it, though, I would say instead that it is difficult to alter that belief in anyone, patient or professional. The overemphasis on fragility isn’t just reinforced by the practices of manual therapists, it’s the reason for many of them.
“Derp” defined as a Bayesian probability concept: the persistent refusal to update beliefs about what is likely to be true based on new evidence.
The word “derp” originally comes from pop culture, but has come to be used most earnestly in political punditry, referring to the extreme mental ruts characteristic of American right-wing extremists. But derpish stupidity is also rampant in health care, and this more technical definition of what derp has come to mean in politics is a pitch perfect description of how quacks defend their beliefs — namely, with self-serving assumptions that are impervious to contrary data, and are literally decades or even centuries behind biology and medicine.
Overheard: a chiropractor speaking of an upper cervical treatment said to a patient, “Your neck is now in God’s alignment.” Not just an adjustment — it’s holy! Oddly enough, and little known to many patients, there is a strong theme of Christian fundamentalism in chiropractic that blends seamlessly with the work, as though chiropractic is a spiritual calling. It is strange and distasteful to virtually anyone but another fundamentalist Christian.
One more thing about that review of knee arthritis treatments: it challenges the common belief that doctors are only in it for the money. In that report, surgeons officially tipped over one of their own cash cows. They denounced one of the most common and profitable knee surgeries (athroscopic lavage and debridement, polishing joint surfaces basically). They “cannot recommend” it, because the data clearly shows that it’s ineffective. (And that writing has been on the wall for a while. For example, see Moseley — a fascinating study.) Certainly there are still way too many surgeries that aren’t evidence-based, and probably unnecessary (spinal fusion comes to mind). But AAOS doing the right thing… well, it’s a big ethical deal, a Good Thing. Dr. Hall again:
Critics who claim doctors are just out to make money, take note: if they were the evil money-grubbers some make them out to be, wouldn’t these surgeons want to promote income-generating arthroscopic lavage and debridement? Wouldn’t they want to suppress information about conservative treatments and keep patients in pain until they were desperate enough to consent to expensive joint replacement surgery? Gee, do you suppose maybe they really are just trying to do what’s best for their patients?
An understatement from Dr. Harriet Hall writing for ScienceBasedMedicine.org: “Since knee osteoarthritis is such a ubiquitous annoyance, home remedies and CAM offerings abound.” Boy, no kidding. That’s from Dr. Hall’s short, clear summary of a major report on treatments for knee arthritis.
And now for a totally uncontroversial post (?) featuring a short, sweet video of a gentle cat, a tired baby, and the Awesome Power of Touch. Aaaw!Cat soothing crying baby to sleep 1:40
Lately it has been fashionable to condemn running as unhealthy in general. For example, John Kiefer’s popular article, Why Women Should Not Run, actually claims that running makes you fatter, and erodes muscle and bone. Yikes!
All this may come as a surprise to you, since you’ve probably noticed that most runners seem pretty fit compared to the average Walmart shopper. Running can be hard on bodies, but it takes mental gymnastics and abuse of the evidence to believe that “that cardio above a walk or below a sprint is bad for you.” It’s preposterous.
Sol Orwell and Skip Bouma (of Examine.com) have written a thoughtful evisceration of Kiefer’s article. It’s a case study in bad science writing that represents the trend of “anti-running claims making the rounds of the blogosphere lately.” According to Bouma and Orwell, Kiefer’s article is littered with unsupported claims, leaps of logic, and — above all — classic bogus citations (particularly clean misses and backfires). It would be hard for anyone to take Keifer’s article seriously after reading this analysis!
Science isn’t broken because we discover serious problems with a study, such as a major conflict of interest, or even outright cheating. That’s actually science working. Taking out the trash. Correcting itself. Checks and balances, being accountable, independently verifying the work of scientists … deliberately doing exactly what does not happen nearly as often or as well in politics, religion, business, or any other domain of life.
These comments are inspired, of course, by the conflict-of-interest allegations about Albert et al and their study of antibiotic therapy for low back pain (3 of 4 authors on the board of a company selling antibiotic therapy). So far, I think the best summary of the debacle is now Dr. Margaret McCartney’s article in the British Medical Journal, and see also Dr. Lorimer Moseley’s eloquent, gracious comment:
I wonder how far any of us are from this kind of mistake — a lazy media release, and eager PR manager, an impending promotion. I reflect on the anguish I imagine the authors are feeling right now and the damage this has done to their reputations and I can hear the whispering in my own heart — ‘Careful! That could have been you.’
And there’s also my own summary in my back pain e-book, now fully updated on this topic — yay for nimble digital publishing!
Another new sassy micro article, criticizing another off-the-wall part of alternative medicine: Applied “Kinesiology”, which has nothing to do with kinesiology, and often wastes the time and money of patients with chronic pain. They deserve and need much better. As with my therapeutic touch article earlier this week, this is another topic I have little patience for, but it’s too common to entirely ignore — so here’s my brief position statement. As usual, critics need to know before commenting that I have plenty of direct experience with every scrap of pseudoscience that I now criticize.
Another new micro article, and the seed of a larger one. I’ll definitely add to this one in time: PubMed Research Tip: A simple tip to help clinicians get more useful results from PubMed
They aren’t free (unless you are a blind or low-vision visitor). I created these to be a nice perk for my best customers, who have bought a bundle of all my e-books, the e-boxed set.
I’ve never written about therapeutic touch before, or gotten involved in the many online debates about energy medicine that are more or less constantly burning somewhere on the internet (especially Facebook). I am a science writer, my plate is plenty full with that, and I just couldn’t be bothered delving into that very anti-scientific topic. On the other hand, I also want to “touch” on every therapy and pain topic, at least a little — that’s my ultimate writing goal for SaveYourself.ca. So I finally got around to it.
Dr. Michael “America’s Podiatrist” Nirenberg:
A middle-aged woman arrived at my office last week complaining of heel pain and carrying a bag of custom-made foot orthotics (orthotics are custom made arch supports that are fabricated from a mold of the patient’s feet). Each orthotic this woman had with her was expertly fabricated by a different podiatrist and yet none of them had come close to alleviating her heel pain. At first I thought maybe these podiatrists didn’t know what they were doing. But, when I learned their names, I knew this woman had seen competent, skilled and reputable physicians.
I asked myself “how could this be?” More interestingly, no two sets of orthotics were even remotely alike. Further, given that nearly all podiatrists learn similar principles of biomechanics, shouldn’t orthotics for a given patient be the same regardless which podiatrist makes them?
Dr. Michael Nirenberg, in his review of a book by Dr. Benno Nigg, Biomechanics of Sport Shoes: The Disturbing Truth About Running Shoes, Inserts and Foot Orthotics
I’ve now updated my orthotics article with this quote:
Most of the time it’s hard not to heal. You couldn’t stop it if you tried — not that you’d want to. The body is going to recover from most kinds of injuries almost no matter what — it’s just a matter of time. As long as you were reasonably healthy before you were injured (and you don’t smoke or otherwise abuse your vitality), healing will usually progress inexorably.
