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.

•

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.

It is the only detailed case for such a relationship that I know of. Travell and Simons devote most of a page to it (vol 1, pp 605–6). They assert that “many clinicians agree that subscapularis trigger points can be responsible for the symptoms of ‘frozen shoulder’,” but they responsibly acknowledge that “competent research substantiation is essential.”

It really is.

Their views on the matter are probably the major reason for the popularity of subscapularis treatment amongst massage therapists. This muscle is often touted as a bit of secret sauce, something that only wiser massage therapists know about. You work the subscapularis via the armpit — nothing like a good armpit rub! — and so it has the mystique of treatments in the “wouldn’t go there without a good reason” category.

Good ol’ “subscap”: subscapular or subscapularis?

And where there’s mystique, there’s confusion. Beware of abbreviations in anatomy. This is a classic example, and an interesting tangent, mostly for professional readers, though a few patients with frozen shoulder might want to slog through it. Or skip to the next section.

The “pros” sometimes don’t understand the difference between subscapularis and subscapular, which is often made worse by the ambiguous abbreviation subscap, which could mean either or both. And it matters! To some therapists, this will seem absurd, the difference obvious: while all subscapularis massage is subscapular (because that muscle is under the scapula), not all subscapular massage is subscapularis (because there are other muscles under the scapula). But I have encountered the confusion both in school and in the wild.

Some back muscles are under the shoulder blade: they are subscapular, but they are not the subscapularis muscle.

A therapist may claim to treat frozen shoulder by doing “subscap” work, but then veer away from the subscapularis treatment intended by Travell and Simons, instead choosing to pull the shoulder blade away from the spine and pressing firmly on the revealed back muscles — which are indeed subscapular, but definitely not subscapularis. There is not even a theory that the subscapular muscles of the back are a key factor in frozen shoulder. At best, they are victims of a troubled area, in need of soothing, but far from critical to a cure.

Buyer beware, eh?

The theory of the connection between trigger points and frozen shoulder

In a nutshell, Travell and Simons hypothesize that subscapularis dysfunction is “quite likely” a cause of frozen shoulder because a cranky subscapularis muscle may cause adhesions within the subscapular bursa (a fluid-filled sack that reduces the friction of the subscapularis tendon as it slides of the surface of the shoulder joint). This bursa is known to be one of the main spots where the freezing of frozen shoulder occurs.

It’s a perfectly reasonable hypothesis, entirely worthy of study. But it’s just a hypothesis. And I see some a major problem with it — don’t I always?

The theory requires enesopathy, irritation of the subscapularis tendon, to be the power source for adhesions in the bursa: irritation of the tendon leading to inflammation of the bursa beside it, ultimately causing the bursa to seize up. That’s a lot of tightness due to subscapularis trigger points, and a lot of inflammation for a situation that does not involve any actual tendinitis or early acute symptoms. Basically Travell and Simons are saying that adhesive capsulitis may be caused by trigger points and enesopathy nasty enough to seize up your bursa … but which you don’t notice until it’s already half happened.

Bear in mind that enesopathy is hardly uncommon. At any given time, most people probably have at least a few enesopathic tendons scattered around their bodies. It’s not tendinitis, just irritation and sensitivity of “yanked on” tendons. And nearly all tendons are associated with bursae. And yet bursae do not, as a general rule, seize up the way they do in the case of frozen shoulder. If they did, you’d expect to see frozen hips, frozen knees and frozen elbows. But frozen shoulder is the only somewhat common condition where a joint capsule really seizes up.

Frozen shoulder sneaks up you. You are aware of gradually increasing pain and stiffness in the shoulder. By the time you notice you can’t do up your bra or reach the high kitchen shelf, you’ve already lost the extremes of your range. By the time your shoulder becomes annoyingly painful, the condition is already well underway.

The major logical problem with Travell and Simons’ hypothesis is that any trigger point trouble in the subscapularis bad enough to nearly destroy the joint should also be extremely uncomfortable and obviously limiting long, long before the joint capsule actually becomes adhered. Remember that bad trigger points are bad — quite capable of causing extremely severe pain, weakness and tightness. So I counter-hypothesize that the subscapularis muscle would have to obviously be in trouble long before the joint capsule is actually in danger.

It’s not about right or wrong, it’s about overconfidence

The concerns I’ve raised are not a deal-breaker for the theory. The theory may well still be correct. It is completely plausible that there is something about the uniquely vulnerable about the shoulder joint, and I would love to see a researcher tackle this.

But the logical problem I’ve pointed out is absolutely a confidence breaker. Remember that massage therapists don’t just do subscapularis massage for frozen shoulder: they tend to do it reflexively, overconfident that it “works” without even being clear about how it works. It’s in the big red books, right? So it must work!

And that’s assuming that they even know the provenance of the idea. Or that they can distinguish between subscapularis and subscapular massage!

Travell and Simons have offered a good idea. But therapists need to bear in mind that it’s only an idea, which could just as easily be wrong as right, for the reasons I’ve laid out here. And frozen shoulder patients need to be savvy and remember: when a massage therapists pokes you in the armpit, it’s not even remotely a proven treatment for frozen shoulder.

…a set of socioculturally and commercially motivated pseudo-truths and false certitudes about the origins, historical context, and the prevalence of acupuncture and related modalities in China have led to its current cult in the West as a New Age panacea that allows the harnessing, guiding and adjusting of a ‘Promethean flame’ naturally to restore health and longevity.

The untold story of acupuncture

I get two interesting things out of this straightforward study: first, it’s yet another great example of how the spine is just not particularly fragile or prone to nerve injury; second, it’s terrific evidence that nerve pinches are pretty rare overall.

“Frequency of radiculopathies in motor vehicle accidents”

As described in detail in my last post, ultrasound is generally understudied, for such a popular therapy, but it is almost completely unstudied with regards to its effectiveness in the treatment patellofemoral pain syndrome. In fact, in 2001, a Cochrane (good!) review of ultrasound therapy for patellofemoral pain syndrome found only one scientific study to report on. And nothing new has been published since then. The almost inevitable conclusion, then:

No conclusions can be drawn concerning the use or non use of ultrasound for treating patellofemoral pain syndrome. More well-designed studies are needed.

Although the authors rightly cautioned that there wasn’t enough evidence to actually draw any conclusions, the scrap of evidence they had to work with did not show a benefit:

Ultrasound therapy was not shown to have a clinically important effect on pain relief for patients with patellofemoral pain syndrome.

It’s hardly surprising: patellofemoral pain syndrome is not one condition. There are many different paths to patellofemoral pain, and thus it is extremely unlikely that any one therapy could possibly have a therapeutic effect on any more than two or three of all the possible causes. On the one hand, it’s certainly possible that some cases of PFPS might respond positively to therapeutic ultrasound. On the other hand, it’s extremely unlikely that many cases would. My opinion is that this puts ultrasound in the “worth a shot” category of therapies, but only just barely.

What about research on ultrasound for osteoarthritis?

Perhaps we can draw some conclusions about the effect of ultrasound on knee osteoarthritis in general? We know that patellofemoral pain syndrome and arthritis are not the same thing, but that they may have some things in common. Thus, if ultrasound were effective for osteoarthritis, perhaps it might be effective for PFPS as well.

But those are big ifs!

Ultrasound for osteoarthritis has been studied a little bit more than ultrasound for PFPS, but the science is still amazingly sparse … and is mostly inconclusive or negative. Another Cochrane review, published in tandem with the one mentioned above, found three times as many scientific tests to report on — for a grand total of three! (Scientific reviews usually find dozens of studies to analyze.) Their findings? The usual:

Ultrasound therapy appears to have no benefit over placebo … for patients with knee osteoarthritis.

And another review — the only other review I know of on this topic, and much more recent — still found nothing to get excited about: the authors came to the familiar conclusion that “the effect of ultrasound is unclear (low-quality evidence).” Remember, although absence of good evidence is not good evidence of absence, if ultrasound actually worked half decently for osteoarthritis of the knee, it should have been fairly obvious even with minimal scientific testing.

Therapeutic ultrasound ignored by science but sold to millions of patients

Ultrasound is ultra-popular … and ultra-unproven.

There’s hardly any research about ultrasound at all! Every scientific paper about ultrasound starts by pointing out there is not enough research on this topic. There are practically more reviews of scientific papers than there are scientific papers to review. A major review of ultrasound for a common knee problem in 2001 comically found only a single worthwhile test of efficacy to report on!

That’s not a lot to go on.

I didn’t think it would be like this. For years now, I’ve been looking forward to delving deeper into this topic, assuming that there had to be a pile of science about it. We’re talking about ultrasound, here: one of the staples of physical therapy! It practically defines the experience of going for physical therapy. Everyone has had that cold gel slapped on an injury, and felt that tingling, penetrating … placebo?

The disconnect between the ubiquity of the service and the more or less total lack of (adequate) research is jarring. A handful of studies is a disturbing joke for a therapy that is worth literally billions in the marketplace! How can that much therapy be sold without a satisfactory body of evidence that it works? Bizarre! This is exactly what I mean by “pseudo-quackery” — popular treatments that aren’t necessarily junk, but are nevertheless sold with a confidence that is out of whack with reality.

This does not mean that ultrasound never works for anyone. It does mean that it has been prescribed and sold to patients for decades with unjustified confidence. Not cool.

The pathetic state of the art and science of ultrasound

“In most cases I consider ultrasound less than useless — that's 8-10 minutes wasted that could be used doing something that might actually help.”

Jason Silvernail, DPT, Board-Certified in Orthopedic Physical Therapy, in an internet forum discussion

Ultrasound is not a difficult therapy to test (it’s easy to fake it), and if it works reasonably well then the results should be pretty blatant: simply compare results in patients who received real ultrasound to patients who get a fake instead. To a shocking degree, these simple tests have simply not been done adequately. There should be hundreds of them in the archives. Instead there are dozens.

Between 1995 and 2008, the science that has been done was reviewed in ten main papers. (See Gam, Windt, Brosseau, Robertson, Welch, Baker, Buchbinder, Ho, Ho, Jamtvedt.) Eight of those were unambiguously negative, some of them strongly so. Authors had almost nothing good to say about ultrasound. Conclusions like this one are the rule:

As yet, there seems to be little evidence to support the use of ultrasound therapy in the treatment of musculoskeletal disorders. The large majority of 13 randomized placebo-controlled trials with adequate methods did not support the existence of clinically important or statistically significant differences in favour of ultrasound therapy.

Windt et al, Pain, 1999

I like that phrasing, “did not support the existence of clinically important differences.” Ouch. Ultrasound’s therapeutic effect has an existential crisis!

Most of these reviews give a nod to some reason for optimism about ultrasound used for a particular purpose, or in a particular way. For instance, the review I just quoted, despite its overwhelming negative conclusion, also notes that “findings for lateral epicondylitis [tennis elbow] may warrant further investigation.” Naturally, that optimism about tennis is contradicted by other studies, of course (Ho, Staples).

In short, it’s all just a discouraging mess, and a classic case (yet another one) of failing the impress me test. If ultrasound were generally effective, it certainly should have performed much better in the few studies that have been done.

