Adapting? Or failing?

How tissue copes with stress is still remarkably mysterious.

Wolff’s law is that bone will adapt to loading. This was first noticed by Julius Wolff in the 19th Century, who got the naming rights. It was greatly refined in the mid 20th century by Dr. Harold Frost, an American surgeon who studied bone biology (and published scientific papers more often than I change my socks). The full details of how bone responds to stress are described in his Mechanostat model.

But bone cells are trapped deep in rigid bone. As biologist Dr. Sheldon Weinbaum put it, they “live in caves.” How do they know what’s going on? How can bone adapt to anything? There are several mechanisms. It’s worth going over a couple of them.

Bone uses microscopic fluid-filled tubes to detect bone stress. The moving fluid tugs on incredibly fine cellular feelers in the tube, and the signals tell bone cells how much bone to make or dissolve. This system fails in zero gravity … which is how Dr. Weinbaum figured out it was there a few years ago.

Equally cool is the way bone uses piezoelectric effect as a signalling mechanism. This was discovered by an orthopedic surgeon, Robert Becker, way back in the 70s, and described in his fascinating book, The Body Electric (this website has a salamander logo because of that book). Piezoelectric effect is a tiny electrical current produced by deformation of a crystal. Bone, as it happens, has a crystalline structure. As the structure is ever-so-slightly flexed by stresses, it lights up with tiny electrical signals to the cells, telling them exactly where the stress is being felt. Clever!

Going soft: Davis’ law

The corollary of Wolff’s law for soft tissue is the obscure and much less developed Davis’ law. No one seems to know who Davis was. Whoever he was, I was only dimly aware of his law before preparing this post. The Wikipedia entry for Davis’ law is anemic.

Although there’s no question soft tissue does adapt to stress, the responses of muscles, tendons, and ligaments are much more complex, varied, and less well understood. Bone is one tissue. “Soft tissue” is a whole spectrum of tissues with diverse functions and properties.

The adaptations of soft tissues are as varied as the inhabitants of a zoo. In it’s mildest form, Davis’ law is simply the “use it or lose it” principle: the growth of muscles in response to exercise, say. At the other extreme of stress — trauma — scarring is a fairly obvious soft tissue “adaptation.” An intermediate example would be the way we can “seize up” — everything from minor transient sticky adhesions between layers of tissue, to significant shortening of structures. Heavily used tendons go through a complex progression of responses to stress that leads to repetitive strain injury if pushed too far.

Flexibility is a wonderfully complex example. On the one hand, it’s obvious that the soft tissues of extremely flexible athletes like dancers, gymnasts and martial artists have been changed by years of stretching regimens — often brutal and injurious. For most of the rest of us, however, there’s excellent evidence that flexibility changes are all in the mind: a neurological adaptation, and not a change in the tissue (see Quite a Stretch). Does a difference in the behaviour of physical unchanged soft tissue count as an example of Davis’ law? Your guess is as good as mine — it’s an almost philosophical question.

Tough love: the thinking behind provocation therapies

Use It or Lose It has a mean bully of a cousin: No Pain, No Gain. Many treatments for painful problems are based on the idea of forcing adaptation or “toughening up” tissues by stressing the tissues — a fairly aggressive exploitation of Davis’ law. These are called provocation therapies.

What could possibly go wrong?

Prolotherapy was invented decades ago to treat back pain by toughening up ligaments by injecting them with an irritant. It has been proven useless for back pain for a long time now — “weak ligaments” are not why people get back pain — but it continues to be tried and tested for many conditions, and there is promising evidence here and there.

A much more modern example of provocation therapy is eccentric loading (contracting while lengthening) of tendinitis. The jury is still very much out on that one.

It’s has always been a reasonable notion to test, but the devil is in the details: what constitutes the “right” amount and kind of stress is extremely hard to nail down — it probably depends on some genetics, for instance — and consequently the results of such therapies have generally always been super duper inconsistent. Probably some conditions and people benefit from toughening up and others don’t. Your mileage will vary! And naturally provocation therapies are inherently risky.

[ Short link to this post: http://saveyourself.ca/395 ]

On April 10 I reported on an odd pain phenomenon (Your brain on water). A terrible, horrible, no good, very bad neck pain I have …

…disappears completely and instantly when I am underwater. It resumes within seconds after getting out of the water, so it does not seem to constitute a “treatment.” It does appear to be a completely reliable mechanism of relief. But the totality of the temporary relief is fascinating.

I theorized a bit about why this might be, but more data would be nice. It would be pleasant and informative to stay in this pain-relieving situation with the aid of a snorkel! I went shopping.

Snorkel shopping

I was disappointed by my unfriendly neighbourhood gigantic sporting goods store with surly, clueless teenaged employees. They had snorkelling kits only, each one including flippers, goggles and about seven pounds of heavy plastic packaging — to protect them from what? Moisture? I could have overpaid for a crappy kid’s kit, or really overpaid for a decent one, and it occurred to me that they wouldn’t really do the job anyway: the relatively short barrel of a snorkel wouldn’t work very well with me sitting underwater and moving my neck around. Likely I’d just end up with a mouthful of water.

Then I got a storm in my brain: I decided to buy a piece of vinyl tubing at the hardware instead. $0.45 per foot! Perfect!

I chose a ¼-inch diameter, which proved to be too narrow. But it did at least provide me an odd tangent to a story that was already odd …

Breathing tube physics

Simply deep breathing while submerged to your chin is a simple way to challenge your respiratory musculature. Why you might want to exercise this way is another topic (addressed briefly below), but for now let’s just say it’s an interesting option, if a bit eccentric.And if you’re really a bit of an odd duck? The exercise challenge can be made more acute — with surprising physics on display — if you add a narrow breathing tube to the equation and sink just a little further into the water.

As I discovered, it’s super difficult to breathe through a narrow tube while submerged, and the hardship spikes impressively with every inch of depth. Even modest water pressure provides substantial resistance to inhalation. The weight of the water presses relentlessly inwards on every square inch of rib cage and belly.

Unless you stop it, the narrow diameter of the tube becomes the sole pressure outlet for the weight of all that water. Air whooshes out of your lungs and through the tube, if you don’t stop it. Put your tongue over the tube end, and you will notice a formidable suction. When you try to inhale through that tube, you have to first match the suction and then exceed it to get any air! It becomes well nigh impossible as you descend.

Hydraulics

Water pressure resists expansion of the rib cage and abdomen uniformly on all sides — and therefore it resists diaphragm contraction. When all of that pressure can only escape through a narrow breathing tube, the effect is startling.

This pressure differential happens with a snorkel too, and snorkelling would be indeed good respiratory exercise in itself, but there are two differences that make all the difference:

1. you’re floating horizontally and therefore much shallower
2. the tube is a fairly large diameter

So both sides of the pressure equation are smaller, resulting in a much more modest force to overcome.

A helmet full of body — ewwwwww!

The breathing tube physics described above were a matter of life and death in early diving suits — the old-timey kind with a big metal helmet and a long breathing tube to the surface. The same physics were at work, but at hyperbolic extremes, due to the depth.

The tube had to be pressurized from the surface to match the water pressure. If it wasn’t, something really horrible happened. Not only was the diver crushed, but — if the depth was great enough — he would literally be sucked into the helmet and tube, reduced to a paste of meat and bone chips. That’s the power of water pressure multiplied both by many square inches and depth! Pressure math is spooky.

The MythBusters quite reasonably wondered if such a thing is really possible. It is. And they demonstrated it. See MythBusters: A Helmet Full of Body. Tip: don’t eat first. It’s one of the most disgusting tests they’ve ever performed.

Water yoga for the lungs?

So why do this weird thing? Well, there are people who actually need inspiratory muscle training (IMT), and good evidence that it works. But that’s mostly for people with a real medical problem to solve (i.e. chronic obstructive pulmonary disease).

I have no great interest in doing respiratory exercise for its own sake, but that’s just me (I have other exercise goals). Many people who will do almost any kind of exercise it for its own sake — water yoga for your lungs, basically, just to be the proud owner of a stronger diaphragm and a greater respiratory capacity. Good for you, if you’re keen on it. And, just possibly, a stronger diaphram might be a way of relieving strain on the other (accessory) muscles of respiration … which may be overused and irritable thanks to a chronic failure to breathe “properly” with the belly … which may in turn be a common source of neck and shoulder pain (see The Respiration Connection).

This setup clearly involves a much more sharply defined and obvious challenge, for those who want that.

What an odd, interesting little detour!

I’ll continue the neck pain story once I’ve had a chance to buy and mess around with a larger breathing tube.

•

See also: Water Yoga: 5 unusual ways to use a swimming pool for therapeutic exercise

[ Short link to this post: http://saveyourself.ca/394 ]

Massage therapists in particular are prone to delusions of grandeur that they can feel things in flesh that ordinary mortals cannot. I had an instructor in massage therapy college who promised the class that we would learn to detect “a grain of sand through a telephone book, and a hand on the other side of a wall.” In the flakier regions of the world of massage, the palpation pretension often blends smoothly with an earnest belief in “energy fields” and extrasensory perception. When that teacher spoke of detecting hands through walls, she was talking about picking up on auras, not infrared radiation or vibrations! Jedi palpation tricks.

Practice and knowledge of anatomy is valuable, of course. I can’t feel a grain of sand through a wall, but after years of practice I certainly can find your infraspinatus muscle in the dark in about three seconds. Through a thick towel. However, therapists routinely fool themselves into thinking they are feeling things under their hands that are not actually there, or things that are might be there somewhere but cannot possibly be detected with any reliability. They do this because of pride, ideological zeal, good intentions, wishful thinking, and active imaginations.

This is palpatory pareidolia.

Pareidolia is a type of illusion or broken perception in which a vague or obscure stimulus — i.e. subtle textures under your skin — is perceived as if it was actually clear and distinct. It is both a source of illusion, as well as our impressive and useful ability to make meaning out of glimpses and shreds of sensation. Pareidolia is:

• why white trash Christians spot Jesus in a T-shirt stain
• why we easily see familiar shapes in clouds, and faces and figures in almost anything
• why the most famously wrong astronomer in history, Percival Lowell, thought he could see canals on Mars

Religious pareidolia examples are so common and culturally significant through history that they have their own name: simulcra. They can seem quite neurologically glitchy. The part of the brain that assigns meaning to things can get dialed up to 11 by religiosity, resulting in some really absurdly over-interpreted perception, and basically seeing God everywhere. (See StuffThatLooksLikeJesus.com for many entertaining examples.)

“Golden retriever? What golden retriever? All I see is a cloud!” Imagine if you really couldn’t see shapes in clouds — what a sad, boring life that would be. Pareidolia can be highly functional and entertaining. But we also need to know how it can fools us.

In the last few decades, a lot of religious feelings have been transplanted from organized religion into very disorganized spirituality and alternative medicine, resulting in many striking similarities between Jesus freaks and new age flakes. Very early in my career as a massage therapist, I encountered my first dramatic example of this, while I was setting up a small office with a colleague. Fresh out of school, I was not yet much of a critical thinker, and was initially charmed and unalarmed by her ideological zeal for alternative medicine. However, our deal fell apart quickly as necessary business communication exposed her glitchy thinking: she was wringing spiritual significance out of every other perception. I remember feeling the first chill of deep concern when we were on the street and spent a few minutes explaining to me how a glimpse of an advertisement on a bus was “a bad omen” for our business plans. I killed the deal when she “saw” an evil pattern in the numbers on our new office door, and demanded that we move to another office.

See what I mean by “glitchy”? It was inevitable that she would inject such bizarre interpretations into her clinical interactions! What “omens” would she have detected in your tissues?

For every glaring case of irrationality like this, there are many milder examples. It’s not a matter of opinion that the brain is easily confused: pareidolia is a fascinating richly neurological phenomenon, the product of a number of well-known cognitive and sensory distortions, and it has many familiar cousins. Many illusions are highly repeatable, like the famous and rather mind-blowing invisible gorilla experiment, from which we learn that we can be totally oblivious to the unexpected.

Pareidolia in manual therapy

We talented at perceiving what we want and expect to see. Over-interpreted perception has always been a big problem for empiricism. The brain is just fantastically good at making up patterns and filling in blanks … and palpation in a therapeutic context provides some rich opportunities for it. It is responsible for who-knows-how-many declarations of “tightness,” for instance. Here are several other candidates for illusory palpations, all common in massage therapy (and chiropractic, and osteopathy, and so on):

• trigger points or muscle knots
• fascial restrictions
• “releases” of many kinds
• vertebral subluxations
• many other asymmetries
• cerebrospinal fluid circulation
• energy disturbances or blocked chi

In each case, the alleged phenomenon may or may not be a real thing, while the perception remains plagued false positives. For instance, cerebrospinal fluid is certainly real, and it does indeed circulate! But no therapist can actually detect that rhythm reliably; if they could, it would nearly be worthy of Randi’s million-dollar prize, and I’d bet against it in a fair test as confidently as I would bet against dowsing or astrology. Fascial restrictions may well be real, and some may even be quite easy to feel, but many alleged detections are certainly wrong (and I’m skeptical that finding them matters).

•

Massage therapists do have exceptionally extensive sensory experience with soft tissue. Perhaps some of the most experienced therapists know muscle texture like a blindfolded painter can tell you what type of paint you’ve dipped her brush in. But even if we can detect amazingly slight differences in tissue texture, that doesn’t know that we know what it means … and pretending otherwise is the thin edge of a wedge of arrogance. It’s not practical, clinical knowledge.

[ Short link to this post: http://saveyourself.ca/393 ]

Why so negative? Why am I so full of bad news about treatment options for things that hurt? Shouldn’t I be a cheerleader instead of a curmudgeon? This is the most common gripe I get from readers. Here’s a typical example from YouTube, where commenters are particularly cranky and illiterate:

i think its so wrong to give out all that nagative response to people who are in pain and desperate for a cure an d some pain relieve! lots of us have't got loads of money to go and see expensive physios! every week! so why don't you get some bonfide people on a video and show us your miracle cure? or your going to share that to the good of man kind.... naarrrr didn't think so.!

Many such complaints from people selling dubious treatments — a coincidence, I’m sure.

On March 26, I answered accusations of “nagativity” from an ethical perspective. To recap, it’s the sad truth that the world of pain therapy is unusually polluted with bad ideas, and pain patients deserve either better treatments or, failing that, at least better information. So even if a health myth is relatively harmless, I’m still going to bust it. It’s an honour thing.

Today’s I will answer it from a scientific perspective. This won’t hurt a bit. In fact, there’s “nothing” to it.

That pun will make more sense by the end of this. Come back to groan at it later.

Just so wrong!

Cynicism is baked deep into science. No one can possibly study the history of science — especially medical science — without becoming super-duper cynical. There are so many strange ideas that have been believed for such outlandish reasons and with such caustic consequences that you can get whiplash switching between laughing and crying. The number of nakedly evil scams alone is just gobsmacking, but it’s dwarfed by the earnest delusions!

Sobering indeed, then, to realize that the treatment of pain is a bit of a medical backwater (see A Historical Perspective On Aches and Pains). While we’ve made huge strides on other fronts, pain treatment has languished in an almost primitive state.

At the heart of every scam and delusion is a medical idea: a notion about what would help and why that turned out to be wrong.And how many medical ideas in history of medical brainstorming have turned out to be worth a damn? Almost none. Maybe 1%.

Indeed, almost all the ideas that we humans cook up about anything at all are flawed and turn out to be wrong. People are wrong-answer-generating machines. But we’re especially prone to wrongness in medicine, because disease and pain and suffering are so complex and scary. It’s all too easy to be wrong when you’re desperate.

It is the business of science to check those ideas carefully. And wrongness is so incredibly common that scientists have learned (the hard way) to just assume that an idea is wrong until proven otherwise. In 1935, that cynicism was given a name, which stuck and became An Official Science Thing. Ronald Fisher, a British geneticist, called it the null hypothesis — the assumption that an idea will amount to nothing when carefully checked.

The null hypothesis is basically cynicism wrapped up in a lab coat.