Chronic pain is different by definition: it doesn’t stop when it’s supposed to. Either healing itself fails, or the pain continues even when the tissues are fine, or a bit of both. Overuse injuries or repetitive strain injuries (RSIs) like carpal tunnel syndrome and plantar fasciitis are slow-motion traumas that often seem immune to recovery — this is what makes them both terrible and fascinating. They are not as simple as they seem. More:
Or: How I made a newbie massage therapist cry once. An update to my main posture article:
Probably the first ever placebo-controlled study of surgery for tennis elbow … and disappointing. The experimenter scathingly concludes:
There is no benefit to be gained from the gold standard tennis elbow surgery over placebo surgery … in fact, the Nirschl procedure may increase the morbidity of the condition in the immediate post-operative period.
~Kroslak. Surgical treatment of lateral epicondylitis: A prospective, randomised, blinded, placebo controlled pilot study. Unpublished. 2012.
Readers often prevail upon me to be “objective,” but it’s an over-rated virtue. Not only will I fail to achieve the ideal of “objectivity,” I assume that my biases are inevitable, constantly egregious, and utterly human. We are all bias machines. We can only keep a bemused eye on this frailty, do some damage control, and try to avoid being emphatic or overconfident about much of anything other than the rise of the sun, death, taxes, and the absurd fallibility of confidence itself.
What works for complex regional pain syndrome? Nothing known. Neil O’Connell: “The trial evidence in CRPS is something of a mess.”
From a review of studies and other reviews of surgeries for back pain: “Although the quality of the reviews was quite acceptable, the quality of the included studies was poor.” So back surgeries have never really been studied properly … but the reviews are quality! Hmm. I’m pretty sure that’s terrible news.
Because people cannot seem to be reminded of this enough: Human beings will get great placebo from any treatment that seems impressive in any way (more invasive, novel, unpleasant, whatever suggests potency). This accounts for most treatment success stories from both patients and professionals. Everyone should know better than to trust those stories — because it’s 2013, not 1913 — but they are still prevalent, given far too much weight, and they hijack most conversations about what works and what doesn’t for stubborn painful problems. As soon as someone says, “Well, it works for me/my patients,” that’s pretty much the end of any useful debate.
Statistically and clinically significant test results for a back pain treatment? Pinch me!
Kjartan Vibe Fersum et al. tested cognitive functional therapy (CFT) with great results, published in the European Journal of Pain this summer. This is probably the best test yet of what I call “the confidence cure.” The big idea is that back pain does not necessarily have anything to do with a damaged or degenerated back, and the cycle of pain and disability can be broken by easing patient fears and anxieties. In this test, CFT worked! Patients got statistically and clinically meaningful results — which is really kind of a big deal — better than manual therapy and exercise. As the authors put it for BodyInMind.org, “Disabling back pain can change for the better with a different narrative and coping strategies.”
I’ve already cited and discussed this study in a few places around SaveYourself.ca, especially my low back pain book. See my bibliography for a more detailed description, or read more about it at BodyInMind.org.
A nice example of anatomical variation: the size and shape of a notch in the top of the shoulder blade is quite variable, and nerve impingement is much more likely if you’ve got the wrong type of notch. More anatomical variation examples:
Reader C.W. wrote with a good correction: it’s “taijiquan,” not “taiqi,” as I have often carelessly written on this website, despite practicing taijiquan for most of my life. This has been in my mental “need to get clear about that” file for the entire time. I’m a language enthusiast (as a writer should be), and I knew that I didn’t have this down, but just had never gotten around to looking it up. I’ve now fixed this in a few places on SaveYourself.ca.
For a gold star, always use either taiji or, even better, taijiquan — that’s the modern Pinyin transliteration. But the older Wade-Giles version, t’ai chi or t’ai chi ch’uan, is still common, and the simplified tai chi is acceptable and common. Just don’t mix up your chi with your ch’i. Ji and chi are not the same thing as ch’i and qi — almost everyone makes this mistake (including me, for many years). Ji/chi is a philosophical concept, a really deep thought, hard to define and translate, but “pole” or “ultimate” will do. Qi/ch’i refers to breath or life energy, like the western concept of vis vitalis (vital force) or the Greek pneuma (breath, spirit, soul). So t’ai chi really is not tai ch’i — moving the apostrophe changes the meaning.
This information added to the article Tai Chi Helps Fibromyalgia, but It’s Not “Alternative” Medicine (and it’s no accident that title uses “tai chi” — for search engines, you’ve got to stick to the most popular spellings).
Placebo is belief-powered relief from symptoms, while nocebo is belief-powered symptoms, or “the placebo effect’s malevolent Mr. Hyde.” And: “The Internet has become a powerful…nocebo dosing machine.” Agreed: nocebo is a genuine hazard when writing about medical problems. Read more:
Progressive mythology: Dr. Harriet Hall’s review (plus some excellent reader comments) of Science Left Behind: Feel-Good Fallacies and the Rise of the Anti-Scientific Left, Berezow & Campbell. A great book idea. This quote isn’t particularly representative of the book’s message, but it’s a very important idea (which I have written about):
Just because a published paper presents a statistically significant result does not mean it necessarily has a biologically meaningful effect.
Science Left Behind: Feel-Good Fallacies and the Rise of the Anti-Scientific Left, Alex Berezow & Hank Campbell
Utterly unsurprising: injecting your own blood doesn’t help tendinitis. Nice to have a decent new trial about this over-hyped therapy though.
The administration of two unguided peritendinous autologous blood injections one month apart, in addition to a standardised eccentric training programme, provides no additional benefit in the treatment of mid-portion Achilles tendinopathy.
Not many good treatment ideas work as well in practice as they do in theory. The null hypothesis is super reliable.
“Impact of autologous blood injections in treatment of mid-portion Achilles tendinopathy: double blind randomised controlled trial”
Thursday and Friday’s trouble with my e-bookstore now seems to be cleared up, but it took a solid 48 hours. Fascinatingly, the slowness of the recovery may have been due to a major hacking incident several weeks ago, which affected basic internet infrastructure: that is, the “Domain Name System” (DNS) may be damaged and/or deliberately slowed down as a security measure. The theory is that corrected information about the location of my e-bookstore took much longer (2 days) to spread around the world than it would have before (2 hours). Here’s an interesting NY Times article about the hacking incident, with good diagrams:
For most of Thursday and into Friday morning, my online store has been flickering on & off like an old neon sign. Geeks are slaving to restore full service, and seem to have mostly succeded at this point. •mops cold sweat from brow• Part of the problem is that the internet “lost” the correct address for the store. That’s mostly fixed now, but there are still some computers out there that don’t know the correct address. Depending on where you live, you might see a weird generic page instead of my actual store. But the correct information is steadily spreading around the world (“Domain Name System (DNS) info propagation”), and I am fairly confident the worst is over. Naturally I’m readily available for any customer having trouble.
