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

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

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

Tricksy, the human mind is.

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

zoom

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

Many myths are well-busted.

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

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

McGuff et al. Body by Science. 2009.

The authors also have a website, Body by Science.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What’s the harm? Oh, there’s harm!

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

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

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

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

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

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

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

Dr. Tim Taylor, a chronic pain specialist from Virginia, has contributed an important new chapter to my book about muscle pain, Save Yourself from Trigger Points & Myofascial Pain Syndrome! This is SaveYourself.ca’s first major collaboration, and a really good one to start with — it’s fantastic to have expert assistance in creating such valuable information for my readers.

Dr. Taylor has written about the medical factors that can make muscle pain stubborn, particularly the harmful effects of statin drugs (i.e. Lipitor) and a variety of nutritional and hormone deficiencies. For instance, sun-deprived readers please take note: it is now well-established by research that most people are not getting enough vitamin D (see Holick), and that this is relevant to pain (see Plotnikoff and Holick). In 2003, Plotnikoff et al wrote rather dramatically in Mayo Clinic Proceedings (emphasis mine):

…all patients with persistent, nonspecific musculoskeletal pain are at high risk for the consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for vitamin D deficiency …

Even watered down, those results should be of great interest to pain patients.

Clueless!

As a Registered Massage Therapist, I was clueless about this for a decade. So tragic! Imagine your physiotherapist, massage therapist or chiropractor working away on your tissues for more than a buck a minute, in vain, blissfully unaware that the real reason you hurt is that you’re D deficient! Or taking Lipitor. Or some other non-obvious medical complication that your doctor is probably also clueless about.

Many therapists will protest that they “know” about the importance of nutritional deficiencies and drug side effects: however, I would bet that, in almost every case, that “knowledge” is mostly just a vague faith that “nutrition is important” and “drugs are bad” — not the same as having a specific knowledge of which drugs cause myalgia, which nutrient and hormones deficiencies matter and why, and what to do about them beyond taking a multi. There is serious medical expertise needed here.

I’ve actually avoided studying and writing about these medical issues, because Dammit, Jim, I’m Not a Doctor! — it’s just generally unwise for me to write about squishy medical stuff, and I’ve got my hands rather full with orthopedics. And so this vital information was previously missing from my book, and I did not have the time or the academic or clinical expertise to fix it. I was painfully aware of it, but there was no easy cure.

Fortunately, Dr. Taylor came to me … starting out as one of my customers.

An important customer

Dr. Taylor was pleased with my book, but he knew that something important was missing. He knew all too well how important medical factors can be in a chronic pain case: he’s lived through that discovery. Dr. Taylor has suffered and recovered from serious muscle pain himself, and it changed his career. Dr. Taylor and his wife Dr. Anna Bittner started a clinic dedicated to chronic pain management, particularly myofascial pain syndrome.

“After many months without success, and being told my pain was imagined, I found internationally recognized experts who treated me with excellent results, and Anna’s fibromyalgia also improved substantially,” Dr. Taylor explains. “I developed a passion for helping other people in pain and offering them the same techniques that had relieved my own pain. This is the most satisfying thing I have ever done as a doctor.”

Dr. Taylor thought my book was worthy of upgrading, and offered to do it.

Dr. Tim Taylor, Richmond, Virginia. After their own successful recoveries from chronic pain, Dr. Taylor and his wife Dr. Anna Bittner started their own clinic, Pain Relief Home.

Who knew collaboration could go this smoothly? I sure didn’t!

I often get offers from would-be collaborators, but no proposal has ever amounted to anything. A thousand things can go wrong with collaborations! It’s like herding cats. Make three points about a document and they will probably misinterpret the first, disagree with the second, and ignore the third.

Not Tim.

Dr. Taylor didn’t just volunteer to contribute, he did it fast and well. Content was delivered weeks before expected. Every email was answered within hours. He was thorough and accurate and reasonable and polite and a productivity machine.

“Show me the evidence” usually doesn’t get such a good answer

At one point I thought we might have had a deal-breaker. SaveYourself.ca is all about the science. This has been a sticking point with some contributors over the years — many have lots of ideas, but not much evidence.

I’d asked Dr. taylor to provide more specific scientific evidence for several points, a fairly tall order. I wasn’t sure what would happen. On the one hand, I thought the evidence probably existed. But, based on past experience, the predictable response was excuses, a 3-week delay, useless references …

Tim provided a good list of specific references the next morning.

A book that’s always up-to-date

This is exactly why I don’t really want to publish a print book. Electronic wins hands-down in this situation. This update is available to my readers now — the most important one-time upgrade in the history of the trigger points book. Anyone who has a current subscription can read it today.

And of course it’s also available very cheaply to past customers. Normally you’d have to buy a new, full-price edition of a book to get an upgrade like this — here it’s just a small renewal fee, even if it’s been years since your original purchase. That’s just better.

Save Yourself from Trigger Points & Myofascial Pain Syndrome!

Myofascial trigger points — muscle knots — are increasingly recognized by all health professionals as the cause of most of the world’s aches and pains. This detailed tutorial focuses on advanced troubleshooting for patients who have failed to get relief from basic tactics, but it’s also ideal for starting beginners on the right foot, and for pros who need to stay current. 213 sections grounded in the famous texts of Drs. Travell & Simons, as well as more recent science, this constantly updated tutorial is also offered as a free bonus (2-for-1) with the low back, neck, muscle, or iliotibial pain tutorials. Add it to your shopping cart now ($19.95) or read the first few sections for free!

  $19.95

You know those T-shirts that say, “I’m kind of a big deal”? Well, I’ve been working on a project that needs that T-shirt. I’ve been a bit quiet in this space recently because that project has been taking big deal bites out of my schedule every day. But it’s now in the bag, and I should be able to announce it by the end of the week. Sharp eyes will actually spot it on the website before it’s announced.

Stay tuned!

I found a great moment in television quote to introduce my article, Battle of the Experts: A guide for patients caught between conflicting diagnoses and prescriptions. It stands on its own pretty well, but for those who aren’t familiar with the show, Sheldon is insufferably overconfident — an über-geek who believes he is intellectually infallible. Sounds like something patients encounter all too often …

You know me to be a very smart man. Don’t you think that if I were wrong, I'd know it?

— Sheldon Cooper, theoretical physicist, in “The Jiminy Conjecture” (an episode of The Big Bang Theory)

It’s rare that I feel “done” with a topic on SaveYourself.ca. But I may feel done with core strengthening, and two lovely new science experiments feel like well-deserved nails in its coffin to me.

With the (perpetual) caveat that all knowledge is provisional and subject to change if surprising new evidence emerges, I think that core strengthening has been disproven as a treatment for low back pain. When I say that it is “disproven,” I don’t mean that the benefits are non-existent; I mean simply that they are too minor to be excited about, and core strengthening does not deserve 90% of the hype that is heaped upon it. (Bear in mind that core strengthening is the sole basis for many popular “cures” for low back pain.)

Core strengthening is no different than “general exercise”

The first new study shows that core strengthening is no different than “general exercise.” This is a 2010 paper by Unsgaard-Tøndel et al in Physical Therapy, comparing core coordination and core strengthening exercises to general exercise. Over a hundred participants worked with “experienced physical therapists” once a week for eight weeks — a nice fair test, a good approximation of what a motivated patient might do.

Paying for eight weekly sessions of training is a greater and more disciplined effort than many people make, and yet still reasonably affordable and achievable — just the sort of therapy that many patients would seriously consider buying and doing. If you can’t make a clear difference with that, then it’s effectively useless for the vast majority of patients.

Pain and disability were measured before and after, and again at a one year follow-up. Unfortunately, there were no differences: “This study gave no evidence that 8 treatments … were superior to general exercises for chronic low back pain.” Sure, perhaps more training would have yielded better results, but how much better? It’s hard to imagine that it would be worth the additional expense and effort for what would probably be only a minor difference at best.

Core strengthening does not improve injury rates

The other experiment, also published in Physical Therapy this year, asked the question: does core strengthening change injury rates? It should, to justify all the energy and bucks spent on it! Alas, this study of more than 1,100 soldiers found that specialized, “precise” core strengthening did nothing to improve rates of low back pain (or any other injury) compared to good old-fashioned sit-ups. Soldier studies are always great because you know they were forced to exercise way more than any normal person would! (Acknowledgement: there was one modest positive difference with precise core strengthening, but it just wasn’t enough for me to care.)

“But they were all doing some kind of core strengthening!” you might protest. “That doesn’t prove core strengthening doesn’t work. Maybe both kinds worked!”

Right you are, as far as that goes. But this is just one piece of the puzzle, and a good one. Consider that the core strengthening “industry” really likes to put on airs and act like it’s critical that you not only to do core strengthening, but that you do it in a very particular way. They really tend to look down their noses at old-fashioned sit-ups, and often allege that they are irrelevant and even dangerous. It’s part of the “mystique” of yoga and Pilates that core strengthening must be done in a clever and “advanced” way. It is the main reason to pay a physical therapist: because the patient believes that there must be some reason for paying $80/hour rather than just doing sit-ups at home. This study demolishes that mystique by showing that it just doesn’t matter how “technical” your core strengthening is.

Meanwhile, there are plenty of other studies to show that no kind of core strengthening is important. And speaking of those …

But wait, there’s more …

To wrap up: an analysis of six other recent core strengthening studies like the two above. Its title asks the excellent question: Can We Explain Heterogeneity Among Randomized Clinical Trials of Exercise for Chronic Back Pain? Translation: “what the hell accounts for the mess of conflicting and generally underwhelming results for exercise therapy?”

As we’ve seen above, studies of exercise for low back pain are underwhelming: while some show some minor benefit, it’s never a big deal, and we’re always left wondering if another way of exercising (or testing) might have produced better results. There are so many ways to exercise, and the science of exercise therapy is generally plagued by this complexity: no matter what the research says, there’s always the real possibility that you might get better results by dialing up a different combination of variables.

Ferreira et al tried to figure out which variables matter. This is quite different than testing to see what kinds of exercise work. The point was to see which variables affect the outcome. If any. In fact, they found only one: “only dosage was found to be significantly associated with effect sizes.” Nothing else mattered: just how much exercise was done.

And even that didn’t matter much. The effect of exercise was small in any case — real, but small.

In other words, according to these results, exercise therapy for low back pain is a fool’s errand for most people, most of the time: it doesn’t matter what kind of exercise you do, just that you do it. If you do enough, you’ll probably get some benefit. But there’s a real problem of diminishing returns: no matter how much you do, the benefits taper off fast.

Core strengthening is discussed at (even greater) length in my book, Save Yourself from Low Back Pain!

After years of generally awful insomnia, in 2005 I entered the big leagues of sleep deprivation and suffered particular savage nightly losses for several months. Desperate, I sought a cure … and found one. I no longer have severe sleep problems (knock on wood). Not everyone is able to do that, of course, but many are, and so I have maintained a good guide to insomnia treatment ever since here on SaveYourself.ca, particularly because insomnia is relevant to chronic pain.

And I keep an eye on the science and other sleep stuff. Recently I found three sleep items to share: A Radio Lab show, a National Geographic feature article, and a stick man comic strip (XKCD) ... all about sleep.

From Radio Lab, a whole show about sleep from 2007, brilliant as always. In particular, I was fascinated by this tidbit that I’d never heard before: that sleep deprivation may do its dirty work by (somehow) interfering with protein folding (starting about minute 29, transcription a bit imprecise because of the complex mix of sound bytes):

Dr. Allan Pack, a “rabid biologist,” has been looking at sleep at the cellular level, and one of the things he’s found over and over and over — shown in mice, shown in rats, shown in fruit fly — is that certain cells in all those different types of animals, when they are sleep-deprived … what happens is that you don’t get proteins properly folded.

Excuse me? Proteins properly folded? This is a phenomenon called the protein the unfolded protein response. But what on earth does that mean? Why do you need proteins to “properly fold”? Well, you’re made of proteins. Proteins are the essence of you. If your proteins are misshapen, if they’re not folded properly, if they don’t have the right three-dimensional structure, and as a result they start accumulating inside the cell, and then these unfolded proteins can start to aggregate together and form clumps inside the cell and essentially clog it up and it’s really quite toxic. Clumpiness equals tiredness!

But when you get sleep, a group of cleaner-uppers have gone through your cells and removed the misshapen proteins so that, in effect, sleep is the best housemaid you’ve ever had, in the hotel of you.

I like that punchline: “sleep is the best housemaid you’ve ever had, in the hotel of you.”

From National Geographic Magazine, “The Secrets of Sleep,” a superb feature article on sleep (entirely available online) about people with a genetic disease who actually die from insomnia — yikes. Reading it, I thought, Wow, when traditional media is good, it’s still really good — NGM produces amazing content.

From XKCD, the webcomic of romance, sarcasm, math, and language, a stick man strip about sleep deprivation that exactly describes how I felt in August of 2005, and how any sleep-deprived person feels when they start to sink down to less than 3–4 hours per night. (Be sure to let your mouse cursor hover over the comic for an extra caption.)

As is my way, all of these links are now rolled into the self-help goodness that is my insomnia tutorial: read it and sleep.

Save Yourself from Insomnia! Serious tips from a veteran of the insomnia wars

An Italian doctor, Luca Sconfienza, believes that he may have a solution to the deal-breaking problem with steroid injections (for plantar fasciitis): a way to make the benefits last. If it’s true, it’s a big deal. But Sconfienza’s claims fit the description “too good to be true.”

Steroid (cortisone) injections are routinely prescribed by physicians for plantar fasciitis (and many other inflammatory conditions). They are often regarded as something of a magic bullet for inflammation, and not without good reason: cortisone has powerful anti-inflammatory properties, and it certainly does have the potential to dramatically reduce pain. But the benefits are infamously fleeting. A review of steroid injections for plantar fasciitis in 2003 discouragingly concluded:

Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree.

But what if you used ultrasound to carefully guide the injection, to avoid injecting (and damaging) the plantar fascia itself? What if the steroids only went into the irritated soft tissue — sort of like injecting the bark of a tree rather than the tree itself? It works a charm, according to Sconfienza, who is known for his work with ultrasound-guided injection therapy.

Sconfienza’s remarkable results

In 2008, Sconfienza presented spectacular results for “an effective, one-time outpatient procedure” that eliminated chronic plantar fasciitis in 39 of 44 patients, with the benefits lasting at least a few months until the results were presented at a conference. The newsworthy results were widely (and generally uncritically) reported: just Google for “Scofienza plantar fasciitis.”

I am more critical, of course — that’s my job. There are some problems here.

Two years later this research is still unpublished and exists only as a press release. Indeed, none of Sconfienza’s guided-injection studies have been published: they all exist only as press releases (there’s rather a lot of them if you search the RSNA website). This does not mean his research isn’t good, legit science … but it is an eyebrow raiser. I have learned to be cautious of press-release-powered science.

There’s no way can I get excited about Sconfienza’s protocol until it’s been reviewed by his peers.

And the research is also unreplicated. No remotely similar protocol has been tested — not even just the injection part of it. The closest is a mid-2010 study of guided injection under general anaesthesia — quite different. Patients improved, but the paper’s abstract doesn’t say how much — so it probably wasn’t much.

And that’s not all

And Sconfienza did more than steroid injection: his injections were combined with dry needling and soft arch support following the procedure. Dry needling is quite a curve ball here that makes it quite hard to know what to do with the information. Gently lacerating the irritated tissue —there’s an interesting combination of words! — is not even remotely a standard treatment, and has not been tested independently at all (try a PubMed search — not one single result). It is about as shot-in-the-dark as a treatment can get. It is supposed to stimulate healing by increasing inflammation: injure to heal, a sort of kick start for healing.

This mix of treatments in one protocol raises some awkward questions. Which intervention produced good results? Was it one of them, the other, or both? Why increase inflammation and then immediately reduce it with corticosteroids? Aren’t those contradictory rationales? If dry needling is a critical part of the treatment, how much is needed? It’s pretty obvious that too much could be a bad thing. If the study was published, we’d know — but until it’s published, you can’t exactly go to your podiatrist and say “please lacerate my plantar fascia with a needle.” You may get quite a strange look.

Indeed, the biggest problem for patients here really is the practical one: do they ask the doctor for the “Sconfienza protocol”? Doctors may or may not have heard of Sconfienza’s protocol, or agree with it. Or they may promote some equally untested variation on it. Treatment standards come from published science — without them, everyone’s just guessing.

While (very) interesting, Sconfienza’s results are just not useful yet.

Sconfienza LM, Lacelli F, Serafini G, et al. What’s New in the Treatment of Plantar Fasciitis: A Percutaneous Ultrasound (US)-guided Approach. Presented at: Annual meeting of the Radiological Society of North America; November 30, 2008-December 5, 2008; Chicago, Ill. Presentation No. SSA13-07. See the RSNA press release.

From the Department of Research Results We Really Hope Are True: “…new research from England says that adopting a low-calorie diet, even later in life or for a short period of time, can activate many of the same touted benefits as an entire lifetime of meager eating.”

Intriguing. I hate to add to the constant noise of conflicting, confusing nutrition science, but it’s an interesting data point, and a lovely idea if true.

New Rules for Low-Calorie Diet

E-books need covers! My books have been sadly lacking in e-book covers for much too long. So I whipped these up in a few minutes yesterday with my right hand while juggling chainsaws with my left. These just don’t display nicely in an RSS feed, so you’ve got to go to the website to see ‘em.

Last week SaveYourself.ca got a subtle upgrade: “meatier” footnotes with extra content are now visually distinct from “boring” footnotes that contain only bibliographic information.

Often on SaveYourself.ca when you click on a footnote, you are rewarded with a nice chunk of bonus reading that really adds something to the main text. I’m a footnote junky. I’m reading Dawkins’ The Greatest Show On Earth in e-book form right now, and I tap on every footnote — it’s like a treasure hunt. What else will that clever Dawkins have to say about this? my brain asks. They seem to be inherently interesting to me: they are somehow more personal, like the Dawkins wants to tell me something extra.

But other times on SaveYourself.ca you click on a footnote an all you get is:

Grundy et al. Lancet. 1984.

Yaaaawn. Great for auditing my sources, mind you, and that really matters. But it’s not exactly a party in your brain.

Until now, there just wasn’t any way to tell what kind of footnote you were going to get. You had to click to find out. It might sound like kind of a non-problem — and maybe you’re right — but there are thousands of footnotes on this website. Surely someone will find it helpful to know that they can pass on the gray ones unless they want the bibliographic data?

I don’t know if I’m answering a need here or not. If anyone has actually noticed this issue and appreciates the subtle upgrade, please let me know — I’m quite curious to know if anyone cares.

Does anyone care?

Wind whistles. Tumbleweed blows throw.

#$@&% footnotes, how do they work?

(That’s a joke quite a few readers may not get, so here’s the explanation.)

Did I spend 800 work hours manually marking hundreds of footnotes as “boring” or “interesting” for my readers? Nope! I work smart. An automated system scans footnotes for the tell-tale signs of bibliographic information and styles those ones differently. It’s not perfect, but it seems to get 98% of them right. Hooray for JavaScript!

How reliable is health information on the internet? Here’s a shocker — not reliable at all!

Dr. Steven Novella wrote about this recently on ScienceBasedMedicine.org, regarding a recent study of the reliability of internet information about 10 common musculoskeletal problems, commenting specifically on sites like SaveYourself.ca:

It is also not surprising that individual sites also scored relatively low on average. An individually run site is only as good as the individual running it, so there is bound to be a great deal of variability. Also, individuals are more likely to make mistakes or have missing information than groups.

Amen!

Indeed, SaveYourself.ca is only as good as I am, and I am probably more likely to make mistakes or (especially) have missing information than groups. It’s just impossible for me to keep all my content completely up-to-date, and there are only so many topics I can cover. Keeping SaveYourself.ca accurate feels like an epic game of scholarly Whac-A-Mole.

On the other hand …

My impression of most institutional and non-profit sites is that they achieve their high reliability by staying safe and shallow. Uncritically regurgitating basic conventional wisdom in a bland and simplistic way is certainly one way to get rated as “accurate”! It’s also a great way to leave readers without the slightest awareness of how the last ten years of science have been changing things.

Hopefully SaveYourself.ca is pulling up the average quality of individual sites. Importantly, I wear my fallibility on my sleeve, constantly emphasizing that all knowledge is provisional, and all scientific evidence is part of an evolving puzzle. That’s a major theme on this website. You can’t huck a stick around here without hitting some kind of epistemological disclaimer.

Or a word like epistemological.

And the referencing! Don’t forget referencing!

There’s another thing that sets SaveYourself.ca apart: referencing. And lots of it. It’s my weird, geeky little claim to fame that only librarians and scholars can truly appreciate. (Getting into this is also a bit of a setup for the subsequent post.)

Way back when I started this thing, in the late 90s, health information online was incredibly primitive. Here we had this magical new information system that “hyperlinked” documents together. It was a bibliographer’s wet dream. Imagine: not just referring to sources, but connecting to sources! Wow! The ability to make it easy for readers to audit your sources was a major upgrade to the entire concept of referencing — to fail to do so was suddenly an ethical blooper of scholarship.

But no one was doing it! Back then, not even scientific journals did it.

So I started.

Health information is now apparently the largest single category of information online (though I always find that a bit hard to believe: can it really be bigger than porn?). And yet, as far as I know, SaveYourself.ca is still the only privately run website about pain problems that has extensive, rigorous and — above all — linked footnoting and referencing. My sources are well organized, prominently displayed, heavily annotated, and almost always directly linked to an original for easy auditing.

I simply don’t see that going on anywhere else, not with health education aimed at the public. And that includes institutionally produced sites.

Speaking of referencing, I actually just upgraded footnotes on SaveYourself.ca. See the next post for details.

Traumeel is a popular homeopathic remedy for aches and pains. It is often presented as it were an herbal remedy, but like all homeopathy it actually contains only trace amounts of its flagship ingredient, Arnica.

A reader recently pointed out that I screwed up some freaky dilution math in my Traumeel article. The math was a calculation of just exactly how little of the herb Arnica montana is really in Traumeel. The math matters, since the argument is often made that it’s a low dilution (for homeopathy) and therefore the Arnica might have a direct medicinal, herbal effect. That argument is a bit of a reach if the dilution is still homeopathically extreme.

Which it definitely is.

Fortunately, my error did not harm my point: both my wrong answer and the real answer indicated impressive dilution. I reworked the math, and the description. In addition to being correct (I hope!) it now better shows that the amount of Arnica in Traumeel is far, far too little for Traumeel to be considered an “herbal” product. Here’s the new math:

Although less than many other homeopathic products, 3X is still a lot of dilution: 7.5 micrograms of actual Arnica in a gram dosage of Traumeel. That’s way less than a milligram — .0075 mgs — in the whole tube. This is what a scientist would call a “trace amount.”

A microgram (µg) is a really, really small amount: one millionth of a gram! So how much is 10µg? Let’s put it in perspective: the same amount of lead would not be considered dangerous, even though lead is mind-bogglingly poisonous. In fact, lead is so poisonous that even a single molecule of the stuff is harmful in theory. In practice, however, the measurable effects of lead poisoning don’t start until you’ve got at least 10–100µg/litre of blood, so that would be 50–500µg total in an average adult male … and at that level the effects would be subtle.

So 7.5µg of arnica is an incredibly small amount — arnica has very little effect on your biology compared to lead, and even 10–100 times as much lead has a negligible effect.

The math!

				grams	micrograms	quantity	comments
.75g diluted arnica	÷	1000	=	0.00075g	750µg	actual arnica per tube	The .75g of arnica on the tube is diluted to “3X,” a.k.a. 1000 times less actual arnica than .75g, so divide .75 by 1000 to get the amount of actual arnica.
.00075g actual arnica	÷	100	=	0.000075g	7.5µg	actual arnica per dose	Assume that a dose is about 1 gram, there are about 100 doses in a tube, so the amount of arnica in a dose is 1% of the arnica in the tube.

Is there an echo in here? Didn’t I have another item about this just recently? I did indeed: on July 8 I shared news that glucosamine made no difference for back pain patients, and here we are again with yet another F-grade for glucosamine, this time for knee pain (which is the problem that most people take the stuff for). If glucosamine were a student, its parents would get called in for a conference about little glucosamine’s poor performance. Perhaps there’s something going on at home? This is how the latest report card reads:

Over 2 years, no treatment [neither glucosamine nor chondroitin sulphate] achieved a clinically important difference in [knee] pain or function as compared with placebo.

(The conventional pain-killer celecoxib did not have any effect either.)

The pile of glucosamine failures is now getting rather tall. This morning Dr. Harriet Hall reviewed the evidence of absence of any glucosamine benefits in more detail at ScienceBasedMedicine.org and concludes that glucosamine proponents

… can always complain that maybe it works for knees but not for hips, or that a different dosage might have worked better, or that it works for some small sub-set of patients. There will always be “one more study” to do. … This new study confirms my opinion that we shouldn’t spend any more research dollars doing “one more study” on glucosamine.