The power of nothing

People had been noticing that most ideas crash and burn when tested long before it became a requirement of the scientific method. I was always naturally inclined towards the null hypothesis. I was often its champion, defending it from believers in untested ideas, before I’d even heard of it.

The null hypothesis is extremely powerful. It’s the winning hand. It’s the safe bet. Because most of the ideas humans cook up are deeply flawed, betting against them is where the smart money is, and betting against the null hypothesis is just throwing your money away. When in doubt, always pick the null hypothesis. Like a casino, it usually wins.

I’m starting to really groove on the elegance of the null hypothesis. It’s as pretty as Occam’s Razor. In fact, they’re cousins. Occam’s Razor says “bet on the simpler explanation.” The null hypothesis is the default “simpler explanation” — namely, that nothing significant is really going on here.

Nothing is boooooring

The legal principle “guilty until proven innocent” is reflected in the null hypothesis: treatments should be considered useless until proven effective. The burden of proof is on the pusher of the idea, and it’s a heavy burden. Treatments must work well and clearly to actually beat the null hypothesis. They must impress.

When a treatment is truly shown to be effective, it’s exciting! It makes headlines, and it should. But it’s also incredibly rare.

The null hypothesis is formidably reliable … but common, unsexy, and “negative.” It wins all the time, but it doesn’t make headlines doing it. Being the champion of sobering reality is a major drag, and the bane of my existence as a writer in this field. Do you think MythBusters would be popular busting myths without explosions? If it was mostly just a show of null hypothesis confirmations? Yaaaaawn.

Without explosions, one way tart up the victories of the null a little bit is to frame them as “debunking.” The comeuppance of an idea is a source of minor thrills. Fortunately, I get lots of chances to do that …

Trying to beat nothing

People are constantly claiming premature victory over the null hypothesis. If a therapeutic benefit is so tenuous that it hangs on debates about p-values and effect sizes, then either it doesn’t exist at all, or it’s so trivial that it doesn't matter if it exists! And yet based on mere scraps of encouraging evidence, the believers will cry, “Eureka! It works!” And it makes headlines.

Not so fast.

This happens so much, and so egregiously, that it seems like the null hypothesis has almost been forgotten by a lot of modern researchers. Researchers should, in a sense, actually set out to prove the null hypothesis. As Cory Blickenstaff, Physical Therapist, put it, “Not doing so means you are trying to prove your pet theory, and in comes Mr. Bias.” It is clear that Mr. Bias has moved in and taken over a lot of research projects! In fact, this is a major point of one of the most famous scientific papers in recent history, by John Ioannidis, Ioannidis: Making Medical Science Look Bad Since 2005.

The need to contradict this kind of nonsense is (literally) my full-time job, and the number one reason that I am “so negative” — because I am honour bound to point out that the null hypothesis probably has not been defeated.

Again.

[ Short link to this post: http://saveyourself.ca/DRAFT-null ]

A new short article: a look back at the experience my wife and I had with bracing for her nasty 2010 spinal fracture. Mostly her experience. But I certainly got to come along for the ride!

Does spine fracture bracing work? A personal story + casual tour of the science & biomechanics.

[ Short link to this post: http://saveyourself.ca/391 ]

It doesn’t hurt down here. Why?

It’s not a coincidence that I write a website about stubborn pain problems: I have always had more than my fair share of them. While not cursed with the grinding, life-eroding pain of the serious chronic pain patient, I am peppered with a never-ending series of minor to moderate annoyances, perhaps due to bad genes, a sadistic poltergeist, or an excess of black bile.

Lately I have had a persistent, moderate and super annoying neck pain in the junction of my shoulder and neck — what I call the “sheck.” Despite everything I know, I have been unable to pent a dent in this problem. It’s been growing for six months, and it has become really quite serious in the last few weeks (wherein by “serious” I mean “bad enough to ruin my mood on lots of days that would have been otherwise perfectly good days”). It is completely predictable. It always hurts when I tip my head forward or to the left. Without fail.

Except in the water.

Water works

I discovered this by accident. I was in the pool cooling off and floating and splashing exhaustedly around after a good hot soak in my sauna. (Heat eases the intensity of the pain reliably, but not much and not for long.) I briefly hyperoxygenated and sank to the bottom of the pool to drift meditatively for a minute, because I’m funny that way. I tested my neck movement experimentally and found it to be … completely painless.

I quickly experimented and confirmed.

I repeated the experiment every day for several days, and it was the same every time.

My neck pain disappears completely and instantly when I am underwater. It resumes within seconds after getting out of the water, so it does not seem to constitute a “treatment.” It does appear to be a completely reliable mechanism of relief. But the totality of the temporary relief is fascinating.

If only I could hold my breath longer!

What’s going on?

This is just an educated guess, but I suspect that modern pain science has a pretty good explanation for this curious phenomenon: water feels safe, supportive and cushiony. Floating is directly and profoundly reassuring … and it goes right to my head (brain), and that has surprisingly potent pain-killing effects.

We know that “pain is an opinion” and that nothing hurts unless the brain believes there is danger. It probably doesn’t seem to you like pain and danger go together in lockstep, but that’s because it’s not strictly you that decides what’s dangerous — it’s your brain, acting quite independently of conscious you,and so there’s usually a puzzling disconnect between what we consciously think of a situation and the pain we actually experience. You may reckon a situation is “safe,” but your brain does no more than take that under advisement, and perhaps it does not even take you very seriously — it’s paying attention to many factors and inputs, and can easily overrule you.

Consciousness is really only a thin scum on top of the deep pond of the brain-mind.

Usually we experience that disconnect in a negative way: things are surprisingly painful. I think my pool experience is a rare, vivid, pleasant opposite example of my brain ruling in my favour: deciding that a situation is much safer than I thought. Certainly I think floating underwater is soothing, and I sought it out for that reason. But I would not normally expect a maddeningly persistent pain to vanish like a magician’s rabbit simply because I felt “soothed”!

My brain, however, apparently thinks that floating is the bomb. Floating seems to persuade my brain that my neck is totally safe. There may be something fairly primal at work. Floating is womb-like?

More questions than answers

Assuming my reasoning about this is sound, there are many interesting and unanswered clinical questions about this. Above all: is it therapy in some sense? Could there be any kind of lasting value to brief blasts of total relief? Could repeated exposure to this experience gradually persuade my brain that my neck is fine in or out of the water? Even if my brain remains committed to the pain outside of the water, could repeated demonstrations of painless neck prevent my brain from settling into permanent paranoia about my neck — that is, prevention of chronic pain? And if it did, isn’t prevention of chronic pain more or less equivalent with therapy in this context?

I can’t answer any of those questions confidently. I do know there’s certainly no harm in trying, and I’ll be seeking out that relief regularly!

If my neck pain finally goes away in the neck few weeks, however, I already know how tempting and wrong it would be to attribute it to a water cure: pains like this are infamously erratic, and I’ve had many unpleasant and long-lasting neck cricks in the past that eventually went away for no clear reason. The clinical importance of the pool time is likely to remain unknown.

Better than nothing

As any pain patient knows, chronic pain lowers your standards. It makes you more open-minded. Sometimes much too open-minded: you’ll take anything, try anything. Even mostly ineffective treatments start to seem attractive, as long as they have any upside at all. This is why pain patients often cheerfully claim that they’ve got a therapist who is a “life saver” or a “miracle worker” even when their main problem is clearly anything but solved. They will heap praise on a chiropractor or massage therapist for producing even erratic, minor and fleeting benefits — because even those are a lot better than nothing, value that can be measured in cold hard cash eagerly spent from a shred of relief.

That’s how I’m feeling about the pool at the moment. It doesn’t really seem like a “treatment.” I’d be very cautious about recommending it as a pain-busting tip. And yet … I’ll certainly be doing it myself today.

[ Short link to this post: http://saveyourself.ca/390 ]

I was going to blog this privately over at my personal blog, Writerly, but I decided at the last minute to share it with my readers here instead. It does have a health angle, and there is a dissection, and a little kitchen “science,” but otherwise it’s waaay off topic. No pain or therapy stuff today! But what the heck? Why not do an off-topic post once in a blue moon? How else are we going to get to know each other? (Well, there is Facebook.)

It’s time to play “How many calories is it really?” I’ve been buying the same sushi “Combo B” from a good hole-in-the-wall sushi joint for more than ten years now, Daikichi Sushi on Burrard (Google maps). It consists of a tuna roll, a salmon roll, and a California roll: 18 lean pieces, almost no sauce. It’s really quite good, especially for the price, which is why I keep ordering it, once or twice a week, for so long.

The chef knows what to do when I walk in! I’m sure he thinks of me as that Combo B guy.

Sushi Combi B!

How many calories is it really? I’ve been wondering for a decade.

Too much?

The Combo B has always seems like just a little bit too much too eat.

For a decade I’ve been eating these and thinking, “I probably really only need 12 pieces. Or 14.” But then I eat the whole thing. Every. Single. Time. Even through long, angst-ridden periods of otherwise highly disciplined dieting, I have eaten the whole thing. There’s some powerful food psychology going on there. I have marvelled at my own inability to save even a single piece for breakfast the next morning.

I have been through many, many phases of rationalizing my Combo B habit. I have devoted lots of brain time to imagining how many calories are really in this meal. I have guessed low to feel better about it; I have guessed high to whip myself with the fear of it. In the last three years of increasingly desperate middle-aged dieting, I have come to appreciate that almost everything I put in my mouth is packed with far more calories than I ever would have dreamed.

It’s not just that a lot of foods are surprisingly energy dense: it’s that those of us fighting the fat are relentlessly crafting complex and emotional assumptions to protect ourselves from the depressing truth that everything we ever loved is turning into a kind of countable poison. Above all, we constantly, conveniently “forget” how calorie-dense all the yummiest things really are. Do you know how many calories are in a tablespoon of peanut butter? It’s “nuts,” yukyuk. It amazes me every time I remind myself — and I’ve had to remind myself about a dozen times since about 2008. These “surprises” have come up countless times, and I’ve generally learned to expect the worst from every check. It’s almost always a rude shock, at odds with the effects of accumulated wishful thinking and layers of denial.

So it’s time to check the Combo B! Tonight I am dissecting it, weighing the rice and the fish and the avocado, and finding out once and for all: how many calories is it really?

Got a guess? Tune in next paragraph for the thrilling conclusion.

Dissected Sushi Combi B!

After everything was piled back on the plate to eat. (It doesn’t taste as good this way. It was kind of like a sushi casserole.)

The thrilling conclusion

I’m thrilled to report that the Combo B’s energy content is actually not depressing. In fact, eating the whole thing has never been an unreasonable meal. It may even be the first ever good example of not tragically underestimating calories. Phew!

The combo weighs 408 grams, which is about 290g of rice and 85 of fish, with the small balance made up of avocado, cucumber and seaweed. Rice is pretty wet stuff, and averages only about 1.2 calories per gram. Fish and avocado are much more energy dense, of course, at about 1.4 to 1.5 calories per gram. I ignored the seaweed and cucumber and soy sauce (altogether they probably add up to less than a dozen calories).

It comes in just under 500 calories — which is really quite a modest meal.

It’s not a tiny meal — it’s about the same as an A&W deluxe hamburger, for instance. But it’s certainly not big, and it is dwarfed by any multi-course feed. Add fries and a sweet bevvy to that A&W burger and the calories will double. I know from past experience that I am capable of packing in as much as 2000 calories in a single meal, if not a fair bit more. That would be a particularly big meal, but it’s definitely do-able, especially if you’re drinking a lot of those calories. The Combo B really is a small meal, and pretty healthy. And quite satisfying too, considering that I usually have the impression that I’ve eaten a bit too much.

I should have done this a long time ago. I could have spared myself years of uncomfortable guessing!

Yay me

This calorie counting experiment coincides with a big personal weight loss milestone: I’ve ditched 25 pounds (11.3kg) of fat since last fall. After I first started trying to lose weight in about 2008, I suffered a series of humiliating defeats over a couple years. I got serious in the fall of 2010 and made my first genuine progres with the help of California trainer, Steve Moyer (The Moyer Method). I couldn't sustain it, but I learned a lot from it. I cooked up a refined plan and tried again … and finally had the right formula. See the whole success story.

I will return to the usual, painful subject matter next week. Thanks for enjoying the detour!

[ Short link to this post: http://saveyourself.ca/389 ]

So why do I do it? Why is SaveYourself.ca so “negative”? Is it even actually negative? Why so much debunking and criticism? In particular, how does it help ordinary people in pain?

I have many reasons, but I only need this one: I value integrity and truth in health care for its own sake, even if it has no significant safety implications. In other words, it doesn’t matter if a health myth is relatively harmless — I’m still going to bust it.

Myths galore

As often as possible, I report on treatments that work and the ideas that make sense, but the next best thing is to warn consumers away from the many ones that don’t — to try to spare patients the insult of wasted time, drained wallets and unnecessary or excessive risks. And there is so much dodgy, over-hyped nonsense in the world of freelance therapy and alternative medicine that you can’t discuss the topic for five minutes without tripping over twice that many myths.

And so my website has steadily filled up with debunking over the years. I didn’t plan it that way. I just had the misfortune to develop a strong interest in a field that turned out to be polluted with vastly more myths than truths.

Lying is bad — I’m pretty sure of that. It is obviously generally unacceptable to directly deceive patients in any context or for any reason … not even for the “power” of a placebo, which is a common justification, and another myth (placebo is not “powerful”). The ethical responsibility goes deeper than simply not lying. If my entire website is trying to answer the question “what works?” then I must answer as honestly as I can.

Unfortunately, the honest answers are often disappointing. Good solutions for people in pain are tragically few.

Special delivery

Much of what people perceive as “negativity” is just the harshness of reality. People tend to shoot the messenger. It is simply not possible to criticize anything that people believe in or sell without provoking a little outrage. In The Science of Why We Don't Believe Science, Chris Mooney wrote:

Given the power of our prior beliefs to skew how we respond to new information, one thing is becoming clear: If you want someone to accept new evidence, make sure to present it to them in a context that doesn’t trigger a defensive, emotional reaction. … We apply fight-or-flight reflexes not only to predators, but to data itself.

Comedian Chris Rock gets to the same point quicker:

Knowledge is like Kryptonite to the ignorant.

I do everything I can to be negative as nicely as I can (without sucking the life out of my writing). For instance, the words “myth busting” have a good-natured tone that can defuse some emotional defensiveness. That’s why the show Myth Busters is called Myth Busters, I think: many people are more willing to pay attention when you frame critical analysis in that way.

Or I’ll use a word like “bollocks,” which has a terrific duality to it: both strongly judgemental and yet more whimsical and less harsh than “bullshit” or “what a load of #%$&@ crap.” Bollocks is a cranky panda, bullshit is a mean bear.

That negativity may not be meant for you

I use many defusing strategies like that. But as I dial up the diplomacy, I can only reduce the severity of the reaction. There will always be a few people who are still horrified by my impertinence. As my caution increases, I gain some things and lose others. For instance, my kindest approach might score me some points with moderates and lessen the umbrage of a few on the far side of the fence, while simultaneously disappointing mentors and annoying some allies — people I actually respect and admire. In short, I’m being “negative” instead of downright harsh.

If your knickers are really started to get twisted over something I’ve written down, there’s a good chance that it simple wasn’t meant for you.There are many contexts and reasons for mythbusting and debunking, and persuasion certainly isn’t the only goal. Often in my writing I’m not really trying to persuade anyone at all: my goal is often to arm like-minded colleagues and patients with more and better information.

For example, this morning I was listening to a very snarky podcast about quackery in general, but especially homeopathy. The tone would have instantly put any homeopathy true believer on the defensive, in a big way (as will this paragraph). There’s no way it would have convinced them of anything except that they were under siege. But the show wasn’t for them, obviously, it was for people like me: listeners in full agreement with the premises of the conversation. Despite the fact that I am already well-informed about homeopathy (i.e. see my Traumeel article), I actually learned some things — and I’m in a great position to integrate that knowledge into this here publishing machine with lots of readers. Those podcasters would consider that to be a major win.