A promising new fitness blog. The State of Evidence-Based Fitness:
“Replication needed” is the ultimate caveat in scientific criticism. It covers all the bases. Everything else is just details. At the end of the day, if promising results cannot be replicated by other researchers, it doesn’t really matter what was wrong with the original research. Either a treatment works well enough to consistently produce impressive results whenever it’s tested … or it doesn’t. Updated article:
Ever run much farther than you thought you could? I haven’t done more than 5km in ages, and I often only do 2km at a time (I’ve never been much for distance as a runner, I like sprinting) … and then suddenly a pair of big 13km runs around Stanley Park in a week! The first run was a total shock, and probably an unwise spike in pavement pounding — honestly, I’m amazed I didn’t hurt myself, prone as I am to RSIs. But I got away with it just fine.
And the 2nd run? I had to see if the 1st was a fluke! I guess it wasn’t — I did just fine again. I’ll be danged.
Superb paper about pain for professionals, with a very broad scope: it’s just called “Pain.” I love a simple title.
Sleep: What the Research Actually Says: A readable review of the effects of sleep deprivation, with good nugget-sized highlights throughout, from my friends at Examine.com, Sol Orwell and Kurtis Frank. One quibble! Nothing about pain. But of course I have something about insomnia and pain (Insomnia Until it Hurts).
This is basically how humans decide what to believe in (e.g. simple correlations, emotional priorities). “I have the power of barking to thank for that.”
This is great! A nicely written reality check on the antibiotics for back pain hype, from PubMed. Great stuff.
Back pain is one of the richest myth mines in all of medicine. An extremely common, often serious, and usually mysterious pain problem = absolutely maximum fertility for bullshit to grow in. There are a great many books about low back pain, and many are garbage, selling snake oil and hype and false hope instead of good information. There are also some fine myth-busting books about low back pain … and mine is one of them.
After a burst of recent interest in my article about strength training frequency, and some good discussions with experts, I made some significant changes and a particularly important correction/retraction regarding the metabolic cost of muscle, the 50-calorie-per-pound-per-day myth. My error was pointed out by James Krieger of Weightology, who has written about it. Here’s a more thorough article about it. The gist of the article was fine, but my original text was definitely wrong and misleading on this interesting tangentially related point. I revised that whole section to minimize the importance of muscle-gain for weight loss, and I now acknowledge the original error: “There’s a common myth that every pound of muscle burn about 50–100 calories, which I carelessly repeated myself in early versions of this article. That number is much too high, and no one seems to be sure where it came from — just one of those things that gets passed around.” I elaborate in a footnote:
I originally got the 50/day figure from McGuff & Little in Body By Science: “Muscle mass is the most metabolically expensive tissue in the body. You require between 50 and 100 calories a day just to keep a pound of it alive.” This is wrong by a long shot. The brain is vastly more metabolically expensive, for instance. This seems like a clear cut case of confirmation bias: McGuff & Little presented this unsubstantiated myth as fact in their book because it would be wonderful support for their big idea … if only it were true. And then I did the same thing! Arg.”
Sometimes I think: manual therapy is getting progressive, more science-based, clinical reasoning is growing up. Yay!
Then I read my email.
If the contents of my inbox are any measure (and they probably are), then, alas, there is still a great deal of work to do. Crazy numbers of professionals in manual therapy have clearly not even begun to understand the need to properly test treatments. And many even fight it!
People ask about this occasionally: no, I don’t actually like my domain name, “SaveYourself.ca.” It smacks of religion & too-good-to-be-true promises and I’m not comfortable with that. It’s a legacy from many years ago when I had no idea what this site would become. I plan to move to a new domain name within a year.
P.S. I may not actually like my domain name, but I do still love my salamander mascot.
Just finished reading a slightly trashy novel, Gone Girl, by Gillian Flynn, and mined it for a couple of nice little quotes: “Sleep is like a cat: it only comes to you if your ignore it.” Perfect quote nugget for Save Yourself from Insomnia! And: “To pretend to be calm is to be calm, in a way,” which made me think of posture/mood interdependence, discussed in Does Posture Matter? (Mostly for emotional reasons!)
A charming, well-produced video summary of why and how to build strength, pitched to the not-so-young-anymore, done by the University of BC (which is in my backyard).
Comedian Louis CK on aging joints:
The doctor shows me an x-ray of my ankle and he’s like, “Yeah, your ankle’s just, uh… worn out.”
“What do you mean? I injured my ankle?”
He’s like, “No, it’s just shitty now.”
Even though brains are in total control of pain, your brain also does a lot of that without you. For instance, brains modulate pain based on a number of other things that are completely out of your control, or rather difficult to control, or even just impractical to control. For instance, if you view a painful hand through a magnifying glass, it will actually get more swollen and inflamed — that is, if you make it look bigger, it will get bigger. And the reverse is true! (See Moseley et al.) Use optics to make it look smaller, and swelling will go down. Incredible, right? Jedi pain tricks!
But here’s the (large) catch: do you have a de-magnifying glass handy? Where do you buy even one of those, let alone a big one? What happens if the pain isn’t in a place that’s so easy to de-magnify, like your low back? Although dang interesting, the de-magnification trick is not generally a practical approach. The effect is real under the right circumstances, but trying to use it as a treatment is like trying to take a magician’s trick home with you. For more about pain and “mind over matter,” see Pain is Weird.
Interesting, impressive new work announced today by Examine.com: a well-crafted new presentation of a huge database of scientific evidence that “clearly tells you what a supplement does (and doesn’t do). Goodbye supplement confusion.” This rabbit hole goes deep, so browse. Look at their “Human Effect Matrix” tables for key topics in particular, which beautifully summarize the science (go right to an example, for creatine). What’s remarkable here is the quality of the presentation. These are not just tables of data! They are quite artful, crafted to emphasize what matters. I would love to have evidence presented like this on SaveYourself.ca, and I do have some of the foundations for it — but I’m a few design and technology leaps away from being able to deliver something like that.
This article updated recently: What can a runner with knee pain do at the gym? That’s handy, but this link is more fun: 20 Reasons Why Going To The Gym Is A Huge Waste Of Time (actually just 20 short videos of hilarious exercise misfortune).example
The power of touch is strong in these two: a sloth lovingly, thoroughly grooms a cat. So affectionate it’s almost creepy…
It has gotten so I can’t answer the phone and actually get any research and writing done. Customer service is fine and necessary, but most of my calls aren’t customer service calls. So, I’ve reluctantly — or is that relief? — switched to screening all unknown calls. Here’s a new voice mail message, tuned for trying to deal with the high percentage of calls I get (“most”) that are at weird hours, generally much too chatty (I'm talking about major league blatherers here), hoping for free advice, hoping to offer advice (generally a patronizing form of criticism), or just looking for a fight (about the subject matter):
This is Paul Ingraham of SaveYourself.ca. I do keep my ringer off and screen all calls, because this is a small business with a globally popular website, and I get far too many inappropriate calls at odd hours. However, I will respond quickly only to customer service inquiries, roughly from 8am to 8pm on the west coast of North America.
Digital rights management (DRM): it’s used by all the big publishers to limit e-book piracy … and we all hates it. You hates it, I hates it. DRM annoys customers, prevents real ownership, makes honest lending nearly impossible, locks e-books to one kind of reader … just yuck. We hates DRM! My e-books are “low DRM.” I do protect my (preciouss) books a little — but a lot less than big publishers do. In particular, it’s easy and fine to lend my e-books!