Therapeutic ultrasound … has fallen out of favor as research has shown a lack of efficacy and a lack of scientific basis for proposed biophysical effects.

Baker et al, Physical Therapy, 2001

Except it hasn’t fallen out of favour — it’s still widely used. The only professionals it’s fallen out of favour with, I imagine, are a small minority of scientists and unusually alert clinicians.

Consider this marketing language from a Canadian company, Shockwave Alberta, specializing in delivering ESWT (a more intense and expensive form of ultrasound, rather popular lately):

Provided you are a candidate for this type of treatment, clinical studies suggest there is a 80–85% chance this technology will improve your condition.

from the Shockwave Alberta FAQ, as of Nov 30, 2009

Here we have an entire company devoted to delivery of therapeutic ultrasound, and selling it with the implication that it is not only proven to be effective, but that they know exactly how effective — to within 5%. Based on the available evidence, do you think it’s actually possible or meaningful to declare that ESWT is “80–85% effective”? Where are the scientific review papers confirming this marvellous triumph of ultrasound? Where is the data to support such a specific promise of therapeutic success?

So, if you do the math, the people of the world spent, um, mumble mumble, carry the three … more than two weeks, 24/7, without breaks, reading that single article. Wow. Must be a good article. You should read it. Take your time.

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

(Except not really, because I’m incapable of promoting an article without giving it a good edit. This one took an hour, and I could easily have spent twice that long.)

“The Unstretchables” is about a basic and neglected concept in therapeutic stretching which puts the value of stretching into perspective. It emphasizes that there are some strict limits on stretching, and if it is otherwise therapeutically potent.

The Unstretchables: Ten major muscles you can’t stretch, no matter how hard you try

It’s a pleasure to talk about a treatment that works, for once. Almost every topic I research for SaveYourself.ca is a disappointment: the evidence for the vast majority of manual therapies is inadequate and discouraging, and sometimes I feel like a stuck record reporting on them, with one therapy after another failing the all-important “impress me” test.

Despite the good feeling I have after reading about the efficacy of sinus irrigation, I am never, ever doing that to myself again! Yuck! Water up my nose is worse than fingernails on a chalkboard!

Neti pots – Ancient Ayurvedic Treatment Validated by Scientific Evidence

Trigger point therapy can be pretty hit or miss. If you do it yourself, you may be less effective than a professional, but at least you won’t go broke trying. It’s best not to pay upwards of a buck a minute for trial and error when you can experiment on yourself at no charge, and safely. This is raison d’etre of this website, actually: in situations where the professionals are nearly as unreliable as you are, save yourself instead of paying for professional shots in the dark. The beauty of trigger points is that you can use the worst things about them to your own advantage. They may be tricky and stubborn and weird, but you have time to mess around. You can wait. You can experiment. You can fiddle. For free. For years, if necessary — as long as there’s evidence that you’re gaining ground, anyway.

At the risk of stating the blindingly obvious, this doesn’t apply in lot of other medical situations. You really cannot and should not experiment on your own with self-treatment of cancer — tragically, these days some people have precisely that idea, and it’s extremely unwise. But with trigger points, you can. Trigger points at their worst are really awful, but they haven’t killed anyone yet. You really can afford to experiment, take your time, screw up, try again, and so on, for as long as necessary.

There are three basic problems with trigger point therapy, for both the pros and their patients:

1. Locating trigger points can be tricky, and it’s hard to treat what you can’t find.
2. Even when you’ve found trigger points, they don’t necessarily go away just because you squish ‘em, stretch ‘em, heat ‘em, or any of the other common treatment themes.
3. And even if they do go away, they usually don’t stay away: trigger points have a nasty habit of coming back.

Fumbling around with diagnosis

Trigger points are really not at all easy to confidently locate, and research has clearly shown that even the professionals cannot really be counted on to find them for you. Thus, hunting for trigger points invariably involves a certain amount of expensive fumbling around. As a Registered Massage Therapist, I am painfully aware that $1.67/minute is flying out of my patient’s pocket every single minute as I hunt around for their trigger points — I had better be damned good to justify that, and the sad truth is that sometimes I’m not.

Case in point: sometime recently I spent a good ten minutes looking for and missing a trigger point in the tensor fascia latae muscle on the side of the hip. My client was chatting away happily, and I wasn’t getting all the verbal cues I needed from him. I spent much of that ten minutes assuming that I was basically already there, until I finally got a word in edgewise and asked him what he was feeling. To my mild horror, it turned out that I’d been barking up the wrong tree. That ten minutes cost him $16, and it was basically completely useless except as “overhead” — more than the usual amount of paid fumbling that is unavoidable in this kind of therapy. My goal as a therapist is to reduce that overhead as much as humanly possible, but there are inevitably some incidents like this, time that is wasted in every other sense.

The right professional may be able to “fumble better,” and give patients a lot of good treatment ideas. But, as your own patient, you definitely have an advantage: you literally have all day to find the right spot.

Fumbling around with treatment

And then there’s the mystery factor, the overall scientific cluelessness about why trigger points form in the firs — place (not what they are, but why they happen) — the impossibility of being confident about exactly what flavour of treatment is going to make them go away. Professionals are definitely not privy to some magic trigger-point-begone formula, and while extensive hands-on experience undoubtedly leads to somewhat higher quality experimentation, it’s experimentation nevertheless, and — once again — our experimenting is expensive.

Case in point: after no less than several years of working with a patient regularly, one day we stumbled upon a different approach to her chronic pain that was distinctly more effective. She called me the next day and said, “Wow, that worked better than usual.” That was a couple of years ago, and we have been using the new approach ever since, consistently obtaining much better results than anything we saw for the first few years. The innovation also led to direct and clear improvements in her self-treatment methods, to the point where — hallelujah — she has stopped coming to see me regularly, and turns up only once in a while for a little “extra help.” But it took me years of regular therapy to stumble on what is, in retrospect, a minor adjustment in my technique that I could have tested at any point. I estimate that this client paid me something like $8,000 for fumbling around with an approach that was wrong for her.

But patients can and should experiment with different approaches willy nilly. As a patient doing self-treatment, you might or might not get results, but at least the insult of a geat expense is not added to your injury.

Fumbling around with perpetuating factors

The third basic problem with trigger point therapy is that trigger points, like Dr. Seuss’s cat, come back. The forces that tended to lead to them in the first place routinely result in their resurgence. Even “successful” trigger point therapy is notoriously prone to being temporary. But, once again, we can snatch victory from the jaws of defeat thanks to the logic of self-treatment: if your benefits are going to be brief, better that they also be cheap!

It’s also largely up to patients to make changes in their lives that make them less prone to persistent trigger points. A good therapist may have excellent suggestions for things to try: but an educated patient is nearly as capable. How hard is it, really, to guess that your crappy, uncomfortable office chair may be the reason your trigger points just keep coming back? If stress seems to be a factor in the stubbornness of your muscle pain, that’s not particularly difficult to figure out — certainly not after doing a bunch of reading on this website — and it’s also a deeply personal problem to solve, and the solution likely doesn’t have much to do with physical therapy or massage therapy.

Case in point: many times I have provided guidance to patients as they try to undertand and solve the problems in their life that may be contributing to chronic pain, whether it’s serious insomnia or a nasty computer workstation. Doubtless most of them would graciously give me partial credit for their successes — at least to my face. But I am aware of many cases where my input was barely more significant than encouragement and reinforcing the obvious, and one young man in particular who really did not need me, but thought that he did. He had a particularly uncomfortable work situation — so much so that it was really quite obvious that he needed to fix that more than any other single thing. From the start, I tried to tackle it on his own, but he insisted on paying me to walk him through it and make trivial suggestions based on my expertise with desks. His enthusiasm and determination was infectious, and for a few sessions I took his money and we had animated, detailed conversations about his ergonomical dilemmas, and I’m sure it was worthless. But soon enough it started to feel like exploitation. Was I helping him? Sure, a little. Was it worth my fee for a young man earning barely more than minimum wage? Not even close. I “fired” him soon after.

•

The clinical experiences I’ve described here all deepened my conviction that “home care exercises” are not just something to prescribe at the end of the appointment, but practically the whole game, and the point of this website.

Ultrasound is ultra-popular … and apparently ultra-unproven.

Today I’m studying ultrasound therapy for musculoskeletal pain problems. Unfortunately, there’s not a great deal to study! There’s hardly any research on this topic at all.

I didn’t think it would be like this. For years now, I’ve been meaning to get around to delving deeper into the topic, assuming that there had to be a pile of science about it. We’re talking about ultrasound, here: one of the staples of physical therapy! It practically defines the experience of going for physical therapy. Everyone has had that cold gel slapped on an injury, and felt that tingling, penetrating … placebo?

Almost everyone seems to assume that ultrasound is proven — good technological medicine. But that just doesn’t seem to be the case. I’m not issuing a verdict here yet, but I don’t like what I see so far: a pathetically small selection of unimpressive studies showing not a great deal, and plenty of papers commenting on the lack.

A handful of studies is a joke for something worth literally billions in the marketplace! The disconnect between the ubiquity of the service and the more or less total lack of (adequate) research is jarring. How can that much therapy be sold without a satisfactory body of evidence that it works? Bizarre!

Is it an e-book, or a service?

Thanks to reader Chris M. for getting me onto this topic today. I’m working on it because Chris pointed out that my patellofemoral pain syndrome e-book was missing a section on ultrasound that it was supposed to have. So I’m doing what I do: a reader-driven update. I encourage readers to make requests like this: it’s one of the neatest things about publishing online. Ask and ye shall receive!

Meanwhile, although the PFPS e-book isn’t sporting its new ultrasound section yet, it’s still excellent, and the new section will be along very soon …

Not ignoring what your body is telling you is the first step to being proactive about your health

So why all the distribution systems? Because some people like RSS, some people are into Twitter, and others are hooked on Facebook! These technologies have become a big deal, and I want my readers to be able to keep track of what’s happening on SaveYourself.ca using the addictive social media technology of their choice. I’ve made a considerable commitment to giving each system the attention it deserves: lovingly crafted Tweets, earnest updates to the Facebook page, and an RSS feed featuring full text so that you can read it right in your feed reader.

Dr. Ronald Melzack: Canadian Medical Hall of Fame

In this 2002 study in Medicine & Science in Sports & Exercise, the core strength of college athletes was tested in 1998-1999, and then in 2000 they participated in “a structured core-strengthening program, which emphasized abdominal, paraspinal, and hip extensor strengthening.” I bet they did a lot of crunches. Boo-yah.

Too bad about the total lack of results!

There was no change in the rates of low back pain before and after all those crunches, and the authors concluded that there was “no significant advantage of core strengthening in reducing LBP occurrence.” Rates of low back pain were low overall in these athletes to begin with, so this certainly isn’t the last word on this subject. But, in this case, core strengthening clearly fails The “Impress Me” Test: if it core strengthening was anything to write home about, surely these athletes would have had less low back pain after all that core strengthening? Surely?

Then, from the The Lancet, along comes one study to rule them all. It’s just too good not to write about, too good not to add it to the pile. This is what we call a “sentinel” study: the last word on the subject for a long time. It offers the kind of scientific certainty that is only possible after rather a lot of other good science has already been done.