[ Short link to this post: http://saveyourself.ca/388 ]

Anatomical models of lumbar spines almost all include a herniated disc — in spite of the fact that the last quarter century of scientific research has consistently shown that herniated discs are of minimal clinical significance in the vast majority of back pain. The niftiest science fact about herniated discs is that so many people have asymptomatic disc herniations — at least 25% of people, many more according to some research, are walking around with diagnosable disc herniations … and yet they have no symptoms at all.

And so, although herniated discs do happen, they are typically much less common and much less serious than most patients, doctors and therapists believe. Meanwhile, several respected experts have made strong statements about the extreme importance of reassuring low back pain patients and not scaring them with ominous-sounding and diagnoses like “herniated disc.” Such diagnoses are usually wrong, or hopelessly oversimplified at best, and needlessly scare the wits out of patients … which is a known risk factor for low back pain.

Nervous low back pain patients tend to have more pain for much longer.

And yet it remains nearly impossible for a clinician to buy an anatomical model of the lumbar spine that doesn’t have a little rubber disc bulging ominously from the spine … invariably coloured bright red, just to hammer the point home! It is also nearly impossible for a patient to look at such a model without worrying.

Model of doom and gloom

Lumbar spine models like this almost all show a herniated disc. Some go a step further and show discs slipped so far they’ve completely left the spine! (Hat tip to Dr. Moseley.)

That little bulging disc looks bad. Or, God forbid, a disc that has “slipped so far out it’s sitting on it’s own?” Here’s pain researcher Lorimer Moseley making this point in a great TED talk. He’s talking about how pain is always worsened when you believe that there is danger … and plastic anatomical models of slipped discs are much too persuasive.

Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on it’s own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

(I laughed out loud at that, and then cheered. I’ve been bitching about these blasted models for years. Long before I’d ever heard of Lorimer, I’m proud to say.)

Such models also undoubtedly also influence professionals. Even if they accept that it’s an oversimplified model, the prominence of herniated discs in most models and anatomical drawings constantly exaggerates their importance.

Anatomical models aren’t cheap, and once a clinician has purchased one, it is likely to stay in his or her office for years, probably even decades. I’m sure there are probably hundreds of thousands of them in offices around the world that are at least twenty years old, and clinicians are still buying new ones right now!

And so this is a great example of how hopelessly obsolete clinical ideas persist for years, even decades, after the field has moved on.

[ Short link to this post: http://saveyourself.ca/387 ]

Usually this syndrome is an overuse injury. But what if it isn’t?

The huge majority of iliotibial band syndrome appears to be closely associated with overuse and repetitive strain. However, there are clearly exceptions.

The most common example seems to be ITBS that arises as a complication of trauma to the knee, either due to accident or surgery. Quite a few people have written to me over the years to inquire about such cases, but I have little knowledge of them — and probably no one does. Even typical ITBS is generally under-studied. Atypical cases like this are not on anyone’s scientific radar, and there is simply no hard information about them that I know of. All I can do is offer a few educated guesses about why they happen and how it might affect treatment.

Trauma may simply cause new biomechanical problems and stresses, which might make you more vulnerable to ITBS. In these cases, it simply takes less repetitive strain to develop a problem, but the problem is really no different from any other case of ITBS. There’s no more hope of being able to confidently know the biomechanics than there is with a normal case, let alone correct them.

Or there might be a more exotic explanation. Repetitive strain injuries involve “failed healing” for a reason we can easily understand: tissue is simply placed under more stress than it can cope with. But could there be situations where healing fails for other reasons? Certainly.

Although generally speaking biology is exceptionally good at wound healing, it doesn’t always go well. For instance, a low but predictable percentage of bone fractures simply do not heal, and no one knows why. It’s a disturbing problem. Surgeon Robert Becker describes it:

As an orthopedic surgeon, I often pondered one particular breakdown of that [healing] energy, my specialty’s major unsolved problem — nonunion of fractures. Normally a broken bone will begin to grow together in a few weeks if the ends are held close together to each other without movement. Occasionally, however, a bone will refuse to knit despite a year or more of casts and surgery. This is a disaster for the patient and a bitter defeat for the doctor, who must amputate the arm or leg and fit a prosthetic substitute.

Throughout this century, most biologists have been sure only chemical processes were involved in growth and healing. As a result, most work on nonunions has concentrated on calcium metabolism and hormone relationships. Surgeons have also “freshened,” or scraped, the fracture surface and devised ever more complicated plates and screws to hold the bone ends rigidly in place. These approaches seemed superficial to me. I doubted that we would ever understand the failure to heal unless we truly understood healing itself.

The Body Electric, by Robert O Becker and Gary Selden, pp29–30

And I have a personal example: for no apparent reason, I have never healed properly from laser eye surgery. My right cornea has never recovered from being burned (while the left recovered perfectly), and I still suffer routine pain and irritation, as though the wound was still almost fresh. My surgeon is apparently one of the world’s most expert cornea specialists. The last time I saw him I asked why a cornea would fail to heal and he literally shrugged — humility, not indifference. He knows as much as anyone has ever known about corneas, but he doesn’t know why mine won’t heal.

There are actually countless similar examples in medicine. Healing of all kinds can fail, and in unpredictable ways. As Becker pointed out, we cannot “understand the failure to heal unless we truly understood healing itself,” which we clearly don’t. (Although Becker certainly found some fascinating biological clues in salamanders … which is why a salamander represents SaveYourself.ca!) It’s fascinating that one organism can literally regrow entire complex limbs, yet we can fail to heal from a little irritation.

So when tissue on the side of the knee is disturbed by accident or trauma, it may not heal properly — a kind of “simulation” of a repetitive strain injury. Without knowing why the tissue refuses to heal, there’s no way to know if it will ever recover. However, this is not particularly different from standard issue ITBS, which is also an injury, and which may also not not be healing properly, even when repetitive strain is removed — screwed up healing may be exactly what makes some nasty cases so nasty in the first place.

The major difference between the two scenarios is just how they started, the speed of the tissue insult — traumatically quick, or overuse in slow-motion. With traumatically induced ITBS, you know that the knee isn’t recovering properly — that’s why there’s a problem. But with overuse ITBS, it’s an open question whether it will recover when given a proper opportunity, when the “seige” of stress is lifted. When that seige is lifted, perhaps your knee will recover quickly and thoroughly. Or perhaps it won’t. Regardless of how it started, you have to give it that chance, and so your approach to the problem is going to be roughly the same: protect the tissues as well as you can, giving them the best possible chance to regain homeostasis.

Until we learn nature’s deep secrets about how healing works, that is the best that you can do.

Super-powered healing

Salamander’s have truly extroardinary regenerative capabilities — far more impressive than any other known macroscopic vertebrate. We don’t know how healing can work so well in salamanders … or why it can fail so completely in humans.

[ Short link to this post: http://saveyourself.ca/386 ]

I take my footnoting really seriously.[^[1]] There are a lot of ways to do it wrong,^[2] so I work hard to understand and correctly explain relevant science. Preparing a new footnote recently — just a single, “minor” footnote for my IT band syndrome book — I was struck by what a huge process/ordeal it is for one teensy little number.

They’re like glaciers: there’s a lot more to them than you can see.

So this is the life cycle of a typical show-me-the-science footnote: one that’s interesting enough to deserve some real effort, but still not important enough to end up as anything much more than a wee footnote. It begins easily enough…

• 30 seconds to notice a scientific paper and make a note to deal with it later. (I find most papers while browsing the RSS feeds for top journals.)
• 10 minutes to add it to the bibliography, tag it, and rate it so that I can find it when I’m looking for the best science updates on particular topics.
• Weeks or months before I finally get back to it. Or longer. A few have waited years! I have a backlog of literally hundreds of papers I want to process like this.
• 5 minutes to really carefully read the abstract and start trying to grasp the nugget of the paper.
• 15 minutes to write a good quality plain language translation of the abstract. The effort has now surpassed what 97% of bloggers would bother with.
• 30 minutes to find and/or buy the full text and read it, highlighting and raising my eyebrows and muttering things like, “Yes, but where’s the chart for that data?” and “Have these people never heard of an analysis of variance?” I would guess that most papers are actually read by no better than 1% of the non-scientists who cite them.
• 20 minutes to mostly re-write my translation now that I actually understand the paper and realize that the abstract was oversimplified to the point of being almost meaningless. (This makes me worry a great deal about all the summaries I’ve written without reading the whole paper.)
• 1 hour to find the best places on SaveYourself.ca to cite the evidence. I have to work a bit of a summary into the text in several different places, and then customize footnotes to match. There’s usually a lot of editing of the surrounding material to reflect what I’ve learned. Most citations I’ve chosen because they generally support my position, but they usually improve my understanding. But if the evidence doesn’t agree with my position? This step can double or triple in length for those citations.
• 10 minutes to revise the summary again, based on all the editing and shoehorning I’ve been doing. I usually think of better and better ways to say explain it as I go.
• 30 minutes to revise other related citations, and then cross-reference them. For instance, if New Study seems to contradicts Old Study, but both have strengths, I need to mention in the summary of Old Study to “see also New Study.” If my understanding of a topic has changed, it could affect the wording of my summaries of a dozen other papers. This step can sometimes get down-the-rabbit-hole complicated — effectively infinite.



What my iMac sees during the final stages of this process.



• 20 minutes for drop-in citations, adding references to the paper in places where it can be “just a footnote” and doesn’t require changes to the text.
• 10 minutes to actually publish all the updates.
• 40 minutes for repairing problems that I noticed mere moments after “finishing.” The act of declaring “all done!” is like a magic incantation that forces some glitch out into the open. In the case of the footnote that inspired this, I was about to call it wrap when my eye chanced upon … a duplicate of the citation, already in the database since 2004, which I did a slapdash job on back then and got half dozen things wrong, but which also contained a particularly elegant phrase of summary, much craftier than anything I came up with this time, so of course I just had to revised everything again to use the superior phrasing. Oh, and the old summary also mentions another closely related paper that should have been mentioned in all the places I’ve already edited. And so on…
• 10 minutes to re-publish all the updates.
• 20 minutes to “debate” it on Facebook with some smartass who harshly criticized my interpretation after reading the abstract and demonstrating a perfect lack of knowledge of statistics.
• Six months later a reader reports a glaring typo in the summary, which of course has been duplicated everywhere the citation is used.

I do something like this two or three times per week, and have for many years now. And that’s how a typical footnote is born — in this case, one which shows (among other things) that about half of people with unexplained anterior knee pain have “hot” kneecaps.^[3]

Notes

1. Patton et al. Head and neck injury risks in heavy metal: head bangers stuck between rock and a hard bass. British Medical Journal. 2008. PubMed #19091761. Comments: It turns out that head-banging, “a popular dance form,” constitutes “a definite risk of mild traumatic brain injury” and the study “helps to explain why metal concert goers often seem dazed, confused, and incoherent.” I can think of other reasons! Part of the reason I wanted to share this beautiful piece of science is that I grew up in a youth culture dominated by heavy metal — a small industry town in northern Canada, Prince George. I was surrounded by head bangers, and they were definitely dazed, confused, and incoherent. And worse! But there is a strong possibility that the daze preceded the heavy metal in many cases.
   
   The risk of neck injury also increases with head banging intensity — although less than one might expect, which we can infer from the way people are able to keep doing it.
2. Ingraham. Bogus Citations: References to “scientific evidence” are routinely misleading and scammy. SaveYourself.ca. 1558 words.
3. Näslund et al. Comparison of symptoms and clinical findings in subgroups of individuals with patellofemoral pain. Physiotherapy Theory and Practice. 2006. PubMed #16848349. Comments: Researchers bone scanned and x-rayed 80 patients diagnosed with PFPS and with many common similar diagnoses eliminated, a nice “pure” selection of unexplained knee pain patients. They divided them into three groups: 17 with pathology, 29 with “hot” kneecaps (metabolically active), and 29 without any findings (5 dropped out). All patients and 48 healthy subjects without any knee pain were then interviewed and examined by a surgeon and a physical therapist.
   
   They could not diagnose the pathologies without the scans — all patients with pain tested about the same, and their symptoms were indistinguishable. Q-for-quadriceps angles were about 4˚ bigger in the afflicted, but the authors carefully explain that 4˚ too small to be reliably detected. The most interesting result of the study is that almost half the PFPS patients had kneecaps throbbing with metabolic activity — that’s a fairly strong pattern.

[ Short link to this post: http://saveyourself.ca/385 ]

In the aftermath of a flurry of inflammation research lately (see “An inflammatory problem,” parts one & two), I have tried to make better sense of icing. Icing is used wherever people suspect inflammation, but that includes at least three quite different biological situations:

1. true inflammation, where an immune system reaction makes sense (lacerations)
2. sterile injury, with an excessive immune response (bruises, muscle and ligament tears)
3. connective tissue degeneration, with little or no classic inflammation at all (repetitive strain injuries)

Icing is particularly popular as a treatment for repetitive strain injury, and I have prescribed it plenty myself. Why? Can ice actually help an injury that isn’t very “inflammatory” in the first place? This is an condensed excerpt from my updated icing article — if you want detail, skip on over there now and read that. Stay here for the skinny.

In case of inflammation

When tissue is damaged, the body responds with a complex array of chemical and neurological changes collectively known as inflammation. For instance, the capillaries widen in a big way to bring extra oxygen and nutrients to the area. They also “loosen,” becoming more permeable, to give immune system cells easy access to the injury. Most of the pain and discomfort of inflammation is due to the immune system reaction.

If the skin is broken, there is a risk of infection, and the immune system reaction is essential — a pure physiological goodness, finely-tuned by evolution to optimize recovery and minimize infection danger. Strictly speaking, if you to want to heal well, don’t interfere with this kind of inflammation!

If the skin isn’t broken, things are different! In this context, inflammation is an overreaction that causes collateral damage and excessive pain due to a weird glitch in biology. There is no need for the immune cells to get all fired up for a sterile, internal injury where there is no possibility of infection. Nevertheless, they do get fired up. It’s a reasonable goal to try to suppress it with ice (and anti-inflammatory medications like ibuprofen). Bet you didn’t know that.Few people do — this is based on surprisingly new science.

Of course, immune system activity is not the only reason injuries hurt. Damaged and stressed cells put out many kinds of distress signals. As with most biological processes, our comfort is not really a priority. In fact, quite the opposite — inflammation has partly evolved to be painful. Cavemen didn’t have ibuprofen and ice, nor did they have the benefit of understanding inflammatory chemistry. In the big picture, super painful inflammation was good for our species: victims were encouraged to stay relatively still while inflammation ran its course like a fever!

But for modern humans, inflammation is … well, it’s overkill. We can afford to “turn it down.” We can ignore the warning of the inflammation to a point. Ice can only turn it down so much anyway, so there’s not risk of missing the pain alarm entirely! Cold slows metabolic activity, numbs nerve endings, constricts capillaries. It limits and controls inflammation. It makes it hurt less. It helps us get through the day. And that’s an especially good thing for sterile injuries, where the inflammation is largely pointless.

Where’s the fire?

And what if there’s not really not much inflammation? What if there’s no fire to put out? Does ice still have a role to play? Yes, some — but not because it’s “anti-inflammatory.”

What’s going on in a repetitive strain injury like runner’s knee or tennis elbow or Achilles tendinitis is painful degeneration — tissue rot, which has more in common with arthritis than inflammation. The chemistry of these situations is very different than classic inflammation, and in particular involves relatively little immune system activity. The most obvious implication of this is that treatments intended to suppress immune system activity — the anti-inflammatories — are obviously not going to work well. And indeed they don’t.

If ice can help a repetitive strain injury in any way beyond brief numbing — no one has ever actually proven it, or shown how it might work. However, it might stimulate miscellaneous minor tissue healing processes. Virtually any stimulatory input to the body, up to a point, can provoke a healthy, adaptive, tissue-building response. Maybe. (See Wolff’s Law). In broad strokes, that is probably the only plausible therapeutic mechanism of icing. Ice may simply be one of the easiest delivery systems for a bit of non-toxic stimulation — a way to stimulating tissue without overloading it, while simultaneously give some temporary pain relief from numbing.