Pain itself often changes the way the way pain works, so that patients with pain actually becomes more sensitive and gets more pain with less provocation. This awful (and surprisingly common) phenomenon is called central sensitization. Everyone should know about this: owner’s manual stuff.
Another “new” article (assembled from past posts, spiffied up, made into a permanent page)
Laura Allen, Massage Therapist, sassing about the packaging and commercialization of massage techniques (usually called “modalities” by therapists):
Join me for a class in the Laura Allen Method, where you will learn how to slap the hell out of people claiming to invent new modalities. How many more do we need? Is there any real possibility that no one has done it before in the history of the universe? As an added bonus I will throw in my special class in Redneck Massage, where I will simultaneously perform cryotherapy and roll out those stress knots with a cold can of Pabst Blue Ribbon while I use duct tape to train your muscles. Whenever I perform a particularly impressive move, I will yell "Hey, watch this sht!" so you'll be sure to repeat it exactly.
Laura racked up a whopping 200+ likes for this comment on her Facebook page, plus many dozens of supportive and appreciative comments. Nice to see that, because I’ve been griping about the modality empires for over a decade.
After years of practice, I can easily find your infraspinatus muscle. In the dark, in about three seconds. Through a thick towel. However, massage and manual therapists often fool themselves into thinking they are feeling things under their hands that are not actually there, or things that might be there but cannot possibly be detected with any reliability. This is palpatory pareidolia: illusions in the sense of touch.Palpatory Pareidolia: Sensory illusions, wishful thinking, and palpation pretension in massage and other touchy health care
I’ve written about this before, but this is a topic “reboot,” with content combined from a few early drafts and whipped into shape for a permanent article:
“Humans can actually compete with & often beat horses at endurance races.” Especially when it’s hot. Which is cool. Here’s the context of that quote, from Daniel Lieberman, on not giving homo sapiens enough athletic credit, from the article Brains Plus Brawn:>>>We’re actually remarkable endurance athletes, and that endurance athleticism is deeply woven into our bodies, literally from our heads to our toes. … We’ve lost sight at just how good we are at endurance athleticism, and that’s led to a perverse idea that humans really aren’t very good athletes. A good example is that every year they have races where they actually compare humans and horses. In Wales, this started a few years ago, I guess it started out as a typical sort of drunken pub bet, where some guy bet that a human couldn’t beat a horse in a marathon. They’ve been running a marathon in Wales for the last, I think 15-20 years. To be fair, most years, the horses beat the humans, but the humans often come very close. Whenever it’s hot, the humans actually beat the horses. … The point is not that humans are poor athletes, because the horses occasionally beat us, but humans can actually compete with and often beat horses at endurance races. Most people are surprised at that. … One of the interesting things about these races also is that they’re so worried about the horses getting injured, that the horses have mandatory veterinary check-ups every 20 kilometers, but not the humans, because humans can easily run 40 kilometers without injury. But if you make a horse gallop for more than 20 kilometers, you seriously risk doing long-term permanent musculoskeletal damage to the horse.
Meanwhile, backstage: Another audio article completed this afternoon. That’s three now! I’ll be publishing them soon, so stay tuned for that. Two more to go, I think, and then it’s back to recording several more audio books.
I’ve also been spring data cleaning! Prepping for the next several years of writing, I’ve purged roughly 10,000 lines of “cruft” (junky data) out of my bibliographic database … leaving >40,000 lines and thousands of much tidier records.
I dare ya: “Try working in a hospital for a while, try to be perfect, try to never have anything go wrong that matters!” This article freshened up a bit…
“The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).”
Source: Dr. Lorimer Moseley, Teaching people about pain — why do we keep beating around the bush?
Patients with back pain and sciatica recovered about equally well with or without disc herniations visible on MRI. Most people recovered (84%) well within a year … and there were actually 2% more good outcomes in the patients with disc herniations! This seems like a rather surprising result, but that is what the research has been showing for years. There is a chance the nearly identical stats are a fluke, but they’d have to be off by a lot to change the take-home message. Even a 20-point difference, ten times larger than this, would still show that a “slipped disc” confirmed by MRI isn’t nearly as worrisome as most people assume.
Unicorn horn velvet! “So anabolic it’s illegal in 9 countries.” “In just 4 short weeks I turned from a wimpy little, hipster dufus into the god Kronos himself!” This is from a very good parody of the hyperbolic claims that are all-too common in the nutraceutical industry.
Fibromyalgia is “widespread pain for three months with no other identifiable cause,” which is just as awful as it sounds. 2% of people suffer from it (that’s a lot), but in an odd and unexplained ratio of 9 female patients for every male. Here’s a good new one-minute video summary from Dr. Rob of One-Minute Medical School:
Evidence-based medicine (EBM) was founded as a named concept in 1990, but its spirit and principles go back to the 16th century, when Andreas Vesalius got it rolling by — and this was kind of crazy at the time — actually checking anatomy instead of just taking some ancient Roman doctor’s word for it. It was a great idea, and it’s been delivering the goods so well ever since that many doctors have been a bit puzzled by the modern EBM movement: what else would you base medicine on? Faith? Wit? Vehemence? The British Medical Journal suggests seven amusing possibilities, and it’s easy to imagine more.).
EBM emerged as something that needed a manifesto and an acronym because, in practice, an awful lot of medicine was still based on things like faith, tradition and vehemence, and not nearly as evidence-based as we’d like to hope. So EBM was an upgrade — a clear, formal call for medicine to do better. It was an attempt to make what Vesalius started “official” (a few centuries late). Unfortunately, EBM may not be enough, which is why ScienceBasedMedicine.org exists.
Er, no, I think not. It’s not inconceivable, but it is pretty far-fetched. It’s generally true that biology ingeniously exploits most properties of nature to get things done, including electromagnetism, and we likely still have things to learn about that. But whatever those systems might be, it’s super unlikely that they have any meaningful interaction with a slightly salty bath, let alone one that’s relevant to aches and pains. It’s even less likely that any such effect wouldn’t be much more obvious in, say, sea water. Even if salty baths just bestowed a vague feeling of well-being and vitality, like mountain air, that would be biologically remarkable … but still well short of a useful medical effect. And in fact salty baths do not have an obvious mountain-air like goodness.
The Epsom salts article has now been updated with this odd tidbit.
A new study in the European Spine Journal shows weirdly good, strong results treating low back pain with … antibiotics? No, really! The implication is that some cases of stubborn and inexplicable back pain may be caused by an infection, and — stranger still — an infection with a wee beastie that may be getting into spines thanks to brushing your teeth. Talk about unintended consequences! Body In Mind has a terrific, sensible analysis by Dr. Neil O’Connell, which is essential reading. There are all kinds of caveats, of course, in particular that the study focussed on a specific sort of back pain in rather carefully chosen subjects — so it’s probably not going to work on the average frustrated back pain patient.