Here’s the references for both of glucosamine’s recent epic fails:

• Sawitzke et al. Clinical efficacy and safety of glucosamine, chondroitin sulphate, their combination, celecoxib or placebo taken to treat osteoarthritis of the knee: 2-year results from GAIT. Ann Rheum Dis. 2010.
• Wilkens et al. Effect of Glucosamine on Pain-Related Disability in Patients With Chronic Low Back Pain and Degenerative Lumbar Osteoarthritis: A Randomized Controlled Trial. Journal of the American Medical Association. 2010.

Not that this evidence will actually stop people from “believing” in glucosamine and buying it in bulk! Glucosamine bottlers will really appreciate everyone’s continued gullibility.

My mis-named cat, Cali, investigating SaveYourself.ca central command and thoroughly backlit by three computer displays: a big 27" display, a 24" display, and another 10" of iPad (being used as a display with the help of Air Display). Here’s she looks like when not so silhouetted.

zoom

My short answer is: yes, and I call it “the confidence cure” (see The Mind Game In Low Back Pain). But it’s a deliciously complex subject. Steve Kamper writing for Body in Mind raises a number of good questions:

… just pump up the expectation volume and you get extra bang for your treatment buck. But what if the expectation effect is all you are getting?

A nice little read for therapists.

Steve Kamper for Body In Mind: What did you expect? Hands-up who thinks a patient’s expectations influence how well they do in treatment?

This post from the Department of Almost Meaningless Anecdotal Evidence. Still, dang if stories don’t carry some weight! So, for whatever it’s worth, here are two anecdotes from my own recent experiences with stretching and strengthening. I’ve had plenty of experience with both lately. I have been training hard this season, playing ultimate once or twice a week and hitting the gym almost every day. I’ve got good news and bad news …

The good news (strength)

Progress is possible! I’ve made real progress on strength. I can lift more. Sad to say I can’t really see it in the mirror. But I can definitely lift more. It’s quite satisfying — it feels like it’s been a long time since I made any obvious progress in my fitness level.

“Micro” workouts have been a successful strategy for me, and they go nicely with the concept of “microbreaking.” I often postpone longer workouts and end up not going at all. But if I limit the workout to about 20 minutes, I keep the date. The result is a nice daily rhythm of bite-sized workouts. The best workout is the one you actually do.

The bad news (flexibility)

Despite a consistent and diligent effort, I have not observed even the teensiest improvement in my hamstring flexibility. I’m a bit surprised: despite my general lack of enthusiasm for stretching, I assumed that I would see at least a modest improvement. I’ve given my hamstrings a good hard, long stretch several times per week for several weeks now, at least the equivalent — for my hammies — of taking a regular yoga class.

The lack of progress is so total that I got curious and decided to compare my hamstring extensibility in two strikingly different situations:

• after a long, stagnant session of writing
• in the hot tub after a good soak

I get so stiff when I’m writing that I sometimes actually have trouble walking for about twenty minutes. And yet apparently the feeling of stiffness is not equivalent with a lack of muscle extensibility, because I had no difficulty reaching my toes as normal, even when hobbled like this. I made careful note of exactly how far I could reach — I can just get my wrist to my toes.

After a bit of a reset — I gave the stiffness a good chance to wear off — I went for a nice soak. The hot tub in our building’s excellent spa was particularly hot.

Absolutely no difference. Not one iota more flexible after a hot soak. Toes at the wrist.

Interesting.

Fair to say that’s pretty expectation-defying, even for me. I’m not going to interpret this. I’m just going to report it and let you stretching nuts put it in your collective pipe and smoke it.

For the full scientific report on the value of stretching, see Quite a Stretch: Stretching research clearly shows that a stretching habit isn’t good for warmup, injury prevention, preventing or treating muscle soreness, enhancing athletic performance … or even flexibility!

Makes sense to me.

News.Discover.com: Wider Smile, Longer Life?

In case you needed another reason to be skeptical about SSRI anti-depressants, beware that they may make you “five times more likely to swim toward light,” where you may be caught by a bird or a net.

News.Discover.com: Shrimp on Antidepressants Not So Happy

Odd! Just a couple days after posting about a not-yet-published study of trigger point squishing — quite a rare subject for research — I came across (via @massagetherapy) an almost identical study that is published. They also reported news that makes massage therapists smile:

…using ischemic compression on shoulder trigger points may reduce the symptoms of patients experiencing chronic shoulder pain.

These studies look so much alike that if you put them both in the same cute little sailor suits you wouldn’t be able to tell them apart. They’re both rather simple and small, they both studied “ischemic pressure” — pressing and holding a trigger point or “muscle knot” until it’s a bit oxygen-starved — and they both produced an unambiguously thumbs-up of a result.

Indeed, this research showed an impressive treatment effect: a score measuring shoulder discomfort went down a whopping 75% in those treated, compared to a mere 30% reduction in people who received treatment in a nearby location. That’s a humongous difference and a great demonstration of a principle I’m always pimping on SaveYourself.ca: therapies should have no problem demonstrating their benefits in a fair test. The results should impress.

And these results impress.

Mostly.

Caveats!

These glowingly positive results will tend to perpetuate assumptions about the nature of trigger points. Even considered together, these two studies cannot be said to actually “prove” anything. They are still too small and their results might not be due to the actual treatment.

One obvious problem, for instance, is that both experiments compared treatment in the right place to treatment in the wrong place. This flings the door wide open for a major confounding factor: patients with shoulder pain would be well aware the sham treatment is a sham, probably dramatically decreasing their satisfaction and expectation of benefit. Meanwhile, people getting treatment in the “right” place will likely feel much better about the treatment and have much higher hopes: rich soil for a placebo effect.

Unfortunately, it is quite plausible that both of these studies simply showed that poking people’s trigger points gives great placebo.

This science stuff is tricky!

Still, we’ll file it all under “promising.” If the effect was a placebo, it was an awfully potent one.

A friend of mine made a movie! And it won a prize!

Kennedy Goodkey is a good friend and his movie is a feature film that he’s been working on for many years about Canada’s mythical lake beast, Ogopogo. After watching him hammer away on this project for what seems like forever, I am thrilled to announce that the film just won the best-in-festival award at its very first festival, beating out competition like Woody Harrelson’s Defendor. The film is The Beast of Bottomless Lake:

Deep in the waters of the bottomless lake known as Okanagan, lives the serpent like creature, Ogopogo. Some say it’s a myth, others say they’ve seen it. For Dr. Paul Moran, Cryptozoologist, it could be his ticket to fame and fortune and the validation he’s always been searching for.

Follow Dr. Moran and his team of dedicated and not so dedicated adventurers as they embark on a hilarious and sometimes tragic expedition to prove the existence of the creature and change our perception of the world as we know it. Oh, and claim the two-million dollar bounty that goes along with it.

Winning a prize right out of the gate like that is a huge deal, and nicely timed since Kennedy is soon to start work on another long term project — parenthood — and would probably really enjoy having a hit show right about now. Congratulations, Kennedy!

Support the film on the evening of July 21!

If you can’t actually get to Kelowna for the next screening — and of course most of you don’t know where that is and couldn’t get there even if you did — then just tweet about it. A few seconds of your time for the love of independent film. Kennedy sez:

We're planning a Twitter blast on opening night, July 21. From the start of the pre-show talk until the end of the Q&A we're trying to get as many people to post about the screening as possible. So between 6:30 PDT and 10:00 PDT (roughly) if people can tweet anything that relates to the screening and add our hashtag — for people who can't be there I'd suggest “Wish I could be at the World Premiere of The Beast of Bottomless Lake #thebeast” as well as any of the many possible links that they could use from our website, the Okanagan Film Fest website or our YouTube videos.

Do it!

Trailer for The Beast of Bottomless Lake

GUY WITH ACHILLES TENDINITIS: I’ve got Achilles tendinitis.

ME: My tendons have felt, I dunno, sort of papery for a couple of years. And I can't pinch them. They're incredibly sensitive to pressure.

GUY WITH ACHILLES TENDINITIS: That’s exactly what mine were like for a couple of years before they got really bad.

ME: Guess I’d better get to work on that.

A bit of a follow-up to my item from a couple days about the power of suggestion reversing the intended effect of muscle relaxants.

Every drug out there in the world, every single one, even the ones that you see on TV, are, in a sense, inside our heads. The only reason those drugs work is because our brain has receptors for them. And why would it have those receptors? Because it can already make them in house. Every pharmacological agent that there is, there is a chemical produced by your own brain that essentially does that thing. It’s like an internal pharmacy in there, just stocked full of drugs …

Terrific Radiolab episode about placebo.

An upcoming issue of Journal of Bodywork & Movement Therapies will include a new study of trigger point squishing. I was lucky to get a look at a final draft, thanks to connections at The Pressure Positive Company, the massage tool manufacturer that supplied the tools.

This experiment has the simple elegance of a good science-fair project. Dr. Dawn Gulick of the Widener University Physical Therapy Department simply compared the sensitivity of trigger points both with and without a simple treatment of pressure — squishing them, that is. That’s an experiment I’ve always wanted to do myself.

In life, and in a massage therapy office, it seems obvious that sore spots in muscles often get less sore when you apply pressure to them, but this apparent phenomenon is strikingly unconfirmed by any research. And we do need it confirmed, because what seems “obvious” to the fallible human mind is often surprisingly wrong. It’s also important to study it because, even if the treatment works, it may not work for the reason that seems obvious. For instance, what if it’s not actually the pressure that’s doing the job, but simply the touch? Or even the social interaction with the patient? You need some careful testing to suss out that kind of thing.

This experiment tested a specific method of squishing: pressing a trigger point firmly and long enough to starve it of some oxygen (ischemic pressure), repeatedly, for several days. This has long been one of the preferred methods of treatment, and it is specifically recommended in my own trigger point e-book as a best-bet protocol, but I have no real idea if that’s really the best way to get rid of a trigger point.

Dr. Gulick et al. measured trigger point sensitivity before and after treatment in 28 people with two trigger points in the upper back. Their conclusion:

There was a significant difference between the pre- and post-test sensitivities of the treated and non-treated trigger points. The results of this study confirm that the protocol of six repetitions of 30-second ischemic compression with the Backnobber II rendered every other day for a week was effective in reducing trigger point irritability.

Excellent!

This is small-scale science, and hardly the last word on this subject — remember, all knowledge is provisional — but the results are encouraging and certainly consistent with my professional experience.

 

The Backnobber

The massage tool chosen for the study, and one of the oldest massage tools around. I own one of these, and it’s a handy device. It’s particularly nice the way it breaks down into a more compact package when not in use. Buy one from Pressure Positive. No, I don’t get a kickback for that: I just like them.

How much does the effect of a medication depend on what you are told about it? Quite a bit, apparently!

This strange and fascinating study in Psychosomatic Medicine showed that a muscle relaxant actually increases tension when the patient is told (lied to) that it is actually a stimulant. The false information is so potent — or the drug is so weak — that its intended effect is actually reversed.

It’s like a Jedi mind trick. These aren’t the drugs you’re looking for.

But the reverse was not true: even when told that they were taking a muscle relaxant (and they were), subjects did not actually relax any more than people taking a placebo … and in some cases less!

And there’s more. This study contains many odd gems, such as the bizarre fact that quite a lot more muscle relaxant was found in the blood of people who had been told that the muscle relaxant was a muscle relaxant. It appears that they literally soaked up more of the stuff from the GI tract when they believed that it was a relaxant! And yet it still didn’t actually relax them any more than a placebo.

Weeeeeird …

Thumbs down! Neutraceuticals are such a rip off.

Recently a reader wrote to me to point out that, in his opinion, recent scientific evidence has begun to support the “conventional wisdom” about chronic anterior knee pain (a.k.a. patellofemoral pain syndrome, or PFPS). That would make my e-book on the topic look bad. I pretty much roll my eyes at the conventional wisdom from the first word to the last.

I would be delighted to be wrong. Being wrong is good. I have an ego, but it’s invested in my intellectual integrity, not the position I held in 2009. (Just this Monday I cheerfully admitted some major wrongness about icing and heating therapy.)

So I went looking for recent papers that might embarrass me.

Super quick review of the conventional wisdom

The conventional wisdom is that PFPS is caused by biomechanical dysfunctions, and that they can be treated primarily with therapeutic exercise. The classic example: in patellar tracking syndrome, the kneecap slides unevenly, allegedly placing greater strain on the knee, which thus leads to pain; but the tracking problem can be fixed by selectively strengthening one side of the quadriceps muscle group.

My wisdom is that the conventional wisdom has resoundingly failed to help patients. Biomechanical problems are real but minor factors and largely untreatable in any case, and the characteristically stubborn character of PFPS is mainly due to a simple but vicious cycle: knees are extremely difficult anatomical structures to rest, with or without minor biomechanical dysfunctions, and once they have been aggravated by over-use they simply have a hard time calming down.

Correlations, schmorrelations

The paper the reader cited was “Concentric and eccentric torque of the hip musculature in individuals with and without patellofemoral pain”, which I was already familiar with. It didn’t change my mind before, and it still doesn’t.

Yes, Boling presented some data in 2009 showing a modest association between PFPS and hip weakness, but it was hardly a smoking gun! The weakness could be either a symptom of knee pain and/or a cause of it. Having a painful knee probably has an impact on how you use your whole leg, and might well cause hip weakness. The literature is overflowing with studies like this, and they collectively produce no clear signal. This one doesn't change the basic (confused) picture, and they continue to be blatantly contradicted by other studies. For instance …

One of the recent studies that I found when I went looking states that “factors related to physical impairments did not associate to function or pain.” They present a long list of the usual biomechanical suspects, including hip strength just like the Bolgla, but they found no correlation at all with chronic anterior knee pain.

(Interestingly, they did find that “psychologic factors were the only associates of function and pain in patients with PFPS.” Now that’s odd, isn’t it? I’ll have to write an article just about that!)

Not-so-conventional conventional wisdom

Here’s another interesting point: Boling doesn’t particularly support “the conventional wisdom,” but rather a new variation on it. Their evidence (vaguely, weakly) suggests that it’s all in the hips. They found “weakness in eccentric hip abduction and hip external rotation.” This is certainly conventional wisdom in spirit (i.e. some biomechanical problem is to blame). But it’s also a whole new biomechanical bogeyman, not one of the usual suspects. This new fascination with hip function is a bit of a fad, an attempt to replace the old usual suspects. Many authors are claiming that there is an “emerging body of evidence” that hip function is critical to knee health. Bollocks. This is highly debatable, especially because most of that alleged “body of evidence” is emerging from one researcher’s public relations efforts: he loves doing press conferences and interviews for glossy running mags, but has yet to actually produce any evidence that any kind of runner’s knee pain is caused by hip weakness. I have criticized the hip strength thing quite strongly and thoroughly.

If the hip-weakness hypothesis is eventually proven — which is possible, despite my objections — it will result in therapists prescribing something new (hip exercises), and not something old (quadriceps exercises). That would really be validation of the conventional wisdom. But I’m not holding my breath.

Gait retraining results are significantly insignificant. Or something.

Also in the not-so-conventional wisdom category is “gait retraining.” If PFPS is all in the hips, then maybe learning to walk again will help your knees? A brand-spanking new study, not even in print yet, offers the closest thing I found to a surprising clash with my previous beliefs. I would not have expected these results:

Gait retraining in individuals with PFPS resulted in a significant improvement of hip mechanics that was associated with a reduction in pain and improvements in function.

Sounds straightforward and good, and they have my attention.

On the down side, the abstract is painfully vague (and buying the whole article would be a bit expensive), and I suspect some hanky panky. In particular, I’m troubled by the fact that their findings about two of their three “variables of interest” were not found to be statistically significant (which they admit), and then they don’t mention the third! Translation: “We measured three important things, and two of measurements were not stastically significant.” And the third? “No comment.”

But then they conclude with “significant improvement of hip mechanics!” What gives? Eh? What was significant?

They don’t say.

Another red flag is the curious statement (very unusual for an abstract) that one measure of improvement was “very close to significant.” This is an abuse of statistics. That phrasing tries to put a positive spin on bad news: there was actually a fairly high chance that the result was just a coincidence. It’s kind of bad form to say “almost” statistically significant instead of “not” statistically significant. I do not think that this word “significant” means what they think it means!

All of this pretty much reeks of researchers who really wanted a pro-gait-training result, and they did some mental gymnastics to make it sound like they got it.

Perception of knee pain is everything

Another experiment which had the potential to make me wrong was a comparison of “supervised exercise” versus “usual care.” I would never recommend supervised exercise, which is very much in the conventional wisdom camp, and a total waste of time in my opinion. But, at first glance, this paper looks like it’s displaying a fat thumbs up for supervised exercise: “Supervised exercise therapy improved patients’ pain at rest and during activity, and self-reported function improved faster than with no supervised intervention.”

Wow! Goody gumpdrops! Get me some supervised exercise for my knee pain, stat!

But wait, read the next sentence:

“The patients' perception of recovery from patellofemoral pain syndrome was not greater among the supervised exercise group.” My emphasis.

Er … what? “Perception of recovery”? “Not greater”? Isn’t that kind of, um, a total letdown?

You bet it is! Simply put, you can measure as many “functional” improvements as you like, and while it might be interesting to the lads in lab coats, it doesn’t matter a tinker’s damn to the patient if they aren’t improved enough to feel better. You can’t say that a treatment “works” when the patient doesn’t perceive recovery. Basically what these patients said was “sure, maybe it’s better in a couple ways, but basically I still have a @!&^$% frustrating case of knee pain.” Patients who can’t preceive recovery regard the therapy as total bollocks.

So in some ways this study showed that (supervised) exercise is good for PFPS. But mostly it showed that it doesn’t do anything that matters. And when you consider the cost of hiring a physical therapist to supervise your exercise …!

Conclusion

Nope, my face is not red. I do not feel embarrassed by my anti-conventional-wisdom position on patellofemoral pain syndrome. It’s not time to change my mind on this yet. And, of course, even if I did change my mind I wouldn’t actually be embarrassed by it.

Perhaps of note is that the polite, constructive criticism that inspired all of this has not amounted to much. A reader raised a concern, but cited only a single example of relevant science (the Boling), and has not responded to my request for additional examples. This is what I would call a “hit and run” criticism: a perfectly good criticism in spirit, but where’s the beef?

But I still took it seriously. I always respond to such criticisms with an earnest spasm of self-doubt: what if I’m wrong? What if I’m publishing something incorrect? It was a good exercise to go trolling through the recent research looking for evidence that I might be wrong about knee pain.

Alas, not this time.

References

• Boling et al. Concentric and eccentric torque of the hip musculature in individuals with and without patellofemoral pain. Journal of Athletic Training. 2009.
• Hart. Supervised exercise versus usual care for patellofemoral pain syndrome. Clin J Sport Med. 2010.
• Noehren et al. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. British Journal of Sports Medicine. 2010.
• Piva et al. Associates of physical function and pain in patients with patellofemoral pain syndrome. Archives of Physical Medicine & Rehabilitation. 2009.

Dr. Stephen Barrett of QuackWatch is the world’s most prominent anti-quackery activist. As such, he is often a target of legal threats. However, the most recent threat is more serious and the case is likely to be an important one: he is being sued by Doctor’s Data, a company that provides medical tests of questionable value to both doctors and naturopaths. Dr. Barrett responded to their legal threats by requesting specific examples of inaccurate statements he’s made, but the company never provided a single such example and just barged ahead and filed suit. This is blatant legal bullying, and in my opinion Doctor’s Data doesn’t stand a chance in court — but it will cost Dr. Barrett a lot of cash to defend himself.

Please support Dr. Barrett with a donation. Here’s Dr. Barrett’s own summary of the case so far, and here’s one from ScienceBasedMedicine.org.

There are three things I’d like to point out about this case and Dr. Barrett, particularly to those of you who don’t like him.

• Please do not believe everything you hear about Dr. Barrett. For obvious reasons, he has many enemies, and some of them have perpetrated smear campaigns. These are well-documented, but unfortunately the truth never spreads as far or as fast as a good lie. I am privileged to know Dr. Barrett a little, and believe him to be a gentleman and about as smart as they come.
• Dr. Barrett is generally reviled by alternative medicine practitioners. To my own readers who define themselves as “alternative” — and I have many — please know that Dr. Barrett has an excellent track record of criticizing all kinds of health care fraud, both within mainstream medicine itself and on its fringes.
• This kind of legal bullying is genuinely discouraging to those of us who try to provide the public with the facts about about health care. Dr. Barrett writes: “Very few people provide the type of information I do. One reason for this is the fear of being sued. Knowledgeable observers believe that Doctor's Data is trying to intimidate me and perhaps to discourage others from making similar criticisms.”

I am one of those few. But even though I do publicly criticize many products and services of questionable value, I do so with extreme caution compared to Dr. Barrett, and there are many more that I do not dare to criticize at all — and they tend to be the ones that need criticizing the most, the nastiest frauds perpetrated by the most profitable companies, which are obviously the most dangerous ones to criticize.

It’s an appalling situation, and the best defense we’ve got is to discourage such lawsuits with negative publicity — to make legal bullies regret their choice to sue. So blog this. Tweet it. Facebook it. Tell your friends. And send Dr. Barrett a few dollars.

“Basically they are the Amway for people who think a metal tube full of 'granulated minerals and crystals' can fix your bad back, make crappy wine taste better, reduce the acidity of lemons, energize your food, etc. I went to a 'wanding party' in Westchester, and it was very weird indeed.”

Weird multi-level marketing company sells $300 cure-all wand

 

A comfrey plant. I harvested a large pile of the stuff once, working for room and board on an organic farm in my wild and free hippie youth.

Here’s a well-I’ll-be-darned study.

These kinds of results are usually published in journals like Herbal Believer and The Journal of Cheering for Herbal Remedies No Matter What.

But this is from the British Journal of Sports Medicine, a respectable publication.

Researchers not only found that ointment made from the root of the comfrey plant is an effective treatment for low back pain, but a “potent” one. Assuming the experimental results are sound, this one’s a rare, clear win for a traditional herbal remedy.

“The results of this clinical trial were clear-cut and consistent,” the authors report. “Comfrey root extract showed a remarkably potent and clinically relevant effect in reducing acute back pain.”

At first glance this certainly looks like an adequate test of comfrey. I will be watching for confirmation studies.

Transcutaneous electric nerve stimulation (TENS) is a popular, common treatment for low back pain.

Unfortunately, this January review of TENS experiments in Neurology found that it showed benefit only in lower quality (class II) studies, and not even in all of those. When tested proper-like in better quality (class I) studies … nada. Thus TENS “is not recommended for the treatment of chronic low back pain.”

I’m shocked.

For many years I’ve held a complex position about ice and heat: see The great ice/heat confusion debacle (soon to be revised). My position has been that heat is better than ice for most acute back and neck pain.

(The only clear exception is when the muscles are clearly inflamed after an obvious trauma. There’s still a fairly clear need for ice when tissue has been damaged. It’s just rarer than people think. This is one of the reasons this is such a surprisingly complicated subject.)

But a recent experiment at a busy emergency department has clearly shown that it probably doesn’t matter much which one you use: their effects are positive, but minor and equal.

This study was not powerful enough to rock my world and change everything, but the evidence is definitely compelling. If I follow my own rules, there’s no way I can avoid taking this seriously: a therapy has to have enough of an effect to impress me when it is tested.

But both ice and heat clearly failed the impress me test here, and so obviously I have to change my mind about something.

I kind of saw this coming

The benefits of ice have always been dubious and minimal because they almost certainly boil down to a reflex effect — because ice can’t really “reach” deep into the tissues to cool any inflammation (even if there’s any inflammation in need of cooling, which is probably much less common than generally supposed). Over the years, I’ve started to wonder if the benefits of heat were dubious and minimal for very similar reasons — also limited to reflex effects, which are probably real but probably trivial.

This experiment seems to confirm exactly that.

The test was simple: give some patients ice packs, and give other patients some heating pads, and see how they do. Just to level the playing field a little bit, everyone also got 400mg of ibuprofen (anti-inflammatory).

The researchers concluded that adding heat or cold to ibuprofen therapy did not change the result. Both heat and cold resulted in “mild yet similar improvement in the pain severity.” They recommend that the “choice of heat or cold therapy should be based on patient and practitioner preferences and availability.”

What gives?

I suspect that what’s going on here is yet another piece of evidence that it’s all about the nerves. The non-neurological effects of both heat and ice are probably barely there, because the body is just incredibly good at maintaining a nice comfortable internal temperature, no matter what you put on the skin. The only effect that either ice or heat can have is on the nervous system — alarming or relaxing, soothing or irritating — and that in turn is strongly determined by context and how we feel about it. And that’s the common denominator, the equalizer, the thing that makes both treatments mildly positive.

It can be said of either heat or ice: sometimes we like the idea, and sometimes we don’t. A person may think that a ice pack sounds just lovely — or they may think, “Ack, yuck, cold!” And the same with heat. It depends.

How we feel about heat or ice is affected by many rapidly changing variables. For example, if we’ve been waiting for an hour, inadequately dressed, in a chilly examination room at the emergency department, cold is much less likely to seem soothing. But, on the other hand, if a charismatic doctor warmly gives us an ice pack … et voila, now the cold pack seems a bit more like needful medicine, and we accept the discomfort as a necessary evil in service of a greater good for our screaming back.

In fact, I’ll bet you 100 bucks that cold packs magically “work” better when given to patients by doctors in hospitals than if they were prescribed by, say, belly dancers.

And so on.