“Some clinicians do lumbar imaging routinely or in the absence of historical or clinical features suggestive of serious low back problems,” but this review of several studies of the subject clearly concludes that they really should not do that. It simply does no good, yet wastes resources and scares patients. As long as there are no signs of a serious underlying condition, “lumbar imaging for low back pain … does not improve clinical outcomes.”

Loud and clear message to doctors: Please stop sending low back patients for MRI scans unless you are really, really, really sure that it’s terribly important to check for something nasty.

“Imaging strategies for low-back pain: systematic review and meta-analysis”

The paper explains that past research has not “reported the reliability of trigger point diagnosis according to the currently proposed criteria.” The authors also explain that “there is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points are conflicting.” Given these conditions, it’s hardly surprising that the conclusion of the study was disappointing:

Physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points.

This is not to say that trigger points cannot be diagnosed, but it does strongly suggest that trigger point diagnosis is probably generally a bit dodgy in practice.

It’s important for both patients and professionals to understand that trigger points are clinically significant on the one hand, but also difficult to diagnose and treat. They are there, and they matter, but it’s hard to treat what you can’t find. This may explain why patients get such unpredictable results when they seek massage therapy for muscle pain.

“Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature”

This has been studied various ways over time, and it’s a confusing mess.

Perhaps a recent study of patellofemoral pain in Manual Therapy can shed some light on it. This was a tiny study of just a dozen people with patellofemoral pain. The researchers found that they had “highly significant” IT band tightness compared to a dozen people without pain.

Seems like a smoking gun. Painful kneecaps and tight IT bands … slam dunk, right? This is exactly the kind of thing that is used as justification for all kinds of common surgeries and therapies.

But this study is practically microscopic, which makes it about as reliable as a hyper dalmation in a park full of squirrels. Unsurprisingly, it’s contradicted by other evidence, such as Devan et al, in which few female athletes with iliotibial band syndrome or patellofemoral pain syndrome actually had tight IT bands.

The major problem is simple logic, though: If IT band tightness is a critical factor for both conditions, then ITBS and PFPS should go together like double and trouble. And yet that is rarely actually the case.

Although ITBS/PFPS can coexist, they rarely do — certainly no more than they would by chance. ITBS almost invariably involves vividly clear symptoms on the side of the knee only. PFPS has more erratic symptoms, yet it usually does not include the distinctive lateral hot spot of ITBS.

So this logical problem is a key to both conditions: no matter how you slice it, something isn’t adding up: “tightness” is failing to be an meaningful factor in one condition, or the other, and probably both.

This is quite a mess of confusing and contradictory considerations and evidence! Obviously — and this is the point — confident diagnosis of a “tight IT band” as a factor in either condition is completely unjustified. There’s no solid ground here.

“Iliotibial band tightness and patellofemoral pain syndrome: a case-control study”

I’m not interested in writing short stories. Anything that doesn’t take years of your life and drive you to suicide hardly seems worth doing.

Yes, yes, yes! This is what SaveYourself.ca has become to me: a project with no edges; a bottomless pit of creative and professional challenge; absurdly larger than any single book; an almost pathologically ambitious undertaking that has broken many of my days and nights already, and will probably continue to do so for years to come. This is why I ask for donations as well as sell e-books.

What I do here is not a “labour of love,” it’s the perfect trap for a writer: I will be doing this not just for years, but pretty much the rest of my days.

The first thing one wants to know about any treatment — alternative or otherwise — is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese.

Dr. David Colquhoun, “Doctor Who? Deception by chiropractors”

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

Is reflexology an effective intervention? A systematic review of randomised controlled trials.

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

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

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

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

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

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

“The reliability and validity of assessing medio-lateral patellar position: a systematic review”

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

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

“Prevention of overuse injuries by a concurrent exercise program in subjects exposed to an increase in training load: a randomized controlled trial of 1020 army recruits”

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

Pain problems freak people out

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

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

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

A placebo is not a long term solution — confidence is

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

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

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

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

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

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

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

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

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

Pain Is an Opinion: What recent discoveries in neurology can do for you now

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

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

“Perceived Insufficient Rest or Sleep Among Adults --- United States, 2008”

Facts do not cease to exist because they are ignored …

Aldous Huxley

Wow!

And then the effect faded.

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

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

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

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

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

Write once, publish everywhere

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

It’s been kind of intense.

More good stuff for SaveYourself.ca readers

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

The solution? Blog the process. Publish the pieces.

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

Er, so? This sounds rather unremarkable.

What struck me particularly about this today was the exceptional bang-for-buck that can be extracted from a simple bucket of balls, worth no more than $200 total (and that’s if you have expensive taste in balls — you could easily fill your bucket for less). Of course, I have long advocated self-massage as a cheap, safe and not-miraculous-but-still-rather-decent method for managing common muscle pain.

Self-treatment is not just a theme on SaveYourself.ca, it is the theme! What’s new here is that, over time, I’m coming to understand that a bucket of balls is really the best of all self-treatment tools for muscle pain: an easy collection to work on, cheap and endlessly useful, adaptable and portable.

Two years ago, I wouldn’t have recommend a selection of balls as a big deal in particular. I was enamoured with (and experimenting with) many other massage tools, many of which I still like. But balls “win” — ultimately, you just can’t do better than a nice selection of balls! No one prone to muscle pain should be without their balls.

That said, even though it’s easy to find a variety of balls (try a pet shop), there is a particular sort of ball, made of a special foam rubber, that has particularly captured my heart in the past year. I recommend that you drop by ShiatsuBag.com and buy the combo pack of balls. No kickback for me here: just genuine enthusiasm. They have a marvelous array of textures.

ShiatsuBag.com

SomaSimple: The So Simple Body

The idea of body types has minimal clinical importance in the treatment of muscle pain. However, my vague and imprecise professional impression is that lean and skinny folk -- ectomorphs -- seem more likely to suffer from body pain than the other body types. I have no idea why this might be the case, but it's been a pretty consistent observation over the years: I have seen many more lean clients with widespread and severe body pain than thickset or muscular people. It's certainly not that large and muscular people don't ever have pain, but they do seem to have quite a bit less. Lucky them!

The popular classification of body types into the three "morphs" -- ectomorph, endormorph and mesomorph -- came from the American psychologist William Herbert Sheldon in the 1940s. Sheldon also associated the body types with personality -- that was really the heart of his idea -- which has never been considered useful by anyone but Sheldon himself. However, his idea for the naming of body types really stuck, and to this day you hear them tossed around by manual therapists, even though there doesn't seem to be much point except that we humans like to classify things. The three types are:

• Ectomorphs are fine-boned and have long, slender muscles and low fat, and are usually called slim, lean or skinny.
• Mesomorphs have medium bones, low body fat, wide shoulders and well-defined musculature, and is the body type of the hunks of the world.
• Endomorphs are big-boned and have higher body fat, usually referred to as either fat or heavyset or thickset.

Again, my impression is that ectomorphs are not only cursed with more muscle pain, but also more interesting muscle pain: more variable and unpredictable symptoms, more vivid and complex referred pain. On the other hand, endomorphs seem to be the most immune to muscle pain, and even when they do have it seems to be more stable and predictable, more "straightforward," with minimal and simpler referred pain.

Mesomorphs seem to be the compromise body type, neither being as immune to muscle pain as the endomorph, nor as prone to it as the ectomorph.

It's nothing short of wild speculation, but there could be a neurological explanation for these relationships. In extremely oversimplified language, ectoderms may be "nervier" people. The body types are named after the three basic tissue types in embryonic development, and ectoderms are named from the tissue that develops into the skin and nervous system. Just as the dominance of these tissues types affects to appearance of the individual, perhaps it also affects function and sensation.

Since 2007, I have been investigated by my professional regulator, the College of Massage Therapists of BC. The charge? Publishing a website so offensive to my colleagues that it warrants censorship and public reprimand. My career is at stake, plus a great deal of money.

And I am going public today.

This afternoon I'll be on the radio, discussing my case with Desiree Schell on CJSR's Skeptically Speaking at 6pm Mountain Standard Time. See the website for a countdown to the live broadcast, or listen later by podcast.

And this morning I am published on the new Canadian skeptical blog, Skeptic North: "Pseudo-quackery in Pain Management: a field with a large gray zone between overt quackery and evidence-based care."

Good artwork sells books and is worth every penny -- but it's nearly impossible to find the right artist, and almost always unaffordable for smaller publishers. Most books just don't sell enough copies to pay for the art. Ironically, if they had good art, they might make enough money to pay for the art …

But it's risky business. You can easily end up paying for a bunch of mediocre artwork, or artwork that is just not quite right for the project. And the wrong artwork is worse than no artwork at all!

The result is that there are an awful lot of books and e-books out there that are barely and/or badly illustrated. Sadly, SaveYourself.ca is no exception. For my e-books, I've stuck mostly to stock photography and simple diagrams.

Until now, I hope. Shayne Letain to the rescue: a friend and talented freelance illustrator, Shayne has been out of my price range for many years. Although SaveYourself.ca isn't making a pile of cash selling e-books, it is finally getting to the point where I can afford to take the chance on an illustrator who seems to "get" what I'm trying to do here.

We've been kicking ideas around for a while, and I'm feeling pretty optimistic! For example, here's a sample of a great little editorial drawing that we cooked up to illustrate the concept that muscle knots (myofascial trigger points) are "toxic" -- that they contain an unusual concentration of metabolic waste, and that's why they hurt. Here's a prototype. More to come soon, I hope!

"Muscle relaxant" is an odd category of drug. There are several drugs of other types that reduce muscle tone — like alcohol, say — but they are not considered "muscle relaxants" because they are not interfering with muscle contraction. A true muscle relaxant is essentially a poison that messes directly with muscle physiology.

If you think about that for just a moment, you'll realize that you really don't want too much muscle relaxant. Amazonians used a muscle relaxant … on their poison arrows. Curare poison relaxes you to death. European explorers encountered the stuff early in their visits to North America, and it led to some of the earliest scientific studies in pharmacology.

The most famous muscle relaxant is diazepam, aka Valium, a benzodiazapene along with several other well-known drugs like Klonopin, Ativan, and Xanax. Like the opioids, the benzos are a "nuclear option" — they interfere with muscle contraction, but they also interfere with a great deal else: like consciousness! And, like the opioids, they are also highly addictive due to the intense feeling of well-being they cause. And, like the opioids, the benzodiazapenes are complex drugs with many effects, both known therapeutic effects and unwanted side effects.

There are also muscle relaxants that aim to reduce muscle contraction without doping you up. Such muscle relaxants are only widely available without a prescription in the form of methocarbamol, best known in Robaxin/Robaxacet and their sister drugs, all of which are mixtures of methocarbamol with some other pain-reliever, such as acetominophen or ibuprofen. The point of methocarbamol is muscle relaxation without drowsiness (and minimal potential for adduction/abuse).