Nevertheless, it’s a marvellously eyebrow-raising and strange test result. I’ve always wondered if “the answer” to low back pain might be like this, something really odd (or, more like, several odd somethings). It’s the kind of answer that is inevitable-ish: all the “reasonable” candidate explanations for most chronic low back pain have been checked and found hopelessly wanting, and all that’s left is the odd stuff that no one’s checked yet. And perhaps it’s this: an infection! Which no one saw coming, any more than anyone “called it” in the 70s that stomach ulcers would turn out to be caused by Helicobacter pylori.
Updated my article about Tissue Provocation Therapies. The update was inspired by a new article by Leonard Van Gelder, a “huge proponent” of Instrument Assisted Soft Tissue Mobilization (IASTM, like Graston). It’s a decent critical review of IASTM, with some fairly harsh words, but it also rests on a foundation of classic error: certainty that a treatment really works. It doesn’t take much reading at TestingTreatments.org (see previous post) to realize that it’s actually impossible to know if a something works based on clinical observations alone. Repeat after me:
“I will not claim to know what treatments really work for pain before they are properly tested.”
“I will not claim to know what treatments really work for pain before they are properly tested.”
“I will not claim to know what treatments really work for pain before they are properly tested.”
Testing Treatments continues to grow & improve, and it was great to begin with. It looks like quite a few new tools and features have been added to the site over the last year. It’s a really terrific resource, maybe even the single best place for professionals to start learning about evidence-based medicine.
As of Monday, SaveYourself.ca now reaches more than 10,000 visitors every day … with great reading time statistics. People who come to SaveYourself.ca stay and read.
Clinical Decision-Making Part III from ScienceBasedMedicine.org: fairly heavy professional reading, but gooood. Dr. Novella is an extremely clear thinker and writer.
More about trigger points today: skeptical revision of Stretching for Trigger Points points out many problems in theory & practice (understatement).
NPR had a hit with this headline recently: “World's Most Popular Painkiller Raises Heart Attack Risk.” Sensational, and not wrong. Diclofenac in particular is an extremely popular drug — we’re talking oral here — and it is associated with serious cardiovascular risks: “There is increasing regulatory concern about diclofenac. … Diclofenac has no advantage in terms of gastrointestinal safety and it has a clear cardiovascular disadvantage” (McGettigan et al). But the difference between oral and topical is extremely important. Topical is not the same thing as swallowing at all. Volatren Gel (or Emulgel) is still a useful product. It has a proven benefit and much lower risks than oral. Scott Gavura wrote about this for ScienceBasedMedicine.org today:
The main advantage of topical NSAIDs is the reduced exposure of the rest of the body to the product, which reduces the side effect profile. Given the toxicity of NSAIDs is related in part to the dose, it follows that topical treatments should have a better toxicity profile. Consequently, the cardiovascular risks of topical diclofenac… should be negligible with the topical forms.
I’ve updated my article on this topic:
I was interviewed about back pain myths by Armi Legge for the Impruvism.com podcast.
It’s the 200th birthday of John Snow, the father of epidemiology, the science of diseases and how they spread. In 1854, Snow mapped cases of cholera and traced the disease to its origin, and proved with a simple test that it was coming from a polluted well: he removed the pump handle, and the cholera outbreak stopped. Naturally, this conclusion was scoffed at by those with competing theories (“bad air”), producing one of my favourite history of medicine stories: to prove that cholera was not in the water, some smartypants biologist drank a glass of the stuff … and got away with it, because he just happened to be immune. It’s a great example of why “experience” is not trustworthy, and why it takes so long to settle even relatively straightforward puzzles in medicine.
Why am I so “negative”? I am often asked this. There are many answers, and the most important has always been that I value truth-telling in health care for its own sake, even if it’s disappointing, and unfortunately a lot of it is. Here’s a nice quote from author Chris Brogan that gives another nice answer: “To truly know what works, you have to learn what doesn’t work first.”
Dr. Steven Novella’s entertaining report on a weird paper in which some acupuncturists “grossly mischaracterize their critics and manage to completely avoid the substance of our criticism.” See also his follow-up post the next day, Another Acupuncture Meta-Analysis — Low Back Pain, summarized thusly: “1 — Acupuncture does not work. 2 — Acupuncturists refuse to admit that acupuncture does not work.”
Often we see inexplicable and “weird” changes in painful conditions, good and bad, and often in response to an attempt at treatment — and yet at the same time it’s incredibly rare to find good evidence that any particular treatment works better than placebo. What could account for this? Using a wide paintbrush: it may be that input changes output, that nearly anything that happens to the body has the potential to affect how the body works. Tissue state is just chemistry, and the chemistry of everything is constantly micromanaged and hyper-regulated. Dysregulation and uncomfortable trade-offs and compromises in these processes are routine, but it’s still full speed ahead, all the time, damn the torpedoes, a chemical balancing act that doesn’t quit until we die. Any input may change the equation — the problem is that it’s incredibly difficult and maybe even impossible in principle to predict what inputs will help, or make any difference at all.
Pelvic tilt is one of the great biomechanical bogeymen, one of those things that gets blamed for a lot of pain and is the justification for a lot of massage and chiropractic therapy. I was taught in school to judge pelvic tilt by measuring the pointy bits. It all seemed very technical. And yet, as I always suspected, pelvic shape is simply much too variable to diagnose pelvic tilt by feel. The shape can vary as much as the position! A new study of cadavers “found that the PSIS/ASIS angle varied from left to right (up to eleven degrees), even when the pelvis was in neutral. The asymmetrical shape of the pelvis in this respect could make it appear that one side is rotated forward compared to the other.” That’s from a superb report on the study by Todd Hargrove at BetterMovement.org:
Gray matter density changes with pain are “interesting but not awfully important epiphenoma”? Neil O’Connell for Body In Mind, with his usual sassy clarity:
“The labeling of nociceptors as pain fibers was not an admirable simplification, but an unfortunate trivialization under the guise of simplification.” — Patrick Wall, 1986 (“The relationship of perceived pain to afferent nerve impulses”). Context and more for that quote in a good, short article by Moseley, “Teaching people about pain: why do we keep beating around the bush?”
Nice reader comment #1: “It is obvious that you are willing to go to explanatory lengths that no one else will.” That’s a great way of putting it. That is the whole idea of feature articles and ebooks for SaveYourself.ca: deep topic diving.
Nice reader comment #2: unusually exuberant! I get a lot of “good site” and “I like the clean style,” but this fellow was really impressed:
This is the most brilliantly designed and executed website I have ever run across, and that covers tens of thousands of sites. If it hasn’t won any major design awards yet, it should have. It’s a work of art.
I think he likes it. I’m not sure, but I think so. Maybe if he were slightly more enthusiastic I could tell…slug:2 nice reader comments
SaveYourself.ca updates, musings, links, news and nuggets, usually related to whatever I’m working on, and often the things that amuse me. You can always find the latest of them on the home page, plus every post ever on the microblog page, and because it’s 2014, everything is “shared” on Twitter, Facebook and Google (and soon also via RSS, which is a little more old school but still really useful).