This would explain why the ice/heat confusion is so great, and why the benefits of either treatment will average out to “modest.”

The risks of ice

There is one thing I’m not changing my mind about here: I still think that ice has the potential to do harm.

Despite the fact that this evidence strongly suggests that both ice and heat are routinely mildly helpful, over the years I have seen many nasty-ish reactions to icing, particularly in the back, particularly when the patient is feeling anxious and vulnerable, particularly when the patient would rather be heated but is given ice for their own good.

Giving ice to patients in hospital emergency rooms is probably quite safe, and I suspect you could study icing in that context in hundreds of patients before seeing a single case go badly, and even then it wouldn’t be very bad. But when a nervous patient who prefers heat is told by a manual therapist that they must go home and ice … things are lot more likely to go sideways. I cannot tell you how many times I have had conversations like this:

PATIENT: My physiotherapist told me to ice, and it’s horrible. My back just seizes up every time!

ME: Why are you still doing it?

PATIENT: He told me I had to.

ME: Would you prefer heat?

PATIENT: Yes!

ME: You have my permission to use heat, if that’s what sounds nicer to you.

PATIENT: Oh thank you thank you thank you!

You could almost turn that conversation inside and out, and make it about a patient who was told to heat but wishes that she could have used ice, but there is one key difference: unwanted ice tends to cause a nastier reactions than unwanted heat. Unwanted heat is irritating but doesn’t tend to cause muscle contraction and pain. Ice does. And that’s directly relevant to neck and back pain. Ice is somewhat riskier simply because it tends to have a stronger negative effect on patients who don’t want to be iced.

And that’s why I will continue to tell people to err on the side of heat.

To read the factoids David Freedman rattles off in his book Wrong is terrifying. He begins by writing that about two-thirds of the findings published in the top medical journals are refuted within a few years. It gets worse. As much as 90% of physicians' medical knowledge has been found to be substantially or completely wrong.

Interesting. But it plays right into the hands of those who want science itself to be “wrong,” just like what I wrote about Ioannidis recently.

I’m sure Freedman’s book, Wrong, is probably well worth reading, but only after an inoculation of reasonable expectations: just take the default position that all research findings and knowledge is provisional. You can only be disappointed by experts if you expect them to be able to pull off “right” in the first place. Only epistemology newbies think that!

Hat tip to Bill for the link.

Experts and Studies: Not Always Trustworthy

I wanted to know how I could volunteer to help Steve with one of his many worthy projects, especially SBM — since SaveYourself.ca has basically the same mission, just with a narrower focus on rehab and pain science.

Steve was gracious and interested and it was a fanboy thrill for me to talk with him for quite a while, but he gets a lot of empty offers, and so I’m sure he was taking me with a pretty large grain of salt. But I stuck to my guns, and almost a year later I’m proud to say that Steve didn’t waste his time talking to me that night.

It’s official

A year later, we now have a well-established working relationship: after a long, casual trial period, we made it official and I’m now on the ScienceBasedMedicine.org masthead as their copy editor. I don’t edit even a quarter of that blog’s massive total output, but I do regularly work with several contributors, especially Dr. David Gorski and Dr. Harriet Hall. It’s a pleasure and an honour, and I learn a great deal from the constant exposure to their writings and our discussions about them.

Interestingly, Steve himself never asks me to edit his posts, because … well, it’s quite a coincidence …

A really, really small world thing (at another party)

Chatting with a friend of mine, Fred Bremmer, at another party a while back, we had a bizarre moment:

Me: So I’m editing for SBM.

Fred: No way, I’m editing for SBM.

I’ve oversimplified that a wee bit, but for real we had both been assisting in pretty much the same way, unaware of the other’s contribution.

Small club.

And plenty of typos to go around!

Corticosteroids are hormones that are produced by your adrenalin glands. (Not adrenalin itself — that comes from another part of the adrenal glands, and it’s a catecholamine. Quiz later!) Broadly speaking, these hormones suppress immune function, dancing and balancing constantly and intricately with other hormones that stimulate immune function. And inflammation is a product of the immune system, so corticosteroids have a nearly miraculous effect on inflammation, pretty much nuking it wherever the two meet. But like nukes, they have a dark side: some harsh side effects. You can’t just willy-nilly soak your system in corticosteroids without paying a price. Many readers may have heard of the many unpleasant effects of the common corticosteroid, prednisone.

Targeted injections, on the other hand, are quite a bit safer. The small amounts of corticosteroids involved are just not enough to be a problem for the whole system. And so steroid injections are a handy way of delivering a potent anti-inflammatory effect right to the source of the problem — think of them as ibuprofen on, er, steroids.

This can work great when you know where the source of the problem is. The evidence showing that they work well for targetable inflammation is acceptable, and one injection is often enough in the case of iliotibial band syndrome (see Noble, Gunter) where the target is fairly clear and accessible. Unfortunately, this is precisely what is often not known about PFPS. Where do you put the stuff?

There is no research at all about the effectiveness of steroid injections for PFPS, and no wonder: there’s too many possible injection sites, too much uncertainty. Corticosteroid injections are usually suggested only by doctors who don’t really know what else to do, and think it might be “worth a shot.” Does that physician know where to put the needle? Probably not.

I’m all in favour of using steroid injections when there is a reasonably good reason to believe that you can target an inflamed tissue. But the problem with recalcitrant PFPS is that you almost never know what tissue the pain is coming from — and in many cases it’s deep inside the knee — so where do you inject? It becomes not so much a shot in your knee as a shot in the dark, with risk factors. I’m not completely opposed to it in dire cases where nearly anything is worth trying, but it’s a weak option at best.

There’s no harm in discussing it, but ask your physician for his or her thoughts on the location of the injection and the reasons for it, and be skeptical if there isn’t a healthy respect shown for the uncertainties. If you do try injections, and three of them do not pretty clearly do the trick, you should probably stop trying, as steroid injections can permanently damage connective tissues near the point of injection. For this reason, some doctors will refuse to do it at all, but most agree that 1–3 injections is no cause for concern.

Neck Pain Evidence Summary

No matter how often a surgeon performs the same operation, it is different each time. Any operating room nurse can tell you that. The sequential precision of predictable steps so exactingly depicted in manuals of surgical technique resembles the real thing about as much as a diagram of human anatomy looks like a human being.

To take something simple: Of the many hundreds of appendectomies I have done during a career of thirty-five years, no two were the same. Even such a straightforward operative procedure for a straightforward disease, divisible into a short series of straightforward technical maneuvers that were standardized almost one hundred years ago, done by an operator of long experience — even under such circumstances every case is a novelty. And some of those novelties can be daunting tests of skill and confidence.

On bedside rounds one day during the period of my training, the senior attending surgeon, a man highly respected for his dexterity and judgment, was asked to name the half-dozen most difficult operative cases he had encountered in his career. After a moment’s thought, he replied that three of them had been appendectomies. His answer surprised no one in the group of interns and residents who were crowded around him. In the few years of our embryonic surgical experience, every one of us had already seen enough to appreciate what he meant.

Although the configurations of human innards do not vary nearly as much as do those of our outards (a word that exists in no dictionary but should), they nevertheless reveal unmistakable variations among individuals — and only surgeons ever find out about them. The way in which an organ is attached by ligaments and folds of tissue to its surroundings, for example, is in general predictable, and yet just enough personal difference occurs that an operator never knows beforehand whether the viscus he is approaching will come up easily into his seeking hands or require deep dissection to free it. Friend appendix, in fact, epitomizes this kind of anatomical uncertainty. Being attached to the large intestine only at one narrow end of its wormlike body, the appendix is free to turn upward toward the liver, downward toward the pelvis, sideward toward the center of the abdomen, forward toward the abdominal wall, or even retrocecal, which means it has tucked itself up behind the bowel into a hidden location. The appendix may be as short as a stumpy inch or as willowy as five or six times that length. There is no telling where its tip may be found. Other organs, though not as variable, have unpredictabilities of their own.

And then there is the problem of fat. The copiousness of the cushions of fatty tissue lying between internal structures depends in general on an individual’s station along the spectrum between leanness and obesity. Thin people are a great deal easier to operate upon than are the chubbies, who hide vital structures deep within thick, greasy blankets of adiposity. Among those concealed vital structures are blood vessels, which have an obnoxious tendency to make uncharted course changes now and then, obstinately refusing to reach their destination via the route assigned to them by anatomy books. Lying in wait for the unwary, or perhaps lurking within a fatty bolster, an unanticipated artery or vein — and nerves are known to do this too — can affect the entire plan of a surgeon’s work, and sometimes its outcome.

Beyond even these considerations, the occasional occurrence of a congenital variation of structure must be taken into account. The operating team always has to be on guard for such an abnormality, especially because it may involve blood vessels or the slender ducts that carry secretions and other vital fluids to their destinations. Some of these inborn irregularities can present major challenges, or at least major surprises. From time to time, for example, one or another viscus or a part of it must be sought in an area of the body where it seems not to belong. I am not at all unique among surgeons to have removed thyroid tissue from the chest, found the right colon on the left side of the abdomen, and taken an ovary or appendix out of a hernia bulging into the uppermost part of the thigh.

Just to promote Nuland’s excellent book, I will continue the excerpt a little longer, even though the topic changes. He goes on to explain many more things that make every operation unique, even the common ones. But then he introduces an exotic case …

I have been referring here to operations done with relative frequency. For the reasons given or others, some cases will be so unusual that they stand out in a surgeon’s mind for the rest of his life. But in addition to that list, there exists a special category within even less commonly done procedures — these are the real rarae aves. By this I mean the one-and-onlies. These are the operations of such a unique type that the members of the team will regale one another with their details when they meet at reunions or conventions decades later, even in farflung parts of the world. Some of these procedures are firsts, or at least firsts in a given hospital — the first organ transplant, the first use of the heart-lung machine, the first video-controlled gallbladder operation — but some are memorable because no member of the team has ever seen their like before or since. Like all surgeons, I have a few of those once-in-a-lifetime adventures tucked away in the back of my mind, ready to be pulled out and relived at a moment's notice.

One of them involves the stomach.

My patient had been an independent citizen for all of six weeks, the first two of which were spent in the preemie unit …

It’s a great story!

But I hate the title of that paper!

I explain why in a new science-geeks-only article:

Ioannidis: Making Medical Science Look Bad Since 2005: A famous scientific paper with an irresponsible and misleading title

(Here we go again with the Epsom salts. Does this topic have a bottom?)

Osmosis is routinely defined incorrectly and used as a wrong explanation for how Epsom salts “detoxify” — all of which is explained in freakish detail in my oddly popular Epsom salts article.

The nugget of science learnin’ about osmosis is just this: osmosis is the movement of water across a membrane, not substances. Most people got this answer wrong on a grade 11 biology test, and haven’t thought it about it since. But trust me: osmosis is water movement by definition.

Anyhoo … osmosis may not be able to transport salt ions or waste metabolites across the skin, but it certainly isn’t kind to bacteria in this equation: it sucks them dry. Which is why reader Dorrie B. recently pointed out something interesting: Epsom salts might be an effective treatment for topical skin infections, as salt is certainly inhospitable to microganisms.

Good point, and good conversation starter, because …

Is that really a good thing?

This is also a great example of how complex these questions can be, because salt bathing might also damage populations of other bacteria on the skin, resulting in higher vulnerability to infection. It is now well understood that every microscopic nook and cranny of our skin — indeed, our entire body, inside and out — is thickly populated with an ecosystem of microorganisms, more diverse than any jungle (see We Are Full of Critters). It is also likely that one of the primary functions of these teensy jungles is to maintain a balance of power, where it’s difficult for any organism to dominate. If soaking in salt water kills bacteria, it might kill off the bacteria that normally live on the skin as well.

So, do people who bathe or swim in salt water regularly suffer any ill effects? Are they more susceptible to new infections? They might well be: a 10% difference would not be obvious even to the victims, but would nevertheless be clinically significant and biologically interesting.

Likely that research hasn’t been done, but my point is just that it’s really surprisingly difficult to say whether or not a given biological effect is “good” — it’s almost never that simple, and that’s always a good thing to bear in mind.

Do Epsom Salts Work? There is (still) no good reason to believe that Epsom salt baths aid recovery from muscle pain, soreness or injury

I narrowly escaped a breast biopsy because of trigger points in the pectoralis major. I’d had bad chest pain for a month. I was on the table, permit signed, draped. The doctor wasn’t sure: she said she wanted another mammogram. I left confused, relieved … but still hurting.

Then I lucked out: my regular internist was puzzled, but thought it might be “soft tissue.” That made me go to a physical therapist. The physical therapist pulled out the big red books [see Myofascial Pain and Dysfunction] on trigger points, and we read together about pectoralis major trigger points. Treatment was a complete success. A month-old severe pain that I had been treating with ice packs in my bra and Lortab — gone!

Janice Kregor, competitive swimmer, retired pediatrician and medical school instructor

Indeed she was lucky. Her physicians acted with admirable caution and humility, and she ended up working with a physiotherapist who was not only familiar with trigger points, but had good information on her shelf and knew what to do with it. Many patients in the same predicament would have been biopsied and continued to suffer unexplained pain.

This RSS feed suffered a major meltdown due to a single trivial typographic error on May 8. Many readers have probably not seen a post here since then. Some feed readers “freaked out” over the typo. Mine did not. Hence I did not notice the problem. For weeks. This is the kind of thing that makes web publishers groan with the pain of it all.

All should be well now. You know, until the the next time an incredibly minor syntax error causes hundreds of my readers to miss dozens of my posts.

All recent posts are on the front page of SaveYourself.ca, of course, if you want to do a little catch up.

I get calls and letters from investment companies, stock brokers, insurance salesmen, and financial planners, congratulating me on my recognition and wanting to meet with me to discuss my financial health, since obviously anyone who's on the ‘Best Docs’ list must have a shitload of cash lying around. They even offer to take me to lunch. Sorry, guys, but whether or not we make ‘Best Docs’ is immaterial to how much a doc really makes. And the reality of most docs today is that we're lucky to support our families. So no, thanks.

Read the whole post on Dr. Grumpy’s blog: “I’m an awesome doc!”

An interview with Dr. Gary Greenberg, author of Manufacturing Depression

Back in December, Billy Joel’s daughter Alexa Ray tried to kill herself, probably because she heard “Piano Man” one too many times. She did a poor job of it. She tried to kill herself homeopathically. And not just any homeopathy — she took Traumeel.

That’s my turf.

Traumeel is (mostly) an extremely diluted preparation of the herb arnica and allegedly good for “aches and pains.” It contains ingredients that would be modestly toxic (probably not lethal) … if they weren’t diluted to the point of absurdity. Alexa Ray’s plea for help led to about .00000000000000001% of her death. The crazy math of it is quite familiar to skeptics around the world, who all blew milk out their noses and slapped their thighs crimson when they heard this precious news item.

You could get more arnica montana by licking the plant — once. Hell, a hundredth of a lick would probably be a higher dose. Alexa Ray’s suicide method was less dangerous than inhaling new car smell. It would be (much) easier (and more fun) to kill yourself with light beer. Death by Nerf bat would have been considerably more efficient.

Last year I wrote a comprehensive analysis of Traumeel that rose to the top of the Google charts, and there it remains — usually second in the listings only to traumeel.com itself. It is a polite article. It is a careful article. One does not want to step directly on the toes of those who profit from Traumeel. My aspersions are … diluted. The article does not ever say that Traumeel does not do anything, it just implies it.

And so does Alexa Ray’s failure to kill herself.

You can’t kill yourself with Traumeel, no matter how hard you try. I promise. Alexa tried, and she is with us still. So is debunking magician James Randi, despite numerous homeopathic overdoses (of another homeopathy remedy, Calms Fortes).

This isn’t a safety feature of homeopathy. What’s more likely: that homeopathy doesn’t work at all? Or that homeopathy is potent medicine but not potent enough to hurt you in overdose? Just how wishful can thinking get?

The only thing this pathetic Joelian incident demonstrates is that the ingredients of Traumeel are so diluted that … that it … that it doesn’t … no, I’m not going to say it. You know how the sentence ends. I will just close with this:

“A leading toxicologist said it would be nearly impossible to overdose on the homeopathic medicine Traumeel,” reported the Daily News.

Um … “nearly”?

• why injuries go bad
• how to temporarily destroy your nerve endings with chili pepper (and why this is a good thing)
• the pain of being a drama queen

“Bio-psychosocial determinants of persistent pain 6 months after non-life-threatening acute orthopaedic trauma”

Clay et al. Journal of Pain. Volume 11, Number 5, p420-30. May 2010.

How often does injury lead to chronic pain? Why do some injured people develop chronic pain and others do not? Researchers kept tabs on 168 patients who suffered non-life-threatening orthopaedic injuries.

54% reported persistent pain six months after the injury and 87% reported that this pain interfered with their normal work activities.

Long-term pain was more likely to the extent that pain was acute at the beginning (independently of injury severity), if patients felt responsible for the injury, and if they were pessimistic or emotionally traumatized. “Psychosocial factors strongly predicted persistent pain, pain-related work disability, and pain severity,” the researchers concluded, and noted that “many of these factors are potentially modifiable and should alert the clinician about the need for interventions in order to prevent the development of pain chronicity.”

“A Randomized, Controlled, Open-Label Study of the Long-Term Effects of NGX-4010, a High-Concentration Capsaicin Patch, on Epidermal Nerve Fiber Density and Sensory Function in Healthy Volunteers”

Kennedy et al. Journal of Pain. Volume 11, Number 6, p579-587. Jun 2010.

Ever wish you could get rid of some nerve endings? It turns out that you can — just apply chili peppers! This experiment showed that nerve endings shrivel away from an application of capsaicin, the active ingredient in peppers. The effect was quite dramatic.

Healthy volunteers took one for the team: a single application of highly concentrated capsaicin on their thighs, for just one hour. The density of nerve endings and sensitivity to various stimuli was recorded before and after, and then checked again after 1 and 12 and 24 weeks. The results were amazing: nerve ending density was down 80% after a week, and pain sensitivity was also reduced (though much less). Touch sensitivity reduced slightly, and heat and cold sensation remained normal.

Over the next several weeks, the nerves regenerated and sensation returned to normal. Given this surprisingly potent effect on nerve endings, capsaicin may be an effective and safe way to treat some pain problems.

“Emotional Regulation and Acute Pain Perception in Women”

Ruiz-Aranda et al. Journal of Pain. Volume 11, Number 6, p564-569. Jun 2010.

This experiment presents clear evidence that “pain is an opinion”: an experience modified by mental and emotional factors.

I don’t think anyone will be surprised to learn that being a drama queen actually hurts. (“Drama queens,” of course, is exaggeration for comedic effect — please don’t actually call anyone in pain a drama queen unless you want to get smacked around.)

Two groups of women were tested for pain tolerance with the traditional, unpleasant method: immersion of the hands in ice water. One group was rated with better emotional coping skills, and (predictably) they were more tolerant of pain than women with poorer coping skills.

Although the results seem unsurprising, the authors say that “currently there are no experimental investigations of the relation between emotional regulation and pain.” Based on this study, it can be assumed that emotional state and skills are relevant to pain management.

On the small water taxi that I take to get here, I was explaining my trip to an islander. I told him that I was a writer coming to the island to work hard, to read scientific papers and write about them all weekend, working from early until late, pausing only for meals and short hikes. I said this with what I thought was great relish, but he replied:

“Wow, that really just sounds … horrible!”

And it is kind of strange, now that I think about it.

Wednesday afternoon front desk insanity

Should You Drink Water After Massage? Only if you’re thirsty!

I had crippling back pain, and massaging Spot #12 was like a miracle, OMG, so easy, where have you been all my life, thank you thank you thank you thank you thank you ….

And I can tell many of my own such stories of instant, amazing relief (and I just told one in the last post, about beating a headache).

And why is that “alarming”?

Because — confession time! — the “perfect” spots aren’t really all that good.

Because I’ve never polished them. Because they have long lacked the artwork they need to shine. Because huge numbers of people have read them with the hope that they are much more carefully prepared than they are.

And because they are not based on much science — they’re based on a lot of fallible observations that I made while working as a massage therapist. I’m not really comfortable with this being my “legacy”! I’m a science writer. I wish there were a little more hard data in my most popular work.

(This is how I like to promote things. By trash-talking myself. Pre-emptively harsh self-reviewing. Nature of the perfectionist beast, I suppose. Sure, they are popular, but so are Britney Spears and sparkly vampires.)

But a website can change its spots!

I’ve been hard at work upgrading the series, trying to make it something that I can be proud of. More and better artwork, more science and footnotes, more examples and stories, and … databasification. A bunch of spot data is now enshrined in a database, and can be coughed up at will in a variety of formats, making the series more and more like a tool. Such features are now visible in each spot article, especially in the form of a lovely quick reference guide to the whole series. Pick one and have a look:

• Spot 1 — Massage Therapy for Tension Headaches
• Spot 2 — Massage Therapy for Low Back Pain
• Spot 3 — Massage Therapy for Shin Splints
• Spot 4 — Massage Therapy for Neck Pain, Chest Pain, Arm Pain and Upper Back Pain
• Spot 5 — Massage Therapy for Tennis Elbow and Wrist Pain
• Spot 6 — Massage Therapy for Back Pain, Hip Pain and Sciatica
• Spot 7 — Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome
• Spot 8 — Massage Therapy for Your Quads
• Spot 9 — Massage Therapy for Your Pectorals
• Spot 10 — Massage Therapy for Tired Feet (and Plantar Fasciitis!)
• Spot 11 — Massage Therapy for Upper Back Pain
• Spot 12 — Massage Therapy for Low Back Pain (So Low That It’s Not In the Back)
• Spot 13 — Massage Therapy for Low Back Pain (Again)

The yowly one

Not in yowly mode.

I can only assume it would have been even worse without my furry early warning system, but within an hour my headache was yowling much more loudly and persistently than my cat — who was by then fed and settled in the “cat sauna.” Lately she has become inordinately fond of sleeping all morning in the bathroom with the heat lamp on (which is not very energy efficient, but extremely cute), apparently because the heat is therapeutic for her cranky ol’ body. I decided to follow her example.

I warmed the back of my head up with one of my big, thick and lovely Thermophore heating pads and then settled in for a dose of urgently needed massage. Then, using a Knobble massage tool, which is just perfect for this particular location, I applied some (really intense) pressures to my suboccipital muscles. And then I followed that up with a good dose of mobilizations (simple neck circles).

Victory

The headache vanished. It’s hard to overstate the degree of success I enjoyed from this simple procedure. It was a severe headache, the kind that could easily ruin a whole day. Success was by no means guaranteed, and I feared the worst. But my self-treatment didn’t just take the edge off — the headache was terminated, quickly and completely. It was gone like it had never happened, and it did not come back.

My massage target there was “Perfect Spot No. 1” — the first in a series of thirteen.

The Knobble

The simple massage tool that saved my head yesterday. (Buy one of these bad boys from Pressure Positive).

Reintroducing the perfect spots

I get stories like this one from my readers all the time. The “perfect spots” articles are the most popular on this website — but somewhat undeservedly (which I will explain next). But I’ve been working hard to upgrade them, lately, and so I wanted to re-introduce the concept with this timely story of headache treatment success.

So what are the perfect spots?

They are thirteen classic trigger points or “muscle knots,” the easiest to find and most useful and satisfying to massage, accounting for a majority of common minor pain problems, and many severe ones. What exactly makes a spot perfect?

• a common trigger point, or a cluster of them
• unusually relevant to a common problem (such as headaches, or low back pain)
• reasonably easy to find and treat
• typically good therapeutic “bang for buck”
• unusually relaxing, satisfying and/or prone to causing “good” pain as opposed to “bad” pain when squished

But what’s this about the perfect spots not “deserving” their popularity? Read the very next blog post.

Read the interview.

Visit The Trigger Point Symptom Checker.

“Causes of excitation-induced muscle cell damage in isometric contractions: mechanical stress or calcium overload?”

Fredsted et al. American Journal of Physiology. 2007.

Intense and unfamiliar exercise damages muscle cell membranes and correlates with a flood of calcium into the cells, causing fatigue. But what causes the damage and starts the flood? Mechanical damage has never been ruled out. This experiment chemically blocked 90% of contraction strength in rats, effectively eliminating physical strain from the contraction equation. The rats’ muscles were then electrically stimulated to simulate exercise without mechanical stress. Unfortunately for the rats — actually, nearly everything about this was unfortunate for the rats — their muscle cell membranes were damaged just exactly as they would have been in a normal, intense rat workout. The implication is clear: cell membranes are damaged in exercise by metabolic stress not mechanical stress. The authors concluded that “cell membrane damage depends on Ca2+ influx and energy status and not on mechanical stress.”

Rats were harmed in the making of this evidence.

But now we know that mechanical stress is probably not what damages cell membranes in exercise. Which is pretty interesting. Thank you for your sacrifice, rats.

“Acupuncture transmitted infections”

Woo et al. British Medical Journal. 2010.

What’s the harm in acupunture? A small but real risk of infection — as with anything that breaks the skin. Acupuncture has not only failed to prove that it works, but this British Medical Journal editorial presents new evidence that it also involves a risk of mycobacteria infection, and even that “… outbreaks of acupuncture transmitted infections may be the tip of the iceberg. The first reports of meticillin resistant S aureus (MRSA) transmitted by acupuncture appeared in 2009. The emergence of community associated MRSA infections may aggravate the problem.”