It’s worth doing. The great advantages of ice as a treatment are not its impressive biological effects — which are unknown and unproven — but its thrift, ease, and safety: treatment options simply don’t get any more innocuous while still having some plausible mechanism of benefit. Therefore ice remains firmly on my “worth a shot” list for RSIs. However, it certainly isn’t “anti-inflammatory”!

[ Short link to this post: http://saveyourself.ca/384 ]

The pain is real!

But are “trigger points”? The more I learn, the more I wonder.

I’ve been promising this for a while. The process begins this morning with a personal introduction: how I came to believe that I need to “go there.” My ebook about trigger points and myofascial pain syndrome is my best-selling product. It is my meal ticket: it literally pays my rent, my food, and keeps the lights on. I wrote it because, during my 10-year stint as massage therapist — 2000–2010, R.I.P. — I got more therapeutic mileage out of the idea of trigger points than any other clinical concept. Or so it seemed. In my experience, I was able to help more people in that way than any other, by far — good bang for treatment buck.

And there’s the problem: I don’t trust “my experience” farther than I can throw it, and I take it as an article of faith that I misunderstood the meaning of many of my clinical experiences. I was never an over-confident therapist. I was prone to earnest self-deprecation and making a virtue of candid confessions of my limitations. And yet I wrote an entire book based more or less on my experience. Experience like this…

The ultimate trigger point treatment anecdote

The three most dangerous words in medicine: in my experience.

— Mark Crislip, MD

A few years ago, during a family visit, my wife’s uncle was suffering from a sickening ache on the front of his shoulder, like a toothache in his anterior deltoid. He was a weathered, cheerful former farmer who’d lived hard and wasn’t the sort to complain or ask for help, especially from his nephew-in-law the masssage therapist — a profession that probably seemed a bit strange to him. However, he was pale with pain, and I’d never seen him so subdued, so he accepted my assistance without much resistance. A quick clinical quiz determined that the problem had been worsening steadily over a few weeks, and had driven him to the doctor where it had been chalked up to arthritis. And yet the pain was off the charts in a joint that is rarely afflicted by arthritis, and had been worsening much too quickly for that diagnosis. If this was arthritis, it was certainly a strange example of the breed! He’d also been told it might be bursitis, a strangely common misdiagnosis that was an even worse fit.

I recognized the signs of what I knew as an active muscle knot or “trigger point.” (And, honestly, I would probably still call it that today — for lack of a better term. This naming problem will come up again.) I recognized the location as being strongly characteristic of a typical pattern of referred pain from the infraspinatus muscle, and one of the more dramatic examples of that odd phenomenon: poke the shoulder blade in back, but feel it in the deltoid muscle on the front of the shoulder. I prodded the infraspinature just so, and sure enough he responded with surprise: “Yeah, hey, wow, that’s it! I can really feel that in the front of my shoulder.” I rubbed the spot with a practiced thumb for all of five minutes, and …

He was cured. Immediate, total, permanent pain relief. I fixed him in less time than it takes me to make coffee.

My uncle-in-law spent the rest of that weekend swinging his arm around, chuckling, and saying things like “Who knew?” and “Well, damn, ain’t that something!” He brought it up every time we visited after that. He mentioned it the last time I saw him, just recently, near death — it was his defining memory of me.

That is the most dramatic treatment anecdote of my career. It was not an unusual sort of clinical experience — I had many similar ones — but it was the high water mark, the best of the best, the most unqualified victory I ever had over pain. The “magic hands” myth was at full power, because the spot I chose to treat was so oddly remote from the pain, so counterintuitive. Nothing is better for massage therapist’s reputation! It seemed like a miracle to him not only that I cured him, but that I did it by pushing a spot on “wrong” side of his shoulder.

The trouble with empiricism

Experiences like that were good enough for me when I was a massage therapist … but I’m not a massage therapist any more. My career has taken a strange turn from massage therapy to science journalism, and it has exposed me to countless worrisome examples of seriously flawed clinical reasoning … most of them shored up with anecdotes like that.

Experience is not enough. Things are not always what they seem, and the mind is afflicted with many common reasoning errors and illusions. It has become my job to study and understand those mistakes. Many of my own beliefs, one by one, have fallen like timber, hacked down by new critical thinking skills. I no longer believe 90% of what I did in my first couple years of selling therapy.

Empiricism is supposed to urge that people be distrustful of authority and go out to look directly at the world. But of course this is a fantasy. It is a fantasy in the case of everyday knowledge, and it is an even greater fantasy in the case of science. Almost every move that a scientist makes depends on elaborate networks of cooperation and trust. If each individual insisted on testing everything himself, science would never advance beyond the most rudimentary ideas.

Peter Godfrey-Smith, Theory and Reality: An Introduction to the Philosophy of Science

The low-hanging empirical fruit is gone from medicine. The handily tested theories are all gone. All the challenges left in health care are the slow-motion and multi-factorial, the microscopic, subtle and psychological — messy etiologies. No one will ever discover the one true cause of chronic pain the way Dr. John Snow proved with a simple test that cholera was coming from a polluted well: he removed the pump handle, and the cholera stopped.Simple, no? Goodness, no, not even that: to prove that cholera wasn’t in the water, some smartypants biologist drank a glass of the stuff … and got away with it, because he just happened to be immune. Experience!

Trigger point science is a bit half-assed

The introduction to my book clearly states that “trigger points are good, hard science.” Hmm. Not quite. There is some interesting science — better than fascia science, I believe — but it doesn’t impress me any more. It’s all a bit half-assed, actually. This week, I will change that introduction.

I feel the need to challenge trigger points as a concept because I don’t trust my own experience any more, and because the science of muscle pain is simply more limited and less illuminating than I once thought. Although there can be little doubt that there is a phenomenon in need of explaining — there are sensitive spots, people do hurt, the pain is real — much less can be said with confidence about the nature of that phenomenon than I would like. So I am planning a series of updates to the book with the general goal of presenting the notion of a “trigger point” as a weak metaphor — much like the more obviously quaint “muscle knot” — more than an actual known thing that resides in meat. It will become a book more about muscle pain than trigger points. Fortunately for me, muscle pain — the sensations of stiffness, aching, or even agony in muscle — is a worthy topic, whatever the etiology, however it works. So I still have a book.

I will also condemn cultish and dogmatic promotion of trigger point therapy as a panacea — which is much too common — and leave my readers with no doubt that many common practices under the banner of myofascial pain syndrome are nonsense or dangerously close to it. I am already critical of some of the worst offenders, but I will get harder still. I will get hate mail, and hateful comments on Facebook … and much of it will cite “experiences” like my own. Won’t that be ironic?

[ Short link to this post: http://saveyourself.ca/383 ]

New article today about the hot “massage reduces inflammation” story making the rounds right now:

Massage reduces inflammation? Not so fast! Some interesting new scraps of basic biology evidence are scientific miles way from proof (or explanation) of therapeutic effect.

[ Short link to this post: http://saveyourself.ca/382 ]

Iliotibial band syndrome — pain on the side of the knee, common in runners — can be a very difficult condition. One of the niftier improvements in IT band syndrome treatment in recent history is an improved surgery:

• Old way: cutting the IT band to loosen it where it presses on the lateral epicondyle of the knee.
• New way: cleaning out irritated tissue from a small pocket under the IT band.

To recap, Michels et al, a group of Belgian surgeons, performed “resection of the lateral synovial recess”: they scraped out some thin, loose, irritated fatty tissue from around a little bursa-like pocket of tissue around the attachments of the IT band to the femur at the side of the knee, right down to the bone. “The synovial recess is debrided with thermocoagulation or a synovial shaver. The resection is completed when the bone of the lateral femoral condyle is visible.”

The study was conducted primarily to test a principle:to try to prove exactly which tissues are the real source of pain, and whether the problem is tightness itself, or if the problem is an underlying issue… literally! They did not cut the IT band itself, so their results were achieved without loosening the IT band.

And their results have been extremely promising. In an updated report in 2011 — which is why I’m posting about it, because the evidence is accumulating and improving — they reported 38 of 40 knees having “good” or “excellent” results — weighted towards the excellent, 81% excellent, 16% good! All patients were back to sports within three months — and every single one of them started out with chronic ITBS. These results compare very favorably with the conventional surgery! A chart makes the difference really pop out:

My, that’s a much bigger slice of blue pie! And it’s “easy,” as surgeries go: according to Dr. Michels, the procedure is not technically demanding, and “can be performed by any surgeon with experience in knee arthroscopy” — which includes most orthopedic surgeons. For much more detailed information about ITBS surgery, purchase my comprehensive IT band syndrome tutorial/ebook.

And now: back to memorizing the great accomplishments of Arab natural philosophers, milestones on the road to heliocentrism, and the defining features of scientific methodology. All of which I am actually enjoying immensely!

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Last week on this here blog: burning Achilles tendons and burning humiliation fueled a long overdue revision of “inflammation” information. And now: the exciting conclusion to our story …

Film Fatale: Tendon!

A recent awesome episode of the podcast Caustic Soda was about the history of movie set accidents. For instance, after a stuntman was killed and eaten by a shark on the set of a 1969 Burt Reynold’s flick, the producers crassly exploited the death (“A realistic film became to real!”), renaming the film “Shark!” This is the setup for a really good tendon joke, believe it or not.

Many years Brad Pitt had a mishap while playing Achilles in 2001’s Troy. You can see where this is going. Believe it or not, he ruptured … his Achilles tendon. This prompted one of Caustic Soda hosts to suggest the film could have been renamed “Tendon!” Which made me spray milk out my nose.

The difference between classic inflammation and … and … whatever the hell is going on in tendinopathy

Last week (and last year) I explained that what’s going on in repetitive strain injuries (RSI) is not inflammation but degeneration — “rot.” Tendons can rot, and the ones under the greatest loads can rupture (mainly the Achilles tendon). It’s simple enough to explain using the wide brush: if stress begins to exceed the capacity of the tissue to repair and maintain itself, then it will starts to fall apart, obviously. (And neglected tissue degenerates, too: use it or lose it, anyone?) But the biological details of this process are hazy, and … if there’s no inflammation, why do anti-inflammatory medications seem to work? Or do they? Is there really no inflammation? Or is it some kind of pseudo-inflammation?

These are the awkward and unanswered questions that stopped the show as I was trying to get through an audiobook version of my iliotibial band syndrome tutorial before Christmas. Now for some answers. (I did a lot of reading to get the answers, by the way, but by far the two most important papers were a review of tendon pathology by Cook & Purdam and a tour of basic inflammation biology by Medzhitov.)

Classic inflammation is what we know from infections and acute lesions: the immune system is out in full force to repel microbes. An infected cut hosts a soup of cells and chemicals, and we mostly know the recipe for that soup now, but almost nothing about what’s going on in RSIs except that there is virtually no immune system presence. So RSI and inflammation biochemistry are clearly not the same thing.

But they might be related. We can’t entirely dismiss the idea of inflammation from RSIs, because the biochemistry almost certainly has some things in common with classic inflammation. With a Schrödinger's-cat-like duality, RSIs may appear to both be and not be inflamed at the same time, depending on how you look at the physiology. It’s really a bit of a word game whether or not to call the tissue disturbance of RSI “another kind of inflammation” or “something else altogether.” All that’s really certain is that degeneration is not about immune system hyperactivity, and is therefore it is unlikely to respond much to treatments intended to suppress that.

That diagram again:

If there’s no fire, stop hosing it down: treatment implications of the lack of inflammation

Given the assumption of inflammation, medications traditionally used to calm inflammation are overwhelmingly the most popular first treatment choice for RSI. If it “burns,” take ibuprofen and “cool” it down with ice. If it’s serious, inject something potent: corticosteroids. That’s the conventional wisdom, and it’s well entrenched and accepted. It never even occurs to most professionals to question it. But these medications are known as “anti-inflammatories” because of their average, typical effects on classic inflammation — on vigorous immune system activity and associated processes. How they interact with the entirely non-classic inflammatory biochemistry of RSIs is a more or less perfect and utter mystery.

So it’s hardly surprising that the collective track record of anti-inflammatory meds in this context is generally shabby and quite unpredictable, neither completely useless nor remotely reliable. To whatever extent they do work for some people, some of the time, is due to unknown and variable chemistry. I review each of the popular specific “anti-inflammatory” options in my full, free RSI article.

The most awkward example is corticosteroid injection, which certainly do have anti-inflammatory properties, in spades, and there is fairly good evidence that injecting steroids right into the heart of an RSI can help significantly in the short term (the long term is an entirely difference matter) … even though RSIs seem to lack the immune cells that steroids primarily affect. What could be going on?

• Maybe steroids don’t work as well as we think (which could be revealed by more and better testing).
• Maybe RSIs cause more immune dys/function than it looks like. This is my favourite theory. It’s not hard to imagine that even just a few well-armed neutrophils could wreak disproportionate havoc. In this scenario, RSIs are not un-inflamed, just inflamed differently.
• And maybe cortisteroids are just helping for some other reason altogether — a happy biochemical accident — because steroids have many roles in physiology.

Rot and rupture are two words you just do not want to be associated with

Alas, my own Achilles tendons appear to be quite rotten, and at risk of rupture — probably the only thing I have in common with Brad Pitt. Although unconfirmed, it’s certainly possible that my tendons could blow at any time. Degeneration of tendon proceeds through a progression of roughly predictable changes, which can be roughly divided into stages.

1. reversible irritation
2. reversible degeneration, no or low rupture risk
3. irreversible degeneration, significant rupture risk

I have progressed through all the classic clinical signs of this process. Ay best, I’m just late in stage two. Probably the best I can probably hope for is that they won't get much worse or shudder snap like old rope.

People do bounce back from stage two, and there is evidence that Goldilocks zone just-right tendon stress can hurry it along. Unfortunately, there's much less reason for optimism in stage three: ruptures are fairly common, and the treatment options are a blank spot on the science map. The hell of it is that the same cautious loading that might actually stimulate healing in stage three could provoke rupture in stage three. Now that is a tough dilemma! Philosophically, I'm somewhat inclined to carefully flirt with rupture: I'd rather try for healing and blow it (literally!) than accept near certain permanent tendon rot.

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Back then, I believed that I was “inflamed.” I was wrong. Despite everything you’ve ever heard or assumed about it, tendinitis isn’t a particularly inflammatory problem. Hardly at all, in fact.

In fact, no repetitive strain injury (RSI) is truly “inflamed” for long, if ever — not in the classic sense of the word. Inflammation that happens at the site of an infection or injury involves very different biochemistry than what’s happening in chronically overloaded tissue, which is much more degenerative in character. Inflammation is always painful and is almost always helped by anti-inflammatory medications. But the pain of any RSI is much less consistent, and mostly unaffected by anti-inflammatory drugs like ibuprofen.

I first learned and published this information in a major new article about repetitive strain injuries just about a year ago, but that was just the tip of iceberg. Even then, I knew that there was more to learn and do. In particular, if there’s no inflammation, shouldn’t anti-inflammatory treatments fail? Why do they sometimes seem to work? Like corticosteroid injections? Something wasn’t right, and I had several books and articles that needed to be updated with some kind of answer.

But I dropped the subject for a while. I needed to sleep on it … about 350 times.

Academic inspiration from pain and embarrassment

Two things got me working on my little inflammatory problem again recently:

1. the Achilles tendinitis flared up again something awful in November
2. I started reading one of my own books

That second reason is going to need some explanation.

I’m creating audiobooks, because the number one customer request I have is to get my books in [insert favourite format here]: print, audio, ePub, abridged, etc … basically whatever I don’t offer yet. So one of the big projects for my business in 2012 is to produce my books in a variety of yummy new formats. I’ve been working steadily on recording the first audiobook, about IT band syndrome. It’s a huge job, but fun: I turn down the lights, close the sound-baffling drapes, fire up the big phallic microphone,show that and … read aloud.