There are also some prescription muscle relaxants, none of which are all that familiar to consumers: carisoprodol (Soma), cyclobenzaprine (Flexeril), metaxalone (Skelaxin), and methocarbamol. Some of these are marketed specifically as remedies for muscle pain. For instance, King Pharmaceuticals claims that Skelaxin produces "fast relief for muscle spasms and back pain."

And then there's Botox — the infamous face-paralyzing drug of the stars! Botox is a special case, quite different from the other muscle relaxants. Like curare on poison arrows, Botox is outrageously toxic and doesn't "relax" muscles but outright paralyzes them, even in small doses.

Trigger point gurus Drs. Travell and Simons wrote rather emphatically on this in their famous text book, sternly concluding "we see no rationale for muscle relaxants in the treatment of myofascial pain caused by trigger points," primarily because a contraction knot is simply not the same thing as a muscle spasm.

Clinical evidence is damning as well as expert opinion. Robaxin and Skelaxin do not produce "fast relief for muscle spasms and back pain" to any meaningful degree, and that's why their usage is not part of best practices in low back pain care. Botox does not appear to work as well as early studies showed either, despite its good reputation for exactly that purpose. There is "strong evidence" that muscle relaxants do some good … but only a little tiny bit.

They are definitely better than nothing (better than a placebo) — which is certainly worth knowing — but not by a lot, and that's the take home message. For instance, although on the one hand there is some good research showing that they muscle relaxants provide a modest benefit in conditions where muscle pain is probably often a significant factor (i.e. neck and back pain), it's a really minor benefit, shown by other good research that muscle relaxants aren't even as effective as ibuprofen. A medication that can't outperform ibuprofen is basically a waste of time, because obviously ibuprofen is no cure for any of the common chronic pain problems.

A 2008 physician tutorial in American Family Physician 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."

If muscle relaxants help pain problems that involve trigger points, it should be dead easy to prove it. The lack of such evidence is damning. It's also damning that there doesn't seem to be much difference between muscle relaxants: "Comparison studies have not shown one skeletal muscle relaxant to be superior to another." So we have a class of drugs that shows little sign of effect, no matter which flavour you use. Whoop-de-do!

The bottom line? As with most of the pharmaceutical options for muscle pain: it might be worth a careful try with physician supervision, but keep your expectations particularly low for the muscle relaxants.

This information is an excerpt from one of five new sections about the effect of drugs in my e-book. In the full e-book, more detail is given, and it goes on the speculate about why muscle relaxants are so ineffective. Also covered are anti-inflammatory drugs, especially the intriguing new ointment Voltaren® Gel, and opioids. I am confident that there's no greater concentration of information like this anywhere else. The only remotely similar source of information is in Travell & Simons' trigger point textbooks, but they provide only a fraction as much information as I have.

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. 129 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 ($14.95) or read the first few sections for free!

I have been persuaded by more and more good quality evidence — and the steady stream of patients with nothing better to say about it than "maybe it helped for a while" — that there is really nothing at all to acupuncture. It's just another folk medicine tradition, about as therapeutically meaningful as a manicure.

So how did it feel to change my mind? Oh, a little awkward. It was like diving into water you just know is cold enough to make you gasp. I felt some emotional resistance to the evidence. I also remember feeling comforted whenever I read anything that seemed to bolster my besieged beliefs, and there was plenty of that. It took me quite a while to notice the disturbing pattern that the evidence supporting acupuncture was of consistently lower quality, while the evidence undermining it was of consistently higher quality.

Things started to get more comfortable when I noticed that I rather liked the doctors, scientists and skeptics who were challenging acupuncture. They seemed ridiculously bright — and I like bright people. I actively seek out people who are smarter than I am, because I figure it's the most obvious way to get smarter: you are who you hang out with. I certainly didn't like them because they agreed with me on much of anything, because we didn't agree at that time. But they won me over.

Having my beliefs challenged by such intelligent people was uncomfortable at first, but it was overshadowed by the desire to understand. Despite my initial reluctance, in the end I'm proud to say that I was much more interested in just knowing how the world works than anything else.

"Many studies provide good evidence for the prognosis of acute low back pain," the authors explain. "Relatively few provide good evidence for the prognosis of chronic low back pain." Their research differs from past studies of chronic low back pain, which tended to focus on patients who already had a well-established track record of long-term problems: in other words, the people who had already drawn the short straw before they were selected for study, and are likely to carry right on feeling rotten. But what if you study fairly new cases of chronic low back pain? How many of them fade away, and how many of them really drag on? Isn't that what it is of particular interest to any low back pain patient during their first few months of suffering?

So these researchers looked at patients who had not recovered from their new cases of chronic low back pain, and found that "more than one third" recovered within nine more months. That's a pretty good number.

Yes, of course, that still leaves two third of patients who continue to suffer past the year-mark — and that's an unfortunate number. However, this is chronic low back pain we're talking about here! The surprising and promising thing is that so many patients — almost 40% — actually do get better by the one-year anniversary of their pain. These are people who didn't get better in the first three months, and who would have been told by many doctors that they officially "chronic" at that point.

Alarmism and fear about low back pain has always been a problem. Patients tend to panic, and many doctors and therapists fail to reassure them that most acute low back pain goes away. But many of those who do reassure them step out of the frying pan and into the fire by simply delaying the alarm for 6–9 weeks: they believe and communicate that if you don't recover in the first three months, you're pretty much doomed to have chronic low back pain.

This study shows that it's not true. You can have low back pain for 3, 6, 9 months … and more than 30% of patients will still recover. This evidence is a great foundation for more substantive and lasting reassurance.

What’s the Australia connection?

Did the people who didn’t recover have anything in common? This study also looked at risk factors, and found some patterns. The patients whose pain just kept going were those who had worse pain, more disability, and more fear (“perceived risk of persistent pain”) — no surprise there. They were also the patients with a history of previous sick leave — not for back pain, but for other things, people who may be generally unwell.

A little more surprising was that they had less education: better educated people recovered more.

And (my favourite) the patients with persistent pain also tended to be non-Australian. That’s right: native Australians in Australia get less chronic back pain than non-Australians in Australia! Not sure what to do with that information — don’t move to Australia and get low back pain, I guess. Sound medical advice!

I was introduced to the fallibility of Cochrane reviews at the Science-Based Medicine Conference in July. And today I spotted my first seriously flawed Cochrane review in the wild, a review of acupuncture for neck pain which makes acupuncture sound kinda good (or least distinctly un-bad). Unfortunately, it is compromised by a blatant author bias in favour of acupuncture.

So, speaking of bias, this is a bit delicate. I am on the record as an acupuncture doubter. Actually, I think that acupuncture has dramatically failed to prove efficacy in the last decade. So it doesn't really look good if I dismiss a Cochrane review that says acupuncture works. Aren't I just ignoring evidence that contradicts my views? How can I explain this?

Simple. It's just a bad review. They happen.

Also, it's okay to be biased and admit it. I'm a pundit. I wear my bias on my sleeve, and you decide whether or not to read on. And my bias says that this is a bad review. I object to it not because it contradicts my position, but because it does so poorly. It fails to persuade. There's nothing "compelling" about the evidence. I am not compelled. If anything, I am repelled. Here's what's wrong with the analysis:

• It considered only ten studies of poor quality (average quality of 2.3 out of 5 on the Jadad Scale, "the overall quality of these studies was not considered high"). So, in short, they analyzed a bunch of mostly terrible data from which you shouldn't really be able to draw any conclusions.
• They drew conclusions anyway. Rather than saying that there is insufficient evidence to draw conclusions — as many other Cochrane reviews do — they are phrased instead as statements in support of acupuncture. According to the authors, there is "limited" and "moderate" evidence of benefits. Limited evidence sounds better than it is: it's really limited ("findings in a single low-quality" experiment, whoop-de-do). Moderate evidence isn't much better: "consistent findings in multiple low-quality trials." And the limited/moderate evidence is cherry-picked from the smallest and weakest of the studies analyzed, of course.
• Like so many other acupuncture studies recently, the authors spin a placebo effect as being a benefit of acupuncture. For instance, they conclude that there is "moderate evidence that acupuncture relieves [chronic neck] pain better than some sham treatments." You have got to admire the sneaky phrasing there: "better than some sham treatments," meaning that acupuncture wasn't better than some other sham treatments. This is not a high bar to get over. A therapy than can only "beat" some fake substitutes cannot possibly be very good! Would you take a drug if it was better than one kind of fake remedy, but no better than another?

Almost inevitably, the lead author has a blatant conflict of interest. Of course, this in itself does not make a paper bad. But it does tweak the cynical bone, doesn't it? What a shock that the author, Kien Trinh, is chair of the McMaster University Health Sciences Medical Acupuncture Program, has largely built his career around acupunture, and has authored "two of the few positive systematic reviews on musculoskeletal conditions with acupuncture" (this acknowledgement is found in his bio). In short, he actually admits to being the only scientific reviewer who has published "positive" conclusions about acupuncture.

But let's suspend judgement on acupuncture for neck pain for a minute. What about back pain? Surely, if acupuncture works as advertised, it should work for both, right? If acupuncture is really working its magic with the body's energy channels — the meridians — then there's simply no good reason it won't work in both places. A rising tide lifts all boats, right? A boat floats as well on one side of the bay as the other! Or it should.

A therapy than can only "beat" some fake substitutes cannot possibly be very good!

But acupuncture's boat sinks like a stone on the low back pain side of the bay. This subject has been studied much more thoroughly, with much higher quality studies than have ever been done for neck pain. Guess what they show? (You can read all about that in my article, Does Acupuncture Work for Pain? Or please see Dr. Harriet Hall's excellent recent critical summary of acupuncture research.)

So we have a bunch of good quality and recent evidence that acupuncture simply does not work for low back pain … while for neck pain we have only a small amount of poor quality evidence that it does work for neck pain.

The SaveYourself.ca salamander proposes a little wager. He's a betting amphibian. When researchers finally get around to doing some truly good quality studies of acupuncture for neck pain, how much do you want to bet that they will come out all nice and positive? Not "kinda" positive, not maybe positive, not the kind of positive that would be debatable, but truly, actually, this-stuff-really-works positive?

Yeah, me neither. I'd rather bet that Glenn Beck will endorse Obama's health care reform.

In my experience, I have often seen patients who have suffered years of chronic pain simply because they never rested adequately. (They may believe that they have, but "taking it easy" for a couple weeks is often not actually enough rest.) This predicament is particularly tragic because rest is so cheap and safe that there's hardly any reason not to try it.

What gives rise to this common misconception that exercise is a magic bullet? I suspect it's mostly due to underestimation of the importance of tissue fatigue, in favour of "structural" theories — the idea that there's something crooked or dysfunctional that has to be fixed first, often by exercising. But even a perfectly normal body can only adapt to so much stress. Long before breaking, tissue gets "sick" — a loss of homeostasis. Once that happens, the tissue loses the ability to tolerate even minor stresses. Activities that used to be just fine are suddenly a problem. There's only one way out of that trap: you have to almost completely stop challenging the tissue.

If you have a chronic pain problem that might be related to overuse, it's worth asking yourself: have you truly rested properly? For more information, see The Art of Rest.

Cricks make neck pain particularly "interesting," in the sense of the Chinese curse.