A common objection to Woo’s article has been that it is “mongers fear” and that he cites old evidence, from the 1970s and 1980s, before sterized needles were widely used. But critics conveniently overlook that Woo also cites modern evidence of infection — about as blatant a case of biased interpretation as you could ask for. And is Woo a fear mongerer? He does not claim that the risk is great: he just reports what is known and titles his piece neutrally. It is always worthwhile to examine treatment risks, and especially when treatment benefits are also hotly disputed. It hardly constitutes “fear-mongering” to report risk data in a medical journal! If not there, then where?

“Strength training and stretching versus stretching only in the treatment of patients with chronic neck pain: a randomized one-year follow-up study”

Häkkinen et al. Clinical Rehabilitation. 2008.

Researchers tested the effectiveness of strength training for neck pain and disability by comparing two different exercise regimens, kicked off with ten group training sessions. A hundred patients participated: fifty did a year of strength training combined with stretching, and the other fifty did just stretching. No significant differences were found in pain or disability.

The authors also noted that patient dedication to the exercises probably left something to be desired, but that’s so inevitable in any group of average people that it can be almost be considered a natural weakness of exercise therapy. So this evidence strongly suggests that strengthening is unremarkable at best as a therapy for neck pain, either because it doesn’t work particularly well, and/or because you can’t get people to do it long enough and well enough even if it did.

“Exercise therapy for chronic nonspecific low-back pain”

Middelkoop et al. Best Practice & Research. Clinical Rheumatology. 2010.

This review of the science of exercise therapy for low back pain included only randomized controlled trials of adults with chronic nonspecific low back pain that evaluated of at least one of the most relevant outcomes (such as pain). The results were positive but unimpressive: “[exercise] effects are small” and there is “no evidence that one particular type of exercise therapy is clearly more effective than others.” This is a reality check and an ego blow for a massive industry devoted to selling patients on many specific and branded styles of exercise therapy. All these findings suggest is really just that “being active” is a little better than not being active, and the type of activity probably doesn’t matter much.

On them hijacked the plan. It is now in the spotlight.

I was dimly aware that the prestigious journal Pain had recently published something startling about low back pain, something out of left field that might gobsmack me when I got around to looking at it … but I just hadn’t gotten around to looking at it.

I wish I’d checked sooner, because wow, this is major stuff. I am, indeed, gobsmacked.

Regular readers will know that I am always going on and on about how an effective treatment should easily shine in a fair test. If it can’t impress us with really clear benefits, it’s really not of much interest, and all debate about it is a bit of a moot point. To the best of my knowledge, no treatment for low back pain has ever been really impressive.

Until now.

Perhaps the first dramatically effective low back pain treatment

A stunning experiment has shown strong evidence that the injection of methylene blue into a painful disc is a “safe, effective and minimally invasive” method for the treatment of discogenic low back pain, far more effective than any other known treatment for low back pain. The surprising results — 19% completely free of pain, and 72% almost so — were published by a credible research group, and with no significant weaknesses in their methodology.

In an editorial in the same issue, low back pain expert Nikolai Bogkduk (see Bogduk) expresses every reasonable caution against premature celebration. As always, Bogduk is rigorous, precise and clear, and his editorial is the next professionals should read about this. Bogduk can be trusted to call bollocks when he sees it, and yet he judges that “there are no lethal flaws in the study” and calls it “one of the most incredible studies of a low back pain treatment ever published.” He describes the results as “astounding, unprecedented and unrivalled in the history of research into the treatment of chronic discogenic low back pain. The results of surgery, rehabilitation, behavioural therapy, and any other treatment for back pain pale into insignificance.”

If the results of Peng et al are true, this intervention will revolutionize the treatment of low back pain. Spinal surgery for back pain will be rendered essentially obsolete. Furthermore, and ironically, the treatment is not subject to any patent, and is readily available. Anyone who performs discography will be able to provide the treatment, at trivial extra cost. For ridding the world of back pain, this study would be worthy of nomination for a Nobel Prize; if the results are true.

Methylene blue is essentially just an anti-inflammatory medication, well-chosen for the chemistry of irritated intervertebral discs. And it seems to work much, much better than anything anyone has ever seen before.

Now what?

First, we wait for scientific confirmation — several research groups are already hard at work on this, and it won’t be long before we find out whether the Peng study was some kind of crazy fluke. I’m optimistic, though: it’s rare for results that persuasive to be over-turned by other experiments. There’s an excellent chance that methylene blue now has a major role to play in the future of low back pain treatment.

Discogenic low back pain — “hurtin’ intervertebral discs” — accounts for a substantial amount of low back pain, perhaps even a majority of cases. If it’s now almost completely treatable, I’m going to have to heavily revise many of my opinions about the nature of low back pain. Indeed, large chunks of my popular low back pain tutorial will be obsolete virtually overnight. But I will relish the opportunity to admit being wrong about several things, spend many hours feverishly re-writing, and the documents’ relevance will be restored … though its importance will be somewhat reduced. Many readers simply won’t need an exhaustively detailed analysis of the crappy and confusing treatment options for low back pain: they’ll just needs some methyl blue squirted into their back.

At least, I hope so!

Epsom salts supposedly relieve aches and pains, but there are many problems with this idea, which I have written about in truly ridiculous detail (believe it or not). It’s not at all clear how salts can get through the skin barrier, which is pretty substantial. But a simple 2006 experiment showed that magnesium and sulfates do get into the blood somehow: their levels were higher after people bathed in dissolved Epsom salts.

But when you encounter surprising results in science, don’t just settle on the first explanation that comes to mind — it could easily be wrong. The study author, Dr. Waring, says that she “assumed that it simply diffuses across the stratum corneum,” and that certainly is possible (despite the problems with it). But what other explanation could there be for the results? How else could magnesium sulfate have gotten into the bloodstream in her experiment? Reader Adrian J. had an unusual idea (which just screamed “funny sidebar!”):

Is it possible that the salt diffuses across the epithelium in the anus and/or rectum, if the anus relaxes to some degree in the warm water?

Wow, that’s some creative lateral thinking! It’s probably a bit of a reach: I find myself (uncomfortably) wondering ... just how much do I relax in a hot bath? That much? And how much salt could diffuse across that more permeable but much smaller membrane? It’s a small target! And I shudder to think of the measures required to test this hypothesis …

So it’s not a particularly plausible idea, which Adrian acknowledged on his own initiative in a follow-up email. But it’s getting air time here because it’s still a wonderful (and fun) example of an important way of thinking about evidence: the creative search for non-obvious explanations for data is very much at the heart of science.

Do Epsom Salts Work? There is (still) no good reason to believe that Epsom salt baths aid recovery from muscle pain, soreness or injury

Latin a bit rusty?

“Meso” is middle, dermal is “layer,” and so the mesoderm is the middle layer of embryonic tissues, which grows into the muscle, bone and other connective tissues of the body — the anatomical infrastructure. Diane is describing structuralism in terms of a preoccupation with that structural layer, the tendency to see patients as uneven meat puppets in need of repairs that can be achieved mainly by pushing and pulling on their muscle and connective tissues.

And why “corpse”? Because such therapy might as well be done to a dead person for all the respect it gives to the importance of the patient's nervous system. She’s saying that such therapy would work about as well on a dead person as on a live person — if it worked at all — because its entire focus is on the shape and texture of their meat.

Language geek afterthought

The Latin root “derm” usually refers to the skin, and many sources define it only in that way, while others show that it also means layer. The dual meaning can also be inferred from its usage in the names of the three embryonic layers — endoderm, ectoderm and mesoderm — which are invariably defined as inner, outer, middle layers and not “skin”. I suspect that skin has come to be the dominant definition because it is the most prominent example of the more general concept of a layer, in the same way that “Levis” are synoymous with “jeans” or “John Hancock” means any signature. Skin is the layer, the alpha derm!

More information about structuralism

Your Back Is Not “Out” and Your Leg Length is Fine: The story of the obsession with crookedness in the physical therapies

Last week was the first season of summer ultimate in Vancouver, and I played with two teams, Ben Hur and Afternoon Delight, losing four out of four games (but having a great time doing it). My training for this season must have been somewhat successful, because I played hard and yet survived to write these words. Games on Tuesday night were followed by only mild DOMS, which has got to be a first — the first games of seasons past have always caused next-day agonies. But it was much harder to get up to speed on Thursday night, and the day after I wasn’t so much sore as just deeply, profoundly knackered. I stumbled around in a mental fog all day.

I am struck yet again by how difficult it is to train for competitive intensities. I suppose more serious athletes must master this challenge, but I have yet to amp up my private workouts to even 20% of the physiological savagery of competition! For a workout to be roughly similar to game intensity, I would have to sprint almost continuously for about 90 minutes. That ain’t happening. To run that fast and that long, I simply have to have a piece of plastic to chase.

Proudest moment of the week’s games: beating a (much) younger and generally fitter player in a straight race from one end of the field to the other. I remember a time when it was extremely rare for me to encounter a player who could keep up with me. Those days are over, but apparently I am still non-slow.

Not actually me.

But that’s how I feel when I play …

Even if we were to overlook the two former hurdles, there is yet a third one to overcome—are manual techniques or specific exercise effective in modifying inherent postural-structural-biomechanical factors? Can foot mechanics, leg length differences, pelvic tilts, vertebral positions and spinal curves be permanently changed, solely, by these clinical tools?

Beautiful! I ache with the healthiest kind of professional jealousy reading this. I wanted to write the same thing, but he beat me to it. Here’s the whole thing:

“The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain”

People out there in on the interwebs often write to scold me for this — how dare I criticize writing when there’s a tipo off my own on the very same page? Why don’t I just stick to the idees?

Of course, whenever I make criticasms of sloppy writing, I do open myself up to a charge of hypocrazy, because there are certainly scattered errrs on my website, probbly even on this veru page. But it’s a matter of dagree. I only criticize someone’s communiation skills when their writeing problem are signicifant and revelant : when the errors are thick and nasty and thick and nasty, when they arre combimed with style problems like SHOUTING IN CAPS!!!, or abusing “quotion marks”; or just horrible spellung and grammer and sentense structure, and and whn they betray ignoranse of the subjet matter,, like a chiropracor who writes the “veterbra” three times in the same short email but incests “I’m a proffesional”.

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

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

Patients with great anxiety, pain and frustration are especially vulnerable to persuasion, or “therapy by charisma.” This is why I really make an effort in my work to be reassuring without offering miracles, to be knowledgeable without claiming to “know” what the problem is. All too often, patients in pain will cling to whatever ideas you throw at them… so you have to be careful what you throw at them! Structuralists rarely seem to show such restraint, and consequently many patients emerge from therapy feeling much too sure of their diagnosis. There is no zealot like a convert! In this context, clinicians can be more like clergy than health care professionals.

Your Back Is Not “Out” and Your Leg Length is Fine: The story of the obsession with crookedness in the physical therapies

[These pictures cannot be shown as intended in most RSS feed readers, so you’ll have to go to the post on SaveYourself.ca to see this!]

… no matter how hard I tried to show the research, very few people believed the evidence. It simply doesn’t fit with ‘common sense’ – because ‘everyone knows’ that how you lift will affect your risk of back pain. Not.

Amen. I wish I had more time to do something with this great little article. Posting a link will have to do for the moment, but this will appear on SaveYourself.ca again.

“Dead Bodies Can’t Feel Pain, or Why Biomechanics and Ergonomics Haven’t Reduced Back Pain

The tyranny of posture exercises

I have met many patients who have been given countless hours of tedious coordination and “neck stabilization” exercises — “core” strengthening, but in the neck — to fix their allegedly dysfunctional neck posture. These patients have often believed for years that there is something wrong with their neck due to a combination of bad luck and laziness, which can only be repaired with diligent exercise.

And the “should” of that therapeutic exercise hangs over them like a dark cloud.

Personally, I have always suspected that all this was all a bit silly. It seems perfectly obvious to me that many people with crazy neck curvatures are fine (or not all that badly off), while meanwhile people whose necks look perfectly normal to me are suffering. This is not a difficult clinical observation to make: neck pain problems are quite a lot more variable than neck postures. Clinicians fail to notice (or make anything of) the inconsistency because they want “something to fix” and it pays to pathologize — it’s good for egos and income to define “normal” more narrowly and attribute pain problems to deviance from the apex of the bell curve. The neck posture hypothesis is a great example of “structuralism,” an exasperatingly common theme in therapy. Therapies based on structuralism tend to show a strong mental bias towards making much of slight deviations from the norm, and generally have a serious lack of scientific support.

And I must — as always — emphasize that biomechanics are certainly not completely irrelevant to neck pain.

Correlation, yes — but it’s a wimpy correlation

For instance, it’s more or less a given — even by critics like me — that there is probably at least some connection between neck posture problems and pain. This is also fairly obvious just from clinical observation: people with strange neck curvatures will not necessarily have neck pain, but they seem to be mildly predisposed to it. Plenty of research data also shows this. For instance, in 2005 McAviney et al examined 277 neck x-rays and found a “statistically significant association between cervical pain and lordosis < 20 degrees” — that is, painful necks tended to be flattened necks, about 10˚ flatter than the lower end of what they defined as normal. This is one of many similar studies.

But the data isn’t particularly impressive, and I don’t give a heck of a lot of weight to those studies. First of all, all of them report mild correlations. In McAviney et al, a “statistically significant” correlation meant only that they reported more of a connection than random chance could account for … but less of a connection than you could easily detect without a spreadsheet. The amount of correlation reported would probably be difficult (maybe even impossible) to observe clinically. Patients with neck pain were only eighteen times more likely to have a severely distorted neck posture (less than zero degrees lordosis, so an actual reversal). That sounds like a lot, but stop and think about that: if neck curvature were particularly important as a factor in neck pain, you’d expect a crazy neck curvature like that to virtually guarantee neck pain: perhaps fifty or a hundred times more likely instead of just eighteen. And none of that concerns most of the people they studied, who had much less dramatic neck curvatures. For those more subtle cases, where you could easily debate whether the curvature was abnormal or not, the difference was much less than “18 times” — still statistically significant, but definitely nothing to write home about.

Wake me up when we have a cause

And not only is the correlation modest, I also don’t put much stock in studies like this because they address only correlation, and not causation at all — they weren’t designed to tell us which came first, the posture or the pain, and they can’t. Purely correlational studies are usually much less clinically meaningful than research designed to establish causation. When you know the cause of [insert bad thing here], that’s something that clinicians can try to fix. When you only know that two things tend to occur together, but you don’t know which one caused the other, or if either of them caused the other, you have no direct inspiration for a therapeutic intervention — you can’t know what to therapize.

The file drawer effect

And, most importantly, the file drawer effect is quite likely to be at work here — a tendency to publish studies that seem to support a hypothesis, while failing to publish a discouraging word. Just as therapists want “something to fix,” journals want “something to publish,” and they are more likely to publish papers that report a small but technically statistically significant correlation between neck pain and posture and make a bit too much of it. And it’s quite easy for a small correlational study to find what they are looking for — all the authors have to do is tweak their definition of “normal,” et voila. And so, for decades, journals have been prone to publish these sloppy, low-power studies that confirm everyone’s I-need-something-to-therapize bias.

But — if that’s what’s going on — the truth is hard to hide forever. It usually takes quite a powerful study with a clearly negative result to finally punch through the bias and finally get published, but it happens eventually. This is why we often don’t see a good quality negative study until quite late in the history of a controversial topic — that’s the file drawer effect. You can see this pattern repeated with virtually every popular therapy that eventually turned out to be bogus: years of weakly positive studies, eventually contradicted by a better study, then a flurry of replication studies that finally pop the bubble (followed by years of therapists being first unaware and then unwilling to accept it).

For instance …

The best data is the worst news

In 2007, the European Spine Journal — an excellent journal — published quite a detailed study of this subject by Swiss researchers. They examined “the correlation between the presence of neck pain and alterations of the normal cervical lordosis,” and I agree with their assessment that it’s probably “the first study to explicitly examine these relationships in detail.” They x-rayed 54 people with a history of neck pain and 53 without, and then carefully measured their necks. What did they find? Zip, zero, zilch: “No significant difference between the two groups could be found.” Emphasis gleefully mine — the data are excellent, and clearly a blow to the popular hypothesis, which really needed some comeuppance in my opinion. It’s quite clear from this quality data that people with neck pain simply did not have more dysfunctionally curved cervical spines.

“The presence of such structural abnormalities in the patient with neck pain must be considered coincidental,” the authors concluded.

So, meh

As Dr. Steven Novella of Science-Based Medicine has often emphasized, “Reliable conclusions come from interpreting the literature as a whole, and not just individual studies.” So there are may be some individual studies that show a fairly good correlation between neck pain and posture. But better science — or at least as good — has directly contradicted those findings, showing no correlation at all. It’s very hard for structuralists to explain that contradiction away. If you look at all the studies together, they all kind of cancel each other out and the net effect is just “meh.”

About a month ago, I just started training for another season of ultimate.

Ow.

I have never started training this out of shape, or this old. These are not exaggerations. I have literally never been this old ever before. And I have literally never been this out of shape before.

I’m out of shape, of course, because I just had the most stressful winter ever, including experiences so incredibly awful and challenging that you can’t really ever laugh about them, except you have to, because what else are you going to do? I drank heavily at times, I often barely slept, and for a month my only sport was “worry” and it was an extreme sport. My wife’s car accident completely redefined hardship for me. I got into the big leagues of crap luck.

So when I went for my first run of the year, a pathetic 12-minute slog …

Ow.

The DOMS (delayed onset muscle soreness) was fierce, like a 2-day brush fire in my musculoskeletal system. From a 12-minute run! But I recovered, and ramped up to half hour runs over the next couple weeks, and then took a leap of faith and played actual ultimate for an hour.

Ow.

Big mistake. There’s a physiological chasm between “30 minutes of jogging” and “60 minutes of sprinting and sharp turns at competitive intensity.” Another 2-day brush fire through my muscles …

A real athlete

I’m living proof that you don’t have to be a particularly good athlete to be a “real” athlete. I know I’m a real athlete because I have been injured many times while hiking, running, and playing ultimate. Clearly, as I push 40, it’s only going to happen more and more often, for less and less performance reward.

But pushing 40 isn’t the end of the line, and this season presents the best opportunity I have had in years to make a bit of a comeback. I will report my progress from time to time here on SaveYourself.ca. With any luck, I’ll get injured again and have yet another opportunity to relate to my readers.

Update: that was my cue

I got injured between writing the draft of this post, and posting this post. I was sprinting towards a frisbee. The frisbee was whipping towards me. The initial point of contact was the tip of my thumb.

Ow.

I re-sprained my 1st carpometacarpal joint, the big thumb joint. It is swollen, it’s a pretty shade of purple, and I could not pinch anything to save my life. This is an injury I have had at least “many” times before, but this is probably the worst incident since the first one in 1997. Once a body part is sprained, it is easier to sprain again — and with each re-injury it gets more like something you wish would not happen ever again.

Here we go again!

“The curve of the cervical spine: variations and significance.”

Gay. Journal of Manipulative & Physiological Therapeutics. 1993.

This review of several papers about neck posture indicates that “a wide range of normal exists in the posture and configuration of the cervical spine,” and concludes, “There is little evidence to support the contention that altered cervical curvatures are of prognostic significance.”

“Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial.”

Ylinen et al. Journal of the American Medical Association. 2003.

This experiment intriguingly found a significant benefit to strength training for neck pain patients, where other studies have failed to find evidence of such a benefit. The authors acknowledge and discuss this interesting difference. Assuming their data is good instead of being a fluke or artifact, the implications are that strength training done in some way probably helps patients of a certain kind — but the mix of variables that produces a favourable result is still a matter of speculation.

“Exercises for mechanical neck disorders.”

Kay et al. Cochrane Database of Systematic Reviews. 2005.

“The evidence summarised in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic mechanical neck disorders, with or without headache.”

“Determining the relationship between cervical lordosis and neck complaints.”

McAviney et al. Journal of Manipulative & Physiological Therapeutics. 2005.

Researchers examined 277 neck x-rays and found a “statistically significant association between cervical pain and lordosis < 20 degrees” — that is, painful necks tended to be flattened necks, about 10 degrees flatter than the lower end of what they defined as normal. They concluded that “maintenance of a lordosis in the range of 31 degrees to 40 degrees could be a clinical goal for chiropractic treatment.”

“The association between cervical spine curvature and neck pain.”

Grob et al. European Spine Journal. 2007.

Perhaps this paper should be titled: “The lack of association between cervical spine curvature and neck pain.” In 2007, Swiss researchers examined “the correlation between the presence of neck pain and alterations of the normal cervical lordosis,” and this was probably “the first study to explicitly examine these relationships in detail.”

Many therapists assume that there is not only a correlation but a causal relationship, a classic example of structuralism. However, looking at more than 50 patients with and 50 without neck pain — a large enough study to be meaningful — the researchers found “no significant difference between the two groups could be found in relation to the global curvature, the segmental angles, or the incidence of straight-spine or kyphotic deformity.” Thus they concluded that “the presence of such structural abnormalities in the patient with neck pain must be considered coincidental, i.e. not necessarily indicative of the cause of pain.”

See also some substantive criticism of this paper.

“A novel method for neck coordination exercise — a pilot study on persons with chronic non-specific neck pain.”

Roijezon et al. Journal of Neuroengineering & Rehabilitation. 2008.

This is a quirky but dubious little study that conveniently omits a critical result from the abstract. The researchers strapped a rimmed platform to people’s heads and got them to practice controlling the movement of a ball rolling on the platform — so, basically a little circus trick. The subjects (only 14 of them) ended up with less postural sway, less jerkiness in neck rotation, less fear of moving, less “disability” and “increased general health” by various measures, all of which is mentioned in the abstract with the promising and confident-sounding conclusion that the results “support the clinical applicability of the method.” Sounds fairly good, doesn’t it? But there’s a huge gotcha: if you read the actual article, it turns out that the results involved no positive effect on pain levels whatsoever. “There was no significant decrease in VAS [pain scale] scores after the four-week training period, or at six-months follow up.” The disconnect between the results and the abstract indicate that the authors probably have a strong bias in favour of structuralism.

“The effect of two exercise regimes; motor control versus endurance/strength training for patients with whiplash-associated disorders: a randomized controlled pilot study.”

Ask et al. Clinical Rehabilitation. 2009.

This small study compared strengthening/endurance exercises with coordination (motor control) exercises for patients with neck injuries. There’s no way of knowing from this evidence whether or not these exercises are helpful (other studies have, though), but it does pretty strongly suggest that neither one has any clear advantage over the other. This contradicts the popular ideas that either neck strength or coordination is particularly important in neck pain cases.

“Exercise prescription for chronic back or neck pain: who prescribes it? who gets it? What is prescribed?.”

Freburger et al. Arthritis Rheum. 2009.

A survey of the prevalance of prescriptions for different kinds of therapeutic exercise for neck and back pain. “Of the 684 subjects, 48% were prescribed exercise.”

“Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial.”

Griffiths et al. Journal of Rheumatology. 2009.

This study showed fairly conclusively that neck pain patients were not helped by neck stabilization exercises. In a straightforward comparison of two groups of 37, one doing general neck exercises and the other doing stabilization exercises as well, there were “no significant differences.”

Once again I will be travelling to Las Vegas this summer to participate in “TAM” — The Amazing Meeting, a critical thinking and (who are we kidding) geek convention. I went to my first TAM last year, and wrote a bizarrely long and cheeky account of the experience that was strangely popular. This year I am particularly looking forward to, roughly in order of importance:

• Beers with like-minded friends from around the world.
• The blisteringly dry canned air in the hotel that will relentlessly rip into my mucus membranes. Oops, this is the positive list …
• Richard Dawkins (I’m a huge fan) of God Delusion fame
• Adam Savage (I’m a huge fan) of MythBusters fame (dude is awesome: listen to his great interview with Desiree Schell of Skeptically Speaking)
• Simon Singh (I’m a huge fan) of giving a legal whuppin’ to litigous chiropractors fame

But the main professional attraction is the science-based medicine workshops, presented by the the team of doctors that created the Science-Based Medicine blog, especially Dr. Steven Novella, Dr. David Gorski, and Dr. Harriet Hall. I have had a working relationship with SBM since I met them all last summer, and I volunteer my time doing some copyediting for SBM. If I were to rename my website, I would probably call it Science-Based something or other.

Extremely concise SBM primer

“Science-based” medicine is a conceptual upgrade to “evidence-based medicine” (EBM) that emphasizes that ideas in health care must make a reasonable amount of sense and clearly pass fair scientific tests before we take them seriously. For more information, see Why Science-Based Instead of Evidence-Based?

I am excited about SBM as a movement because I see a dire need for its sensibilities in health care and health information. I predicted that SBM — the idea and the blog — would become a big deal, and I was right. It’s really taking off, and I’m really proud to be involved. It will really be a treat to meet with the SBM writers at TAM8!

Which raises an interesting footnote to the previous post about physiatrists.

My wife has been doing the rehab thing in a pretty big, dramatic way since her car accident. Interestingly, her physiatrist told her last week to stop doing physiotherapy. Why?