It’s like telling a bedtime story. About knee pain! Every child’s favourite.

It’s also a perfectionist’s worst nightmare, because reading aloud makes every glitch obvious. One of the best things about my books is that they are constantly improved and updated — a pretty cool idea for health care information. New customers always get the latest, and old ones can come back and get a fresh edition at a huge discount. The dark side? The books are never done, never truly polished. There’s always an update that doesn’t quite jibe with something older, a fresh batch of typos, or a clunky redundancy. I can’t read through the whole book every time I update a section, so all too often I’ll make a point in an update without remembering that it was already made two years ago two sections below; the dreaded You Just Said That error is fairly common. Of course, these things jump right out at you when reading aloud.

I correct things as I go, and it’s actually a terrific editing method. But all the glitches are a little embarrassing: How many people have seen THAT error now? I think with a groan.

But it got much worse when I hit the inflammation information … oh dear. Incomplete, contradictory, not up to my standards. I found myself stopping the recording in the middle of a passage, my face red, burning (ha ha) with embarrassment. I take my work seriously, and here was information I’d been selling to people in pain that really didn’t cut it. Ack.

Plus, my heels: ow!

My Achilles tendinitis has just been awful again lately. It kicked up around the end of the fall ultimate season, and was seemingly been quite aggravated by wearing my OESH shoes (which I’m very intrigued by, and this is not an indictment of the shoes — more on that later). This time I knew my tendons weren’t actuall “inflamed,” but I had a burning ha-ha personal interest in understanding the treatment implications of that — still a bit of a mystery to me after a year of procrastinating on the topic. Certainly ibuprofen (anti-inflammatory stuff) wasn’t working for me! I’m highly gut-tolerant of vitamin I — it just doesn’t seem to make me grumbly in my tumbly like most people — but it just wasn’t touching the tendinosis. For my sake — and for my readers — I realized it was time to upgrade my comprehension and go down the rabbit hole of inflammation physiology that I’d been avoiding for most of a year.

It didn’t take much reading to realize that my heels are in some pretty serious trouble, and tendinitis is anything but “simple” and boring. That idea was wrong to the point of being delusional!

The biology of pain is never really straightforward, even when it appears to be.

— “Reconceptualising pain according to modern pain science”, Lorimer Moseley

To be continued!

What’s really going on in hurtin’ tendons? Am I going to rupture? Do anti-inflammatory treatments fall flat? Or not? What does it all mean? Tune in next Monday for the exciting conclusion!

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Recently I made one of my once-in-a-while appearances on SkepticNorth.ca. I’m in their roster of reserve guest myth busters. This time Scott Gavura (the Skeptical Pharmacist) recruited me early one morning for some short-notice debunkery of a sloppy Globe & Mail piece on delayed onset muscle soreness (DOMS).

I felt like the Batman getting the bat signal, but instead of being a billionaire martial artist gadget freak called to fight crime, I’m a middle-class amateur athlete gadget freak called on to fight … bad science journalism. An endless chore. Just like Batman’s.

Anecdotes to the rescue!

The Globe & Mail sloppily recommended Epsom salts, massage, and light exercise for muscle soreness. In fact, none of those will do anything or much, just like every other alleged treatment for DOMS. There really is no cure for DOMS but time. Inevitably, we saw some anecdotal evidence to the contrary in the comments. OCTriathlete stood up for massage with this story:

I was lucky enough to receive a leg massage from a family member who is educated in massage but not a professional. However, I was unlucky in that the massage was interrupted after only one leg was complete!! The next day the leg that received the attention was only hinting at the sensation of the heavy workout the previous day. The leg that missed out? It was DEEPLY sore for 2 days. So there you have it- my own little scientific (however unintentional) experiment

Lucky him! I’ve done that experiment intentionally a half dozen times in my life — because it’s a no-brainer! — and I’ve never observed the slightest difference. If only. And in the early days I did it with the greatest of optimism and the full-on mental bias of someone paying his rent by selling that therapy. I love massage for many reasons, but recovering from a harsh workout has never been one of them.

Nevertheless, replication is the soul of science! And there’s nothing like a good scientific excuse for a massage, I always say. So I tried again.

From the Lab of Me: an experiment with a sample size of one

Purpose: To test massage-aided recovery from delayed onset (post-exercise) muscle soreness. Systemic steam heating — I have a lovely steam room at my disposal — was used as an adjunctive therapy.

Methods: I totally thrashed my biceps at the gym, deliberately pushing into the danger zone to generate wicked DOMS. It worked a charm: my guns were mighty sore by the end of the day. Soreness spiked with the slightest contraction and therefore easy to evaluate. The next morning, sensitivity was equally savage on both sides. In a toasty steam room, I massaged the crap out of my left upper arm for several minutes, using strong deep palm stroking, which was super unpleasant. The things I do for science! Then I compared soreness at regular intervals by flexing simultaneously.

Results: Soreness in my biceps was identical at all testing points after massage: 5 and 20 minutes later, and about 1, 6, 12, 24, 36, 48 and 72 hours later. The soreness was extremely intense from 24 to 48 hours, fading quickly after that — the usual pattern of recovery. And entirely symmetrical.

Conclusion: Neither strong massage or heat produced any effect on DOMS in this little guinea pig.

O anecdote — how I want strangle thee

I wonder what would happen if we took Occam’s razor to OCTriathlete’s anecdote. What is more likely?

• Massage has an incredibly potent effect on recovery — almost perfect pain elimination, the likes of which, if true, should revolutionize athletic recovery. But this miraculous effect has never been demonstrated in a fair test, and not for lack of trying.
• OCTriathlete simply had one leg that was more thrashed than the other to begin with for some reason. Or: memory and the story have come to support an attractive idea. As memory and stories do.

I know which bullet point I’d bet on.

Maybe OCTriathlete truly got a benefit. I’m being very skeptical, yes, but I’m not actually saying that he couldn’t have actually enjoyed a nice effect. Physiology differs. The evidence on massage for DOMS isn’t entirely negative — just mostly, and distinctly underwhelming where it’s positive. There could be interesting cases on the edge of that bell curve, and OCTriathelete could be one of them — slightly pulling up an unimpressive average.

But … Occam’s razor cuts hard and deep on a story like his.

If anecdotal evidence were actually reliable, then most folk medicine would still be the best medicine available today. If there are a lot of testimonials for something, people like to say that there “must be something to it,” but not only is that not true, it’s practically the opposite of true: testimonials are actually a sign of the wrong kind of thinking about medicine. The history of anecdotal evidence has given us almost every silly belief you have ever heard of: every naked superstition and outrageously dangerous quackery has had its zealots, converts, and emphatic testimonials, sometimes in extremely large numbers. People have sworn that snake oils work even as they were being (literally) destroyed by them. For a whole bunch of wonderfully entertaining examples, spend a happy hour listening to Caustic Soda’s terrific Quackery episode.

And what are those all beliefs are based on? Exclusively?

Anecdotes!

Perhaps a personal experiment like mine — an antimonial — is a just a little bit of an anecdote antidote. I love massage, but I’m not kidding myself: if it helps DOMS, it doesn’t help most people much.

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• I think it’s an excellent chunk o’ journalism
• I’m sure looking forward to the book
• it makes me I wish I’d been meaner to yoga in the past on this website
• I don’t think it’s particularly “sensationalistic” (as many yoga apologists have asserted, of course).

It’s a given that any athletic activity has both rewards and risks. (Look no further than head injuries in football for a prime example.) The problem is that risks are a really rotten price to pay for many of the the more ridiculous motives for bothering with yoga in the first place. The most cringe-inducing moment in the article is Iyengar’s assertion that stimulating the thyroid with intensely loaded total neck flexion is “one of the greatest boons conferred on humanity by our ancient sages.” That’s the worst-case scenario, and from one of the most successful yoga teachers of all time. Scary.

The closest I’ve come to any significantly yoga-critical writing is an article about the “tyranny“ of yoga. Its reputation is so strong that people think that they MUST do it, especially for back pain. I contradict that pretty strongly, but I’ll be making this article even stronger now!

The NYT article has some fun photography, which really adds to the piece.

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About a year ago, I wrote an article about some fascinating new science showing why your immune system routinely, cheerfully reacts to internal injuries where there is no possible risk of infection — a previously unexplained phenomenon from the X-files of physiology. Neutrophils are the culprits, and it turns out that they are doing it because they overzealously react to a cellular component, mitochondria, as a foreign organism. This intriguing science had great power to explain some kinds of pain. Nifty stuff. The article: Why Does Pain Hurt So Much? How an evolutionary wrong turn led to a biological glitch that condemned the animal kingdom — you included — to much louder, longer pain

This “feature” of biology is really crappy, but it gets worse. As if overzealous neutrophils aren’t bad enough, they actually get busier when you exercise moderately — the holy grail of health and fitness, the single best thing you can do for your health. This is just not fair! It’s like a horror movie monster that gets bigger when you attack it. As nicely summarized by Alex Hutchinson, a 2011 study in the journal of Medicine & Science in Sports & Exercise by Syu et al shows that:

Regular, moderate exercise boosts the ability of the neutrophils to get to infection sites quickly (chemotaxis) and attack the bad guys (phagocytosis). And in fact, the neutrophils are still ultra-alert for a couple of months after you stop training. In addition, the researchers found that regular exercise extended the life of the neutrophils.

Busier, more effective, longer-lasting neutrophils sounds great to most people, and this science has been reported widely as “good news.” But a “boost” to immune function is never as simple as it sounds or all good news, and the counterintuitive price of better infection-fighting could be vulnerability to repetitive strain injury, slower healing, and pain chronicity — by reacting more strongly to aseptic cellular trauma, as well as real pathogens.

Put these two pieces of science together, and you have an explanation for one of the great catch-22s of the human condition: exercise is good for you, but it often hurts more than it seems like it should. Athletes and active people are prone to many poorly defined aches and pains — not just the entirely predictable delayed-onset muscle soreness, which may itself be partly due to neutrophil activity, but a panoply of not-quite-injuries, undiagnosable annoyances that hurt too much for too long, but then either fade away just as you’re starting to wonder if you need to see someone about it, or they get eclipsed by something else. Many active people know all to well what I mean: pains that are more than DOMS, but less than injuries, although some of them turn out to be the early warning signs of problems that escalate and become major hassles, significantly restricting performance and competitiveness — and sometimes even driving people away from exercise altogether, because the cost is just too high.

And that cost may well be higher for some people than others. It’s hardly a reach to guess that this self-defense system is probably more active in some people than in others. Just as science has shown that certain foods really do taste unpalatably bitter to some people with unlucky genetics, it’s likely that the consequences of exercise are genuinely more uncomfortable for some people.

P.S. About immune “boosting” generally

The hopelessly simplistic claim of immune “boosting” is one of the most prevalent bogus concepts in all of quackery and health fraud, right up there with “balancing” and “detoxifying.” The immune system is far too complex to be turned up like a thermostat for general benefit, and every change in immune function has unpredictable side effects. This is an important general point that doesn’t just apply to today’s example of immune “boosting,” but basically all of them. See Dr. Harriet “SkepDoc” Hall’s excellent article, Boost My Immune System? No Thanks! Dr. Hall also posted about inflammation on ScienceBasedMedicine.org just last week.

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Biology and anatomy coolness! Stephen Levin is an orthopedic surgeon with a special interest in tensegrity biomechanics — the physics of anatomy and how living things are able to move and maintain their shapes. His website is a good starting place for reading about tensegrity, and the history page is a good introduction to the site.

Biotensegrity could seem like quite a flaky concept at first glance, and the idea has certainly been co-opted for dubious purposes over the years. Carlos Castaneda abused “tensegrity” thoroughly, and Dr. Levin writes that he has “moved to the term ‘biotensegrity’ to try and clearly distinguish what is science and what is ‘new wave mysticism’ in regards to biologic structures.” Also, many therapists claim that tensegrity has significant clinical implications, which is quite a pretentious reach, and one of the best examples of making too much out of basic biology. For instance, tensegrity comes up routinely as a vague justification for manipulating fascia (along with a lot of other nonsense). Biotensegrity is nifty biology, but it has about as much to do with hands-on therapy as quantum physics does.

Nevertheless, there is much of interest here for the true therapy geek. For example, Levin discusses the role of muscle tension in posture in some detail: Muscles at Rest. It’s mostly too technical for the average person, but a long time ago I wrote a fun, light article about some of these ideas (which I’ve just updated with this link): Ten Trillion Cells Walked Into a Bar.

“Never stand when you can sit, never sit when you can lay down, never stay awake when you can be asleep.” This succinctly summarizes the Darwinian concept of least energy expenditure and survival of the fittest. Biology will always take the easiest (least energy) way to perform a task, and all we have to do is compare which of our concepts of bodily functions is least energy requiring and that will be the most likely path of evolution.

Dr. Steven M Levin, elaborating on an old army aphorism

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A very light item, this. It’s the season for whimsy.

Warning: you may keep you trying over and over again to see if you can outsmart your foot. You probably can't. This phenomenon is pretty hard-wired into your nervous system.

1. Lift your right foot off the floor and make clockwise circles.
2. Now, while doing this, draw the number '6' in the air with your right hand. Your foot will change direction.

And there ain’t nothing you can do about it! Naturally it works with any counter-clockwise motion of the hand — “6” is just handy way of describing that.

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I call myself a science “journalist” these days, and a journalist ought to be objective. Right? I am routinely criticized for a lack of it — always by somone who disagrees with me. And sometimes I am praised for my neutrality — always by someone who agrees with me. But I am not impartial on any of the controversial questions in my field, I’ve never met anyone who is, and I don’t aspire to it. This is the best explanation of trouble with objectivity I’ve ever found:

In pro journalism, American style, the View from Nowhere is a bid for trust that advertises the viewlessness of the news producer. Frequently it places the journalist between polarized extremes, and calls that neither-nor position “impartial.” Second, it’s a means of defense against a style of criticism that is fully anticipated: charges of bias originating in partisan politics and the two-party system. Third: it’s an attempt to secure a kind of universal legitimacy that is implicitly denied to those who stake out positions or betray a point of view. American journalists have almost a lust for the View from Nowhere because they think it has more authority than any other possible stance.

Jay Rosen, The View from Nowhere: Questions and Answers

“Objectivity” is mostly a pretentious delusion. Beware of experts who lay claim to it. Look for someone with the View from Somewhere — from someone who isn’t afraid to disclose their biases.

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When I sit down to write every day, I’m trying to imagine that I’ve got to explain difficult concepts in pain, injury and rehabilitation to Homer Simpson.

Sometimes extreme simplification is unavoidable.

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“Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review”
Steiger et al. European Spine Journal. Epub ahead of print. Nov 2011.

Does spinal function improve in low back pain patients who exercise? Does it improve in the way that it should? It certainly ought to — that’s one of the core assumptions of core training. In this 2011 analysis of trials, researchers hunted for correlations between clinical outcomes and spinal functional performance, but found little or none. Even when patients felt better, their backs didn’t work better… not even (and this is important) in terms of spinal functions that were allegedly specifically related to the type of back pain they had. If well-designed exercise plans for the right kind of patients actually improved spinal function as “advertised” by advocates, there should have been much clearer signs of that here. As back pain researcher Neil O’Connell put it, this data “suggests that if there are specific subgroups for whom exercise therapies have benefits, then the improvement in those subgroups was not likely due to the suggested ‘active ingredient’ of the exercises given.”

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Recovery from repetitive strain injuries like iliotibial band syndrome or plantar fasciitis often require what feels like an unreasonable amount of resting. People resist adequate resting for all kinds of reasons.

There is a particularly common objection to the suggestion to rest thoroughly: the fear that you will “go to pot” or get critically out of shape. (This fear is often expressed by the most fit people, who are in the least danger.)