Because a crick often does not "hurt," per se, it is often treated like a poor cousin to neck pain. The use of the word "crick" tends to trivialize the problem. It's true, when neck pain exceeds a certain degree of badness, no one calls it a "crick" anymore — the word feels too lightweight.

But it is important to understand that a feeling of stuckness can be every bit as bad as severe pain. Never underestimate the power of a neck crick to make a person perfectly miserable. Not all pain is painful. It is possible to suffering without hurting. Some of the worst neck cricks don't "hurt," per se: they nag and irritate to the point of nearly driving people out of their minds. I am not exaggerating. I have seen people showing every sign of severe chronic psychological distress, quite literally unable to function well mentally because their neck will not stop harassing them.

Until this summer, the neck pain tutorial was only 10,000 words, and — I confess — not the crown jewel of my publishing empire. It had character and some great ideas, but lacked the "everything you could possibly want to know" quality that my other tutorials have. I couldn't live with that. All summer long, I worked steadily on updates — another 10,000 words or so. The big push finally came in the last two weeks: another 20,000 words or so, bringing the neck pain tutorial to proper book-length, hopefully without losing it's charm.

Almost every single section was overhauled, and many new sections were added. Dozens of references to more recent scientific research were integrated and their significance explained, including several good new studies less than six months old. My head is swimming with the implications of new neck pain research — and most of it got written down.

This update is free for many existing customers: anyone who purchased the tutorial since May 1 has already been given complementary restored and extended access to the tutorial (just use the links you received when you originally purchased the tutorial), plus free renewal for any 2009 customer who sends a request by email — just ask.

Add the neck pain tutorial to your shopping cart now ($14.95) or read the first few sections for free!

Today's offering: three possible, scary causes of neck pain. Not likely causes, folks, just remotely possible, worth considering for a moment. Hypochondriacs, please avert your eyes!

Bornholm disease, or epidemic pleurodynia, or epidemic myalgia or any of several other interesting and colorful names such as Bamble disease, the Devil's Grip, and The Grasp of the Phantom! I swear I'm not making those up! Bornholm disease is a genuine and crazy-sounding viral disease that feels like a vice-grip on the chest and lungs, is strongly painful, and sometimes also causes neck pain. If you feel like you can't breathe, you should look into this. The infection is temporary. I bet out of the next million readers, not not one will discover that his or her neck pain is caused by Bornholm disease. Still, it's good to be thorough!

Trichinosis (or trichinellosis, or trichiniasis) is a parasitic disease caused by eating raw or undercooked pork and wild game. It can be mild or severe or fatal, and digestive disturbance is likely. It can also cause spasming and widespread muscle pain, including the neck. There's a laundry list of other symptoms, so if you've got a strange assortment of problems and neck pain, read more about it.

Thyroiditis, inflammation of the thyroid gland in the throat, can be difficult to diagnose, causing a bewildering array of vague symptoms, just like trichinosis above (but less like being poisoned). If your neck pain is accompanied by symptoms like fatigue, weight gain, feeling "fuzzy headed," depression and constipation, consider checking with your doctor.

Various forms of spinal traction have always been available to desperate low back pain patients, and two facts are clear about this therapy to date:

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

However, 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^TM. (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 tutorials on this website: I am going to start selling true tutorials!)

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 hype covers up a nearly perfect lack of evidence to support the use of any kind of traction, let alone extremely expensive traction. That's the real problem here. Daniel again, from his excellent overview of the subject for professionals, "Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media?"

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 Cochrane 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 brand 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).

None of this means that traction never has any merit — it just means 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 hard sold for a high price to vulnerable, desperate patients.

Need a "true" tutorial about low back pain or neck pain with more analysis of your options? Well, that's what I do!

Who hasn't had a crick in the neck? This tutorial isn't the last word on this surprisingly complex subject, but it is a detailed, sensible and scientific survey of what makes a neck crick tick — and your treatment options. Ideal for any frustrated patient with a jammed cervical spine, it's also helpful for many a therapist not really sure how to treat this quirky phenomenon. Ships with a free bonus, SaveYourself.ca's valuable trigger point tutorial! Add it to your shopping cart now ($14.95) or read the first few sections for free!

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

No (good) scientist or doctor or therapist is foolish enough to think that everything written down in a medical journal is "true." All scientific information — everything — is subject to skepticism. Nothing can be taken at face value.

And science is the methodology system that teaches that attitude.

Fraud is a human problem, not a problem with science. Science is the best available system for combatting the human tendency to deceive ourselves and each other. Like democracy, it's flawed … but the best option we have. It's not a surprise when science fails to perfectly illuminate our world — it's an assumption that it will fail. A mechanic knows that cars will break down and need fixing, and scientists know that ego and greed will break what is "known" and need fixing.

That said … here are three spectacular and creepy recent examples of fraud in medical science:

"Anesthesiologist Scott Reuben revolutionized the way physicians provide pain relief to patients undergoing orthopedic surgery for everything from torn ligaments to worn-out hips. Now, the profession is in shambles after an investigation revealed that at least 21 of Reuben's papers were pure fiction, and that the pain drugs he touted in them may have slowed postoperative healing." Read more about Scott Reuben in Scientific American.

Turns out medical publisher Elsevier has an entire division devoted to publishing fake journals for money for pharmaceutical companies. See Laika's MedLib Log for a detailed analysis.

Based on a leaked document, The New York Times reported this week that "one of the principal means by which [pharmaceutical company] Forest hoped to persuade psychiatrists, primary care doctors and other medical specialists to prescribe Lexapro was by finding many ways to put money into doctors' pockets and food into their mouths." This isn't really a surprise to anyone, but it's interesting that Forest was caught with its hand in the cookie jar. Read the New York Times article.

Despite all this beauty and peace, my neck still hurts.

I have some personal experience with most of the topics that I write about on this website. Even if it's just a little, I find that my own pain is a powerful stimulant to the writing process! When I write about neck pain treatment options, I really care.

The source of neck pain is a particularly difficult clinical problem to solve. As my neck pain tutorial explains in detail, the bottom line is that therapists and doctors really should not be diagnosing neck pain with much confidence — it's usually just not possible. There are too many possible causes, and too many of them are poorly understood.

One possible source of pain is the dime-sized, knuckle-like facet joints. And there's an interesting way to find out: cut off the nerve supply to the joint! If your pain stops, voila, presumably that's where the pain was coming from. This is called a "medial nerve block." The medial nerves are wee nerves that carry pain sensation from the facet joints. Without those nerves, the facet joint can't hurt you. So a successful medial nerve block gives a rare degree of diagnostic confidence, and should be considered as a diagnostic tool in basically every case of stubborn neck pain.

Nerve blocks may also work as a treatment.

In 2008, researchers gave medial nerve blocks to 120 chronic neck pain patients, and found that they produced "significant relief and functional improvement" in "over 83% of patients." This study is widely cited as virtual proof that nerve blocks "work," and it is the main reason that anyone is enthusiastic about needles for neck pain. I think it is good evidence, and it's absolutely an option chronic neck pain patients should consider.

However, as always, you have to read the fine print. There are numerous reasons to curb your enthusiasm …

1. "Over 83%" of patients sounds awfully good — and it is, for a neck pain treatment — but it's hardly everyone. More than 1 in 10 people were not helped, even after a facet joint was "confirmed" as the source of pain by an earlier nerve block.
2. In science, the words "significant improvement" do not mean "cured": they mean statistically significant. And statistical significance is not really all that exciting. Those who were helped were not necessarily helped a lot — just enough that we can say, "Yep, that treatment was better than nothing." So many of those people almost undoubtedly had results that were somewhat less than miraculous. And it gets worse …
3. These patients didn't just get one needle in the neck and then walk out the door with their "significant improvement." They walked out the door … and then came back again a few weeks later for another dose. And another. The average number of treatments over the course of the year they were studied was, wait for it … three and a half, plus or minus one. That's off to the pain clinic with you three, maybe even four or five times per year to get your "significant results." That's a fair amount of getting stabbed in the neck, I have to say. Is this procedure starting to sound a little less awesome than it did at first?
4. As implied by the repeat treatments, the benefits of treatment were not exactly long term. The average duration of average pain relief was 14–16 weeks, and with massive variation of up to half that time. Some patients were getting their statistically significant but probably not stellar symptom relief for only half that time — about a couple of months. No wonder they needed repeat treatments.
5. And, of course, it's a minimally invasive procedure, and all invasive procedures have higher costs and risks, and should be avoided unless absolutely necessary.
6. Last and definitely not least, these patients were not compared to patients receiving any other kind of treatment or no-treatment or a placebo, which I find really strange. It leaves us wondering how well they would have done with no treatment at all. Neck pain is notoriously unpredictable. People who receive no treatment routinely experience "significant relief" for no apparent reason. And so this study, although interesting, is hardly the last word on the subject. It may actually be quite misleading.

   And all this is made even worse by association — the evidence so far shows that blocks for low back facet joints don't seem to work anywhere near as well as what this experiment showed in the neck. There are all kinds of reasons why it might work better in the neck than the low back, but it strongly emphasizes the complexity of the equation: we don't really know why it would work in one place and not another.

If all that doesn't dampen your enthusiasm, then nothing can. After all those caveats, the SaveYourself.ca salamander says "meh" to nerve blocks for neck pain. Is it worth considering? Certainly. Great for some patients? Probably. It is a big deal? The end of all neck pain? The Holy Grail of neck pain treatments? No — it really is not.

P.S. For much, much more of this kind of detailed, no-nonsense analysis of treatment options for neck pain, see the full neck pain tutorial. Who hasn't had a crick in the neck? This tutorial isn't the last word on this surprisingly complex subject, but it is a detailed, sensible and scientific survey of what makes a neck crick tick — and your treatment options. Ideal for any frustrated patient with a jammed cervical spine, it's also helpful for many a therapist not really sure how to treat this quirky phenomenon. Ships with a free bonus, SaveYourself.ca's valuable trigger point tutorial! Add it to your shopping cart now ($14.95) or read the first few sections for free!

"Most runners have an unjustified faith in the benefits of stretching," says Paul Ingraham, a runner, massage therapist, and health journalist (saveyourself.ca) in Vancouver. "Plentiful research has shown that stretching doesn't help someone warm up, ease muscle soreness, prevent injury, or enhance performance. In fact, no measurable, significant benefit of stretching has ever been proven."

Runner's World, "The Rules Revisited," September, 2009, p. 59

Cooper adds some nice points:

Why is it that many Kenyans don't stretch? Why was legendary coach Arthur Lydiard not a fan of stretching? Why does Galloway say, "In my experience runners who stretch are injured more often, and when they stop stretching, the injuries often go away"?

The whole article is excellent. In addition to stretching, it challenges several other pieces of conventional wisdom with valid alternative views:

• You have to put in lots of miles to run a good marathon.
• Speed workouts should feature numerous repetitions with short recovery periods.
• You should gradually build up to a training peak, starting with slow base work and adding speedwork, before you race.
• Cross-training is fine on recovery days, but hard efforts should always be running workouts.
• Strength training will make you a better runner.
• Emphasize carbs when you're marathon training, especially before and during long runs.
• Drink lots of water. (I have a full article about the water issue.)
• Shoes correct the problem.

