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This post started out on Facebook, and had to be deleted. I shared a probably-too-good-to-be-true news item about fibromyalgia to criticize it and make fun of it. I should know better. The result was predictable: people started sharing it uncritically, passing it on without my context, or any similar context of their own, or even a hint of reserving judgement. In short, I quickly created a bunch of the same hype that I was trying to suppress. Ugh. Oops. So I took it down.
Here’s the article I was criticizing: “Fibromyalgia Mystery Finally Solved!” The writer is just a teensy bit over-heated about this science news. Such unbridled optimism is kind of adorable:
The announcement … undoubtedly has patients all over the world rejoicing that the mystery of Fibromyalgia has finally been solved.
There’s a problem with this kind of “mission: accomplished!” medical science reporting that usually isn’t mentioned: the lack of empathy for the patient. Most chronic pain patients feel like they’ve been jerked around by experts for ages, told about a zillion conflicting things. The last thing they want is more big hopes: if they buy into it, if they “rejoice,” they risk dire disappointment and pointless distraction.
Hope is always a double-edged sword in chronic pain. Allegedly good news is always uncomfortably awkward, like being given a lovely pie that might be full of berries and sugar … or more pain.
I don’t know if I’ll write about this research yet. Maybe.+ It’s a year old. This isn’t fresh. I went looking for some analysis of this study, but so far I haven’t seen anything but breathlessly optimistic news based on a press release from the company that paid for the research. That company’s motives are unclear to me: not necessarily suspect, but certainly murky. Whatever I write, it won’t contain the words “rejoice” or “solved” or “total cure.”
Dr. Sandeep Juahar’s book about his bleak experience as a physician seems to be at odds with the autobiographical accounts of other doctors that I have read, most of which present a healthy mix of optimism and cynicism about their work and profession. It’s the same with the doctors I know personally, who all seem to be vigorous idealists of one sort or another. Their awareness of the failings and limitations of medicine is clear, but balanced by a strong and admirable enthusiasm to improve. If medicine is the unmitigated disaster that Juahar seems to think it is, I would expect to see a lot more doctors declaring it.
I have an article about statistical significance that, for years, griped about how P-values are abused and misunderstood while also — sigh — perpetuating the most common myth about P-values. A statistician politely pointed this out to me. I argued for it a bit. “It’s not wrong,” I protested. “It’s simplified. There’s absolutely no way to properly explain P-values without confusing the hell out of my readers. This is about writing and communication, not stats.”
“No,” he insisted. “This is not the simplified truth. It’s just plain old wrong.”
He was right. It took me hours of reading to satisfy myself of this. And then I spent hours more revising my article. It was probably one of the most difficult explaining jobs I’ve ever tackled. I now understand P-values, and I’m confident the article is finally correct. But … is it a better article? Will you understand P-values after reading it? I’m not so sure. I may have been embarassingly wrong about P-values, but I was probably right all along that they are damned near impossible to explain to a general audience without crippling simplification.
Still, I made a heroic effort, and wrangling words is what I do best, so give my explanation a try. How did I do?
I’m moving my office across town at the end of Oct, from downtown Vancouver to the quieter neighbourhood — still central Vancouver, but no longer right downtown by the ocean, where I’ve been for the last 14 years.
Moving is chaotic! Right now I’m surrounded by a forest of boxes. Customer service will continue more or less normally, but probably a little more sluggish than usual. And I probably won’t reply to non-critical messages until mid-November. Thanks for your patience.
Todd Hargrove recently published a terrific new article exploring chronic pain as an emergent property of complex biological systems. In this view, unusually stubborn or bizarre pain is the tip of an iceberg of stress-induced meltdown, rather than the result of any one problem (or in addition to it). Making fancy ideas useful is a great strength of Todd’s writing, and he wraps up with some superb practical ideas that I heartily endorse:
Pains associated with these conditions will probably NOT be effectively treated by focusing sole attention on the locally painful areas. The problem doesn’t live there. As Peter O’Sullivan has stated, we should give up looking for a “magic bullet theory” of non-specific low back pain. Instead, because the problem is more about supersystems than subsystems, it should be addressed by interventions that target this more complex and global level. These might include working on diet, sleep, exercise or mindfulness-based stress reduction. These are the “big rocks” that we should make sure have been put in the jar before we start reaching for tiny grains of sand like improving posture or strengthening the core.
Many people have huge room for improvement in the way they eat, sleep, exercise or handle stress. They might be more motivated to make those improvements if they better understood the connectivity of all the different systems in the bodyMany people have huge room for improvement in the way they eat, sleep, exercise or handle stress. They might be more motivated to make those improvements if they better understood the connectivity of all the different systems in the body, and their potential relationship to chronic pain.