“Physiotherapy is over-rated,” he said.

He encouraged her to take it easy and enjoy her “holiday.” His point: she’s going to heal either way, with or without a bunch of physiotherapy exercises. While some might argue that she will enjoy faster and more complete healing and reduced risk of complications with the assistance of a physiotherapist, he was arguing that the cost-benefit analysis isn’t so obviously favourable. He wasn’t saying physiotherapy is worthless … just probably not worth continuing at great expense.

Interesting. Food for thought.

Physiatry, or physical medicine and rehabilitation (PM&R), is the medical speciality devoted to rehabilitation and many musculoskeletal problems not addressed by other doctors.

Think of them as “super physiotherapists.”

Their job is to restore optimal function to people with injuries to the muscles, bones, tissues, and nervous system (such as stroke patients). This field has a broad scope, and many physiatrists may only be interested in and knowledgeable about more serious injuries and diseases (i.e. not muscle pain, even severe and chronic muscle pain). For instance, a physiatrist is managing my wife’s rehabilitation from her fairly serious Asian car accident in February.

A physiatrist is the medical professional most likely to be the best kind of doctor to treat difficult muscle pain. Although their expertise may be focussed on rehabilitation from serious injuries, they are also more likely to be well-educated about muscle pain (yay!) than any other kind of doctor, and thus they may be able to accurately diagnose, locate and treat trigger points. You may need to do quite a bit of calling around to find a physiatrist with these interests and skills, but it’s probably worth the effort if you have serious chronic muscle pain.

This never works out — the “quick” part, not the strength training (although perhaps that too). I’ve spent about seven hours now slogging through the confusing mess of inconclusive science.

There’s one study in particular that really threw me. I had pretty much decided to rule against strength training, to say that its value is just too uncertain to recommend. And then I stumbled on this: a 2003 experiment published in Journal of the American Medical Association that showed good improvements in neck pain and function after a whole year (yikes) of good adherence to a strength training program — interesting because, the authors explain, “Previous randomized studies have not shown active training to be effective,” and they cite several examples (and there are others since then, as well).

Indeed, there’s very little evidence that strength training is useful for neck pain, and that’s what I was going to emphasize. But then along comes this experiment with dramatically different results! Why did this one study find such a clear effect? The authors addressed this directly. Indeed, they went on for several paragraphs discussing all the possibilities. This point jumped out at me as a great example of how difficult science can be:

There are also several … conditions that cause neck pain, which should be treated by means other than special neck exercises. In our study, we tried to exclude these diseases as much as possible.

It’s absolutely possible that other studies of strength training for neck pain made this error: including too many patients whose neck pain was much less likely to be helped by strength training. This emphasizes two important ideas at once:

1. Ylinen et al’s data shows that certain kinds of neck pain patients may be helped by strengthening, but …
2. …their data also shows that other kinds of patients may not be helped by strength training.

A “yes and no” result (and blindingly obvious, really). But it’s such a great example of how careful you have to be about what question you ask in a scientific experiment. Other studies showing that neck pain is un-helped by strengthening are not necessarily “wrong” — they have correctly answered the question, “On average, for most patients most of the time, does strengthening help any kind of neck pain patient?” No, it does not — it’s not a cure all. That’s good information, especially because neck strengthening is so routinely prescribed.

But, if we accept Ylinen et al’s evidence, then maybe it’s just a matter of knowing which kind of patients should get the prescription and which shouldn’t. That is also good information, obviously, and at first glance it seems to be the “better” research that shows us the way to “better” strength-training prescriptions. But here’s where the complexity gets dialed up to eleven.

The study found good results, but they don’t know why they got those results.

They discussed many possible reasons. And if we don’t know which of those reasons actually accounts for the difference in results — and we really don’t, it could be any of them or all of them or some of them and there’s absolutely no way of knowing with any real confidence — then trying to prescribe strength training correctly is basically impossible. We simply don’t know why those people did so well. No clue.

This is exactly like a classic example from science history: the cure for scurvy. Famed explorer James Cook was the first ship captain to keep his crew from dying of scurvy on a long journey, but he did it by throwing all possible scurvy cures at the problem. One of them was correct … but which one? A lot more sailors died in subsequent decades because other “experts” kept making their own educated guesses about which of Cook’s measures was the real McCoy.

The stakes are a lot lower with neck pain and strengthening, but in principle the problem is the same: there’s not much point in trying to prescribe neck strengthening until we know what it was about this experiment that actually produced good results. As interesting as the data is, all it really tells us is that, for some unknown reason, it probably works for some people, some of the time, when done a certain way. But which people, which times, which ways? And do you really want to invest a year of your life in diligent strength training for your neck when we don’t understand the variables? When we know that, on average, neck strength training fails?

No wonder the question hasn’t really been answered yet. And so much for my “quick” update!

“Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial”

THEM — You say it’s hard for patients to find good trigger point therapy. You shouldn’t say that! We certify good trigger point therapists!

ME — You have about fifty practitioners in your directory, concentrated in a handful of major cities, with a certification no one has ever heard of, for a country of more than 300 million people spread over almost 10 million square kilometres. That’s one certified therapist for about every 60,000 people and 200,000 square miles. If “needle in a haystack” is the new “easy to find,” then sure, I’ll say that your certified therapists are easy to find.

THEM — Well, you still shouldn’t say that it’s hard to find them!

ME — Call me when your organization has grown by at least an order of magnitude and your website doesn’t look like it was built by chimps.

Two years later that organization still has only about 100 certified therapists in its directory, and yet remains one of the largest directories of its kind. If you live in a big city, there’s a fair to middlin’ chance that you can find one of those therapists. But certification of trigger point therapists is still generally a mess, with several businesses and organizations competing to be the standard, and — sorry everyone — no one looking like an obvious leader. Even my own efforts are part of the mess: a sanity-inducing part of the mess, hopefully, but nevertheless a good example of how everyone and their dog is out there trying to provide “the best” information/training/therapy in this field.

My list of resources is not complete, but it is a good start, and it’s quite carefully produced and annotated. I certainly welcome suggestions from my readers. For inclusion, an organization or business must be defining the field in some way, and they must have a strong online presence. In the digital age, it is not good enough to merely be good: you have to look good online and provide real substance to visitors.

The trigger point therapy and muscle pain resource list

And the BCA has paid a high price for it. Their reputation is certainly far worse off now than it was before (Streisand effect). The BCA has probably done us all great favour by reminding us that the chiropractic industry cannot defend many of its common practices by any means except legal bullying. It is important for the kind of thinking that motivates such attacks to be exposed.

In my mind, no incident in the whole Singh saga stands out more vividly than the day the BCA published its list of “scientific studies” supporting their position, for which any high school science teacher would have given them a failing grade: an amateurish assortment of irrelevant and cherry-picked studies of the lowest possible quality, which says more about the intellectual poverty of their position than any other single thing has.

That, or perhaps just the word “bogus.”

The Guardian: Simon Singh libel case dropped

So what a happy coincidence that Dr. Harriet Hall, the The SkepDoc, recently let me know that my new article about Traumeel (homeopathic arnica) had come up in fifth place on a Google search for Traumeel. Today it’s second only to traumeel.com, well ahead of any other critical review, and indeed the only listing that isn’t promoting Traumeel. That’s a search engine home run, and it happened practically overnight: only a handful of my articles have ever gotten such a strong showing on a major search term. Traumeel is the world’s most popular homeopathic product, so the search volume is huge.

As people set out to learn more about Traumeel this week, a great many of them will find and read my heavily-researched article. In the months and years to come, it will be seen by tens of thousands of people, and probably continue to be the most prominent source of information available about Traumeel. Even more remarkable is that there’s a strong possibility that SaveYourself.ca supporter can push it to the top of the search listings — or least ensure it keeps a hold on spot #2 — simply by linking to it. Since that goal is in reach, I’d like to encourage anyone with a website to link, link, link. Here’s the permalink for copying and pasting:

http://SaveYourself.ca/traumeel

Does Traumeel Work? A detailed review of Traumeel®, a homeopathic remedy (not herbal) widely used for muscular pain, joint pain, sports injuries, bruising, and post-surgical inflammation

This is my 100th post since I switched to more blog-like writing last November 4. You can now count on seeing fresh, hot content on the front page every day or two — at least as long as I’m not in a Thai hospital like I was in February.

In ancient times — when the internet was new, before blogs even — I published only articles and tutorials on SaveYourself.ca, more complex and substantive than “posts,” built Ford tough. Beefy, detailed articles (sometimes absurdly so, like the one about Epsom salts or the one about patellofemoral pain) have always been one of the selling points of the website.

But that depth is a double-edged sword: it takes so blasted long to create long articles and tutorials that, if I do nothing else, weeks can go by with no sign of life on the site and nothing to show for my work except a growing computer file and some coffee stains on my desk. Visitors might be left with the unacceptable impression that the proprietor has been out to lunch since the last solstice.

For instance, in a while I’ll announce a major new article about ultrasound that has taken me months to get ready from prime time.

So I started “blogging the process”: sharing chunks and nuggets of information along the way in the form of “posts” — 100 so far. Most posts are transplanted article updates and additions. I look for ways to improve articles and tutorials, update and upgrade them, and then share the update here in the form of a post. Readers can watch the site evolve. Even the longer posts — like a recent one about lactic acid actually being increased by massage — are excerpts from articles. That post was simply a new section of a much bigger article, Does Massage Therapy Work?

No, he doesn’t. Dr. Ferber’s public pronouncements continue to champion the theory by making too much of scanty evidence, and it’s still just another theory in a long series of theories about the One True Cause of running injuries. Nothing has changed. No compelling new evidence has been published. But the hype machine is still churning this stuff out.

Not that I expect quality science journalism from running magazines, but this is the kind of language that results in the exasperating and constant churning of “the truth” in science. Patients and media consumers are bombarded with so-called “conclusions” … which are then inevitably replaced next month because there was never really enough data to say anything with confidence in the first place.

Does Hip Strengthening Work for IT Band Syndrome? Despite its popularity, “weak hips” is a weak theory, and there is no compelling evidence that hip strengthening can treat or prevent running overuse injuries of leg

So yesterday was optimization day: I did geeky things under the hood of SaveYourself.ca to make it even faster, especially for people with slower and less reliable internet connections, which are still common around the world and in rural areas. Yes, I am thinking of you!

Honey, I shrunk the website!

This page, for instance, was shrunk — about 60% — before it was sent to you over the internet and then re-inflated before your computer showed it to you. A smaller file can be sent much more quickly through the bottleneck of a slow internet connection. The speed gain is awesome. On a dial-up internet connection, my trigger points tutorial takes a mind-numbing 32 seconds to load — but when it’s compacted before sending, the user waits only 12 seconds, a huge speed bump. You’re welcome. Quite incredible, and it wasn’t even really that difficult to do.

Even on a fast urban internet connection like mine, this little trick consistently still improves page load speeds by about a 20%, from 1.2 seconds down to 1 second. That’s right: .2 seconds less, baby! Zoom zoom! That sounds ridonkulous, but it actually does matter when averaged out over very large numbers of impatient visitors over months and years. 2000 visitors/day × 3 pages per visit 365 days × .2 seconds per page load is … great Scott: several straight days that my visitors would otherwise be just staring at pages loading!

Cache only, please

I also optimized “caching.” Caching is [geek talk], and definitely [geek talk] makes a lot of [geek talk] sense, ha ha ha! It has no effect at all on a first visit — but every visit after that is made more efficient by doing things like using graphics (i.e. the salamander logo) over again rather than re-downloading them on every page.

Platelet-rich plasma (PRP) injection isn’t having a great year. The best PRP research to date was published recently, showing that it was no better a treatment than injecting saline solution into inflamed tendons.

The evidence about PRP is not as uniformly negative as I thought, however. I just discovered a mid-2009 study from the American Journal of Sports Medicine that showed some benefit to PRP for muscle strain.

However, it was a small study and an animal study: a few rats were harmed and treated for our edification. While interesting, a larger experiment with humans is essential to give us any confidence in PRP for muscle strain. For now, the larger Journal of the American Medical Association experiment carries more weight.

And I don’t want to completely dismiss a treatment like PRP for muscle strain just because one good study of PRP for tendonitis was clearly negative. It’s certainly biologically plausible that PRP could fail with tendinitis but still succeed with muscle strain.

Indeed, the American Journal of Sports Medicine paper actually reported that there was a difference between the effects of PRP on two different kinds of muscle strain. According to their data, PRP worked better on a more serious strain injury, where regeneration of muscle tissue was part of the healing process. PRP might assist with that regenerative process, but have no effect on a less serious strain where no regeneration is occurring.

But the combination of aggressive marketing of PRP with a dearth of evidence is still ominous, and this is still definitely an experimental therapy being oversold.

“Use of autologous platelet-rich plasma to treat muscle strain injuries”

Between 1992 and 2006, seventeen hundred dancers were evaluated at a dance medicine clinic; only 24 of them had stress fractures (quite low), and conservative therapy had failed in only 7 cases. Those dancers were operated on: their fractures were stabilized with “drilling and bone grafting or intramedullary nailing” — good old carpentry-style surgery! They did well — shins that had previously refused to knit finally knitted. Recovery was slow but steady in all cases, and they were all dancing normally again by about the six-month mark.

“Surgical treatment of refractory tibial stress fractures in elite dancers: a case series”

This does not square with the popular wisdom that anatomical asymmetries and “poor” posture are going to make you hurt. Indeed, it flies in the face of dozens of popular theories about the causes of common pain problems. It is not a difficult clinical observation to make, and yet it tends not to get made or discussed. Why?

Clinicians fail to notice the inconsistency because they want “something to fix” — and if you broaden the definition of “normal,” there is obviously less to pathologize, less to diagnose, less to seem knowing about, and less to recommend to the customer. Diversity undermines clinical mojo. So it’s not generally in the interest of therapists to “normalize” patients and characterize their anatomical quirks as harmless. Quite the opposite! It’s better for egos and income to define “normal” more narrowly and attribute pain problems to deviance from the apex of the bell curve, giving naive customers the impression that you are terribly clever to have identified their idiosyncratic problem.

And of course there’s just good ol’ confirmation bias. Once you lean towards asymmetries as a cause of pain, you start noticing and emphasizing only the cases that seem to confirm that expectation … and ignoring the ones that confound it. Health care is so full of puzzles that it’s effortless to write off anything that doesn’t confirm your bias as an inexplicable oddity — you can even claim humility, shrug, admit “I don’t know,” even as you conveniently overlook that the data you’ve just dismissed could actually have taught you something.

In fact there are quite a lot of people who are walking around with all kinds of fascinatingly uneven bodies who doing just fine, thank you very much.

The short answer is no: don’t use an elliptical machine if you’re trying to avoid knee stresses. But …

Elliptical machines eliminate the jarring of running, but still involve knee loading — of course. As a risk factor for PFPS they seem to be in a strange gray area: quite a few people over the years have reported to me that they are actually okay with elliptical training (even when they have trouble with many other activities).

Elliptical machines are clearly not as hard on the knee as running for most people, and yet they’re certainly much harder on the knee than some other activities (knitting, say). Only your experience can guide you: if you have no symptoms after elliptical work you can assume that it is probably safe, but please remain alert. The more determined you are to eliminate all risk factors, the more you should consider eliminating elliptical machines one even if isn’t obviously doing harm.

“Those who believe that regulation is a substitute for evidence will find that even the most meticulous regulation of nonsense must still result in nonsense.”

This is often quoted, but rarely with the source cited or a link to the full article. It’s short, accessible and well worth a read. Here it is:

“The role of complementary and alternative medicine”

The science writer Simon Singh has won … the right to rely on the defence of fair comment in a libel action.

“It is extraordinary this action has cost £200,000 to establish the meaning of a few words,” Singh said. Lord Judge ruled that compelling authors to expensively defend their opinions as if they were facts “is to invite the court to become an Orwellian ministry of truth” (see the full decision). Clearly this is one of the most significant decisions in the history of libel law. But what does it mean to science journalists around the world?

Hopefully this is the beginning of the end of “libel tourism,” the practice of finding a way to sue in the UK because most accused can’t afford to defend themselves, regardless of how goofy the accusation is. Every lawyer in England knows about this decision, and many will advise caution to clients — bullying journalists and other critics around the world is now more likely to be a legal dead end, and much more likely to be a public relations disaster.

Lawyers and judges around the world are watching as well. For instance, recent Canadian Supreme Court decisions created new legal safety for bloggers and online publishers like myself, giving more weight to the value of free expression, and referring directly to Simon Singh’s case as an instructive example. As one would hope in a free society, criticism is not inherently libellous in Canada, and a writer is free to write. Libel is much worse than merely have a a contrary opinion!

Simon’s victory is also a blow to the confidence of those who try to evade a scientific debate they can’t win by switching to litigation. It is a legal truism that you pound the facts if you have them, and you pound the table if you don’t. The British Chiropractic Association doesn’t have the facts, so they’re pounding the table instead. From the decision:

By proceeding against Dr Singh, and not the Guardian, and by rejecting the offer made by the Guardian to publish an appropriate article refuting Dr Singh's contentions, or putting them in a proper prospective, the unhappy impression has been created that this is an endeavour by the British Chiropractic Association to silence one of its critics.

This public shaming is a dire blow to the reputation that the BCA set out to defend. Their critic is now front page news and has been dramatically given the right to defend his words as fair comment instead of having to “prove” that his opinion is a fact as most defendants in the UK are forced to do. Even though there may still be a trial, today’s decision makes their conflict a (very public) debate again … as it always should have been.

Fortunately, I don’t think being interviewed for PhysioGuru.com makes me a guru. (Or a physiotherapist, for that matter.) It’s just an interview about how I made the switch from therapy to writing — something many readers have expressed interest in over the years. If you’re interested in writing and publishing, have a look.

By shutting off a single gene, researchers think humans could regenerate damaged tissue just as newts do.

And salamanders. It should say salamanders (newts are just one kind of salamander). Remember, sallies are the only macroscopic vertebrates that can grow entire missing limbs, joints and all — other regenerators are either microscopic, or much more limited in their abilities. Salamanders are super cool! That’s why I use one for the SaveYourself.ca logo and mascot.

It’s pretty pie in the sky still, but the genetic potential actually exists to heal almost magically from massive injuries — just like the comic book character, Wolverine … and salamanders.

Research in the massage therapy field is still in infancy partly due to a lack of research infrastructure and a research tradition. The result is that most registered massage therapists are not accustomed to reading, analyzing, conducting, writing case studies or applying research in their own practice.

Amen. At the very least, Registered Massage Therapists need to start reading journals, and/or subscribing to blogs (like this one!), that report on the science. New research that affects the work of manual therapists is being published every single day, and I would estimate that there’s something at least once a month that I’d call “important.” (See the last post for a great example.)

“Vision of Specialization for Registered Massage Therapists”

Wiltshire et al subjected 12 people to intense hand-gripping exercises to boost blood levels of lactic acid and other waste products of muscle physiology. Then they measured those substances with and without basic sports massage. Their data showed that massage significantly “impairs lactic acid and hydrogen ion removal from muscle following strenuous exercise by mechanically impeding blood flow.”

Massage actually slowed down recovery from exercise, as measured by lactic acid levels.

That’s quite a surprising result that applies a firm push to the side of this classic sacred cow of massage lore. It’s also yet another nail in the coffin of the daft notion that massage “detoxifies,” and yet another reason to be suspicious of any therapist who talks about “detoxification” (as is often done to rationalize adverse effects of therapy that actually have other causes). Massage has many interesting physiological effects, but getting rid of acid in your blood is not one of them.

SaveYourself.ca is getting big. With enough content to fill several books, some (modest) profits and enough daily readers to fill a couple of (midsized) auditoriums, it has become critical to get some quality control happening: a second pair of talented eyes to catch typos and nitpick word choices.

So, please welcome Brian Clarke, my new freelance editor-at-large.

It’s tempting to fluff this up and make it sound like Brian is a staffer, but I made the decision ages ago that I would never try to make SaveYourself.ca seem like more than it is: a small business, a new-economy e-business, small, agile and personal. Brian is an old friend, and editing for me is nowhere near a full-time job for him. It’s all very low-key and casual.

Still, it’s a significant entrepreneurial step for me to pay an editor even part-time, and Brian is a power tool: mind like a steel trap, a librarian’s training (and much else besides), and a genuine talent for making my writing better.

Brian will now handle all correction-related email. Spot a typo? He’s the typo killer. Please send reports to brian at saveyourself dot ca.

This is not what Brian looks like. It is, however, almost exactly what his cat looks like. Mine too, by coincidence.

• either a normal bursa (padding) that has become irritated,
• a bursa that has grown in reaction to stress, like a callus,
• and/or a deeper, bursa-like pocket of tissue around the fibrous attachments of the IT band to the knee

Hint: all of these bullet points contain the word “bursa”! A bursa (plural bursae or bursas) is a peculiar bit of anatomy: a small sack of slimy (synovial) fluid, like raw egg white, which reduces friction between structures, such as between skin and bone, or between a bone and a tendon. The name comes from the Latin for purse.

Historically, many professionals also thought of iliotibial band syndrome as a bursitis. For a long time, that idea seemed to be doomed. For instance, the lack of a bursa under the IT band at the knee was reported by three other groups of researchers focussing on this issue:

1. In 1996, Nemeth showed that “the tissue under the ITB consists of a synovium that is a lateral extension and invagination of the actual knee joint capsule and is not a separate bursa as described in the literature.” They’re saying it’s bursa-like, but specifically saying it is not actually a bursa.
2. In 2007, Fairclough et al reported that “a bursa is rarely present, but may be mistaken for the lateral recess of the knee.” They called the structure a “lateral synovial recess.”
3. Then in 2009, Michels et al actually targetted tissues in the lateral synovial recess with literally surgical precision. They didn’t find bursae either!

Yet Hariri et al operated on what they called “bursae,” provided nice pictures of the inflamed bursae that they removed from people’s knees, and got good results. So what is going on here? Clearly not all of this can be quite right! Is there a bursa in there or not? What gives?

This is simply a nice little unsolved mystery, a good orthopedic puzzle.

Personally, I rather like this notion of a pathological bursa that grows in response to stresses, like a callus. I actually had no idea that any such thing existed until I read about it (in Hariri) … but the moment I read about it, it made perfect sense. Why wouldn’t the body do exactly such a thing? Clearly body parts toughen up in all kinds of ways in response to stress: why not internally?

On the other hand, if the point of forming a callus is to cope with stress, it doesn’t seem to be doing a very good job in people with iliotibial band syndrome! Perhaps there are simply limits? A pseudo-bursa can only do so much, and then it gets irritated? Perhaps without it people would get even worse pain, and sooner?

Many questions! Few answers! But it’s all interesting. (To anatomy geeks. And people with knee pain.)

Snake Oil? Scientific evidence for popular health supplements

Psoas, So What? Massage therapy for the psoas major and iliacus (iliopsoas) muscles is not that big a deal

It was an important study, but still just one study. I was eager to see another.

Another was published a few months later. An American group took a slightly different approach, but also operated without cutting the IT band, and also removed irritated tissue from under it (see Hariri). Like the Belgians, they got excellent clinical results, once again validating the concept that ITBS is not a tendinitis — the IT band itself is not the irritated anatomy.

Two studies still isn’t proof, but it’s getting there. And these surgical experiments were inspired by quite a bit of prior evidence, especially Fairclough et al’s important paper in 2007 (“Is iliotibial band syndrome really a friction syndrome?”). This is shaping up to be a tidy little triumph of scientific medicine, of careful and expert exploration for the real “root cause” of a painful problem.

In contrast, the effort to identify a biomechanical risk factor for ITBS — hopefully a treatable one — has just bombed. After decades of perpetually underwhelming research and dozens of pet theories, we still can’t predict who will get this condition, and there is still no clearly effective manual therapy for it.

Therapists really need to stop thinking in terms of “what’s crooked or out of whack” to explain and treat iliotibial band syndrome.

How much benefit, though? Contrasting is unlikely to work any miracles. There is no particular reason to believe that contrasting would make large differences in healing.

A few good scientific studies could tell us how effective contrasting actually is, but unfortunately the subject has barely ever been studied, and the small amount of research that has been done is of such poor quality that it’s basically useless. A review of the science of contrast hydrotherapy concludes that there is no science of contrast hydrotherapy: no research has ever been done that provides useful evidence that it works or does not work.

This review highlights both the lack in quantity and quality of research regarding the efficacy of contrast therapy for sports recovery.

Contrasting remains a popular and plausible but untested form of treatment.

“Contrast therapy—a systematic review”

Perhaps the looming health care crisis and the attention that rising health care costs is currently receiving will make this kind of no-nonsense rigorous scientific assessment fashionable in Western politics. Removing worthless modalities from the health care system is certainly in the interests of efficiency and cost-effectiveness.

Homeopathy Gets a Reality Check in the UK

In health care, half of all recovery times from illness and injury are above average — and many of those people will say nice things about whatever therapy they were spending money on at the time. But their stories are only half the story.

To our great peril, the limitations of anecdotal evidence are not understood by most health professionals. It is still routine to find health professionals giving anecdotes vastly more clinical weight than they deserve, as though hearing a handful of positive case reports is really all they need hear to be convinced. There is an epidemic failure to respect the well-known fallibility of human perception and testimony, so obvious to us in so many other ways.