Buy the issue to find out what the alternative viewpoints are!

Falsehood flies, and the truth comes limping after: an ironic problem with the same Runner's World issue

I have excavated a mother lode of irony from this issue of Runner's World magazine: a more or less perfect demonstration of how difficult it is to communicate the results of science to a general audience.

There's another article in the issue — "All in the Hips," p. 46 — that uncritically promotes the idea that hip strengthening can treat and/or prevent lower leg injuries. This idea is primarily the pet theory of Dr. Reed Ferber of the University of Calgary's Running Injury Clinic.

Ferber's confidence in his theory is well out of proportion to the evidence. He regularly promotes it with press releases and new scientific review papers that simply repeat his interpretation of the same old inadequate evidence. When he first started doing this a few years ago, it might have only been a case of excessive optimism.  Years later, it seems increasingly obvious to me that Ferber is much more interested in his reputation than the truth.

So he's in Runner's World promoting a new myth to a new generation of runners … even as I am quoted trying to debunk the (still prevalent!) myths of the last generation. There is basically no hope that the average reader will know that Ferber's advice is really weak. Most will believe the article. About a million Runner's World readers are going to conclude that hip strengthening "probably" works!

While my message is now pretty much always to "curb your enthusiasm" about virtually every popular idea in pain and injury science, it's drowned out by the roar of other experts who are promoting their pet theories to a public that does not have a fraction of the savvy (or time!) that they require to call foul.

What a mess!

For those who care to take the time to dig for the truth, you can read all about the weakness of Ferber's theory:

Does Hip Strengthening Work for IT Band Syndrome?

Unlike countless proponents of trigger point therapy, I go out of my way on this website to warn chronic patients that trigger point therapy will probably not solve all their problems. On the one hand, trigger points are surprisingly clinically significant and somewhat treatable, and thus they present a remarkable opportunity; on the other hand, trying to find good trigger point therapy is like trying to find a good bagel west of Boston. This new study by Lucas et al does a nice job of explaining the problem: therapists basically can't be trusted to find trigger points. And it's hard to treat what you cannot find.

Trigger points are promoted as an important cause of musculoskeletal pain. There is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points are conflicting.

Alas, this paper was not reporting the results of a good new reliability experiment that would really tell us whether or not it's possible to reliably diagnose trigger points. Rather, it was a survey of the state of the art: what science has been done so far? A confusing mess, unfortunately: "reliability estimates varied widely for each diagnostic sign, for each muscle, and across each study." Researchers have not "reported the reliability of trigger point diagnosis according to the currently proposed criteria." If researchers haven't applied the "currently proposed criteria" … how likely is that the average clinician has a clue how to reliably find a trigger point?

Answering my own rhetorical question: not bloody likely.

The take home message of the paper is that practitioners in the real world probably do not know how to find trigger points reliably. Indeed, if tested, most of them would likely be ignorant of the best known criteria for diagnosis. This jives 100% with my observations "in the wild" — despite the theoretical potential of trigger point therapy, few patients seem to be able to find good help for their trigger points, and the failure often starts with clinicians who don't even know where to look for common trigger points, let alone a thorough understanding of best diagnostic practices. I have repeatedly encountered cases where well-trained therapists appeared to be oblivious to the most obvious of "perfect spots" for massage.

Unsurprisingly, the conclusion of the study was a disappointing (but inevitable):

Physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points.

Noted. Sigh.

The good news: massage can help neck pain

Now for the good news: despite our imperfect grasp of trigger point diagnosis, it appears that massage (even of uncertain quality) really can help neck pain. This is an extraordinary study in two ways: first, well-designed studies of the effectiveness of massage are just vanishingly rare; second, the results are not just positive but strongly so, and actually pass the "impress me" test. The experiment didn't just show that massage "worked," it showed that massage worked really well (dramatically better than the intervention it was compared to, an educational booklet).

Yay for massage! If this is what we can do even when most of us haven't got a clue how to properly diagnose muscle knots, imagine what we could do if we could properly diagnose muscle knots!

Strongly positive results are practically unheard of in scientific tests of popular therapies. Most such therapies totally bomb the "impress me" test. If they show any sign of providing a benefit to patients at all, the benefit is almost always minor and vague — underwhelming, as I love to say. ("Underwhelming" is my favourite word. So useful. So descriptive of so many expensive therapies!)

An important caveat: as I would have predicted, massage for neck pain was only temporarily helpful. But I certainly would want to have been one of the patients getting massage therapy, because the benefits were still twice as good as the educational booklet at four weeks. So "temporary" benefits in this case means "several weeks," which is really not bad! People are certainly willing to pay for that, in my experience!

The truth is never bad news, of course, and I'm going to use this as an example of honouring the evidence even when it irritates me. But damn … this is going to rock my boat a bit.

For years now I've been under the impression that Botox injection flipped the switch on trigger points, just turned 'em off completely, zap, done — no more trigger point until the Botox wears off. That didn't necessarily make it a good treatment option for patients: it's invasive, there are risks, it's difficult to reliably inject the actual trigger point, and so on. But the evidence of the effect of Botox on trigger points was terribly important theoretically, because it showed something vital about the physiology of trigger points. (Botox blocks the release of the neurotransmitter acetylcholine, making it impossible for muscle to contract.) If Botox stops a trigger point, it proves that a trigger point is contractile. If you know how to break a trigger point, then you know how it works. It really helped to push back the scientific darkness around muscle pain.

Only I guess it didn't!

This doesn't necessarily mean that Botox doesn't do anything to trigger points, or that it has no relevance. (For instance, Botox may do exactly what I thought it did, but it's so difficult for practitioners to reliably inject it into exactly the right place that it is highly unreliable as a treatment.) But it does mean that Botox now fails the "impress me" test — its effectiveness and significance is no longer certain, no longer reliable. It is, at best, debatable.

I am going to have to re-write some things on this website.

The evidence is also a poetic addition to one of my favourite points about back pain: it demonstrates that spinal fragility is not the cause of back pain. If stabilizing the spine with cement doesn't resolve symptoms, it strongly suggests that instability wasn't the problem to begin with.

I may be out on a limb a bit here with my interpretation. I might be twisting the evidence to fit my pet theory (good ol' "confirmation bias", seeing what I want to see). Strictly speaking, the only thing this evidence can tell us is what it told us: patients with osteoporotic fractures who got vertebroplasty recovered no better than those who only thought they got vertebroplasty.

But I'm willing to be out on that limb! The rationale for vertebroplasty has always been cave-man simple: Ooog. Vertebrae busted. Hurt. Thag make stronger. Inject glue. Ugh. Supposedly these fractures are painful because the spine is unstable — hardly an unreasonable assumption — and therefore stabilizing them will help. Except it didn't! Not in these patients. So maybe it's not the instability that's causing all the pain.

This is completely consistent with a whole bunch of other evidence that back pain has little to do with how unstable or crooked your spine is, despite the fact that countless therapies are based on those assumptions. You can read all about that in my for-sale low back pain tutorial, which offers a great deal more information like this. Read the first few sections for free here: Save Yourself from Low Back Pain!

Reality Check! You Probably Shouldn't Bother With Epsom Salts

Generally speaking, explanations for how Epsom salts relieve aches and pains are really vague: the terms "osmosis" and "detoxification" are carelessly thrown around with no real understanding of them. People often mistakenly believe that osmosis refers to the movement of substances — ions and molecules, but that is wrong by definition. Osmosis moves water, not particles. As for detoxification, this term is so hopelessly confused and abused that it barely deserves discussing. Suffice it to say that people who confidently claim that Epsom salts detoxify never actually know which toxins, or how Epsom salts deals with them.

However, occasionally you'll see Epsom salts (or magnesium in particular) more exactingly described as a "calcium channel blocker" with the implication that blocking your calcium channels is "good for pain."

Unsurprisingly, it's a misleading oversimplification. It's not a heck of a lot more meaningful than "detoxification."

Calcium channels are itsy bitsy — molecular scale — holes in cell walls that let calcium in and out as a trigger for a bunch of biochemical business. They exist primarily in heart muscle, blood vessels, muscles, and neurons. There are a number of druggy ways to interfere with them, including magnesium. Calcium channel blockage is a reasonably well understood bit of physiology, and the main clinical usage of calcium channel blockers is to decrease blood pressure by reducing the strength of muscle contraction in the heart and blood vessels. Although other effects undoubtedly exist, there is no particular reason to believe that they have any potent effect on any flavour of pain.

Lots of people are walking around with calcium blockers in their blood. Calcium blockers aren't rare drugs. Since there are numerous drugs that block calcium channels in various ways, it's a bit implausible that there would be some kind of powerful pain-killing effect that no one's noticed. I don't think, as a rule, that people on calcium channel blockers are walking around feeling no pain, like a superpower.

Yes, it is possible that magnesium absorbed through the skin does something different, something good, for certain kinds of pain. After all, different calcium blocker drugs have different effects! But there's not a shred of good, direct evidence of it. So it really boggles the mind that anyone would toss this idea around with any confidence. Seriously, they're pretty much making it up as they go — wild speculation.

Want to learn more about Epsom salts? There's lots more!

Many painful problems are much more mysterious, and there are many theories about why people hurt. Debate can rage for years about whether or not a problem even exists. Reliability studies are one of the best ways to end these arguments: if health professionals can't usually come to the same diagnosis about the same patient, something is wrong. Sometimes a little reliability science is all patients really need to make a decision.

But you know what my scientist clients tell me?

"Stick to armchair science. You're better off."

It's okay not to know! It's okay for the jury to be out. And it had better be, because there's still a great deal of mystery in musculoskeletal health science. Most of the scientific evidence that I interpret for readers of SaveYourself.ca clearly fails the "impress me" test. Even when it's positive, it's often only sorta positive. Even when there's evidence that a therapy works, it's usually weak evidence: some studies concluded that maybe it helps some people, some of the time, while other studies showed no effect. I'm supposed to get excited about this? To justify confidence in a therapy, we want really good evidence, evidence that makes you sit up and take notice, evidence that ends arguments because it's just that clear.

Anything less is kind of lame. Anything less is underwhelming. Anything less fails to impress!

Thus, "controversy" about many popular therapies is much ado about nothing. Factions get almost hysterical fighting over scraps of evidence! Why would anyone — patient or professional — get excited about a therapy that can't clearly show its superiority in a fair scientific test? Where's the excitement in a debate about a therapy that is clearly not working any miracles?

Science, as they say, really delivers the goods: missions to Mars, long lives, the internet. A therapy has to deliver the goods. It's got to help most people a fair amount and most of the time, or who cares? Until it impresses you, it's just some idea that hasn't yet showed much promise.

We must somehow find a way to make peace with limited information, eagerly seeking more, without being dogmatic about premature conclusions.

Science Science And The Game Of 20 Questions, by Val Jones

It was 40–45˚C in Vegas (for those of you who don't speak Celcius, that's "really frickin' hot"). The conferences took place in a hotel/casino of dubious quality, well off the strip. It wasn't that it was a dive: it was shiny and new, actually. But it was enormous and noisy and completely lacked a soul. Fortunately, I wasn't there for the hotel.