You certainly won’t “go to pot” in a month. Or two. Or even six. And all the more so because there are plenty of ways of staying in shape while protecting and resting your injury. But you certainly will go to pot if you never heal. First things first. It takes what it takes. And the only thing worse than having to rest for a while is failing to heal entirely. In general, you have to be healed before you can maintain or develop fitness, let alone optimize it.

(If you’re worried about getting fat specifically, there are many experts saying loud and clear that calorie intake is by far more relevant to fatness than exercise. Just eat less when you’re not exercising!)

It takes what it takes…

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This is a reprint and (significant) revision of a short article from late 2009. It never made it into the low back pain tutorial, as intended.huh?In theory, I write updates for my tutorials and major articles and share some of the highlights in the form of blog posts. I call it “blogging the process.” In practice, I often end up just writing a blog post, and then realizing, months later, than I forgot to actually use it in a book or article … by which time I often want to revise it … It is now officially a new short chapter for that book. However, it is also relevant to recovery from nearly any pain problem …

The opposite of rational, informed confidence is “wishful thinking” — and it is the single biggest threat to the health care consumer. When you’re in pain, it’s too easy to hope for a cure where there are only promises. Snake oil salesmen know this; in fact, they depend on it. They know that people are particularly vulnerable to wishful thinking when they’re suffering, and they exploit it. It’s a particularly scummy flavour of intellectual dishonesty.

The most familiar example of a rational, informed confidence cure is when you go to a good doctor frightened by a strange and unpleasant symptom, and she compassionately chuckles and authoritatively explains why you have nothing to worry about: the condition is common and easily treatable. She spells it out for you, and it’s obvious that she’s probably right: she is speaking from plenty of direct experience. If she says it’s not a big deal, it probably isn’t! You walk away not only with some “real” medicine … but you are almost certainly feeling much better before you even take it.

That’s not the “placebo effect,” even though similar forces are involved. A placebo is based on a deception. But there’s no sugar pill in this scenario.

There are various ways that the confidence cure works its magic on patients in pain, but the main one is that “pain is an opinion” (Ramachandran) and “100% of the time, pain is a construct of the brain. ” (Moseley). No matter what is happening in our bodies, it is the brain that decides how dangerous it is and whether or not it hurts and how much. Authoritative reassurance changes the pain equation in a meaningful way. In fact, it literally changes the meaning of your sensations. This is why it is increasingly considered real therapy to educate patients about how pain works: to deliberately induce a confidence cure.

Pain freaks people out. Many common painful conditions are characterized by strong patient fear and anxiety that — sadly — does not get relieved, because so few health professionals understand them well enough to offer credible reassurance. For instance, in the case of low back pain, fear is usually well out of proportion to the true severity or dangerousness of the problem — and not only are attempts at reassurance tentative and ineffective, many health care professionals will actually scare the patient by reinforcing any number of common, ominous-sounding myths about low back pain.

Effectively, properly reassuring a patient in pain does not create a “placebo,” per se — it’s not fake medicine and a comforting lie. There’s a genuine therapeutic effect there, but it’s based on rational, informed confidence.

But placebo also has a “genuine therapeutic effect,” doesn’t it? Aren’t we always hearing about the “power” of placebo? In both cases, the patient has been led to believe that they are going to be fine, and that belief in turn can actually reduce pain and suffering: so what’s the difference? Why is it fine to aim for a confidence cure … but sugar pills are ethically verboten? It’s complex, but the medical ethicists have been working on that question for a long while now, and there’s a strong consensus — it’s not okay to fool patients. In treating pain, there’s a particularly good reason for that.

A placebo is not a long term solution!

Placebo is not so powerful after all. Much of what is labelled “placebo” is actually just the appearance of an effect created by statistical and research glitches, and what remains is relatively trivial. Dr. Steven Novella:

Placebo effects are mostly just as much an illusion as precognition or talking with the dead. Pain is the notable exception, which makes physiological sense. Pain is a subjective experience, evolved to have adaptive features that are highly situational. There are times when pain should be very bothersome, and other times when it’s more adaptive to be able to ignore pain. So it is no surprise that mood and expectation have highly influence the reporting of pain.

So to the extent that you can change people’s moods and expectations about pain, they really will experience less pain and suffering — but often that is still not much better than an illusion. The big problem with placebo for pain is not just that it’s ethically wrong to get it by lying to patients, even for their own good, but also that it doesn’t work very well. The therapeutic problem with “fooling” people with a pure placebo is simply that most people rarely stay fooled for long! And then they usually end up more hurt and scared than ever before.

And bitter.

But if you can get the same soothing effect on pain without lying, not only are you morally safer, but — and this is the important part — you also get a much more robust effect.

For instance, consider the example of a true snake oil, a therapy that is expensive and totally bogus. (It’s so tempting to give examples! But I’ll steer clear of that, so that the point isn’t derailed by controversy. Or manufactroversy.) Initially, a placebo effect will be powered by mostly the charm and conviction of the seller, and the desperate hopes of the patient. But most patients — even many of the suckers — have that little voice pestering 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 it’s a bogus therapy. That’s when hope rapidly turn to ashes — so much for that nice placebo effect.

The beauty of an ethical confidence cure is that you get a much more lasting effect — one that is much less likely to be taken away from you later by the discovery that you were being ripped off, or just told what you wanted to hear. That’s the difference: a placebo is not a long term solution, but rational confidence based on good information is. And it’s a huge difference. Therapy must not induce placebo through disingenuous means, or using that weak sauce to justify treatments that have no other effect.

Knowledge reduces uncertainty, which reduces stress and anxiety, which reduces pain. It is the job of shamans, not health care professionals, to bullshit their way into a placebo effect for their clients.

[ Short link to this post: http://saveyourself.ca/369 ]

Alex Hutchinson’s science journalism on exercise is a perfect fit for SaveYourself.ca. If I were trying to focus on exercise science as a writer, I might just give up, because Alex already has it so well-covered. Fortunately, there are many classic exercise topics I am thrilled to leave to him, rather than tangling with them myself.

I just bought his new book, which looks fantastic: Which Comes First, Cardio or Weights?: Workout myths, Training truths, and Other Surprising Discoveries from the Science of Exercise. I have no doubt that I will be citing it regularly for a while.

Alex blogs quite steadily at Sweat Science.

[ Short link to this post: http://saveyourself.ca/368 ]

Some of my books are on “niche” topics — injuries and pain problems that are generally neglected by researchers and authors. For instance, you can find countless summaries and short articles about iliotibial band syndrome (runner’s knee), but my big tutorial on the subject stands alone as the only book-length exploration of the subject. There has been nothing else anywhere close to that detailed for many years now, let alone anything in the style of good quality science journalism.

The “competition”

Contains “chapter after chapter of boilerplate about things like how to find a doctor…”

I keep a close eye out for new competition in those niches. A while ago I noticed that a new book about iliotibial band syndrome had appeared on Amazon, The Official Patient's Sourcebook on Iliotibial Band Syndrome. I made a note to myself read it, and hopefully learn something — had someone finally written something that might compete with my tutorial? Or at least complement it? When I returned recently to buy it, I found the following review:

Complete ripoff. This is not a book about Iliotibial Band Syndrome, even tho the title would lead you to believe it is. The book contains a few sentences about IBS, and then chapter after chapter of boilerplate about things like how to find a doctor, or how to research nutrition, how to use a library. I am astonished that the publishers had the gall to publish such a ripoff.

I didn’t waste my money verifying this: the world is already awash in scammy, useless information about this problem. For instance, to this day the execrable www.itbs.info — ugly, wrong, unmaintained for years — still bizarrely tops Google’s search results for “iliotibial band syndrome.” I have no doubt this “book” on Amazon is just as pointless and misleading as the reviewer says it is.

[ Short link to this post: http://saveyourself.ca/367 ]

The risks of head banging. Recently the excellent science and skepticism podcast, the Skeptic’s Guide to the Universe, covered a bizarre study of the effect of prayer for patients who were already dead — “retroactive remote intercessory prayer.” It turned to be spoof research, part of a tradition of semi-serious studies of absurd topics in the Christmas edition of the British Medical Journal. (Papers that get taken seriously with alarming frequency.) And then, completely by coincidence, I found this:

“Head and neck injury risks in heavy metal: head bangers stuck between rock and a hard bass”
Patton et al. British Medical Journal. Volume 337, Number , pa2825. 2008.

It turns out that head-banging, “a popular dance form,” constitutes “a definite risk of mild traumatic brain injury” and the study “helps to explain why metal concert goers often seem dazed, confused, and incoherent.” I can think of other reasons! Part of the reason I wanted to share this beautiful piece of science is that I grew up in a youth culture dominated by heavy metal — a small industry town in northern Canada, Prince George. I was surrounded by head bangers, and they were definitely dazed, confused, and incoherent. And worse! But there is a strong possibility that the daze preceded the heavy metal in many cases.

The risk of neck injury also increases with head banging intensity — although less than one might expect, which we can infer from the way people are able to keep doing it.

And repeat…

Unsurprisingly, head-banging can cause both neck injuries and brain injuries, which might why heavy metal music fans seem dazed and confused. And yet the neck tolerates it surprisingly well, and injuries are more rare and minor than you might expect, even with much more violent neck movement than most people ever do. Good perspective!

•

Circus-freak neck anatomy. The Amazing Owl Man! You don’t see this every day. Enjoy this campy, cringe-inducing bit news reel about a dude who can “owl” his neck — rotate 180˚ degrees! — if we can believe our eyes:

What are we to make of this? Is this anything more than an eye-popping novelty? I have no idea how he can do that, but can I extract some clinical relevance from it anyway? Natürlich! (As my high school German language teacher used to say.) A couple points:

• This is a fine example of anatomical variation. The point of that article is that professionals tend to focus too much on the variations they can see (or think they can) while “invisible anatomical oddities are probably the cause of many stubborn and severe cases, and probably makes some of them virtually impossible to recover from.” For every case like this owl-necked dude, there are probably a hundred less dramatic and obvious examples of funky anatomical variation. (And even he had to work at it.)
• At the same time, it’s also a fine demonstration of how even substantial anatomical abnormality and grossly extreme vertebral movement is not necessarily painful or problematic. If this guy can do this with no ill effect, it generally soothes our worries about much subtler “misalignment” or degeneration. According to most chiropractors, we all live in constant danger of impingement of our spinal nerve roots, and that we must pay through the nose to keep our spines “in line.” In fact, as this example shows, nerve roots actually have a lot of wiggle room. Obviously this is a weird and special case, but it’s also hardly the only way that we know that nerve roots are generally quite hard to pinch.

Of course? What if he actually broke his neck doing that? What that pinch any nerve roots?

•

True dislocation without symptoms. The patient pictured here, as reported in New England Journal of Medicine, had no “pain, weakness, or parasthesia”!

Traumatic dislocation.

For perspective, here’s an example of a spine that is genuinely “out of line.” Although this is a serious dislocation, the patient was quite healthy. See Akhaddar.

A similar case report in the journal Spine describes a man who was born with part of a neck vertebra entirely missing. He also had no serious symptoms until he fell one day, and his unstable spine was dislocated. After that he certainly was symptomatic: he had “severe” pain. However, he had only pain, and no neurological symptoms.

[ Short link to this post: http://saveyourself.ca/366 ]

As I work on my own video series, I’ve started to pay more attention to what other people are doing with video. Laura Allen is a massage therapist and writer in Rutherfordton, North Carolina. I got a kick out of her folksy 3-minute debunking of a classic massage myth. Laura’s no-nonsense southern twang and well-chosen words are perfect for this job!

How many massage therapists are still out there telling their clients that massage gets rid of toxins in the body? On any given day on Facebook, I see about half dozen people at least making that claim … Would you maaahnd sharing with us exactly how that happens?

— Laura Allen, Massage Therapist, writer

Massage isn’t the only place toxins come up, of course. Massage therapists should avoid using the term if only to put some distance between their profession and more common and serious abuses of “toxins.”

The idea of “toxins” is usually used as a tactic to scare people into buying snake oil of one sort or another. It’s not that there’s no such thing as a toxin — obviously there are toxic substances in the environment. The problem is the kind of people who toss the idea around, and the reasons they do it (profit), and the inevitable lack of any specific claim or scientific evidence to support it. “Detoxification” may be the single most common marketing buzzword in alternative health care, and yet exactly which toxins we’re talking about, or exactly how they are disposed of, is never explained by anyone selling a product that supposedly detoxifies — because they don’t know. For more information, see “Detoxification” Schemes and Scams (from QuackWatch.org).

And see also: Should You Drink Water After Massage? Only if you’re thirsty!

[ Short link to this post: http://saveyourself.ca/364 ]

Tim Arndt, BS, RTSM, CSCS, and all round rational fitness dude

Tim Arndt is a rare sort of professional: a rational trainer and fitness counsellor, genuinely interested in what the science says, and happy with a good debunking. And Lord knows there’s plenty need for debunking — in the fitnessverse, there’s more even more myths than in the therapyverse!

And so he loves it here, of course. Because I’m all about the science (click to chuckle). After discovering SaveYourself.ca, he was keen to interview me for his blog (www.MatrixFitEd.com/blog). I had fun answering his questions about what I do and why I do it, and it reads quite well.

[ Short link to this post: http://saveyourself.ca/365 ]

Q: In your stretching articles, if I am not mistaken, you have mostly discussed it based on its effect on the muscle (kinda), but do you think it could have any positive effect on tendons? I have read a textbook about sports training and its effect on the human body, and it says that stretching can be good for the tendons before training.

A: Yes, my main stretching article mostly discusses muscle and not tendon, although it’s important to note that muscle and tendon, although quite distinct, blend together quite seamlessly. Much of what we think of as mucle is an extension of tendinous tissue, and vice versa. It’s impossible to draw a line where tendon stops and muscle starts, and if stretching doesn’t do much to muscles, it probably doesn’t do much to tendons either. Most likely a “positive effect” of stretching on tendons is minimal or nil.

But … what kind of effect? We would have to very precisely define what “good for” actually means! This is a common problem: “good for” is often much too vague a concept.

Q: I know this isn't helping much but I remember it said something about aligning the weaker/used parts of the tendon with the stronger/less used parts of the tendons, and in that way it could reduce the chance of tendon ruptures occurring.

A: Okay, that is an example of what “good for” might mean … but it’s extremely implausible.

In general, tissues are stimulated to growth and repair by the same forces that they normally have to deal with (and also the same forces that occasionally overload and overwhelm them and cause overuse injury or trauma). In general, that stimulus is dished up far more efficiently and thoroughly by normal (and athletic activity) than by any isolated deliberate exercise therapy.

Cells inside of tendons generate collagenous fibres and absorb others as needed in response to stresses, constantly remodelling and tweaking the tendon so that it is optimized to cope with the actual stresses it encounters all day, every day. (Organisms always act on the assumption that the immediate future will probably be similar to the immediate past — that doesn’t always work out, but it’s a pretty good rule of thumb.)

However, tendons are quite static compared to other tissues, and remodelling is slow and “conservative” — a sort of “if it ain’t broke, don’t fix it” policy? — so they are not going to remodel much or quickly. Even a very strong stretch to a tendon constitutes an extremely brief input of stimulus relative to the context of an entire day or week of normal usage of the tendon. It probably takes months of regular, consistent, and significant new stresses for a tendon to change.

For comparison, consider how bone remodels — and bone is much more dynamic and responsive than tendons are. If bones are subjected to strong new stresses, they will change, slowly but steadily getting thicker and tougher in just the right way to cope with that stress. But it takes a lot! Now, how much do you suppose you could influence that process by deliberately applying a force to the bone? Even a fairly heroic twenty-minute application per day — far more than anyone would ever bother stretching a single tendon, or pair of tendons? And even if it could work, what are the chances that the deliberate application of force would be a good enough “simulation” of natural biomechanical stresses that it would elicit the desired, relevant adapation? A simulation might be good enough in principle in some cases, but in general it’s just not going really be very much like the stresses that the tendon actually has to deal with in the real world — and therefore fundamentally inefficient way of preparing for it! If it works at all.