People also often brace their back for ordinary low back pain based on the assumption that the brace will protect their joints. But it’s unclear that braces can actually do what people hope they’ll do.

Ten years ago, to determine how much a back brace really braces, German researchers used “telemeterized” implants — steel fixation rods with meters on them — to measure the effect of common braces on spinal forces. Three types of braces were examined: The Boston overlap brace, the reclination brace, and a lumbotrain harness.

They found that “none of the braces studied were able to markedly reduce the loads” on the implants. There was some reduction — just not “marked,” nothing to write home about.

More surprisingly, some of their measurements showed that bracing increased loading on the implants! That does seem possible. The spine is an extraordinarily dynamic structure. Somewhat like slouching into a comfortable chair, use of a brace might actually cause some sloppiness of spinal function, resulting in “resting” on fixations and joints, rather than using muscle to support and control the spine. That’s just a guess, but it seems like a reasonable one to me.

All good health professionals are emotionally sensitive to their patients’ suffering … but not like this!

Here are three lessons about injury (especially low back pain) and recovery that I’ve drawn from my experience so far. None are particularly surprising to me — not so much learned as reinforced — and I’m sure this list will grow:

1 — Joints pop more after trauma! I’ve said this to patients for years without really being sure of it, but now I’ve witnessed it dramatically. Kim’s back barely popped before, but now pops so much that it’s been a struggle for her to accept that it’s normal. It seems extreme.

2 — Muscle pain is king. My wife crushed one vertebra, snapped a tip off another, and had steel braces screwed into the bone above and below … but that’s not what hurt. She has had some back pain, sure. But muscle pain in the area — especially the hip, many inches from the fractures — has consistently been by far the most significant source source of symptoms. Muscle is clinically underestimated!

3 — And neurology is queen. The evidence is overwhelming that what you think about your pain is a critical factor in your experience and recovery (see Pain Is an Opinion and The Mind Game In Low Back Pain). Countless times I have observed Kim react to similar stimuli in different ways, depending on the mental context. Nervousness makes things hurt more! And confidence makes them hurt less.

• fly first class for the first time in our lives,
• watch our medical escorts deal with the maze of logistics and legalities of medical transport,
• and sail through airport lineups on the fast track. (The only thing you have to wait for as an injured passenger is de-planing. You get to be first for everything else — but you’re the last to get off the dang jet! It was peaceful, in a way, because the question “how much longer?” question was pre-answered: until the end.)

It was the medical transport service that was what really made the trip interesting. The basic problem of medical transport is that airlines don’t really want to take injured passengers. From the airline’s perspective, Kim was a legal disaster just waiting to happen. People like to sue airlines. Pilots have the legal right to refuse any passenger, and they do. We heard horror stories about this before we left.

It’s the job of the medical escort company to deal with all of that. Safety is job one, of course, but our nurses were also experts in cutting through red tape. For instance, we all made the decision together that we avoid the use of a stretcher, because Kim was doing so well, and because seeing a stretcher really makes an airline ask a lot more questions …

Stretcher at 2 o’clock, unleash the red tape!

We faced a (minor) crisis when ticket agents spotted Kim being wheeled into the Bangkok Airport on a stretcher. The ambulance attendant thought he was being helpful bringing her all the way in to meet us, but our nurse escort muttered with mild alarm, “I told him not to bring her in here yet! I didn’t want them to see her on a stretcher!”

Sure enough, a supervisor hustled out when he saw the stretcher, and our escort had to play it cool and offer reassurances, even getting Kim to demonstrate her ability to walk. In this case, the supervisor was easily reassured, but it all depends on the person you’re dealing with. Sometimes, apparently, the nurses really have to get clever or pull rank — if necessary, they can even phone up some pretty serious people to tell lowly supervisors to back off.

It was a bit nerve-wracking to watch at time, because time and safety were interconnected for us. But they got us through all the hurdles, and Kim turned out to be surprisingly capable.

First class, ooh la la

So Kim and her escort flew business class on Cathay Pacific Airways — highly recommended — and got utterly spoiled by amazing customer service and assorted luxuries. Some of that service extended to me, as I was a special guest in their section, permitted to visit my injured wife. During my drop-ins, I was offered things like hot towels and wine in an actual glass instead of a plastic cup. Ooh la la! Kim’s nurse even swapped seats with me for an hour, and I got to nap in his fully-reclining booth seat.

However, for 90% of the trans-Pacific flight, I was still stuck in economy class on a particularly crowded and baby-infested flight — as unpleasant as it usually is.

I did luck out a little though: two people were removed from the plane for security reasons at the last second (sucked to be them) … and they were in my row, so I suddenly got elbow room. A little elbow room makes a big difference on a 12-hour flight!

The price tag for this method of travel

Somewhere in the neighbourhood of $30,000.

So buy travel insurance! And if you’re ever stuck abroad due to illness or injury, you will probably need a medical transport service to get you home. And ask your insurer to work with Fox Flight Air Ambulance — they were truly amazing. Even if you’re stuck without insurance, still contact them — they have the skills to get you home as safely as possible, and maybe for $30,000 instead of $50,000!

Quite a bit longer than I want to live in a hospital, even with the shorter scenario.

I have no idea when I’ll get around to it, but this experience is certainly going to inspire some writing. I am getting a lot of really intensive, personal experience with spinal injury rehabilitation. Like I didn’t know enough about back pain already …

I’ve written a new short article inspired by this research:

What’s the Harm? Rare but real adverse effects of massage therapy

A new study in the Canadian Journal of Emergency Medical Care compared ibuprofen and a muscle relaxant (cyclobenzaprine or Flexeril) for patients with serious soft-tissue injury in the neck. Groups of about 20 patients received one, the other, or both. Results were statistically identical for all patients. This test showed no benefit to using or adding a muscle relaxant for acute muscle strain in the neck. The study is too small to be powerful, but it certainly shows that there’s no clear advantage to muscle relaxants in a situation where they are often assumed to be an important medication, and the results are consistent with other research results.

The surprise here is not just that muscle relaxants weren’t obviously superior, but that they even performed as well as ibuprofen! Despite the many kinds of muscle relaxants, and their many possible uses, as a class of drug they are remarkably unimpressive in the management of common pain problems. A 2008 physician tutorial in American Family Physician (see See et al — that’s not a typo, the lead author’s name is actually “See”!) nicely sums up the blah state of the evidence:

Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain.

And “skeletal muscle relaxants should not be the primary drug class of choice for musculoskeletal conditions.”

Medical care for low back pain has a split personality: the experts “get it” and their opinions are widely published and accessible, but general practitioners either haven’t read the guidelines or ignore them. A new study in the Archives of Internal Medicine shows that family doctors aren’t caring for low back pain the way that their own expert colleagues recommend.

The paper presents strong evidence that general practitioners are simply not using best practice guidelines for the care of low back pain, even many years after they have been widely publicized in the medical literature. Williams et al looked at more than 3500 new cases of low back pain, comparing the advice patients got to the advice they should have gotten:

…the usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time.

In particular, GPs:

• failed to reassure patients
• prescribed unnecessary, expensive and emotionally intimidating medical testing to look for largely non-existent and/or irrelevant “structural” problems
• failed to prescribe simple pain killers which could reduce symptoms and anxiety with virtually no risk
• failed to recommend massage therapy, even though it has always been an intriguing option, and is now also an substantively evidence-based treatment option (as established by a good quality scientific review in 2008)

(The Williams paper doesn’t discuss that last one — indeed, the survey predates the evidence — but it’s a pet peeve of mine that strongly fits in with the pattern of failing to give good advice.)

In a weird way, this website depends on front-line health care professionals failing to give good care. The whole point of SaveYourself.ca is to provide better information — the kind of information that you should get but often don’t get from most health care professionals. So it’s strangely reassuring to me when doctors and scientists publish detailed criticism of their own practices, confirming that there really are common problems with low back pain care, and that there really is a need for better information.

So this new paper strongly validates my position that patients are routinely getting poor quality information about low back pain — and could really use a readable and current guide to low back pain management. And, interestingly, so can the doctors. I know I have have many GP customers already, but I’d like to see more of them buy and read my ebook — they could clearly use it, and would probably find it much more enjoyable to read than a scientific journal.

I am posting this from the airport in Taipei, during a long wait for a flight to Bangkok, on my way to Thailand to meet Kim, and take care of her for a few weeks before she can be flown home.

Publishing this website is more of a lifestyle than a business, and I will not stop working entirely. I wouldn’t want to, even in a crisis: my work is an anchor for me, and there were be long, quiet hours to tap away on the ol’ laptop while Kim rests and recuperates. At the same time, I think it’s safe to say that customer service emails will probably be a slower than usual, and some kinds of email will be deferred for weeks. If I can answer something quickly and easily, I will. If there’s a critical purchase issue, I will respond to that as soon as Thai internet connections will allow.

Thank you in advance for your patience.

About a year ago, standing on a sidewalk on Davie Street in downtown Vancouver, I showed my parents an eBook-reading app on my iPhone.

Their eyes widened in fascination. There were exclamations, and a stream of questions. That’s an entire book? How did you get it? Do you have others? How many fit “in” there? Suddenly they really wanted to touch it. I had previously shown them other apps — productivity apps, utilities, novelties, games — with relatively little effect. They are readers, so it was a reading app that got their attention.

Days later, they both had their own iPod touches, and were actively experimenting with buying and reading eBooks They quickly became more experienced than I am with the (poor) state of digital publishing industry. The discovered that the reading apps — there are several excellent ones — were way ahead of the supply of eBooks. eBooks are currently easy to read … but somewhat hard to get, with relatively few books available and a maze of ecommerce and licensing complications, proprietary formats, security issues, and so on.

The writing is on the wall

A year later, though, they are more or less up and running with a steady diet of eBooks on their iPod touches. My sixty-something parents are constantly reading eBooks. They favour the reading app Stanza, and they get their books from the Fictionwise eBookstore. Although many say that they can’t read a screen comfortably, my parents say it’s great: the bright, high-contrast, backlit screen makes text pop out. The font and text size can be changed easily, and read in either portrait or landscape format.

I believe that this is what is known as “the writing is on the wall.” The eBook cometh. A decade later than music, but it’s finally happening.

Correction: The writing is on the … iPad.

The eBook cometh because Apple cometh. The iPad is built for many things, but reading eBooks most of all. Apple is going to shake up the publishing industry the same way it shook up the music industry. I believe that the iPad will change the way people read.

This isn’t a technology website, so I’m not going to get into an argument with the people out there who are rolling their eyes at the iPad. They can say it’s “just” a big iPod touch all they like: the user experience is going to be excellent, and my parents will buy one, and so will an awful lot of other people. And eBooks will become a big deal, fast.

ePub format

Apple surprised everyone by supporting the ePub format for it’s new device. It was nicest thing to do: ePub is a free and open e-book standard. Although I have no doubt Apple and it’s partner publishers will have measures in place to protect their intellectual property, the use of the ePub format is progressive and promising.

It is a move clearly intended to democratize eBook publishing, to make it more by the people, for the people. As with digital music, it will tend to encourage decentralization of the industry, cut out middle-men, and probably put fatter shares of the profit in the hands of authors. Sound too good to be true? Literally the day after the announcement, Amazon significantly changed its profit-sharing, suddenly giving authors a much larger cut.

Why the sudden Amazonian generosity? Because they can read the writing on the wall, too. Because they can hear a freight train coming down the tracks they’re tied to.

SaveYourself.ca will definitely go iPad

My “tutorials” are book-sized web pages with some simple interactive pages. Sometimes I call them eBooks, because they are books, and they are electronic, but they are not really “eBooks” — they are web pages. There are some really great advantages to that format, so I have resisted selling my eBooks in the “traditional” eBook format — PDF — for years now.

I’ve always hated PDFs. They are awful to work with and maintain, and customers have all kinds of problems with them. I’ve never seen PDFs as the future of reading — they were just a Band Aid for the mess of document formats from the 80s and 90s, something to get by on. They were never good for serious screen reading, and never will be.

The ePub format on the iPad does look like the future of digital reading. So it’s time to publish the SaveYourself.ca books in ePub format. It is time to get ready for the future.

Traumeel® is a popular homeopathic Arnica ointment for aches and pains, with a strong reputation for being “good for” muscular pain, joint pain, bruising, and sports injuries.

But people believe in a lot of things that don’t work. What about Traumeel? Do fifty people who use it post-surgically obviously recover faster than fifty people who don’t? Has such a test even been properly done? Where’s the beef?

I’m pleased to announce a major new analysis of Traumeel, certainly one of the most detailed articles about Traumeel available anywhere. This is free content that adds substantially to the value of SaveYourself.ca tutorials and eBooks — virtually everyone with a chronic musculoskeletal problem has tried Traumeel, or been offered it. Now my readers can learn just about everything there is to know about it:

• How much Arnica is really in there? And does it matter? Does Arnica work even undiluted?
• How did homeopathic Arnica keep people from going out to dinner?
• If poison ivy were as diluted as the Arnica in Traumeel, could it still hurt you?
• NCCAM has massive funding to study and validate treatments like homeopathy, so what evidence have they produced with their millions?
• Can patients even tell if healing time was “accelerated”? Do people know what normal healing times are?

And much more!

My favourite part of this new article is about the scientific paper that tested how long it took people recovering from nose jobs to feel confident about going out to dinner. Patients who took Traumeel took longer. If you read anything in this new article, read that part!

Does Traumeel Work? A detailed review of Traumeel®, a homeopathic remedy (not herbal) widely used for muscular pain, joint pain, sports injuries, bruising, and post-surgical inflammation

I have never tinkered much with the pricing of my tutorials/eBooks. They’ve been USD $14.95 pretty much since I started selling them, about three years ago. Today I decided it was time to push them up to twenty dollars.

The value of the tutorials is not in their ability to cure. I do not offer “treatment systems” or miracle cures. SaveYourself.ca is not that kind of website.

What they do offer is critical analysis of all the treatment options — which often helps people choose to avoid unnecessary and costly therapy. This is why customers have told me that I’m under-charging: because I’ve assisted them out of the therapy grinder, helped them ditch treatments of dubious value, and helped them understand cheap or free self-help alternatives.

A few readers have even donated as much as $100 for this reason: because the information saved them from spending hundreds or even thousands of dollars on many over-priced and under-proven therapies.

Now 90-day subscriptions!

Most scientific journals charge $30 to $50 to access a single article for a single day.

I’ve always wanted to offer a much better deal to my own customers. Thanks to improving technology, I’m now able to bump the subscription period up yet again, from 60 day to 90 days. Once customers have paid for access, customers can now visit the tutorial for three months!

And, as before, customers can renew their access inexpensively months or even years down the road, to regain access and find out what the latest science says. On average so far, tutorials are updated 10-20 times per year.

Advanced Tutorials: Eight incredibly detailed, referenced, readable tutorials for eight common pain problems

Curiously, in a strange case of licensing backfire, David Graston himself is no longer in control of the Graston Technique® brand; he markets a new system called Sound Assisted Soft Tissue Mobilization (SASTM®), distinguished primarily by the use of tools made from ceramic instead of steel. There's also a third fairly-well known example, ASTYM® (stands for “a stimulation”). I was not previously aware of these competing modalities.

They are all rather similar, of course — virtually indistinguishable from a patient’s point of view, certainly. Graston publishes a chart showing the differences between the systems, but virtually all the differences are system-marketing benefits.

One of the most noteworthy things about the Graston website is the lack of meaningful references to relevant science. When I learned of these other systems, I went to see if by any chance they offered any meatier scientific support for their sales pitches.

ASTYM publishes an impressive-looking research page with dozens of references. However, the references are all just basic science articles about the physiology of healing, stuff that’s tangentially relevant to ASTYM at best. This is somewhat like responding to the question “Does it work?” by saying, “I am smart. I can cite science papers about physiology.” That’s terrific, but … does it work?

The ASTYM folks prominently cite the same trivial Davidson et al article that the Graston website leans on.

They list only a single study that directly involved ASTYM in any way. However, despite being rather experienced at tracking down scientific papers, I was unable to find what they were citing — either it doesn’t exist, or isn’t correctly cited. And it’s a study of only 20 subjects in any case (smaller than small) — barely worth mentioning even if it is real.

So much for the impressive-seeming presentation.

Graston’s SASTM website does not present any scientific information whatsoever, but “To request a research packet, please fill out the contact us form.” Why not just publish it? Perhaps because there’s really nothing to publish?

The Graston Technique review is now updated with this information:

The Graston Technique®: Magic steel massage tools that supposedly scrape the pain away, and “resonate” in the therapist’s hands

And I have a different job than most writers on ye olde internets. My job is to produce really well-researched articles and information resources that evolve over time. I can’t post-and-forget. I have to post-and-integrate. Researchers at the University of Not Really demonstrated in a nonexistent study that my workload breaks down something like this, accurate to within five miles:

I’m not sure if I got my math right there, but you get the picture. It’s that second one that keeps me from posting new content as like-clockwork as I’d like. The cat doesn’t help much either.

On the other hand, they’re a blight! Not just ugly and cluttery — which is bad enough — but routinely displaying ads for products and services that are diametrically at odds with the articles they’re decorating.

This is a fundamental weakness of AdSense ads: they backfire when you’re content is critical of something. Google matches their ads to keywords in your content, but Google’s big ol’ digital brain can’t tell the difference between:

Scientology is better than puppies and rainbows.

And …

Scientology is a steaming pile of wishful thinking only a weak-minded fool could fall for.

Criticize Scientology on a web page, and Google will cheerfully give you ads promoting Scientology. Yuck! Write an article about what nonsense intelligent design is … and get ads for organizations promoting intelligent design. Write an article about moon-landing conspiracy crap … and get ads from moon-landing conspiracy theorists.

Or, in my case, criticize upper cervical chiropractic (NUCCA) … and get ads for NUCCA practitioners. Sigh. Epic advertising relevance fail.

I just couldn’t live with that any longer. The mental dissonance was jarring. It left a bad taste in my mouth.

You can block individual advertisers, but it’s hopeless in my case: I would need to block 98% of the advertisers, and there would always be more. Also, without ads from chiropractors, there would hardly be any other ads!

How much money did I make from AdSense? Oh, never much: about $20–25 per week — not enough to get hung up on it.

In theory, the long term value of clean, uncluttered content will drive e-book sales and replace the advertising revenue. Crossing fingers.

There is an interesting exception, though: if you get tired enough that a lot of motor units start failing to contract, the switching system fails because there aren’t enough motor units available for smooth contraction. This is why muscles start to shudder and quiver with very intense exertion! Cool, eh The switching system is mind-boggling in its efficiency and complexity, and a fantastic example of how much more physiologically complex muscle tissue is than most people realize.

1. It might work occasionally, a little bit, for some patients.
2. But no one really has a clue.

Serious criticism from serious people

This topic has been well-covered by several effective and credible critics. Good summaries include Dr. Harriet Hall’s article for LiveScience.com, a detailed critique by the formidable Dr. Stephen Barrett, and a scholarly but readable article (ideal for professional readers) by a chiropractor, Dwain Daniel, in Chiropractic & Osteopathy.

3. It is routinely prescribed and promoted with unjustified confidence.
4. There is a risk of injury.

Chiropractors have found ways to make traction sound better and cost more than ever before, by doing it with extremely expensive machinery (doubtless it goes “ping”) with names like (I am not making this up) the DRX9000 True Non-Surgical Spinal Decompression System™. (You have to love the “true” in there. From now, everything I market is going to have “true” in it. No longer will I sell mere e-books on this website: I am going to start selling true e-books!) Once a chiropractor has purchased such a machine, he or she is more less obliged to hard-sell it in order to pay for it.

A machine that goes “ping” — the DRX9000 True Non-Surgical Spinal Decompression System™.

The most recent incarnation of traction therapy is non-surgical spinal decompression therapy which can cost over $100,000 [the equipment, not the therapy]. This form of therapy has been heavily marketed to manual therapy professions and subsequently to the consumer.

Daniel, Chiropractic & Osteopathy, 2007

The SDT hype covers up a nearly perfect lack of evidence to support the use of any kind of traction, let alone extremely expensive traction, so much so that the Florida Attorney General’s office launched a lawsuit against the largest manufacturer for “false and misleading claims.” It’s the combination of cost and a therapy that’s experimental at best that’s the problem here. Daniel again:

There is very limited evidence in the scientific literature to support the effectiveness of non-surgical spinal decompression therapy. Considering the cost-benefit relationship, many better researched and less expensive treatment options are available to the clinician.

A 2007 review of traction therapy for low back pain reports that experimental results “consistently showed that traction … as a single treatment for LBP was not more effective than placebo, sham treatment or other treatments.” Regardless of a few modestly positive studies, traction continues to be hammered in other studies, like this fresh new one from the European Spine Journal with a good, rigorous design that showed absolutely no difference between traction and placebo.

Incidentally, traction for neck pain is similarly devoid of any clear support from science (see Graham).

And what about risks? Obviously, if you are pulling on painful lower backs with powerful machinery, there are risks. SDT has been promoted as a safe therapy. However, Daniel reports:

This was a case report of a 46 year old male with a three month history of radicular pain consistent with a S1 radiculopathy. During his 5th session he suffered a severe exacerbation of his pain with marked enlargement of the disc protrusion requiring urgent microdiscectomy.

Personally, I recall three cases of severe negative reactions to SDT in my decade of clinical work. In the most memorable example, my patient described going for therapy with a minor low back pain, and experiencing rapidly escalating discomfort in the machine, leading in just seconds to a pop, excruciating pain, and “screaming.” This extraordinarily poor outcome was followed by a long period of much more severe, chronic low back pain. I remember his case clearly because he attributed it almost entirely to the SDT. He considered himself injured by the technique, and was seeking therapy for its long term consequence many months after the injury.

Incidents of minor harm are likely to be much more common than serious ones, of course.

None of this means that traction never has any merit — it almost certainly does help the occasional patient. But it does mean that it doesn’t pass the impress me test (not by a long shot). The SaveYourself.ca salamander says: spinal decompression therapy should never be sold aggressively for a high price to vulnerable, desperate patients. On principle, you should not give your hard-earned money to chiropractors who unethically push this “technology” without clearly informing you of its limitations and risks.

All high-functioning systems — both evolved and engineered — usually walk a fine line between performance and blowing up, and typically fail with age. For instance, all flying machines tend to require intensive maintenance and are more or less constantly falling apart and being put back together. The SR-71 Blackbird fighter jet, the world’s fastest throughout its career, tolerated such extremes of heat at full speed that its parts needed room to expand, and so they were engineered to be loose-fitting on the ground, resulting in all kinds of challenges and risks, such as leaking expensive and explosive jet fuel like a sieve — by design!

Muscle is probably similarly volatile, not just full of compromises, but extreme ones — performing on a razor’s edge between performance and vulnerability, and with potentially significant consequences even to relatively minor deviations from operational norms.

As a simplistic example, with a strong shot of adrenalin, you can get super-strength out of muscles simply by recruiting every muscle fibre to contract simultaneously, instead of only a few at a time as with the relay system we normally use. Such great strength is possible only by paying a price of rapid muscular fatigue. Natural selection picked the balance point: if we were any stronger in general (via this mechanism), we’d get tired too fast and be food for big cats and such; any less strong, and we’d be so weak that we couldn’t run fast in the first place.

Never mind athletics or combat! Every day, your muscles have got to pull off miracles of fast, responsive, intense function in the course of performing quite ordinary actions. That function almost certainly comes with biochemical price tags. In a general way, this is probably why we get trigger points — they are glitches in an impressive but imperfect system, nonlethal and uncomfortable trade-offs for having muscle that is rather amazing in terms of performance. If I’m right, we should expect to see trigger points crop up (activate) at their operational extremes — and indeed we do. They tend to form in response to things like over-exertion, cold, injury, as well as anything that challenges the system as a whole like stress, sleep deprivation, and smoking. Systems fail and misbehave when challenged.

This evolutionary theory of trigger point formation is also somewhat consistent with the age of victims: children don’t suffer from trigger points anywhere near as much as adults. Myofascial pain syndrome seems to get rolling in the 20s, peaks in the 30s and 40s, and then levels off, not getting much worse in subsequent decades of life. Why don’t the young ‘uns get trigger points? Evolutionarily speaking, it would be a really bad idea if your muscles kacked out by your 20th birthday simply because of their own high-functioning! Not a good system! Nature would be hard on people born with that system, with the usual effect: more getting eaten, less breeding.

But past the age of 20? In the barbaric mists of history, your ability to survive into a third decade was largely a moot point, evolutionarily speaking: most everyone passed on their genes by that point (probably a few times), and you were worm food by 30. Evolution didn’t “see a need” for muscles that could perform miracles with no consequences for three decades. So we didn’t get them. And we never will. Broadly speaking, this is why aging sucks: once you are past breeding age, you are in biological territory that evolution can’t touch.

Vitamin D for Pain: Update of Research Evidence

The “good therapist” is largely a myth, in terms of effectiveness.

The huge majority of people with chronic pain carry right on suffering from pain chronically, no matter who they pay for help. (Nowhere is that story of disappointment told more charmingly than in Paula Kamen’s dazzling book, All In My Head: An epic quest to cure an unrelenting, totally unreasonable, and only slightly enlightening headache.)