I went to this conference primarily to meet an intellectual hero of mine, Yale neurologist Dr. Steven Novella. Dr. Novella is the founder of the Science-Based Medicine movement, approximately as smart as they come, and a swell guy. I had two opportunities not only to meet Dr. Novella, but to sit and chat with him at some length at two different (excellent) parties. That's what conferences are for, really: the presentations can be great, but the real action happens at the coffee breaks and parties.

Dr. Novella was every bit as approachable as I hoped. So were his colleagues: I also met and chatted with several other physicians while I was there. Dr. Harriet Hall, the The SkepDoc, a retired Air Force flight surgeon, is an incredible person and speaker: a relentlessly rational, composed speaker with a wonderfully sly sense of humour. She seems like the last person to crack wise when she starts talking in her quiet, steady way; but she slips in these understated humour bombs at regular intervals until, slowly but surely, you realize she's actually the most hilarious doctor you've met in years.

These kinds of social and intellectual connections are of immeasurable value to me. As SaveYourself.ca grows more popular, it has attracted the attention and earned the approval of many physicians. As I write more, I meet them more. As I meet them more, their influence and ideas and constructive criticisms significantly enhance to what I'm doing here.

So, I'm sure you're wondering: what is "science-based medicine" anyway, and why did I got to a conference for it? I mean it sounds great and all, but what's the big deal? I'm glad you asked! In a nutshell, science-based medicine is just a sensibility or philosophy of medicine that says that ideas in health care have to make sense and be reasonably consistent with what we know about physiology. It doesn't reject any idea outright: it just asks that, the stranger an idea is, the more it needs to be tested before getting a thumbs up as "medicine." Here's a short article that goes into a little more depth: Why Science-Based Instead of Evidence-Based?

A physician recently shared story of a patient whose breast cancer diagnosis was delayed because the early symptoms were difficult to distinguish from much more common forms of back pain. The story inspired me to provide some upgraded guidelines for patients here on SaveYourself.ca: rules of thumb and warning signs to help patients decide when to worry, and when not to.

And professionals too, as usual. The guidelines are a careful translation of the best and most recent medical guidelines into plain English — useful for anyone concerned about back pain, your own back pain, or your patients' back pain.

You can read the new guidelines here: The Bark and the Bite of Low Back Pain

And yet the SaveYourself.ca bibliography is the largest of its kind in the world. It contains an incredible amount of surprisingly readable information about musculoskeletal health science, and it is now possible for visitors to search and sort the bibliography with powerful new features launched this week.

My bibliography has been huge for several years, but until now it was impossible to access the whole database in a useful way. It was basically just presented in a big list. The new interface makes all that data into a much more versatile and user-friendly research tool. Columns can now be hidden and shown, so you can see a little data or a lot of data at once. Keywords and full text searching can now show records, or highlight them within the list. Searches for any or all your terms or keywords are a snap. And the foundations have been laid for several more nice features that will be rolled out over the next few months.

Try the New Bibliography!

The bibliography is much more than just a compendium of journal articles, books and websites: it's also annotated. Hundreds of records are explained and discussed in the notes for that record. Since 1997, I've been writing notes on these sources, commenting on their significance, why they are interesting, what the punchlines are, whether or not I like them and why. But all that annotating, all these years, was mostly invisible to SaveYourself.ca visitors.

So it's not just a bibliography: it's a readable reference.

And entries are also linked to the original source material whenever possible (usually). Linking to sources is the soul of this website and good health care information. It is one of the most important ways that you can trust information on SaveYourself.ca: not only are all important points supported by references, but in most cases you can easily check the reference for yourself. There are still hundreds of scientific journals being published online that do not do this — major publishing companies are still not leveraging the power of the internet to make references easily auditable.

SaveYourself.ca is way ahead of the curve here.

Health care information is huge on the internet, but virtually all of it is unreferenced — and even when it is, sources are often difficult to audit. Or, when you do audit them, you find out that they are obsolete, irrelevant, unimportant, or misinterpreted. By making sources easy to check, SaveYourself.ca has been doing something extraordinary and new under the sun. And now doing it better than ever!

Try the New Bibliography!

Think of it as ibuprofen in a gel. It's a topical anti-inflammatory medication, and FDA-approved to treat osteoarthritis in "joints amenable to topical treatment, such as the knees and those of the hands." What is an "amenable" joint, exactly? Relaxed and agreeable? No, just accessible: they mean it's good only for joints that aren't covered by a thick layer of muscle, like the shoulder. The medication can only get into joints if the joint is just under the surface of the skin.

For those amenable joints, though, Voltaren Gel delivers medication directly to the joint, while sparing the gastrointestinal tract from the harshness of NSAIDs (many people can't stomach ibuprofen), and almost eliminating the risks associated with having the stuff spread throughout your tissues.

It's a pretty good idea, and it's pretty obvious that there are some likely off-label uses. For instance, it might be quite helpful in helping to reduce the pain of iliotibial band syndrome or plantar fasciitis, and many other superficial inflammatory conditions.

I'll integrate Voltaren Gel into the site soon, adding to the many treatment options already offered for those conditions.

Unfortunately, the most recent and largest study, "Effect of therapeutic exercise and sleeping neck support on patients with chronic neck pain: a randomized clinical trial", published in Journal of Rheumatology, was also the least encouraging and had some serious design flaws, at least in terms of answering the pillow question.

Researchers compared results in four groups of about three dozen people with chronic neck pain: a group with exercise therapy, with neck support pillowing, with both, and with neither. The group that got pillow therapy alone did not enjoy a statistically significant improvement, and thus pillowing in this experiment completely bombs the "impress me" test: if pillows matter much at all to neck pain patients, then they should have performed better than that!

So the jury is still out. Obviously, the jury is still out in almost every way. Neither scientists, nor therapists, nor patients really have a clue what kind of pillow will make a difference, or if any pillow will.

More detailed analysis and recommendations can be found in SaveYourself.ca's advanced neck pain tutorial.

A great many patients have heard these explanations for their pain, especially neck and back pain, so it's a shame that they are both wrong.

Together, "protective spasm" and "pain-spasm-pain" are two of the classic myths of muscle dysfunction. The body does not uniformly react to trauma by immobilizing the area with muscle spasm, and — even if it did — spasm does not lead inexorably to pain and then more spasm. Indeed, if anything, injury tends to inhibit muscle contraction — protecting the injured area more by shutting it down than by stiffening it up.

The old concept of a pain-spasm-pain cycle does not stand up to experimental verification either from a physiologic point of view or from a clinical point of view.

Physiologic studies show that muscle pain tends to inhibit, not facilitate, reflex contractile activity of the same muscle ...

In 1989, Ernest Johnson, editor of the American Journal of Physical Medicine, summarized overwhelming evidence that the common perception of muscle pain being closely related to muscle spasm is a myth and that the myth has been strongly encouraged by commercial interests.

from Muscle Pain, by David G Simons, Siegfried Mense and IJ Russell, p259

The muscle spasm myths are not especially destructive myths. They are more interesting than scandalous. Nor are they even completely wrong — there is such a thing as muscle spasm, after all! They can indeed occur in the aftermath of certain kinds of traumas. The myths are more like a misleading oversimplification than capital-M myths. Exactly how muscle behaves in the aftermath of a trauma depends on many different factors, such as the severity, type and location of trauma. Muscle is definitely de-activated in response to severe fractures, for instance, because it really doesn't make much physiological sense to spasm when pulling on broken bone.

So muscle has a good repertoire, reacting in many ways to many different situations. And there are undoubtedly duelling and changing reflexes: situations where the body isn't quite sure how to respond, and handles the it differently over time and as conditions change. A true, pure, and long-lasting spasm is virtually unheard of (outside of neurological diseases). I have had my hands on thousands of patients with alleged back and neck spasms, but "spasm" is just not an accurate description for any more than a handful of them. High muscle tone and a hardened, ropy texture are common — but "spasm," as properly defined? It really just doesn't happen. And, even if it did, it wouldn't be a pain-spasm-pain cycle.

Perhaps it's semantics — some might argue that a hard, ropy muscle texture is a "spasm" — but I'm afraid that just doesn't wash with me! That's like telling a mechanic that one car engine is pretty much like any other. The definition matters, and muscle spasm is just not a correct, meaningful definition for what's going on in muscle people with unhappy muscles.

So the main problem with the whole spasm thing is not so much that's it's wrong, but that it's a distraction from much better and more specific descriptions of neck pain. Muscle doesn't cause pain by spasming — but it does cause pain! How?

One reason that the spasm myth persists is that there is a similar muscle problem: a common kind of muscle dysfunction that is so much like a spasm in terms of the sensory experience that most patients never know the difference. And yet it's a (very) different beast! This related phenomenon is the common "muscle knot" — technically known as a myofascial trigger point. A muscle knot is a highly localized spasm — a small patch of muscle tissue that clenches, hurts and causes feelings of profound stiffness. Think of it as a mini spasm!

This article is an adapated excerpt from some new writing I did yesterday for SaveYourself.ca's detailed neck pain tutorial. In the future, I plan to offer quite an extensive free article about muscle spasm myths. This has been the beginning of it.

Muscle pain tends to be underestimated. It can be worse in almost every way than most people suspect, which leads almost inexorably to misdiagnosis. Understanding this can make many otherwise alarming situations a little less alarming. I recently had my own experience with a particularly savage "quick-start" trigger point: an arresting spike of trigger point pain in my upper right neck.

It was an extraordinary experience, both for its intensity and because of the nauseous quality of the pain. Again, the onset was nearly instantaneous, as fast as turning your electric guitar amplifier up to "11." There was no possibility of doing anything else until it was resolved. My adrenal glands went berserk, I broke into a cold sweat, and the blood drained from my face (I was in the bathroom, so I had a mirror handy for this observation). It felt like I'd been stabbed in the neck with a poison dagger. If not for my extensive experience with muscle pain, I surely would have "panicked." But, despite the awfulness of the pain, it was obvious that it was muscular — this is a trouble spot for me, and I'd had less severe experiences with the same problem a few times before.

I attacked the spot with immediate, vigorous massage, instinctively using the "stripping" technique: sliding my thumb tips in a strip the length of the affected muscle fibers. Interestingly, it was somewhat like being in a tug-of-war. It was pulling one way, I the other. I had a clear sense that I was "fighting" the muscle, trying to squeeze the contraction knot out of it, to physically resist the localized spasm.

I must have won. After what seemed like a few minutes of cold sweating and frantic self-massage — probably only about 90 seconds — it started to ease up. A couple minutes later, most of the pain was gone. The adrenalin reaction lasted longer than the pain.

On the bright side, it seems likely that a calm and prompt response to an incident like this can resolve it almost as quickly as it starts. In general, I think response time is critical for such trigger points: the faster you rub them, the faster they go away.

The trigger points tutorial now includes a new section with a complete discussion of this phenomenon. Basic self-massage tips are available for free, of course.