So why the new format? In 2010 I decided I had to “blog the process”: that is, blog about my feature articles and books while I create, update, and update them. That strategy was quite successful, to the tune of about 450 posts, including many that “went viral.” Alas, instead of blogging the process*, I found myself “processing the blog,” a dog being wagged by its tail, slaving away on posts for their own sake, often with only a foggy notion of how I would ever actually use the content in a book or major article.
Ergo, microblogging! This is a fun, efficient way for me to promote the site and show that “the lights are on and somebody’s home” … while I continue to focus mostly on the important work: creating and updating best-of-breed feature articles.
No joke: my Epsom salts article is now funnier. Whimsy added where possible, for example the paragraph about vaginal absorption:
A number of readers have asked if the vagina might be an absorption route. A fair question, but this has the same problem as anal absorption: too small and too tight. After quizzing several amused female friends about it, I am confident that it would be highly irregular for any respectable quantity of bath water to percolate into one’s ya-ya.
Some nice dissection-perspective on connective tissue and stretching here. (And some kind words about SaveYourself.ca as well—thanks, John Underdown of TailoredPT.com.)
Glucosamine’s benefits for osteoarthritis are like “taking a car from 40mpg to 42mpg” but “better than nothing.” Good comprehensive analysis of glucosamine from Examine.com. I’ve updated my nutraceuticals article.
Like-new posture article has been a big viral hit last 2 weeks: more than I expected. If you missed that news, see:
Another terrific quote from Sam Kean’s very charming 2012 book about genetics, The Violinist’s Thumb. Not super on-topic for SaveYourself.ca … but I still think a lot of you will love it.
Sexy in most creatures means brawny, well-proportioned, or lavishly decorated—think bucks’ antlers and peacocks’ tails. But singing or dancing can also draw attention to someone’s robust physical health. And painting and witty poetry highlight someone’s mental prowess and agility—talents crucial for navigating the alliances and hierarchies of primate society. Art, in other words, betrays a sexy mental fitness.
Fred Wolfe on The Fibromyalgia Perplex: “It is discovered that the true meaning of fibromyalgia is not as simple as is usually believed.” Boy, no kidding. I have now read FMPerplex.com “cover to cover,” so to speak. I like Dr. Wolfe’s style, and I’ve learned a fair bit (and updated the introduction to my muscle pain tutorial). Here’s a recommended post:
A strange idea? Or maybe it’s just obvious that lots of somatic sensation is regulatory. A study finds “stretching routines may contribute to a favorable autonomic activity change…” Study:
“Acute effects of stretching exercise on the heart rate variability in subjects with low flexibility levels”
The naturalistic fallacy: “One of the biggest boners in ethical philosophy.” Another terrific quote from Sam Kean’s very charming 2012 book about genetics, The Violinist’s Thumb. This is relevant to natural/barefoot running. Full quote:
Remember that most of our genetic predilections for behavior were shaped by the African savanna many thousands if not millions of years ago. So while ‘natural’ in some sense, these predilections don’t necessarily serve us well today, since we live in a radically different environment. What happens in nature is a poor guide for making decisions anyway. One of the biggest boners in ethical philosophy is the naturalistic fallacy, which equates nature with ‘what’s right’ and uses ‘what’s natural’ to justify or excuse prejudice. We human beings are humane in part because we can look beyond our biology.
I had 997 followers this morning. Then I started trash-tweeting the clinical importance of posture. Now I have 994. Some say I’ve been too hard on posture importance, some say not hard enough! I lean towards “not enough.” Best criticism of my posture article so far? I don’t mention potential for nocebo & unintended consequences of advice [Now corrected]. Belief in postural dysfunctional can probably drive a nocebo + spinoff beliefs about vulnerability + harmful zeal for “correction.”
“Posturology” is the cheesy, popular term for the mostly made-up “discipline” of studying the relationship between posture and pain, and even diseases. Posturologists (I can barely write that with a straight face) tend to assume their own conclusion: they just take it for granted that poor posture does cause pain and then look for confirmation. And so there are many, many scientific papers that seem to present evidence of a connection between posture and pain, but most of them suck (see Guimond et al for a good example) and “posturology” is mostly a slummy pseudoscientific research backwater. There may actually be something to learn, if only posturology research was better quality, but most of it has to be just chucked or at least taken with a huge grain of salt.
I only critisize someone’s communiation skills when their writeing problem are signicifant and revelant!
A year ago we got a new massage myth: “reduces inflammation & promotes mitochondria.” Bollocks. Here’s what I wrote:
Want some good science news about massage therapy? Okay! Massage clearly reduces anxiety & depression. Great article about what massage does for “an individual’s feelings, moods and emotions”:
SaveYourself.ca is now routinely professionally edited — even cleaner, sparklier articles — by JoAnne Dyer of Seven Madronas Communications.
Audiobook versions of two of my books are now available:
For a while, these are going to available at no additional charge — an optional download for all customers. In the future, as I add extras like this, they will only be available to customers paying a little more for access to everything. But they’re on the house for now!
These books took me about a year and a half to produce, with the help of my audio and video production guy. I installed sound baffling drapes to cover the walls of my office. I bought a good microphone. I dusted off decade-old skills from my radio days. I only spent about 30 hours doing pure recording, but plenty more was spent setting up and cleaning up, experimenting, troubleshooting the technology, and so on. I lost two recording sessions to tech gremlins. I re-recorded a half dozen from scratch, simply because I wasn’t happy with how they came out.
Audio production is a costly process, so it was also important to edit, update and polish every chapter before recording. That roughly tripled the duration of the project, but it also meant that that the e-books got a thorough fine tuning as they were being converted.
And production will now speed up! These first two audiobooks are full-length, unabridged versions — too long! I will be creating executive summary versions of the ebooks in the future, and those will be turned into much shorter audiobooks.
You can’t very well treat core instability if you can’t diagnose it as a problem in the first place. This test of the reliability of core strength testing was a clear failure: “6 clinical core stability tests are not reliable when a 4-point visual scoring assessment is used.” Even if core strength is important (a separate question), this evidence clearly shows that no one should be claiming to be able to detect a problem with core weakness in the first place. A bit problematic for core dogma.
Just added this citation to my article about reliability studies—it's a really good example of poor reliability. Later I will add it to a half dozen more articles.
“Gunshot wound diagnosis is reliable.” From: Is Diagnosis for Pain Problems Reliable?
“What’s the best solution?” I get this question constantly. There’s no “best solution” for any hard pain problem … only a few imperfect options.
Reader question of the week: “Do i got the IT band syndrome?”
(An ESL reader, to be fair. Regardless, it’s beyond me why people think I can diagnose by email.)
Kind customer feedback of the week: “Thank you for a very edifying yet witty tutorial.” Referring to my e-book:
The discovery of barefoot heel-strikers adds to “lack of certainty about what makes for ideal running form.” From a NY Times article, “Is There One Right Way to Run?”
“My chiropractor says this is because the top of my neck attaches to my head. Is that a common problem?” ~ Doc Grumpy
One thing about my job: I get a lot of email from patients everywhere…a constant, endless, informal survey of treatment practices and prevalent ideas. This allows me to write things like “many people believe” with some authority. I actually do know better than, say, the average clinician.