About alignment … the specific notion that tendon stretching will “align” its fibres is a particularly dubious and overly optimistic concept. Tendons are well nigh impervious, rupture only with extreme forces (and/or when already compromised), and change only in response to long term “just right” overloading. It’s relevant to understand that they are so tough that they are the strongest link in the chain, and in many cases they will tear away from their moorings on bone (avulsion fracture) before the “rope” breaks. For a mere stretch, collagen fibres don’t line up obediently any more than they already are — tendons are, in general, have impressively well-aligned microscopic orderliness to begin with.

It’s also extremely important to note that study after study after study has shown no injury prevention benefit to stretching — that’s covered exhaustively in the stretching article — and that would include tendon injuries. Tendons are clearly not getting injured any less frequently in people who stretch a lot.

If you want to reduce the chances of your tendons rupturing, then the way to do it is to expose them to a bunch of activities. Push the envelope just a little: enough that they are challenged, but not brutalized! Just the right amount of stimulation.

Got your own questions? Fire away.

[ Short link to this post: http://saveyourself.ca/363 ]

Just for fun — and to experiment with recording and prepare for producing audiobooks — I recorded an audio version one of my favourite articles, A Stretching Experiment: What happens when you stretch your hamstrings intensely for several minutes a day in a steam room?

A Stretching Experiment
Audio Edition — MP3 format — 21MB 

Meanwhile, I’m now about half way through recording the first of eight audiobooks. It’s a long job, but once you get rolling it’s pretty simple. Every day or two, I just park myself in front of the microphone for an hour or two and read!

Me & Kim, at Vancouver Co-op Radio

I have some history with audio and radio work. Back in 2002 I was part-time host of a Friday night co-operative radio show called Loose Canons. Each week we did an hour of anything on a theme — total creative freedom. Also: a buttload of work for no pay. I gave it up to focus on freelancing for the Canadian Broadcasting Corporation … and massage therapy.

[ Short link to this post: http://saveyourself.ca/362 ]

New toys: One of the many little things hold up production was the quest for an iPhone tripod mount — trickier than you might think, given the number of iAccesories in the world. The SnapMount works great, and it’s cheap like borscht.

Video and audio production work is proceeding steadily here at SaveYourself.ca World HQ, wherein “steadily” means “just as fast as one guy and a part-time subcontractor with a mischievous toddlershow off can possibly manage.” I’m investing a lot in upgrading my production methods … and it’s better to get these things right ASAP, so there’s a certain amount of endless getting ready going on.

While you patiently wait for more, the original IT Band myths video has now been “remastered” — like a Star Wars movie, but with a smaller budget and a smaller ego — and re-released as individual myths: #1, #2, and #3. And #4 is out (see below). And #5 is in progress.

Why did I “remaster” the videos so far? Viewer satisfaction with the original version was satisfactory. Comments poured in, such as “I have never seen a video about IT band myths” to which I would add “this good.” Some people said some other things. Regular readers (now “viewers”) generally agreed that I hadn’t particularly botched it or anything, and it’s possible that I was even a little bit clever with the animations and all that jazz. Nevertheless, in video there is always room for more improvement than you can afford:

• Fonts are now larger and readable on small screens.
• Colour saturation has been fixed — the original was pathetically washed out, thanks to a really annoying Mac video bug.
• The long-winded introduction explaining who I am and several other things no one actually cared about except me, has been replaced basically by me saying hello. (Despite my best efforts to respect that the internet does not have an attention span, I was unable to resist the dreaded yada yada yadas in my first attempt.)
• Arcane video production problem solved.
• Another arcane video issue addressed.
• Still more video production weirdness dealt with. (P.S. Shove it, Adobe.)

The fifth, due to be released incredibly soon now — practically by the time you are done reading this, I would think, or at least by Christmas — will introduce some new production methods, such as live action! That’s right: you are going to have to look at me while I talk about IT band syndrome.

The current myth videos series

Video #4 is a video version of the article, Does Hip Strengthening Work for IT Band Syndrome? If you really want to master the subject, read the article:

[ Short link to this post: http://saveyourself.ca/360 ]

No, really, you will actually laugh — it’s like stand-up comedy. Australia’s Lorimer Moseley, Professor of Clinical Neurosciences and tireless pain researcher, is one of the best public speakers I’ve ever seen, and this is a must-watch video for anyone with chronic pain (and the professionals who care for them). Does he say “groovy” just a couple times too many? Maybe! But it is groovy … mate.

Highlights from the video

It’s entertaining, but it’s also serious. As Lorimer points out, chronic pain is an enormous social and medical problem, costing Australians (and everyone else) much more than several other common pain problems combined. Understanding pain really matters, and there’s some extremely important wisdom about pain in this video. Here are three quotes that jumped out at me:

How do we convince people in pain that we understand that they are in pain but it’s not just about the tissues of their body? A key conceptual shift that we think is really important is that you can understand that pain is the end result, pain is an output of the brain, designed to protect you … it’s not something that comes from your tissues.

This all becomes really important when pain persists … the brain cells that produce pain get better and better at producing pain. They become more and more sensitive…

Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on it’s own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain.

I laughed out loud at that last one, and then cheered. I’ve been bitching about those blasted models for years. Long before I’d ever heard of Lorimer, I’m proud to say. (What really gets me cranky about them is that the damned things aren’t cheap, and once a clinician has purchased one, it is likely to stay in his or her office for years, probably even decades. I’m sure there are probably hundreds of thousands of them in offices around the world that are at least twenty years old, and lots of clinicians are still buying new ones right now! Aaaaagh! Maddening!)

But wait, there’s more…

While you’re at it, see also Body In Mind and Lorimer’s 4-minute video introduction to that excellent organization and website. Much of what you see here on SaveYourself.ca is strongly influenced or inspired by BiM research and articles: they do the “heavy lifting,” and I translate and integrate their insights into my articles and tutorials. Not that they aren’t quite capable popularizers themselves!

In the video, Lorimer mentions that it would be fun to do an experiment with a pain knob that “goes to eleven” (reference to the classic mockumentary, Spinal Tap). That’s an image I actually commissioned to be illustrated (by Gary Lyons) for SaveYourself.ca several months ago … and here it is!

[ Short link to this post: http://saveyourself.ca/359 ]

How can you trust health information online? Everyone knows you should look for footnotes and citations! But even when you see them … are those citations any good? Do you have time to check? Would you even know what to look for if you did?

Citations get used, but I see a lot of problems, up to and including the dreaded “backfire citation” — a citation that actually undermines the point instead of supporting it. An awful lot of bloggers cite with all the scholarly sophistication of a hungover undergrad. (Possibly because they are hungover undergrads.) They just cherry pick whatever “source” seems to say whatever will back up their point. Or includes some words that seem relevant.

Recently xkcd genius Randall Munroe did a (typically brilliant) job of explaining why so many online citations aren’t worth the pixels they are made of, and total bollocks can be perpetuated in perpetuity:

Comic from xckd, by Randall Munroe.

Here in the Salamander’s domain, citations are harvested and hand-crafted masterfully from only from the finest pure organic heirloom artisan fair-trade sources. If I had a TV ad for this, there’d be oak barrels and a kindly old Italian gentleman wearing a leather apron and holding up sparkling citations in the dappled sunshine before uploading them to ye olde FTP server.

For more about bogus citations like the big reach and the backfire and the name drop, see:

[ Short link to this post: http://saveyourself.ca/357 ]

“Iliotibial band syndrome: an examination of the evidence behind a number of treatment options”
Falvey et al. Scandinavian Journal of Medicine & Science in Sports. Volume 20, Number 4, p580-7. Aug 2010.

This is a paper about stretching the IT band. The ominous threat of IT band “tightness” is the basic assumption behind much of the conventional wisdom for treating IT band syndrome (runner’s knee). In particular, patients and professionals by the millions believe that pulling on this structure is a good use of their time and energy. However, in 2010, Irish researcher Dr. Eanna Falvey and her colleagues found some hard anatomical evidence that is hard to square with that conventional wisdom.

by Gary Lyons

How much does the standard IT band stretch actually “elongate” your IT band?

They started by scrutinizing IT band anatomy in corpses.

For instance, they checked and confirmed that, yes, the IT band really is “uniformly” and “firmly” attached to the thigh bone, “from greater trochanter up to and including the lateral femoral condyle” — in other words, the full length of the thigh. (This fun fact of IT band anatomy was first identified by Fairclough et al in 2006.)

The IT band does not slide around.

Then they carefully measured the mechanical effect of a basic IT band stretch (like the standard one illustrated at right) plus a more sophisticated stretch. A “good” IT band stretch — if any such thing exists — is hard to pull off, and people tend to neglect key components like knee flexion. But suppose you did everything right: how much would you actually change the length of your IT band? How far would it move?

About 2 millimeters — an overall change in length of less than half a percent.

In other words, the IT band was effectively unaffected, making it one of the unstretchables. And that was including knee flexion, in a stretch carefully applied to corpses by anatomists! If that doesn’t move the IT band, certainly runners don’t stand a chance.

And so, unfortunately, conventional iliotibial band stretches, prescribed and described practically everywhere — even the better ones — are simply not able to do the job. And that’s assuming it’s even a job worth doing (which is another major can of worms, which I open in the full IT band syndrome tutorial).

[ Short link to this post: http://saveyourself.ca/356 ]

I have been casually collecting tools for self-massage for many years. It never ceases to amaze me how just the right texture or shape can seem to make all the difference — great sensory satisfaction from subtle differences. Although I use tools to treat my own “muscle knots” (trigger points), my enthusiasm is quite independent of any clinical concerns: whether it “really works” and why. I loved the sensations of massage long before I was massage therapist, and although I am now retired from that work, I continue to collect massage tools and experiment with them.

Interestingly, several of my favourites all come from the same place: The Pressure Positive Company. I think perhaps they share my obsession with massage tools, because they make a bunch of good ones. Here are my impressions of several of their inventions (and one they just distribute) …

Read more …

[ Short link to this post: http://saveyourself.ca/355 ]

This an entirely personal post, which will mostly interest my regular readers, friends and family. However, I do like all visitors to SaveYourself.ca to know that this is a small business. In fact, it all fits in one tiny room — which took two years to convert from a massage therapy office to a writer’s office.

This is quite a visual post and really best to read it online.

[ Short link to this post: http://saveyourself.ca/354 ]

Eating collagen to maintain your cartilage? Pharmacist Scott Gavura for ScienceBasedMedicine.org:

From a dietary perspective, your body doesn’t care (and can’t tell) if you ate a collagen supplement, cheese, quinoa, beef, or chick peas — they’re all sources of protein, and indistinguishable by the time they hit the bloodstream. The body doesn’t treat amino acids derived from collagen any differently than any other protein source. For this reason, the idea that collagen supplementation can be an effective treatment for joint pain, osteoarthritis, or any other condition, is highly implausible, if not impossible in principle.

This is an issue with several nutraceuticals and supplements: regardless of whether or not we need them, it may not be possible to get them by eating them.

This is why many drugs have to be injected: because digestion destroys them, you have to put them right into the blood stream so that they can be used by the body. Some substances can be eaten and absorbed, but many can’t. “Bioavailability” is a significant problem with the logic of several popular nutraceuticals.

[ Short link to this post: http://saveyourself.ca/353 ]

Spotted on a T-shirt:

To save time, let’s assume I know everything.

That would be more convenient … but I suppose it would defeat the purpose of this website, which is to check all assumptions rather carefully.

I laugh, but this is actually how some people act, of course. There's a noisy “expert” that I regularly encounter on Facebook who is the embodiment of this, er, slogan. He wants to tell you how it is, and he wants you to take his word for it — he invariably refuses to elaborate or substantiate, because he’s simply too busy and expert for that. Not too busy to have posted his opinion in the first place, mind you. But too busy to back it up!

[ Short link to this post: http://saveyourself.ca/352 ]

All too often, massage therapists respond to healthy criticism of their assumptions about their work in a defensive way, equating criticism with insult. Here is how one massage therapist (and one of my readers) responded to that attitude in an online discussion:

The research and subsequent change in some massage beliefs is not to make therapists feel belittled or inferior … it's about making us more knowledgeable, therefore making us more professional and better respected.

— Choice Kinchen, massage therapist, Your First Choice Massage, Midvale, Utah

This is exactly the right idea. It is not expressed nearly often enough, or firmly enough. If massage therapy is to be taken seriously, then massage therapists must take science, research and continuing academic education seriously.

There is no room for amateurism in health care.

[ Short link to this post: http://saveyourself.ca/351 ]

Is yoga good for back pain?

After the publication of a new study, everyone seems to think so but me. Probably because I am a cranky yoga-hating jerk. (That’s a joke. I actually rather like yoga.)

Recently I posted a triptych of scientific smackdowns of stretching for common goals like injury prevention and soreness (see Herbert, Kay, and Pereles). It was all bad news.

I am becoming well known as Mr. Wet Blanket — to the point where most of my hate mail starts with some variation of “Don’t you believe in anything?” I think my job is to try to understand and report whatever is true, or as near to it as I can get, even if it’s disappointing. As if believing in something was the goal of health care! Nevertheless, even I get tired of all the bad news, and so I try to make a point of being positive. At the end of the triptych post I wrote:

Stay tuned for discussion of some mildly good news about yoga and stretching for back pain …

Not such good news after all

I take it back! As I looked into this hot science story, it got steadily more disappointing. “Mildly good news” was quite the understatement. Proof of the existence of a trivial benefit is really not good news. Proving that something barely works is (literally) almost the same as proving that it doesn’t work at all. This is a chronic problem with many allegedly effective treatments and therapies for pain: they may work a little, but they fail to impress.

The yoga study in the news right now is the second of a pair by the same group (Karen Sherman, Daniel Cherkin, et al.), one in 2005 and a new one, both comparing yoga to other therapies. It has been widely reported as “stretching and yoga work for low back pain,” with only a few writers emphasizing the interesting point that yoga performed no better than stretching. However, there’s an entirely neglected angle: I haven’t seen anyone report that both stretching and yoga are equally damned with faint praise by this study, and — worse yet — even that modest praise is quite possibly an illusion due to a significant weakness in the design of the study.

Yoga fails to beat stretching or other exercise in a fair fight

The new experiment compared how back pain might be affected by:

• yoga classes
• normal stretching classes
• reading an educational booklet

And the same research did almost exactly the same thing in 2005, with essentially identical results, but instead of the normal stretching class they used:

• conventional therapeutic exercise classes

Both yoga and stretching seemed to be somewhat effective, but neither was any better than the other — which is a bit of a blow to yoga pride. I feel a bit glum about it myself. I rather like yoga, personally, and it would suit me just fine if it could kick some regular stretching-class buttinsky in a fair fight. Alas, no — apparently they are pretty well matched.

Equally modest effects of both yoga, stretching and exercise

In the new study, the impact of both yoga and stretching was modest: really only just detectable. About a 2.5-point difference on subjective scale to 11 is a pretty weak sauce. Exercise classes did about as “well” in the 2005 study. Some people might even say that it’s too much hassle to go to a bunch of yoga classes (or stretching classes, or conventional exercise classes) for such a modest benefit — better to just take in a few extra episodes of Big Bang Theory while nature takes its course! Yoga isn’t entirely risk-free, and if you take a class it also takes time and money.

An important point here is that these results are completely consistent with a strong general pattern we see in low back pain research: if patients do almost anything to help themselves, or receive any kind of therapy — it doesn’t seem to matter what — then they tend to get better a bit faster at first, then levelling off into the same slow but steady recovery pattern that nearly everyone experiences with or without treatment. For more about that, see Neil O’Connell’s short article, Back pain: It ain’t what you do it’s ….?

Lack of blinding and the frustrebo effect

More subtle still — this science stuff is hard — a sneaky “frustrebo” effect could well account for the apparent modest benefit here. Frustrebo effects are caused by a lack of blinding: everyone knows who is getting what kind of experimental treatment, which means that they can all be biased about it, skeptical or optimistic or disappointed, and such biases definitely matter in research like this.