The weird thing about British libel laws is that they are heavily weighted against writers and free speech. Defense costs are so high that few defendants can afford justice. Although libel suits in the United Kingdom can cost millions of dollars, thousands of people — including several celebrities — have been rallying to Singh's defense.

The Sense About Science campaign has issued a statement of support, which has already been signed by an incredible list of people, including James Randi, Richard Dawkins, Ricky Gervais, Sir Martin Rees, Penn & Teller, Stephen Fry, Martin Amis and Steve Jones. You can sign the statement and (better still) encourage others to sign up.

Read the statement and sign it!

Of course they got better at the trick! Practice makes perfect. Get someone to repeat a motor task, and they will get better at it. The real question is, did getting better at rolling a ball around on their head make their neck pain better?

The researchers thought so. The subjects ended up with less postural sway, less jerkiness in neck rotation, less fear of moving, less "disability" and "increased general health" by various measures. Sounds fairly good, doesn't it?

However, as usual, I'm a bit suspicious.

First of all, it's pretty hard to be sure of anything based on 14 patients (if just one or two subjects has something unusual going on, it throws the stats way off). Also, I'm not in love with how incredibly vague the measures of change were: decreased disability in "one out three indicators"? So, um, presumably there was not decreased disability in two out of three indicators, so how good can that be?

Not very good, it turns out! Funny how the authors fail to mention this in the abstract, but the technique had absolutely no effect on the subjects' pain. None whatsoever. "There was no significant decrease in VAS [pain scale] scores after the four-week training period, or at six-months follow up." All the various positive outcomes mentioned in the abstract had nothing to do with pain. That seems like kind of an important omission, don't you think? This is why you have to read the fine print! Sheesh.

The authors conclude that the results "support the clinical applicability of the method." That might be a little strong. I suspect these researchers are probably firmly on one side of a controversy: they probably believe that posture is a significant factor in neck pain. Not everyone agrees with that. There is ample evidence that patients really do not need to worry about neck curvature — according to Grob, for instance, a much larger study with more specific conclusions, "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."

This funny little ball-balancing study might seem to support the neck posture hypothesis, and that's how the authors have interpreted it. I think the results are interesting, but I have to take the interpretation with a huge grain of salt. Neck coordination exercises may well improve neck coordination (imagine that!), but if they don't also reduce pain, it's kind of a big "so what." This evidence proves nothing about posture or coordination as a factor in neck pain.

For more information about neck pain, see SaveYourself.ca's advanced tutorial on the subject. Note that this tutorial is currently undergoing a number of great upgrades, and all recent and new customers will be granted extended access to ensure they get all the new information as it rolls in.

Read the first few sections of the neck crick tutorial for free!

Sure, perhaps more or better qigong would have done the trick: but how much more? Exactly what kind of qigong? The experiment was not perfect, but it's still useful: if three months of garden variety qigong can't produce any therapeutic effect for neck pain, it's probably not worth busting a gut trying to do more and better qigong.

Even though I've "retired" from taiqi, I will always notice new taiqi students making the classic beginners' mistakes, like reaching too far — because it looks cooler and more Chinese. But over-reaching looks silly to any experienced taiqi practitioner! I used to demonstrate this to students by asking them to pause in an over-reached position, and then throw them off balance by pushing on them with my pinkie finger. That always got the point across!

I actually practiced qigong and taiqi for many years. I originally learned taiqi from Sam Masich, and continued for over a decade as a casual student. I actually started my massage therapy practice by offering a free exercise class on Sunset Beach in downtown Vancouver, incorporating many aspects of qigong. To this day, I admire these traditions for their aesthetics and physical and mental challenges.

Qigong is full of claims and legends of healing power. I am extremely skeptical of these claims. I saw some neat things in my years of practicing qigong and martial arts, but never anything spooky — just amazing physicality. The results of the Journal of Pain study do not surprise me at all: I wouldn't expect qigong to do much for neck pain, except perhaps a minor benefit from the stimulation of rhymic movement.

Genzyme takes a small sample of your very own cartilage cells (chondrocytes) and grow them into a surplus population of several million spares that a surgeon implants back into your knee. This is somewhat like tossing some grass seed on a rough patch of lawn, only it requires a bunch of folks with advanced degrees, and it costs USD $20,000–35,000.

For my readers — particularly many of you who have chronic patellofemoral pain syndrome (kneecap pain) — I've got good news and bad news about Carticel and ACI. It's both miraculous and limited.

Read more about Carticel and autologous chondrocyte implantation.

As usual when I write about knee arthritis, this information will soon be integrated into my massive tutorial on patellofemoral pain syndrome, and eventually will be available only to customers.

On the other hand, there's more research than one person can keep track of and write about, and more all the time. There's enough that I could probably pick just a single one of my eight pain problems and pretty much fully occupy myself with studying and writing only about that. Consider the new low back pain guidelines that I wrote about in the last post: I could spend the whole day on that, reading the paper carefully, reporting on it, making dozens of adjustments to my low back pain tutorial to reflect the new information …

Keeping up with eight? Sometimes I wonder if it's really possible. No, I take that back: I don't wonder, I know it's not possible. My consolation is that all eight tutorials are already vastly more detailed and useful than just about anything else readers can find.

Regular readers will know that I have been striving to post new content here on the front page "almost every day" in 2009.

Let's get real: I'm probably not going to make it! I'm going to pause the blog for the next several days at least. There are numerous distractions. Several articles and tutorials need updating based on research that I've blogged about, but haven't had time to fully analyze and integrate into the site.

I have a massive academic assignment to complete as I work on finishing up my Bachelor of Health Sciences.

And this week my nasty shoulder injury flared up seriously again — a substantial and extremely uncomfortable setback that makes it difficult to sleep or type. The one good thing about it is that my now extensive experience with acromioclavicular separation is going to make for a great tutorial. Meanwhile, I need to study it more for my own sake, and get to work on a referral to a surgeon. Clearly, my shoulder has little hope of ever working properly again without some surgical assistance.

So this space will be quiet for a little bit. But, rest assured … lots will be happening behind the scenes!

To most readers, that sounds like doctor code for "it's all in your head." But that's misleading: low back is not "all in your head" any more than an ulcer is all in your head, but it is affected by what's in your head. Our emotional relationship to low back pain is a critical factor in low back pain. Don't brush it off as touchy-feely. It's not — it's neurology, folks.

Other interesting highlights of the new guidelines are the condemnation of (and I'm very happy to see this) three popular treatment ideas that have never been particularly effective: facet joint corticosteroid injection, prolotherapy (repeated injections of irritant material to stimulate an inflammatory response), and intradiscal corticosteroid injection. The APS says all three are "not recommended." Good on 'em. I don't recommend them either.

For more of this kind of sensible, straight-talking science-based information about low back pain, see my advanced low back pain tutorial.

Note: a couple days after posting this, I have added several substantive updates to the low back pain tutorial.

Bromelain is one of two pineapple enzymes, plus a few other compounds. It's best known as a meat tenderizer, but may have anti-inflammatory properties as well. Somewhat less of a "neutra" and more of a "ceutical", bromelain could possibly have the potential to be used in place of anti-inflammatory drugs.

What jumps out at me about bromelain is that the evidence looks a little better than for some of the other popular neutraceuticals. Some half-decent research has been done on it, although nowhere near enough to actually come to anything like a conclusion.

In 2004, Brien et al reviewed one dozen studies of bromelain research to date in Evidence-based Complementary and Alternative Medicine. (More might have been done since then — I haven't checked yet.) Despite a blatant conflict of interest (Brien works for a bromelain manufacturer), the review seems balanced, and the authors do not fail to point out weaknesses in the evidence or concerns about adverse effects. Their conclusion is cautiously positive, and it does seem to be justified by the evidence reviewed: clearly bromelain does something to help people with painful osteoarthritis.

"The currently available data do indicate the potential of bromelain in treating osteoarthritis."

However — and this is really important perspective — we already have medications that "do something" to help people with painful osteoarthritis. To really qualify as a replacement for existing medications, bromelain would not only have to work just as well, but also have fewer side effects. "Effective but safer alternative treatments would be of benefit to osteoarthritis sufferers," write Brien et al.

This has not even remotely been established yet, and until it is bromelain is nothing more than possibly effective neutraceutical that might or might not have fewer side effects — and no one actually really has a clue about that yet. Remember that side effects can be rare and widely variable, so even if many people have no problems, lots of others might — you can't say that bromelain has no side effects just because you got away with taking it!

This is a big topic. Today I'm just going to begin the process of reporting on these supplements and I'll add to this article over time.

Treatment efficacy for her always varied wildly. She kept coming back because, sometimes, she felt a lot better for a little while. But, just as often, the hour seemed almost wasted, the surface barely scratched. We often speculated about possible causes for the complexity and persistence of her symptoms, but I never felt confident of anything except the obvious: that she has a great many severe muscle knots.

Recently, her seemingly infinite supply of symptoms was substantially explained.

Following a severe flare-up of pain — much worse than the usual — her physician diagnosed a large separation of the pubic bones (diastasis symphysis pubis, DSP), where they meet in the front. Some diastasis is normal during and following childbirth. But this was a more dramatic separation, more of a dislocation. Almost certainly, this has been the ultimate source of a great many of her symptoms for years now.

What is remarkable about this, I think, is that she never experienced any clear, well-defined pain at the joint itself — and thus I never suspected the presence of DSP. It never even crossed my mind. Here we have what is essentially a dislocated joint that was not clearly producing symptoms at the location of the joint — in a marathon runner, no less, someone who puts in long hours pounding pavement — and I just didn't realize that was possible. Not only does it surprise me, but I have recent experience with another case of DSP in a runner that certainly did hurt right at the joint — very much, with every impact! So apparently it can go either way. Just what determines whether or not someone with diastasis feels pain at the joint or not I cannot begin to claim to know.

Obviously this was a diagnostic failure on my part, though I don't quite know how I might do better in the future. When one rare problem drives complex and shifting symptoms throughout an entire region, but without actually obviously hurting at the site of injury, it's hardly surprising that it would elude detection.

There are so many possible factors contributing to a complex case of musculoskeletal pain that one can quite easily waste a great deal of time and money on wild diagnostic goose chases. On the other hand, it's possible I could have identified this DSP long ago with some relatively straightforward assessments — not a wild goose chase, but just a little diligent checking.

It now makes more sense to me to thoroughly check the integrity of every tissue and structure in a problem area, regardless of whether or not there are any obvious reason for doing so. A complex pattern of extremely persistent pain in a region is justification enough for checking every checkable thing, however improbable it might seem. Evidently, myofascial pain syndrome can quite easily be powered by a non-obvious epicentre: like stars swirling around a black hole, symptoms can orbit an otherwise invisible problem.

Fascinating.

And why was distance running advantageous for early humans? There was no Boston Marathon back then! Probably because it allowed us to run down faster prey — virtually all prey animals are faster than we are, but they also quickly overheat. As long as a clever human hunter knows where prey is running to, and slowly but surely catches up, eventually the victim gets heatstroke and becomes … well, easy prey.

Listen to Dr. Rolian interviewed on Quirks & Quarks:

"Short Toes for the Long Run"
from Quirks & Quarks (CBC Radio One), Canada's award-winning radio science program