Shocker: science sez applying kinesio tape had no effect on muscle strength. Daft idea to begin with. See Vercelli et al.
Fun fact: an image Search for “kinesio taping” gets lots of SEXY shots. Huh! Ladies, many of one particularly hot male model. Yow yow!
“Immediate effects of kinesiotaping on quadriceps muscle strength: a single-blind, placebo-controlled crossover trial”
Reader finds my insomnia article Googling “when does sleep deprivation become lethal.” I can relate to that question.
Late last year I reversed a carelessly anti-creatine position. I reconsidered this supplement and publicly acknowledged that it is a safe and effective ergogenic aid, capable of reducing muscle fatigue at the gym. And then I tried it. And that went badly. I developed severe insomnia — and this was before I read that some people may have trouble sleeping when they take creatine. I can now add to that ancedotal evidence.
I have struggled with insomnia my whole life. It’s a problem I know much too well (see Save Yourself from Insomnia!). I know its ways, and in particular I almost exclusively have trouble with “sleep maintenance” — I get to sleep just fine, but then I wake up. This creatine-powered insomnia was a mirror-image: I had a lot of trouble getting to sleep, but then I’d finally crash hard and even sleep in. This was all quite peculiar and unprecedented, and it didn’t take me long to get suspicious. Normal sleep was restored within 48 hours of stopping creatine. I performed pretty poorly at the gym during that 3-week period… probably because I was so fatigued!
So my creatine experiment was a bust, but that doesn’t mean creatine doesn’t work. My vulnerability to sleep problems is nothing new. Almost anything can wreck my sleep: a hangnail, a thrilling episode of Big Bang Theory, a good idea, you name it. Creatine gets added to my list of sleep-wreckers, but I’m sure most people probably don’t have a problem with it. Nevertheless, it seems to be well worth mentioning.
“They can get their foot almost 45˚ to the shin. (Normal range of motion for a westerner is ~10-20˚).” ~ Todd Hargrove
“…most systematic reviews of acupuncture published in China don’t search the literature thoroughly & don’t evaluate it properly. … There is ample reason to be suspicious of the conclusions of [Chinese] systematic reviews [of acupuncture].”
Case report & disturbing X-ray of a traumatic neck dislocation… mostly asymptomatic. Even very serious injuries can cause amazingly little pain. Fascinating!
I will have to look into “Exploding head syndrome.” Plus a couple others. 13 weird studies.
“Sensory clutter”: I don’t know how yet, but soon I will find a way to use these words. (Update: I still haven’t! But I will!)
Honest fan mail: “The honesty of your articles is freaking fantastic.”
I do try to avoid dishonesty!
It’s usually not possible to tell if a treatment made healing “faster.” There are few ways or none to actually improve on the biological process of healing. We can’t tell the body, “Hey, heal better, will ya?”
AllTrials.net is trying make sure ALL research results are reported—not just results that make drugs look good. I’ve signed the AllTrials.net petition & donated. Here’s my petition statement:
As a health writer earnestly trying to respect the evidence, I have been amazed and dismayed for years by all the fixable glitches in the pursuit of knowledge — such as the file-drawer effect. I am thrilled by the prospect that even one of these problems might be solved by smart collective action. Go AllTrials, go!
1-Minute Medical School: Here’s a promising new YouTube video channel: Dr. Rob Tarzwell’s One-Minute Medical School, where “medical topics are broken down so the key point is presented understandably in sixty seconds.”
Rob has been a friend of mine for a few years, and I know him to be a master of splainin’ his knowledge, which is freakishly impressive: he is literally the most educated person I hang out with (and I know some pretty educated people). Dr. Rob is also a regular medical expert guest on a great podcast, Caustic Soda, a show of black comedy about everything and anything gross and horrible and fascinating. So that gives you a clue about Dr. Rob’s style. This is not a boring guy.
Much of this video series will probably not be about pain topics, but Dr. Rob also has specific expertise in that area, so I’m really looking forward to seeing some 1MMS videos on that topic — and I’ll share them here when they come, and embed them here and there around the site where they will help. Meanwhile, many of my readers will probably enjoy some of his other topics, like anaphylaxis or wrist bones.
p class="css_caption">Wrist Bones 1:00
I have lived & loved many of the flaky & sloppy ideas in health care that I criticize and debunk today. I’ve added more information about my background to my bio page.
Thumbs down to simple #stretching as a treatment for seizing up.
I’ve written 424 blog posts (roughly 175,000 words) since I started “blogging the process” about two years ago — that is, as I go through the process of creating very detailed articles and tutorials, I share bits and pieces of what I’m working on as I go, using a blog format. So my blog posts are all in some sense excerpts or rough drafts of larger projects. I very roughly estimate that I actually wrote more than double that much, but only blogged about 175,000 words.
I’d never heard “anecdata” before. Cute.
Still working this idea, finding every angle: brains control pain… not minds. It’s a subtle but vital difference.
This little blog post has been making the rounds, and I like a lot of what it says, and there’s no question it’s nicely in tune with a core concept of my website — taking health care into your own hands as much as possible. And there are a great many straightforward ways to do that (like avoiding the kinds of ergonomics disaster shown in the picture). But I have a quibble…
The author writes: “Animals just like you have been taking health into their own hands and paws for millions of years.”
Hmm, yes, we have … and hoo boy does that sentiment ever ring hollow for the victims of dire medical problems and chronic pain, and even the hundreds of millions of people who struggle just with fitness, or ruinous addictions. I have personally witnessed a great many cases of people who, believing themselves to be “educated” and “empowered,” vigorously pursued expensive, risky, and futile treatments for chronic pain problems. I witnessed so many cases like this — so much bad self-help — that I decided to devote the rest of my career to trying to help all those self-helpers with better information.
Human animals are really not innately good at “taking health into their own hands.” Left to our own devices, we routinely, royally screw it up! And we are tormented with countless afflictions utterly beyond our power to prevent or treat, with or without professional help. And so it goes.
Reston was not anaesthetized by acupuncture. It’s a myth: he got a freakin’ epidural! Much of the popularity of alternative medicine and acupuncture in particular can be traced to 1972, when journalist James Reston wrote about his emergency appendectomy during American President Nixon’s trip to China. Legend has it that he was “anaesthetized” with acupuncture needles. Dramatic! Inspiring! And false.
By his own account, Reston was chemically anaesthetized in a thoroughly medical manner, an epidural — “a normal injection of Xylocain and Benzocain, which anesthetized the middle of my body…and then pumped the area anesthetic by needle into my back.” And, by his own account, Reston received no acupuncture of any kind until 24 hours later, and even that was for “considerable discomfort” — not the severe pain assumed by virtually all re-tellings of the story.
For detailed sourcing, and a bunch of other surprising (and unflattering) stuff about the history of acupuncture, see Dr. Kimball Atwood’s excellent, scholarly, fascinating acupuncture series on ScienceBasedMedicine.org.
Therapists: please consider not trying to “fix” flesh. Address the nervous system. Just help patients remember what it’s like to feel safe & good.