I have a low opinion of the ethics of health “professionals” who promise miracle cures to chronic pain patients. Nothing is easier to sell than false hope to people in pain — they are one of the most motivated groups of potential customers there is. Half mad from their symptoms, their minds are pried too far open to bad ideas by agony. They will grasp at any straw, consider anything, and pay for anything, if there is the slimmest possibility of relief.

Exploiting people in that mental state is morally equivalent to the work of faith healers. It’s low. It’s cruel. Good intentions and the occasional placebo effect cannot give it honour.

The ugly truth is that not every health problem has a solution, and this is particularly true of most chronic pain problems. Any honest chronic pain specialist — physician or manual therapist — will tell you that. But a century of genuine scientific miracles, one after another for decades, has given us all a collective case of medical overconfidence, and it seems as though there “must” be a treatment out there, somewhere, for every problem.

But the only miraculous thing about most quack cures for pain is the size of the egos behind them. So much for “humility” in alternative medicine.

Over the years, I have been told by a few manual therapists that it would “put them out of business” if they were honest about their limitations. That’s a strange combination! Admitting in one breath that you have limitations, but carelessly concluding in the next that you daren’t admit it — how tagic and untrue. Patients deeply appreciate candid honesty, even self-deprecation. A therapist’s practice can easily be built-in on overt humility.

Pain is tough to treat, period. In your search for relief, stick to professionals who are candid about that: they are the ones who are actually more likely to find a way to take the edge off a little, and not take your money for bogus treatments. That’s mostly what makes a “good therapist.”

Last summer a reader asked me what I think of platelet-rich plasma (PRP) injections — the injection of a concentrated preparation of your own blood into irritated tissue, usually a tendinitis or similar condition like iliotibial band syndrome or plantar fasciitis — to stimulate healing. I replied quite optimistically at the time:

Incredibly, I have no strong objection to PRP. This is rare! I am a grump and not easily impressed. The huge majority of therapies I get asked about strike me as mostly pointless shots in the dark. By contrast, PRP injections seem like they have a reasonable rationale, there’s a bunch of promising evidence, and they are quite unlikely to have any significant risks. Wow. Cool.

Of course, I would caution you against singing its praises: there’s a huge gap between “promising” and “proven.” If it works for you, great! But don’t promote it as a treatment that “works” — one experience means nothing. For all we know, future research will show significant problems and limitations. This is precisely what has happened with countless other therapies.

And that is precisely what just happened to PRP, only a few months later. Yesterday, the New York Times reported bad science news for platelet-rich plasma injection, and I am now once again just as unimpressed by PRP as I am by most other too-good-to-be-true treatments:

Now, though, the first rigorous study asking whether the platelet injections actually work finds they are no more effective than saltwater.

So another treatment bites the dust. I don’t want to completely dismiss a treatment like PRP just because one good study was clearly negative, but the results immediately and seriously afflict PRP with the how-good-can-it-possibly-be problem — how good can it be if it fails the best testing so far? Initially promising in many ways, PRP will now undoubtedly now be mired in years of controversy. Wait and see, check the evidence in five years: it will be a mess of contradictions and no clear answers. PRP will probably die a slow death, only beaten into submission over many years by a growing pile of underwhelming evidence, even as its proponents continue to overconfidently sell the service.

• “Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy: A Randomized Controlled Trial,” an article in Journal of the American Medical Association, 2010.
• “A Case Study In Aggressive Quackery Marketing,” a webpage on ScienceBasedMedicine.org.
• “Popular Blood Therapy May Not Work,” a webpage on New York Times.

Graston Technique is an expensive and painful massage technique that uses savage-looking steel tools to apply achieve intense, scraping pressures that supposedly cure by breaking up scar tissue and fascial restrictions. The official website makes the deliciously silly claim that the expensive tools “resonate like a tuning fork,” guiding practitioners like dowsing rods. Really? Wow. How could I not write about this? As good as Dr. Hall’s analysis is, I just had to have one of my own. The bottom line: I can hardly imagine a dodgier treatment. Read all about it:

Subluxation theory originally proposed that spinal joint dysfunctions have broad health significance — that a spine out of line causes not only pain, but visceral disease as well. Various degrees of this extraordinary belief are still common amongst chiropractors today — particularly those who adjust only the upper cervical spine (NUCCA). Subluxation has always been a major distinguishing feature of the profession, chiropractic’s biggest raison d’etre. Dr. Harriet Hall of Science-Based Medicine points out:

Without it, the whole rationale for chiropractic collapses, leaving chiropractors no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions.

Although controversial for decades, surprisingly few chiropractors have publicly denounced subluxation theory (and those who do are met with a chorus of outrage from large numers of chiropractors who still believe in it). This new paper is a rare example. The authors analyze subluxation theory and dismiss it: “No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions … this leaves the subluxation construct in the realm of unsupported speculation.”

Dr. Harriet Hall explains the significance of the paper in an article for ScienceBasedMedicine.org, The End of Chiropractic. As with most of Dr. Hall’s writing about chiropractic, it inspired a larger number of comments: 170 at last count.

The End of Chiropractic

This post is an excerpt from my book-length tutorial about trigger points (muscle knots). I heavily revised these sections over the last couple months, inspired by comments made by Dr. Mark Crislip at the Science-Based Medicine conference last July, and by a growing awareness of the importance of pain system dysfunction — the idea that, regardless of the source, severe and chronic pain can lead to a general breakdown in pain perception. — Paul

Sometimes people have a hard time believing that their pain could be caused by trigger points because it’s just so bad. How could it be caused by “just” muscle? It’s important to understand that nearly any amount of pain and misery is possible with trigger points, and with the human nervous system in general. There are three noteworthy kinds of worst case scenarios:

1. unusually numerous and/or severe trigger points (being a “triggery” person)
2. rare but extreme cases where trigger points seem to “take over” and the diagnosis of myofascial pain syndrome no longer seems adequate
3. isolated but fast and savage trigger point activation [note: further discussion of this concept is not covered in this post]

Given the global reach of this tutorial and the ease of digital communications, I have had the opportunity to talk to people suffering from more horrible trigger point problems than I would ever have guessed existed. Working in relative isolation here in Vancouver in private practice, I might well have never come across such cases, even after decades of clinical work. But, thanks to this website, I have heard tales of the worst of the worst. And the extremes are surprising.

For instance, I recall a reader from one of Canada’s eastern Maritime Provinces who, after giving birth, developed an alarming collection of hard nodules in her abdominal musculature which seemed to have most of the typical diagnostic signs and symptoms of trigger points. And yet there was nothing typical about their severity: they caused intense and constant pain, shortening her muscles so much that she could barely stand up straight, as though her body was doing a permanent sit-up. These trigger points didn’t go away in response to any therapy she tried, and she had certainly tried a lot of therapies before she spoke to me. She had been in pain like that for more than three years when I spoke to her.

As severe as it was, though, the severity was really the only unusual thing about it — in all other respects it seemed like a typical case of trigger point pain. For instance, the problem remained “regional” (it hadn’t spread throughout her body) and her trigger points acted like trigger points — just really horrible ones. She was a classic case of a “triggery” patient: someone whose muscles were extremely prone to extreme trigger-point formation for unknown reasons. There was probably some X factor in her case, something about her that predisposed her muscles to this fate. But her doctors had certainly cleared her of any obvious diseases, and having X factors that complicate myofascial pain syndrome is the norm. Almost every case of myofascial pain syndrome is aggravated and sustained by poorly-defined X factors. The problem is that, in her case, she had some crazy “perfect storm” that resulted in one of the worst cases I’ve ever heard of — one of the worst that was still clearly myofascial pain syndrome, anyway.

There’s another way to be “triggery”: instead of being bizarrely intense, trigger points can also be bewilderingly numerous — an endless plague of more or less average trigger points. This is particularly striking in the young, who seem prematurely aged by the profusion of pain and stiffness. I have seen many minor examples of this in my own massage practice, and heard about more dramatic cases from readers around the world. They are characterized by common symptom themes — for instance, an area like the low back, or the right side of the body, may consistently be the most troubled — but also by a steady supply of unpleasant surprises in other areas of the body, and constantly shifting cravings for pressure in different location.

Such patients often present a great clinical challenge for a massage therapist, in that they seem to want to be massaged everywhere at once, and no sooner do you arrive in one area than they declare that the target has moved. In many cases, I suspect it’s not that therapist and patient are struggling to “find the right spot,” because there is no one “right” spot. Instead, the patient’s priorities and cravings are shifting rapidly: as helping hands “take the edge off” one spot, the patient’s nervous system decisively announces the next-most-desperate area requiring attention. A perfect analogy is the way that a back scratch can seem just perfect one moment, but then the next moment there’s a great urgency for the scratch to be “just a little lower.” I think the same thing happens in triggery patients, but the pain gives it a disturbing urgency. If you consider how strong the “just a little lower” feeling can be, how strong must it be in someone experiencing serious pain? No wonder it sometimes seems as though such a patient can’t be satisfied!

As bad as this scenario can be, I’ve heard of even worse. Unfortunately, although it’s rare, there seem to be some people who’s experience of myofascial pain is defined by trigger points that are both extremely numerous and intense. Push far enough along the spectrum of badness in that direction, and the diagnosis of myofascial pain syndrome ceases to be meaningful.

Rare but extremely severe cases of myofascial pain syndrome

Turn the volume up loud enough on an average sound system, and the music stops being music.

That seems to happen to a few unlucky people who start out being merely “triggery” — a bad enough situation to begin with. The pain signals become so loud and overwhelming that they lose their meaning, and the patient is crippled by vicious and widespread chronic pain, just as severe as painful diseases like rheumatoid arthritis or complex regional pain syndrome. In these patients, trigger points (muscle knots) seem to have taken over the whole body, the problem changed into something altogether different in the process — a whole that is greater and nastier than the sum of its parts.

In July 2009 in Las Vegas I encountered an interesting analogy to this puzzle at the Science-Based Medicine Conference. Mark Crislip, MD, an infectious-disease specialist from Portland (and host of the popular podcast Quackcast), gave a superb presentation about the hypothesis of “chronic Lyme disease.” He made a strong case that it is a misnomer, a meaningless diagnosis, an overconfident attempt to define a problem that cannot actually be defined.

Some patients do seem to have some kind of post-infection meltdown. They don’t still have an infection any more in any sense that we understand infection. But someone is going to have to explain these patients to me someday.

And that is precisely how I feel about patients with unusually severe chronic trigger point pain: I don’t think that they have myofascial pain syndrome in the same sense that we understand normal muscle pain — clearly their cases have gone beyond that, but just as clearly they have had “some kind of meltdown,” and “someone is going to have to explain” them to me someday. Although these cases seem to have their origins in the same kind of myofascial trigger points that Travell and Simons described so thoroughly, it is equally clear that this can lead to a new kind of predicament in the body, one that is more scientifically puzzling than muscle pain (as if we needed any additional mystery here).

All painful conditions share some characteristics, regardless of the source of the pain. As with any chronically painful condition, the pain of trigger points probably becomes difficult to distinguish from wholesale malfunction of the “pain system” — the sum total of all the neurology and psychology that controls pain perception. Speaking generally, then, what is strange and extreme and difficult about these patients may “simply” be the nature of pain system dysfunction. It isn’t so much that they have severe trigger points (though the probably do), but that their pain systems have been “fried” by the experience.

Pain is informative — or rather, it should be informative. It is supposed to tell us about problems and threats, teach us what to avoid, tell us when to lie still. Pain system dysfunction begins wherever pain starts to lose meaning, and that can begin quite early in any painful problem. Anyone who’s had a headache for a few hours will be happy to tell you that they’re not learning anything useful from the pain!

Pain system dysfunction is peaking whenever pain perception becomes seriously mismatched to reality: when non-painful stimuli become painful, when “everything” starts to hurt regardless of whether there is anything wrong or not, when the volume of pain is out of proportion to the severity of anything actually happening in the tissues. In such situations, it is no longer your “tissues” that are hurting, but the nervous system itself. The pain has become autonomous.

And yet there could well still be something wrong in the tissue as well — which tends to ensure the persistence of the meltdown. Imagine waving a magic wand over such a patient and instantly restoring normal pain perception: what would the patient perceive? Perfectly healthy, painless tissues? Not likely! Probably pain would improve significantly, but the restored nervous system would still be obliged to report a number of problems: either the original tissue pain, and/or new tissue distress that arose from the terribly dysfunctional situation. Having scrambled pain perception is probably hazardous in itself.

“Injury patterns and injury rates in the circus arts: an analysis of 5 years of data from Cirque du Soleil”

Thixotropy is an obscure physical property of some fluids, which become thin when agitated or stressed. You can easily simulate thixotropic effect in beach sand, near the water’s edge: stamp your feet in the sand, and it starts to liquify.

Thixotropic fluids in the human body include synovial fluid in joints, mucus, semen, and the gelatinous and poorly-named goo called “ground substance” — the stuff that gristly connective tissue fibres are embedded in like bits of coconut in Jello. Ground substance is the most plentiful thixotropic substance in the body.

The theory is that massage limbers you up by inducing thixotropic effect in your connective tissues. There are (at least) four things wrong with this:

1. Although thixotropy is indeed one of the reasons that we feel like we loosen up a little as we move around, it can only account for a small amount of “loosening.” Thixotropy makes connective tissues more pliable, not stretchier. The extensibility of tendons and ligaments is determined by the properties of the collagen fibres that give them their bulk and tensile strength, and they are (much) stronger than steel cable.
2. More importantly, who cares? The whole idea that it’s therapeutic to have “looser” connective tissue is bogus in any case. There are few therapeutic situations where you would actually want looser connective tissue, and even in those situations the problem could not be solved by thixotropy.
3. Even if it works in some small way, thixotropic effect is going to be temporary, fading within seconds or minutes after hands are removed. When the stimulation stops, so does the thixotropy.
4. Last but not least, thixotropic effect is simply minor, occurring all the time with or without massage. Massage undoubtedly does induce it, but almost certainly less than ordinary physical activity (just like with circulation).

More to the point for SaveYourself.ca: how does vitamin D reduce falls? The authors explain: “Vitamin D has direct effects on muscle strength modulated by specific vitamin D receptors present in human muscle tissue.” Muscles like vitamin D, and “these benefits translated into a reduction in falls.”

Fascinating.

But the real question for me (and most of my readers) is whether the effect of vitamin D on “strength and function” has anything to do with muscle pain? Perhaps. Or perhaps not. I’m afraid it’s just unknown. But given that vitamin D supplementation is safe and inexpensive, it certainly seems worth experimenting with.

“Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials”

Steroid (cortisone) injections and iontophoresis (injection without a needle, using a small electric charge to drive a drug through the skin) are routinely prescribed by physicians for plantar fasciitis, and many other inflammatory conditions. They are often regarded as something of a magic bullet for inflammation, and not without good reason: cortisone has powerful anti-inflammatory properties, and it certainly has the potential to dramatically reduce pain, especially in the short term.

Steroid injections are certainly not an unreasonable treatment option for plantar fasciitis, especially for a stubborn case. And yet, as with many other popular therapies, there is shockingly little science to back it up, and there are also some concerns.

Only two proper scientific tests of steroid injections have ever been done, in 1997 and 1999. Both found the same results: steroid injections were helpful in the short term only.

What about the science since then? A decade has gone by — surely there’s more and better research by now? Unfortunately, no: we’re still waiting for that. All the studies done in the last ten years, about one a year — Yucel, Tsai, Frater are three recent examples — have not been serious attempts to show the efficacy of steroid injections, but instead have focussed on peripheral issues like what kind of injection-guiding technology works best. It’s all worthwhile stuff, but fairly useless in terms of finding out if steroid injections “really work.” They offer something like “circumstantial evidence” in a courtroom — it’s suggestive, but it’s not proof.

So, although there’s little doubt that they really do relieve at least some pain in the short term, it’s still a wide open question about lasting benefit. Can steroid injections alone solve plantar fasciitis? Nobody knows, but it seems unlikely. A comprehensive The Cochrane Collaboration review of the science in 2003 discouragingly concluded:

Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree.

And there’s danger! No injection of anything can be completely safe, and cortisone in particular — especially in this location — has the potential to do as much harm as good. Cortisone’s best-known problem is that it “eats” connective tissue with overuse, which can be bad news for any anatomy, but especially an anatomical structure like the plantar fascia, which is a high-performance piece of tissue, and already strained to its limit by definition in every case of plantar fasciitis, especially the bad cases. Plantar fascia rupture (yikes!) is one of the risks of steroid injection. Tatli et al describe a few other possible complications:

• the destruction of your natural heel cushion (plantar fat pad atrophy)
• direct nerve injury from the injection (lateral plantar nerve, see Snow)
• a bone infection (calcaneal osteomyelitis, see Gidumal)
• burning of the underlying skin (only from iontophoresis), which is the least of these complications, but still rather undesirable in a situation where burning pain is already a major problem!

Your odds of avoiding these complications are good, but the stakes are high. They probably won’t happen, but it’s really bad news if they do. They can make a bad case of plantar fasciitis even worse, even permanent: “Fascial rupture and fat pad atrophy are especially serious complications as they can lead to intractable complications” (Tatli). If you thought you had a stubborn case of plantar fasciitis now, wait until you’re in that boat.

Given the known and plausible risks, you should never consider a cortisone injection until the virtually risk-free options discussed so far have already been tried. But let’s keep this in perspective: although the dangers are certainly real, they are not great, and they are probably well worth risking, especially if you’re already a mess and have nothing to lose.

Steroid injection in moderation may be a great way to reduce the pain in the short term, while other therapies take care of the longer term. My recommendations:

• Discuss it with your doctor and make sure that he or she shows an appropriate level of concern about complications. Avoid accepting steroid injections from a physician who seems to think it’s a magic bullet — that’s never a constructive attitude.
• Only use steroid injections in moderation — probably no more than three injections. Use it only to manage pain in the short term while other, safer therapies are also being pursued.
• Avoid steroid injections if you have any sign of the complications, or if you develop them after any injection.

When one tugs at a single thing in nature, he finds it attached to the rest of the world.

— John Muir

Massage is beneficial for patients with subacute and chronic non-specific low-back pain in terms of improving symptoms and function. Massage therapy is costly, but it may save money in health care provider visits, pain medications and costs of back care services. The effects of massage are improved if combined with exercise and education. The beneficial effects of massage in patients with chronic LBP are long lasting (at least one year after end of sessions).

Sounds pretty good, doesn’t it? But I’ve been burned by Cochrane reviews before — they aren’t all good. You can never take the abstract of any paper at face value: you simply have to read the fine print. There’s a great deal to consider about this paper, both good and bad. I’m going to examine it critically, but fans of massage should not feel alarmed: after a rocky start, this analysis eventually loops back around to a good-news conclusion.

Still, I have some concerns about these conclusions, and it’s important for me to be extra critical of science about massage therapy (see the sidebar). Despite the good news in this study, let’s look at the bad news first.

Comparing apples to orange cars: 13 completely different massage therapy studies

The glowing conclusions of the Cochrane review were based on just 13 trials (about 1600 participants) — quite a small number of scientific papers to review, and they were not generally of high quality. More than half were deemed to have “a high risk of bias,” and the studies were all over the map in terms of what they studied and how they studied it. It would be hard to imagine a more diverse group of experiments.

Reviews of science are looking for the common ground between studies. There’s not much point in combining data about different things: you want to compare apples to apples. This review was saddled with comparing apples to … orange cars. Almost everything was different in every study:

• the practitioner credentials and experience were different
• the massage techniques used were different
• the techniques used as a comparison to massage were different
• the types of low back pain being treated were different
• even how success was defined (outcome measures) were different

What a mess!

Massage techniques in these studies ranged from traditional Thai massage to “one 30-minute session of deep cross-friction massage” to “acupuncture massage.” One paper even used reflexology! That’s not reasonable: reflexology is not massage therapy, it’s massage-esque quackery. And — here’s a shocker — reflexology was the only kind of massage therapy that didn’t perform well.

Clearly, this was not a review with nice, apples-to-apples data. These 13 studies had almost nothing in common except that they were all experimenting with some kind of massage-like therapy for some kind of back pain. Generally speaking, if I encountered a mess of data like this in any other context, I would regard the results as nearly meaningless just because of this problem alone.

But please read on — this isn’t over yet.

More bad news: no truly good data

Although some of the studies were certainly stronger than others, not one of them produced truly good data. The best of data of the lot is merely “okay.”

When you want to know if a therapy works, you compare it directly to a fake treatment. That’s the bread and butter of evidence-based medicine: does treatment X work better than something known to be useless? And yet, out of all this data, only two studies hit the nail on the head and actually asked the question “Does massage work for low back pain?” by comparing massage to a sham treatment. (And they were not even the best studies, for other reasons. They were just the ones that had the right idea.)

Every other study either measured some outcome other than pain (pain quality, functional status, return to work), and/or compared massage to some other therapy instead of a proper sham (manipulation, mobilization, relaxation, exercise, etc), and none of them really answers the question “Does massage work?” For instance, if massage works better than mobilization, it’s nice to know that you might want to get massage instead of mobilization — but what if mobilization actually makes low back pain worse? Hypothetically? The apparent superiority of massage could be an illusion!

Comparing one poorly understood and controversial therapy to another poorly understand and controversial therapy does not really produce the most meaningful results.

But massage still wins: lots of positive results, and the most positive results in the strongest studies

Despite all of these problems, massage “wins.” Regardless of the study (excluding the reflexology one), massage performed brilliantly — no matter what kind of massage, no matter what kind of low back pain, no matter what it was compared to, no matter what outcomes were measured.

Best of all — the results were positive even in the higher quality studies.

So all the inconsistency is actually a blessing in disguise: if virtually any kind of massage can outperform basically any other therapy you compare it to, regardless of how you define success, that bodes well. It starts to seem safe to assume that well-trained and experienced therapists might do even better, maybe even a lot better.

But how positive was positive?

One of the biggest problems with the science of alternative medicine is that proponents of unproven therapies often try to make the most out of a small positive result, blowing it way out of proportion and acting like it’s a big deal (often for decades, long after plenty of subsequent evidence should have stopped the debate). When people want to know if a treatment works, they don’t mean that it works “kinda, sorta, maybe, a little bit.”

So it’s another good sign that one of the best studies of the 13, well-known to me for many years now, produced extremely good results. Massage therapy as delivered by well-trained Ontario therapists didn’t just work better than “exercise,” it was dramatically superior on each of three different outcome measures: patients had way more reduction in pain intensity and quality and much greater improvement in function, both immediately after treatment and still a month later. Booyah! That passes the impress-me test! (I am rarely impressed.)

This is precisely the opposite of relying only on the weakest science to prop up a useless treatment. Here we have weak studies showing positive results, and stronger studies showing even stronger positive results, and that’s what you expect from a treatment that “works” — when properly tested, it performs.

So, is massage therapy for low back pain “proven” to be effective?

Ha! Not by a long shot. There’s much more work to be done: dozens of studies instead of “a dozen.” Ideally all of them should be bigger — 100 subjects at least — with much better quality control and consistency in the type of massage tested. And no reflexology! But, unlike virtually all other popular low back pain therapies, the science so far is genuinely promising, instead of underwhelming.

Presumably this is why massage has, over the years, gotten a tentative thumbs up from many medical low back pain experts. For instance, Dr. Richard Deyo of Seattle was dismissive of all other manual therapies for low back pain in his excellent low back pain tutorial for the New England Journal of Medicine, yet he wrote that “promising preliminary results of clinical trials suggest that research on massage should be assigned a high priority.”

Several years later, the research still isn’t much better than preliminary, but the signs are even better than they were.

• Scientific journal titles are now automagically consistent. Instead of manually entering them, official abbreviations are now matched to a database of journal titles. Data goes in easier and comes out better.
• Similarly, the production of links to PubMed records has been automated: rather than a messy database of thousands of links, 10% of which seem to be broken at any given time, virtually every PubMed-able link will now work every time, no matter where it appears on the website.
• Although still due for more upgrades, the display of individual bibliographic records has been upgraded with much better links, especially groovy link options — this window or that window — for any links.

Here’s an example, using a citation that will feature in some upcoming posts:

Bibliographic record for “Rat tendon morphologic and functional changes resulting from soft tissue mobilization”

Of course, I didn’t stop writing either … just posting. I estimate that I produced roughly 10,000 fresh words over the holidays, plus about 40 new records for the bibliography (along with the tech upgrades just announced), most of which I will be rolling out over the next couple weeks even as I press on with several other current projects. Yep, that was sure a nice “holiday”!

SaveYourself.ca will now go into stealth mode for a few (holi)days.

I won’t stop writing — never that! — but I will take a break from posting until 2010. This gives me a chance to focus on behind-the-scenes writing and research projects. For example, I posted recently about therapeutic ultrasound, but I still need to go back and finish the official, final ultrasound article, and then integrate all of that information into each of several tutorials — about 10 hours of work, at least. So there may not be anything new on the front page for a while, but I'll still be up at 6am every morning tappety-tap-tapping away — just with some Bailey’s in my coffee.

Merry holidays, everyone, and thank you to all of my readers and customers. See you here in January.