If this is actually how serious chronic pain works, then we should see relatively weak ties between chronic pain and any particular sign of generally poor health (such as obesity, or insomnia), and much stronger correlations between chronic pain and any of several signs of poor health. In other words, we should see a pattern of people who were a bit of a mess before the pain even started. But… do we see that? It’s hard to tell. I am aware of many contrary examples, cases of severe chronic pain in robust people, and they are all the more tragic because of it. But those examples can’t tell us much, unfortunately. In fact, if the systems perspective is valid, I expect it to produce all kinds of surprising cases, and be maddeningly difficult to prove — like trying figure out what kind of atmospheric conditions cause the worst storms.
Chronic pain has indeed been one of the toughest puzzles in the history of medicine. Whatever we know about it in 50 years, I bet the systems perspective will be involved in some way.
Please, never hesitate to (politely) tell me that you think I got something wrong (heck, I know it’ll be popular if I admit it). Here is good example from my mailbag. Reader TW thinks “measuring force in pounds is a disgrace for your books.” I agree. He continues:
Your audience is probably quite international — which is where the SI system of measurements is used. As far as I know, it is at least taught in science classes in the United States and Canada as well. The SI system is clearly superior! As you advocate clear thinking, I would love to see if you use SI measurements primarily. The Imperial system is outdated and only used in North America.
Officially, Canadians are on the metric system. Unofficially, we often still do as the Americans do. Some metric measurements we have adopted wholeheartedly, like the kilometre. But most Canadians still give their height and weight in feet, inches, and pounds. I entirely agree with the criticism, and I’ve done a round of conversions, particularly where most needed. I can’t promise there aren’t some Imperial strays — it’s a really big website — but it’s much improved.
The Painful Quotations page now has an even 200 quotes about aches, pains, injury, therapy, and science and critical thinking. There are many more to come over time. When I realized it was close to 200, it was virtually effortless to dig through my files and boost it up to that nice round number.
I have really noticed this in my publishing career: self-effacing mea culpa blog posts are always super popular... but I routinely get vilified for (correctly) calling bullshit. (This suggests an effective strategy for blogging success: be wrong a lot, admit it a lot!)
It’s easy to win forgiveness for being wrong; being right is what gets you into real trouble.
I recently got a question about the value of FAST (“focused aspiration of scar tissue”), a minimally invasive surgical treatment for tendinopathies like tennis elbow or Achilles tendinitis. According to one doctor’s press release, it’s “advanced technology” — of course! — “designed to remove the source of tendon pain.” Good luck finding any other kind of information about it. There are no clinical trials of FAST. It seems to just be tendon scraping (debridement, if you want to be more formal). The mechanism is unclear, obviously speculative, and based on the rather simplistic notion that one can “remove tendon scar tissue” or “diseased tissue” from tendons to solve the problem. Bad tissue is bad! MUST CUT OUT. I also saw a number of references to “stimulating” recovery, which is quite a different idea (see Tissue Provocation Therapies).
Giving it the benefit of the doubt: maybe it can work on some kinds of patients. Tendinopathy develops in stages, and in the degenerative later stages there might be something to scrape away, for whatever that’s worth. Or not, because degenerative tendinopathy is mostly characterized by a kind of withering of the tendon (acellularity and disorderly connective tissue), and not by anything that can be removed. And in any event “there is little capacity for reversibility of pathological changes at this stage” (Cook 2009). Many cases never get that far in the first place and wouldn’t be candidates even in principle, since they involve little or no obvious “diseased tissue” in the first place, and even if they do it’s almost certainly a symptom of tendinopathy, not the cause of it. So the whole idea of a treatment based on the removal of tendon crud is dubious.
There’s a never-ending supply of minimally invasive procedures for stubborn musculoskeletal problems, like platelet-rich plasma (PRP), which has probably reached peak hype by now. They are easy to sell, because they sound simultaneously impressive but still quite safe. They can be potent generators of false hope and drainers of wallets, and they are all highly suspect for this reason. But FAST seems more desperately in need of some proper testing than most.
I am often mistaken for an “expert,” but no, not in my subject matter: I am merely well-acquainted with the work of many actual experts. I’m a liaison, translator, and popularizer. I’m good at that, and it’s good work if you can get it. Many of the actual experts are also acquainted with me, and they follow and check my work. These days, I can be confident that if I get anything too far wrong, I’ll hear about it from a source I can trust. But the only thing I am truly expert at is the craft of writing and web publishing … and even in that I am humbled by the achievements of others, of course.