Now here’s a good example of how EBM gets abused, co-opted: “appearing to build up the evidence base.” Context here from @doctordoubter:
You “need a placebo [surgery] trial when the outcomes are ‘soft’ (subjective: pain).” ~@doctordoubter Placebo surgeries are necessary and ethical. I’ve been arguing many years we need surgeries for pain compared to shams. More:
Static stretching vs. “fancy” PNF stretching: which works better? Hold-relax, right?
It’s common for stretching enthusiasts to dismiss my concern that stretching is not all that useful with the concession that, of course, static stretching is quite pointless, but fancier methods (their methods) are “obviously” clinically useful. By far the most common example of allegedly superior stretching is the broad category of “proprioceptive neuromuscular facilitation,” and more specifically the hold relax method. Supposedly this approach works better than mere pulling on muscle. However, this test of the immediate effects HR-PNF versus static stretch on hamstrings was a bust: they both increased flexibility equally well (for whatever that’s worth).
No significant differences were found when comparing the effectiveness of HR-PNF and SS techniques. Both stretching methods resulted in significant immediate increases in hamstring length.
“Immediate effects of quantified hamstring stretching: hold-relax proprioceptive neuromuscular facilitation versus static stretching”
My role at ScienceBasedMedicine.org is basic…but I did write their about page. And I am proud of that. (And everything I’ve ever written about SBM is just my take on what I’ve learned from Drs. Novella, Gorski, Atwood, Crislip, Hall…)
entire biggish article about rhabdomyolysis.
Lactic acid is not a dead-end, “bad” metabolic waste product, and it does not cause post-exercise soreness. This is a pernicious and seemingly un-killable myth. It originated with “one of the classic mistakes in the history of science,” according to George Brooks, a Berkley physiologist. See Gina Kolata’s clear overview in the New York Times, or a concise professional summary by Robergs in Experimental Phsyiology. For a deeper and geekier, but excellent read, see Dr. Goodwin’s entertaining rant about the prevalence of the lactate myth in the 2012 summer Olympics coverage.
Apparently it is a myth that muscles are “paralyzed” by anaesthesia. Tone remains! A resting muscle shrinks 20% when cut. “There is a constant battle to relax the muscles during some procedures.” Doubtless I know some people who will now say, “I could have told you that. If you’d asked.” Too bad I didn’t ask!
The tone is mediated by the CNS. Some believe there is some intrinsic regulation of tone — that is, the muscle sets its own tone — but Dr. Steven Levin directly refutes this with some pretty sound logic: “Curare works at the neuro-muscular synapse, so it is the CNS that maintains the muscle tone, including the resting muscle tone (RMT). In my many years of doing surgery, I have never cut a muscle that did not retract unless it was curare-ized (and even then there is some contraction), so it is a primitive function, maybe some of it spinal, present even in deeply anesthetized creatures.” That’s from this page, a bit hard on the eyes and heavy reading, but neat stuff.
“It is recommended that radiological imagining should continue to be used.” Indeed! That would be quite good at getting results, I imagine.
I’m on the board of a new Canadian science advocacy organization, Bad Science Watch. We will work to get science into Canadian politics, where it can do the most good. We’ll be focussing on any issue where science is relevant to Canadians, so obviously health science issues will be a big part of that. Bad Science Watch Executive Director, Jamie Williams:
“The Canadian public has been poorly-served by a government which displays little respect for objectivity and science. Consequently, weak consumer protection regulations allow the sale of products and services that don’t work, and Canadians are exploited by the unscrupulous or misinformed.”
Relevance to SaveYourself.ca? That’s easy: being involved in projects like Bad Science Watch, and editing for Science-Based Medicine, keeps me interacting with (and learning from) some extremely serious people and big ideas. It’s hard to overstate how valuable those relationships are, and how great it is that I can call up one of my fellow BSW board members, or fire off an email to any one of several geniuses at SBM, and ask, “Check my thinking on this?”
Warning: you may keep trying over and over again to see if you can outsmart your foot. You probably can't. This phenomenon is pretty hard-wired into your nervous system.
And there ain’t nothing you can do about it! Naturally it works with any counter-clockwise motion of the hand — “6” is just handy way of describing that.
As promised a few weeks ago, I have published a really huge under-the-hood update to the guts of my largest book, which will soon spread to the others like an infection you want.
Let me try to make this real.
Basically the book now automagically “knows” all about its own sections — how many, what they are called, etc — and can automatically spit out a table of contents and more. This makes it approximately a zillion times easier for me to update the book. You would not believe what a hassle it used to be. (Just try keeping a huge table of contents in sync with a giant book. I dare ya.)
So it will literally be about 5 times faster for me to actually publish an update — which means I will do more of them.
Showing what’s changed and why in a document — especially a document about health care and chronic pain — is as important as citing, footnoting, and democracy. Really. That’s why Wikipedia does it.
More tumbleweeds? Okay, fair enough: this is like a tough sell, like pitching electronics to the Amish. There’s nothing really obviously wonderful going on here from the customer perspective. But trust me: this update is actually a ginormous deal. The product just grew up technologically. It’s ready for the next decade and beyond.
I made a glaring error. I described the results of Carlesso et al like so:
The authors found that increased neck pain is 25% more likely with SMT than if you did nothing or stuck to safe and neutral treatments.
No. Wrong. Bzzz! Thank you for playing.
This morning I received a note from Lisa Carlesso, PT, MSc, first author of the paper, letting me know that I got it wrong: although her data showed that 25% number, it was not a statistically significant number. And that’s significant.
If there were any noteworthy increases in neck pain following this kind of neck treatment, presumably clearer data would have emerged. Thus the paper concluded that there is “strong evidence that neck manipulation or mobilization does not result in an increase in neck pain.” I’m not sure if I quite agree that a statistically insignificant number constitutes “strong evidence” so much as just generally low confidence in the results (and Carlesso acknowledges this in the paper as well, practically in the next sentence: I basically saw in the data what I wanted to see. Funny how that works. “However, the limitations of the Strunk study and the low GRADE rating remain, affecting confidence in the estimate.”)
But I am guilty of doing something I’ve accused others of doing: emphasizing a statistically insignificant number to make my point. When the numbers lean your way but fail to reach statistical significance, it’s called a “trend.” A trend in favour of a therapy is often trotted out as if it were supportive evidence. I did the opposite, and so I am doing the walk of shame now. Bad science writer, bad! I erroneously thought the number was statistically significant, probably because I’m a debunker by nature, and I basically saw in the data what I wanted to see. Funny how that works.
(Gosh, I wonder what system of knowledge-seeking could possibly compensate for that aspect of human nature? You get a gold star if you guessed “science.”)
Not much, really. “Here be statistical dragons.” There are so many ways that all this stuff about treatment harms can be wrong that I can’t really walk away from this feeling like I’ve learned anything terribly important one way or the other. The hard statistical bottom line is that statistically insignificant means that no conclusion can actually be drawn — the data was no more than suggestive. Interestingly, Lisa Carlesso pointed out that she has written another paper about how difficult it is to study adverse effects. Indeed!