How can I get relief from low back pain right now? Forget cure: I’d settle for treating the symptoms right now. Can I at least do that? Is there anything that can relieve the pain in the short term?

It only took a few moments of stumbling around to realize that there’s really no good answer to this question. “It depends” and “not really” came up pretty quickly. It depends on what the (usually unknowable) origin of the pain is, and, no, there’s not much that is likely to make the pain back off significantly … not even temporarily.

Still, even without a satisfying answer, it’s a good question to try to answer, and quite different than the question I’m usually trying to answer: how do we end low back pain?

Short term pain relief isn’t impossible, it’s just unreliable and unpredictable _ a crapshoot. There are many interventions that might provide relief, but none that can be counted on. If we lower our standards, here are some of the interventions that have a fighting chance of providing at least some respite from symptoms.

Drugs. It’s clear that medications are not an effective solution for low back pain — indeed, “it doesn’t even touch it” is a pretty common comment from frustrated patients, regarding even the most potent drugs. However, unreliable is not the same thing as useless. Some people, some of the time, can get a least a little relief from virtually any of them. Here are some brief comments on the most popular options. All are worth cautiously experimenting with, and all are problematic and pointless in excess.

The commonly used over-the-counter medications are anti-inflammatories like ibuprofen, Tylenol, codeine, alcohol and muscle relaxants.

• Acetominophen (Tylenol) and ibuprofen (Advil, Motrin, Voltaren gel) may provide mild symptom relief.
• Opioids are the nuclear option: codeine (most readily available in small doses in Tylenol IIs and IIIs) and “Hillbilly heroin” (Oxycontin, Percocet) are all capable of inducing deep relaxation, euphoria, and making you “not care” about the pain. They also have serious drawbacks, of course, such as turning you into a useless lump, and the hair-raising risk of a life-altering addiction. Before you try opioids for trigger point pain, ask yourself the question, “Do I want to risk a decade-long addiction and rehab drama?”
• Muscle relaxants come in several varieties, but only one that is widely available without a prescription: methocarbamol, as found in Robaxin, Robaxacet and similar brand names. The most famous muscle relaxant is diazepam, aka Valium, a benzodiazepene along with several other well-known drugs (Klonopin, Ativan, and Xanax). Like the opioids, the benzos are another “nuclear option” — they interfere with muscle contraction, but they also interfere with a great deal else: like consciousness! Unfortunately, muscle relaxants are amazingly ineffective: “these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain” (See et al).
• Alcohol is hard on your system in many ways, and hangovers actually increase muscle pain. However, anecdotally, moderate usage seems useful for taking the edge off nearly any kind of pain via sedation and the “I don’t care if it hurts” effect.

Ice or heat, whatever seems most appealing. Ice can backfire, aggravating muscle pain in particular, but it can also provide relief. Patients should choose what seems right: although odds favour heat, patient preference is always key. I am forever encountering patients who crave one, but have been told to do the other by a professional. Do what feels right. For instance, ice is most likely to be temporarily useful in patients experiencing acute, “hot” pain where there is a mostly aesthetic, non literal impression that the region actually needs to be cooled down — so cool it down! But be ready to switch to heat when ice starts to feel less appealing. Or vice versa. Heat is more likely to appeal to most low back pain patients. Taking your time with a good hot bath or shower is one of the most reliable symptom relief tactics — although it’s virtually guaranteed to be minor and temporary, at least it has a fighting chance of taking that edge off. Heat is also virtually risk free.

Mobilizations, stretching and traction — which I collectively think of as “wiggling and squirming therapy,” the common denominator being movement — all have the potential to relieve symptoms … but also considerable potential to worsen them, depending on the case. How far to push it is a difficult question, because breakthroughs are possible with persistence. Swinging your hips around in a circle 20 times may do absolutely nothing, but 50 times could both help or hurt. Intense, risky stretching has been known to succeed where moderate stretching failed … and, of course, it’s also been known to injure people. It’s a gamble.

Chiropractic adjustment (spinal manipulative therapy) has been proven to be modestly effective in the treatment of low back pain — roughly equivalent to drugs (for a good recent research example, see Jüni et al). Despite its underwhelming benefits for most people, it might be worth pursuing as a symptom relief option because a few patients do get greater relief, and because SMT’s benefits are infamously temporary — i.e. unlikely to “cure,” but perhaps helpful for managing symptoms. Unfortunately, this is the least convenient and most expensive of the options presented here, and there are risks: some people’s symptoms are worsened, not helped, and the danger seems to be greatest with the patients most likely to seek help (nasty, acute cases where anxiety is strong).

Self-massage will fall flat in many cases, but it probably has the greater potential for substantive symptom relief than spinal adjustment, with lower risks, and free — just lie down on a tennis ball. If I had to choose just one pain relief strategy for low back pain, it would undoubtedly be self-massage. Like chiropractic adjustment, benefits of basic massage are infamously temporary — but at least it’s safe and cheap to try!

I’d love to hear some other suggestions by email. Have you come across a method of relieving low back pain? Something that’s less than a cure, but better than nothing?

Readers, meet The Pressure Positive Company.

The Pressure Positive Company, meet my readers.

What’s remarkable about Pressure Positive is a rare combination of sensible massage tools and classy, ethical promotion. Their website avoids the big promises and irritating hype that characterizes much of their competition. Instead, they offer substantive good quality information about myofascial pain syndrome. They don’t claim that their tools will “cure” anything — just help. They don’t bombard visitors with pseudo-scientific rationalizations for their products — they’re just massage tools, and that’s good enough.

This may sound unremarkable to you. But how much marketing email do you get from alternative health product makers?

The competition isn’t pretty

I get a lot of sleezy marketing email: email from dodgy companies marketing to health professionals, with crap websites and products that usually seem ill-conceived at best, dangerous at worst. Some are probably well-intentioned but desperately need to hire a professional web designer. Many are more like spammers who’ve decided to try their hand at marketing a “legit” product instead of penis pills.

Compared to all that … Pressure Positive is in a different league, the difference between a dollar store and Macy’s. Communicating with them has been a breath of fresh air in every way. When they contacted me, it was because they were genuinely interested in the science of manual therapy, public education, and the work that I’m doing here at SaveYourself.ca. Because of this, I have quickly come to appreciate them as more than just a maker of massage tools, but as a new partner.

Pressure Positive has been around for quite a while, since 1979, longer than any other massage tool manufacturer I know of. Their best-known tools are their oldest, the Backnobber® and Jacknobber®. And … the The Knobble® II.

Oh, Knobble II® — where have you been all my life?

The Knobble® II in action. Massage tools don’t get much simpler than this, and I like that.

My favourite Pressure Positive tool so far is the $10 Knobble® II — which I used to save myself from a nasty headache about 24 hours after it arrived in the mail. Somehow Pressure Positive has managed to reinvent the wheel with this product. It seems to have an answer to that burning massage tool design question, “What is the best possible way to transmit force from the hand to a point without limiting the user to any particular angle or grip?”

The answer, apparently, is to make a good, grippy handle that perfectly fills the palm, and then extend it into a radially symmetric pyramid. Its symmetry is the key to its success, I think. Most massage tools (include several of Pressure Positive’s other offerings) are asymmetric, and the user must adjust it in relationship to the target. That’s not a bad thing: for some nooks or crannies of your body, the right asymmetry will be ideal. But the same tool will also be wrong for some other nook or cranny. But the Knobble’s symmetry makes it a beautifully grip-agnostic generalist of a tool; no matter what you’re aiming at, it grips the same way, which makes it feel much like a hand-replacement than a tool.

And why (why, why?) didn’t I have a tool already that I could drop the weight of my head onto? I have a large collection of tools, and not one of them allows me to settle my suboccipital muscles (Perfect Spot No. 1) onto a hard point. The simple, short, pyramidal shape of the knobble is stable under my skull; the point is bulbuous enough to take my weight, but sharp enough to deliver satisfying, focussed pressure. Weirdly, there just wasn’t anything else like this in my collection — yet it’s ideal for applying pressure to one of the single best targets for self-massage in the whole body.

I look forward to reviewing other Pressure Positive tools, several of which are equally well-designed.

The Pressure Positive Company

The Cluster Headache, by JD Fletcher

Cluster headaches are nasty migraine-like headaches of such savage intensity that they have been nicknamed “suicide headaches.” Many experts have theorized that there is a link between trigger points and cluster headaches.

In 2008, Head and Face Medicine published one of the only papers available on the subject. Although this research was “preliminary and uncontrolled” and is not powerful enough to prove anything, its results were noteworthy and promising — the kind of results that should inspire more research.

All of 12 patients with chronic cluster headaches (a kind of migraine, nicknamed “suicide headaches”) had myofascial trigger points, and treating them (with injection) produced “significant improvement in 7 of the 8 chronic cluster patients.”

The authors speculate that trigger points are not the original cause of cluster headaches, but a complicating factor:

… we believe that the mechanism underlying the presence of active TrPs in each of these primary headaches is similar: chronic pain or repeated acute pain sensitize muscular nociceptors creating active trigger points which, in turn, contribute to potentiate headache pain. This kind of vicious cycle explains why the number of active trigger points has been found to be higher in patients with chronic primary headaches than in healthy subjects or in patients experiencing less frequent headache attacks.

“Myofascial trigger points in cluster headache patients: a case series”

Spinal Accessory Neuropathy Associated With Deep Tissue Massage

Her condition has advanced quite a ways, however. She is not getting treatment, and I am concerned about her and finding it harder and harder to be on the bench.

Recently I dove into the subject to satisfy my own curiosity, and to eliminate certain uncertainties in my own mind. I have never had a good understanding of adhesive capsulitis. I’ve worked with only a few cases of it, and read almost nothing — the basics, of course, but nothing compared to the amount of research I’ve put into other topics. I’ve always been aware that the condition is poorly understood and “controversial by definition,” as one author put it.

So, when I waded into the literature this morning, I expected exactly what I found: a mess!

Frozen shoulder suffers from a lack of scientific research, scarcely more than a few dozen papers in the last decade (and only five clinical trials this decade, studying almost as many different treatment methods). But that’s more or less par for the course — most musculoskeletal conditions are woefully understudied.

Disturbingly, in the case of adhesive capsulitis, there isn’t just a lack of research, but extensive disagreement and inconsistencies concerning treatment methods and even their safety. Although certain physical therapies are often recommended, and perhaps supported by some of the evidence, some authors strongly assert that such methods not only don’t work, but are dangerous and can significantly prolong recovery. (Some believe that forceful mobilizations of the glenohumeral joint are dangerous, not helpful.)

Although it’s common in the manual therapies for there to be arguments about what works better, it’s relatively rare for a common therapeutic approach to actually be condemned as harmful, while being recommended by others without even a mention of the controversy. If you had no other information, and you read three statements by experts recommending a treatment as dangerous, and three other experts recommending it as effective without even acknowledging the controversy, what would you make of it? That’s an almost impossible call to make.

Experts also seem to have substantially mutually exclusive theories about the condition. Interesting ideas are put forth by some experts and totally ignored by others. For instance, Travell and Simons proposed a role for myofascial trigger points in the condition (which I wrote about a few days ago). Although the theory certainly has weak points, it seems to be a pretty important idea to consider and study … and yet, many years after publication, that idea is still 100% absent from all other literature that I have found so far.

Given all of the above, no therapist should be pretending to “know” how to treat adhesive capsulitis. Obviously no one really knows much of anything about this condition. That is amazingly true of most musculoskeletal problems, but it appears to be especially true of this one.

And so I will be studying it more, and writing about it, trying to get to the bottom of it, for the sake of a wife with a shoulder that’s hurting badly enough she might actually be interested in my advice now. Unfortunately, I fear this topic may be bottomless, and I really won’t know what to tell her!

The evidence supporting SMT does indeed exist. Unlike much else in alternative health care, spinal manipulative therapy for spinal pain has passed some fair scientific tests. Thus, perhaps it should not be considered “alternative” medicine, but simply medicine. But how strong is that evidence? Why is there still so much arguing about it?

The effectiveness of a therapy needs to be quite clear and significant, after decades of study. And if it’s not, how good can it possibly be? That’s an awkward question for a lot of alternative therapies.

Case in point: this fall, the Annals of the Rheumatic Diseases published a pretty good test of SMT. The researchers took a hundred patients with nasty, fresh cases of low back pain, and delivered half of them into the care of chiropractors, and the other half into “standard care” — advice and ordinary pain medications, namely. Note that it has often been argued that SMT is best for acute low back pain, not chronic. So this is right in chiropractic’s strike zone. If there is anything special, anything even remotely impressive about SMT, it should have done rather well in this contest. It should actually pretty much pull out a can of whupass on “advice and meds.” One would hope.

It didn’t.

There was basically no difference between the groups. They did equally well — or equally poorly, if you prefer. All the patients had the same experience that pretty much everyone with chronic back pain has: they got better slowly but surely over the course of a few weeks, roughly exactly as they would have without any therapy at all. The researchers found that “SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain.”

Now you might say, “Well, good: chiropractic was as good as drugs, so it could replace drugs. That’s good!” But those drugs, taken in the quantities the subjects took them, are cheap and safe as houses. And their low cost was roughly appropriate for their took-the-edge-off effectiveness. Chiropractic therapy, by contrast, would have cost an order of magnitude more. And required appointments with chiropractors.

So, yes, SMT “works” — but how well? How impressed are you by SMT’s performance in this test? On a scale of ten?

“A randomised controlled trial of spinal manipulative therapy in acute low back pain”

What is your opinion on the use of a dense foam roller on the hip, glutes and sides of the thigh? Does it do anything or is it just another snake oil solution?

Foam rollers have limited usefulness in the treatment of IT band syndrome, but are probably not quite as bad as “snake oil.” Most people use foam rollers for this condition imagining that it is a form of deep massage for the IT band itself, intended to lengthen the IT band, and this is no more possible with a foam roller than it is with any of the other very intense IT band massage techniques. Like any deep massage of the IT band itself, there is at most a minor and temporary change in the texture/length of the IT band, but it is simply too tough a structure to be actually be “lengthened” by this or any other method short of a scalpel. I’ll explain this in much more detail below.

What makes foam rollers potentially useful for the self-treatment of IT band syndrome is that they are a particularly good self-massage tool for the hip musculature. They may be a good way to aid trigger point therapy in the hips, specifically in the tensor fascia latae and gluteus maximus muscles, which control the tension of the IT band directly. To the extent that foam rollers help that process, they are relevant.

But that’s not that great an extent. I think that trigger point release in these two muscles is technically relevant to ITBS, but in practice it yields only a minor benefit to the condition. Trigger point release is an uncertain business. Even if you can pull it off in this area, the question remains: does a small amount of temporary loosening of the IT band even help? It’s somewhat akin to loosening your shoelaces to try to deal with a rock in your shoe. If the rock is still there, loose shoes is probably not going to do a lot of good. This is one of the major points of my ITBS tutorial.

Because it’s so common, the remainder of this post is an excerpt from the tutorial about massaging the IT band itself, explaining exactly why it’s almost entirely pointless.

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Direct treatment of the IT band and the underlying quadriceps muscle is the most common kind of massage therapy offered for iliotibial band syndrome, and probably also the most simplistic and useless. Typically, strong Swedish massage is used to allegedly “lengthen” the IT band and or “unstick” it from the underlying quadriceps, and the intention of this treatment is rarely any more complicated than that. Patients are routinely instructed to perform the same massage treatment on themselves using a foam roller at home. It’s a painful place to massage strongly. In this section, I’ll show that it’s also almost completely pointless.

Some therapists may also claim that the underlying quadriceps (vastus lateralis) muscle is also the target of the treatment, but they’re unlikely to have a clear idea how quadriceps massage is supposed to help, and the focus will usually still be on the IT band.

So what’s the problem with these treatments? They betray a lack of understanding of the condition, the anatomy, and of connective tissue.

The IT band is unbelievably tough

The iliotibial band syndrome is a massive structure, the largest tendon in the body, made of a bio-rope stuff that is slightly elastic but with a greater tensile strength than steel cable. It cannot be elongated by any known method short of surgery, and certainly not by rubbing it or (even sillier) rolling over it. Here’s an absurd exercise to demonstrate how silly it is:

1. Measure a leather belt.
2. Stretch the belt on the edge of a table.
3. Grease up your elbow with some lubricant.
4. Slide your elbow along the length of the leather belt. This patient feels no pain: be as brutal as you can stand.
5. Re-measure the belt. How’d you do?

Now consider that leather is actually less strong that tendon. Leather is skin — remarkably tough, with a much lower tensile strength than tendon, and actually much easier to tear. Indeed, tendons are so tough that they basically don’t tear. Ever. For any reason. Muscles will tear before tendons tear! Tendons will rip of a chunk of the bone they are attached too long before they tear (called an avulsion fracture) — because bone has a lower tensile strength, and is the weak link. Starting to get the picture? Even if you halved the thickness of that belt, hung it from a strong hook in the ceiling, and pulled on it with all of your body weight, it would probably still hold you.

So … good luck trying to “elongate” the IT band with massage.

Even if you could elongate the IT band by rubbing it, this would surely not be the easiest way of doing so. This is a tendon we’re talking about here: tendons are what tie muscles to bones. If you want to change the tension on a tendon, change the behaviour of the muscle. That’s not easy either, but at least it makes a certain amount of logical sense. If you want to loosen your hamstring tendons, should you massage the tendons? Or the hamstring muscles? The muscles, of course!

The dead giveaway that therapists who do this treatment are really not thinking it through is that they usually ignore or minimize the hip muscles: the muscles that actually control the tension on the iliotibial band. I know that this is the case because I ask clients, “Did your previous massage therapist work on muscles in your hip at all?” They routinely reply, “Nope, just the side of the thigh.”

If these therapists were trying every possible way of loosening the iliotibial band, I could perhaps forgive their attention to the tendon itself, but they are not: they are typically hammering away at the toughtest tendon in human anatomy, while ignoring the muscles that actually pull on it and control its tension.

What about thixotropic effect?

Some therapists might try to argue that “thixotropic effect” is the method behind their madness. An obscure property of connective tissue, thixotropic effect is the tendency of connective tissue to become softer when heated and kneaded. This is a real thing. However, thixotropic softening is a really transient effect: as soon as the heating and kneading stops, the connective tissue rapidly reverts to its previous state, like a piece of warm plastic thrown into a snowbank.

What about adhesions?

Some therapists justify IT band massage by arguing that the IT band is “stuck” (adhered) to the underlying quadriceps, and that this accounts for IT band tightness. But this hopelessly confuses the ideas of elasticity, tightness and freedom to slide. Like thixotropy, adhesions are a real thing — tissues can become stuck together by a slight chemical bonding of hydrogen atoms that protrude from the surfaces of connective tissues like the hooks and loops of Velcro. The elasticity of tendon is dependent entirely on the molecular structure of the protein molecules that make it up ... not on the ability of layers of connective tissue to slide over each other.

The adhesions justification is particularly out in left field because ignores the normal anatomy of the IT band, which is actually anchored to the femur for most of its length — it’s not free to slide in the first place, so it can hardly be deprived of that power by adhesions! You can’t make the IT band for lengthwise sliding without quite a bit of messy work with a scalpel.

And, even more important, even if you could, it’s still not the same thing as “loosening” the IT band. A tight IT Band could, in principle, slide just fine. Tight muscles and tendons generally do slide over underlying structures just fine. Freedom to slide and tightness are simply not the same thing.

The adhesions justification is emptier still: adhesions probably don’t even exist under the IT band to any significant degree anyway. But such adhesions are only a clinical problem in people who are significantly immobilized due to paralysis, and even then they can be broken up relatively easily — this is just stickness, not scarring. In active people — like virtually all patients with IT band syndrome — it is basically impossible to develop any significant adhesions, anywhere in the body.

So, adhesions: probably don’t exist in this location, have nothing to do with IT band tightness at all, and can’t prevent slide the IT band never possessed in the first place. So it’s really quite the mystery why therapists are so busily trying to break them.

What about the quadriceps?

Some therapists may argue that long, deep strokes up and down the length of the iliotibial band are actually intended to massage and treat the quadriceps.

Trigger points in the quadriceps might contribute to pain, tightness and dead heavyness in the thigh and knee. To the extent that quadriceps massage relieves those possible trigger points — which will not be great, if all that’s done is long, deep strokes instead of proper trigger point therapy — it might provide some temporary symptom relief. “Happier” quadriceps musculature could also lead to slightly altered hip and knee function, and thus it’s conceivable that there would changes in IT band syndrome — but would those changes be beneficial? Lasting? Or significant? No one knows any of that.

Dubious as those possible benefits are, they rarely seem to be the actual therapeutic intention of the technique, and thus they are unlikely to be pursued competently. The fantasy of IT band lengthening is likely to be the focus of treatment, with quadriceps treatment proposed as a tepid “bonus” justification.

Sadly, I have also seen therapist justify quadriceps massage with yet another grave misunderstanding of anatomy: they think that the quadriceps actually controls IT band tightness directly. This is a “not even wrong” problem — it’s so wrong that it’s not clear what they think that they know. Quadriceps are not anatomically related to IT band tension, period.

It’s basically the same as prodding with fingertips to see exactly which bit of anatomy hurts … only the prodding is with a needle deep in the neck. And it’s not as painful as it sounds. It’s only a mild provocation. If the injection causes the same kind of pain that the patient normally suffers from — “is that it?” — that disc is quite likely a factor in your neck pain. On the other hand, if the poked disc does not produce any all-too-familiar discomfort, then the disc probably is not to blame.

Despite the simplicity in principle, it’s certainly not a perfect diagnostic method. It’s no more a sure thing than any other diagnostic method for neck pain, but it certainly has the potential to clarify the situation. Some discography results may be ambiguous or just dead wrong, while other results may be crystal clear. Surgeons have expressed concerns about false positives, lack of standard methods, and numerous potential confounding factors, such as a neck with multiple partially involved joints. Because of such problems and probably others, discography does not have clear scientific support for diagnosing low back pain: The American Pain Society gave a thumbs down to provocative discography in their official guidelines for low back pain.

But the situation is different for neck pain. Discography received strong scientific endorsement in 2009 with the publication of a paper in Pain Physician. Manchikanti et al make the strong and positive statement that, despite the controversies, “cervical discography plays a significant role in selecting surgical candidates and improving outcomes.”

Is discography truly more useful in the neck than it is in the low back? Or is the difference simply due to the complexity of the problem, with different authors finding different answers? It’s impossible to be sure, but probably not necessary either: there’s enough good sense in the method and supporting evidence for it that it’s in the “worth a shot” category. It’s certainly not appropriate for new cases of neck pain, but for patients struggling with long term pain there’s not much to lose and a real hope of a clarified diagnosis. Discuss the possibility with your physician.

In July 2009 in Las Vegas I encountered an interesting anology to this puzzle at the Science-Based Medicine Conference. Mark Crislip, MD, an Infectious Disease specialist from Portland (and podcaster: see Quackcast), gave a superb presentation about the hypothesis of “chronic Lyme disease.” He made a strong case that it is a misnomer, a meaningless diagnosis, an overconfident attempt to define a problem that cannot actually be defined.

Some patients do seem to have some kind of post-infection meltdown. They don’t still have an infection any more in any sense that we understand infection. But someone is going to have to explain these patients to me someday.

And that is precisely how I feel about patients with unusually severe chronic trigger point pain: I don’t think that they have myofascial pain syndrome in the same sense that we understand normal muscle pain, but they clearly have had “some kind of meltdown,” and “someone is going to have to explain” them to me someday. Although these cases clearly seem to have their origins in the same kind of myofascial trigger points that Travell and Simons described so thoroughly, it is equally clear that they led to a new kind of predicament in the body, one that is much more scientifically puzzling than muscle pain.

And I can’t deny it any more: I really am sick. License-to-loaf sick. This-isn’t-funny-anymore sick.

This head cold developed in the a deceptively gradual way. It seemed like no big deal for so long that I didn’t take it seriously, but it just kept working on me, and now the virus is clearly winning. And that means it’s time to get some reading done. The cat will be delighted: oodles of lap time!

I particularly enjoy reading books that are on the periphery of my own expertise, because that’s where the best learning always happens. Books by physicians about medicine and biology are perfect: they contain ideas alien enough to surprise and delight me, but still close enough to my own knowledge that I can make all kinds of serendipitous connections and extrapolations.

And it’s all so humbling, too. It’s impossible to read a book by a surgeon like Nuland (or another favourite of mine, Atul Gawande) without being constantly reminded that my work as a Registered Massage Therapist is, well … sort of easy. Not that there aren’t tough problems in musculoskeletal care (there definitely are), but the medical stakes are nothing like what many doctors confront on an almost daily basis. Doctors in general, and surgeons in particular, are constantly presented with hair-raising no-win situations. It’s all rather impressive.

Nuland kicks off his first chapter with a fascinating account of anatomical variability of the viscera. And so I’ve read barely three pages, and already I’ve got something to do: some excerpts will make a great addition to my own article on the topic of anatomical variability (You Might Just Be Weird: The clinical significance of normal — and not so normal — anatomical variation).

But not yet. Right now I need to post this and get back to the couch. The cat is getting impatient.

I will be posting only easy stuff for a while — quotes and so on — until I’m back to full power.