The stretching group was probably a frustrebo-free zone, but the reading group was likely afflicted with it at least a little, because those poor souls consigned to a rather dreary arm of the study, deprived of either a lovely stretching or yoga experience. They might well have reported more negatively and/or actually had a slightly worse outcome … thus creating the illusion of small benefit to both stretching and yoga in comparison. If frustrebo accounts for even a portion of the reported effect of yoga and stretching, that would pull them below the level needed for any clinical significance.

To yoga or not to yoga?

So where does that leave us? Despite the distinct lack of encouragement from science so far, there are many reasons why people may choose to do yoga that have nothing to do with whether or not it speeds along the average case of chronic low back pain. A good list of other benefits — like the fact that it’s just good exercise — plus low risks and costs, plus the potential for certain types of yoga to be more effective in some cases, all keep yoga in the “worth a shot” category.

Nevertheless, yoga is definitely not proven effective for low back pain by this new study. Other writers are mentioning the problems with the study’s design like an afterthought, while they (or their editors) put the “good” news in the headline, while the flaws and concerns are pushed below the fold, if they are mentioned at all. I refuse to ignore the fact that there is not only a significant weakness in the study, but the kind of thing that could make both yoga and stretching seem more effective than they really are. I’d like to think my response is not “negative” but just “honest.”

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Fancy medical machines

… which produce a stupendous number of diagnostic red herrings.

Gina Kolata for the New York Times:

The pitchers were not injured and had no pain. But the M.R.I.’s found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says.

And …

“It is very rare for an M.R.I. to come back with the words ‘normal study,’ “ said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. “I can’t tell you the last time I’ve seen it.”

No kidding. I’m not sure I’ve ever had a conversation with someone about their MRI that didn’t involve speculating about the significance of something the scan revealed.

Although I’ve noticed a bit of an uptick in MRI awareness in my mail bag, generally speaking patients are still overwhelmingly fixated on and concerned about whatever their MRI showed as the “obvious,” objective, dire cause of all their pain … and no one seems to have so much as hinted to them that it might not be quite that cut and dried.

This comes up most often in the context of back pain, and I discuss the overdiagnosis of “mechanical” and MRI-able problems in great detail in that tutorial.

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Are you sure this is worth your time?

The evidence continue to accumulate: stretching does not do what people hope it will do. Here we have three interesting recent papers — two large reviews, and a huge clinical trial — showing that stretching does not reduce post-exercise muscle soreness, does not reduce the risk of injury, and does not enhance muscle performance … three of the classic common reasons for stretching. None of this is a surprise. Much of the science covered by the reviews has been around for a quite a while. It’s all just more reinforcement for a theme that has been loud and clear for a long time now.

Stretching for muscle soreness?

“Stretching to prevent or reduce muscle soreness after exercise”
Herbert et al. Cochrane Database of Systematic Reviews. Number 7, pCD004577. 2011.

Does stretching help either before or after exercise to reduce soreness? Still no. This large review of many scientific studies concluded with a clear thumbs down: “The evidence from randomised studies suggests that muscle stretching, whether conducted before, after, or before and after exercise, does not produce clinically important reductions in delayed-onset muscle soreness in healthy adults.”

Stretching to enhance performance?

“Effect of Acute Static Stretch on Maximal Muscle Performance: A Systematic Review”
Kay et al. Medicine & Science in Sports & Exercise. ePub ahead of print, Jun 8, 2011.

Are there benefits to pre-exercise muscle stretching? Still no. In this huge review of the scientific literature, researchers looked at more than 4500 studies before choosing about 100 to look at more carefully. It’s no surprise in 2011 that they showed a pattern of “overwhelming evidence that stretch durations of 30-45 seconds … imparted no significant effect.” A little more surprising was that they also found some evidence that more thorough stretching reduces muscle strength. I wouldn’t take this too seriously, but it certainly emphasizes the lack of benefit: if anything, it swings the other way. “The detrimental effects of static stretch are mainly limited to longer durations (≥60 s) which may not be typically used during pre-exercise routines in clinical, healthy or athletic populations. Shorter durations of stretch (<60 s) can be performed in a pre-exercise routine without compromising maximal muscle performance.”

Stretching to reduce injury?

“A Large, Randomized, Prospective Study of the Impact of a Pre-Run Stretch on the Risk of Injury in Teenage and Older Runners”
Pereles et al. www.usatf.org. June 15, 2011.

Does pre-workout stretching reduce risk of injury? Still no. As the title promises, this is an unusually large study of pre-run stretching, with more than 2700 participants, and decisively finding “no statistically significant difference in injury risk between the pre-run stretching and non-stretching groups.” Injury rates for all kinds of injuries were the same, with or without stretching. It’s almost as though stretching made no difference at all. But make up your own mind! (This paper is not quite ready for prime time, and is not yet published in a journal, but you can read the whole thing.)

All of these papers are not cited and integrated into my own thorough review of stretching. Read much more here:

Quite a Stretch — Stretching research clearly shows that a stretching habit isn’t good for much of anything that people think it is.

Stay tuned for discussion of some mildly good news about yoga and stretching for back pain. Meanwhile, if you like, get started reading about it on Sweat Science — and take note of my initial thoughts.

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Not long ago — inspired by a comic strip — I wrote about how a lot of research results are reported in a way that makes them seem more “significant” than they really are. Statistical significance doesn’t mean much on its own, but it gets lobbed around like a synonym for “important.” I described an example of a recent study of chondroitin sulfate, one of the major nutraceuticals. It’s results were statistically significant, but small — clinically trivial.

That’s significance error #1, and it’s a surprisingly common bad science “trick” or truth bender. It works well and fools a lot of people — sometimes, I think, even the scientists or doctors who are using it — because the usage of the term “significant” is often correct, but just not the whole story. It’s a subtle and technical lie of omission.

I knew that. And yet apparently I didn’t know the half of it. It gets much worse: a lot of so-called “significant” results aren’t even technically correct. And that’s today’s topic: significance error #2.

A widespread, stark statistical error

This bomb comes from a recent analysis of neuroscience research. A number of writers have reported on this already. It was described by Ben Goldacre for The Guardian as “a stark statistical error so widespread it appears in about half of all the published papers surveyed from the academic neuroscience research literature.” Dr. Steven Novella also wrote about it for ScienceBasedMedicine.org recently, adding that “there is no reason to believe that it is unique to neuroscience research or more common in neuroscience than in other areas of research.”

And it is not. Dr. Christopher Moyer is a psychologist who studies massage therapy:

I have been talking about this error for years, and have even published a paper on it. I critiqued a single example of it, and then discussed how the problem was rampant in massage therapy research. Based on the Nieuwenhuis paper, apparently it’s rampant elsewhere as well, and that is really unfortunate. Knowing the difference between a within-group result and a between-groups result is basic stuff.

I will add a diagram to the reporting: something sorely missing from the other explanations I’ve read. It’s not a particularly difficult error to understand — which makes it even stranger that it seems to be so common — but some visuals are quite helpful. In a sense, it’s more of a logical error than a statistical one: statistics about the wrong numbers. I will also explain why this error matters more in studies of massage therapy and chiropractic, and other therapies with lots of interactions.

A significant difference … between the wrong things

Clinical trials are all about comparing treatments. To be considered effective, a real treatment has to work better than a fake one — a placebo. A drug must produce better results than a sugar pill. If the difference is big enough, it is “statistically significant.” There are a lot of details, but that’s the beating heart of a fair scientific test: can the treatment beat a fake?

What you can’t do is just compare the treatment to nothing at all and say, “See, it works: huge difference!” The problem is that both effective medicines and placebos can beat nothing — it doesn’t mean much until you know the treatment can also trounce a placebo. On its own, a “statistically significant” difference between treatment and nothing at all is the sound of one hand clapping, not so much incorrect as just incomplete (but a statistics professor would certainly flunk you for it). A meaningful comparison has to be a statistical ménage à trois, comparing all three to each other (analysis of variance, or ANOVA). The error is the failure to do this: Nieuwenhuis reported that more than half of researchers were comparing treatments and placebos to nothing, but not to each other.

Massage is better than nothing! Too much better …

Studies of massage therapy are particularly plagued by this error. Why? Because massage is so much “better than nothing.” The size of that difference looms large, and so it’s all too easy to mistake it for the one that matters — and fail to even compare the treatment to a placebo. And it’s really hard to come up with a meaningful placebo. It’s notoriously difficult to give a patient a fake massage. (They catch on.)

Statistics does not care about these difficulties: you still can’t compare massage to nothing, stop there, and call the difference “significant.” You still have to do your ANOVA, and massage still has to beat some kind of placebo before it can be considered more effective than pleasant grooming.

This research problem is not limited to massage, but massage is probably be the single best example of it. It crops up when you’re studying any treatment that involves a lot of interaction. The more interaction, the worse the problem gets. It’s a big deal in massage research because massage involves a lot of interaction, much of which is pleasant and emotionally engaging. Interaction with a friendly health care provider has a lot of surprisingly potent effects: people react strongly and positively to compassion, attention, and touch. The problem is that those benefits have nothing to do with any specific “active ingredient” in a massage. Grooming is just nice. It’s like pizza: even when it’s bad, it’s pretty good.

Much of the good done by therapists of all kinds is attributable to potent placebos driven by their complex interactions with patients, and not by anything in particular that they are doing to the patient. To find out how well a therapy works, it must be compared to sham treatments which are as much like the treatment as possible. This is hard to do, and it has rarely been done well. It’s much more typical to compare therapy to something too lifeless and “easy to beat,” to much like comparing it to nothing at all instead of a real placebo. And there’s the difference error: comparison to the wrong thing, statistical significance of the wrong difference.

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I have always really paid for my workouts. I get DOMS (delayed onset muscle soreness) something awful, and always have — some unsolved mystery about my biochemistry. It starts soon after a run or a game of ultimate, and last 2-3 days. The only thing that helps is being as fit as possible at all times: if I take a break, it will be nasty when I get back to it. After griping to my (excellent) doctor about this recently, he recommended that I try arginine supplementation. Why?

Amino acids and healing

Both glutamine and arginine are abundant non-essential amino acids (protein building blocks). Both are needed for tissue repair, which is the basic reason for thinking they might help with exercise recovery. There is not much reason to emphasize arginine over glutamine, since the rationale for using both is pretty similar — and similarly weak, as their clinical effects are generally complicated and under-studied.

Glutamine is the most abundant non-essential amino acid in the body, much of it stored in muscle. Both glutamine and arginine can become depleted in people recovering from major injury and illness, in which case they are regarded as “conditionally essential” — that is, essential during emergencies, when there’s a great deal of tissue rebuilding going on. For this reason, glutamine especially is used medically to treat the critically ill, but the value of this is still scientifically controversial. Arginine is used less, mostly because of safety concerns.

Extrapolating from that extreme (and sort-of medically endorsed) usage, athletes and bodybuilders take a lot of the stuff because they believe that their exertions may be so harsh that they run low on amino acids in the aftermath, and they hope that topping them up will help them repair and build muscle. However, it is unlikely and generally implausible that healthy athletes are ever glutamine depleted in the first place, and therefore it is also a bit unlikely that they can benefit from supplementation for this reason.

There are other possible reasons. Both of these amino acids, and a few others, generally have a mess of barely understood properties which might be relevant to exercise performance and recovery, such as stimulation of growth hormone production, or dilating blood vessels. Guessing about how this stuff works out in the real world is basically gambling with your biochemistry, though.

State of the research for arginine and glutamine supplementation

Basically, it’s poor. Both glutamine and arginine supplementation appear to be faith-based, not evidence-based.

I spent about a half hour this morning poking around for glutamine/arginine science on the web and PubMed, and determined only that they are nearly unstudied in the context of athletic performance. 99% of search results are places to buy the stuff, with another .9% being blog posts enthusiastically recommending it because “research has shown” that it works (almost always mentioning what research). I was unable to find any thorough critical analysis of either (although MayoClinic.com has dry but thorough evidence summaries for both).

There’s some encouraging scraps of basic science about both amino acids, but even their medical usage — glutamine for critically ill patients — remains controversial because the evidence is incomplete and conflicting. So there’s really no hope that we will know any time soon what, if anything, either of these substancs do for something as trivial as a little bit of exercises muscle soreness after exercise.

(Update shortly after publication: someone pointed out a clinical trial of glutamine for DOMS, with promising results. Interesting, will investigate.)

Meanwhile, there are numerous safety concerns for chronic supplementation of either. For glutamine “neurological effects were the most frequently observed,” and arginine is “associated with death in certain groups of heart patients.”

Glutamine and arginine are just two of several nutraceuticals I have reviewed. For more information about other nutraceuticals, like glucosamine and chondroitin, see: Do “Nutraceuticals” Help Arthritis and other Aches and Pains? — Debunkery and analysis of supplements and food-like medicines (nutraceuticals), especially glucosamine, chondroitin, and creatine.

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We are, each of us, a multitude. Within us is a little universe.

— Carl Sagan

I came across that quote recently, and it was an obviously perfect fit for a couple old favourite articles:

• We Are Full of Critters: The human body is a colony of ten trillion co-operating cells
• Ten Trillion Cells Walked Into a Bar: A humourous and unusual perspective on how, exactly, a person is even able to stand up, let alone walk into a bar

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My analysis of fascia science continues with a 2006 paper showing that fascia has muscle cells in and can contract. This topic needed a little more work, so I’ve made it into a new article:

Does Fascia Contraction Matter? — The contractile properties of fascia are probably real, but biologically unsurprising and clinically trivial.

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Finally! This work has been postponed basically since the earliest days of my career as a writer in this niche. I’ve been “meaning to get around to that” for literally several years now. No longer. The first video is done.

Feedback

My readers and customers always think of things I didn’t, and see problems I missed. Please let me know what you think of this first effort. A lot more videos are coming, so the sooner I work out the kinks, the better.

“People like to watch videos”

Jason Snell, a MacWorld editor and a writer I’ve followed and admired for years, recently published a video of himself messing around with Apple’s intriguing new “Siri” voice command tech for the iPhone 4S. The video got a lot of traffic and attention, particularly because Siri is generally amazing, but still makes just the sort of amusing, mockable error you might expect: taking Jason’s dictation, Siri typed “iPhone 4 ass” instead of “iPhone 4S.”

The amazing iPhone 4 Ass

So cute! Steve Jobs would have laughed. And then fired someone.

The next day, Jason tweeted this:

Lesson learned: People like to watch videos. Siri, remind me to make more videos.

That’s why I’m now (finally) getting serious about producing videos for this website: video is taking over the internet, because people love it, and I cannot ignore it any longer.

Plus, it’s fun to work with. Fun and hard work …

A ridiculous amount of work

Animation was an ambitious video style to start with, but I chose it because it’s good at punctuating concepts in a way that no amount of “talking with my hands” can pull off. (And I’m camera shy.) This video is just eight minutes long. How long do you think it took to bake those eight minutes?

1. 8 minutes
2. 8 hours
3. Way, way more.

Number 3 is the correct answer: about 35 hours, spread out over a couple weeks, which rough equals about three hours of production effort per minute of video. Yoiks.

I will speed up. This first project involved significant initial investments and one-time only setup jobs, learning curves as steep as cliffs, and major production experiments and mistakes that I will never have to do again. For instance, I had to hang draperies on three walls of my office to prevent echoing — a significant, one-time-only detour. And I had to learn to do serious work with new equipment and complicated software I’d only ever tinkered with before.

The tech and gadgets

The video was made primarily with Apple’s Keynote, which is great for syncing animations to a voice track, and then stitching sections in iMovie. I recorded with a Blue Yeti USB mic — an impressive piece of equipment that can do things that no consumer mic was capable of a decade ago, when I was doing radio work. Back then, that kind of mic would have cost thousands.

Throughout production, I was impressed at how I have upped the ante yet again for the amount of computing power and storage I need. For years I have had “more Mac than I need,” because I’m a tech hobbyist and I like things to run as smoothly as possible. But this job really needed computing power, and it was a pleasure.

The Blue Yeti USB mic

This type of microphone used to cost ten times more, and was only seen in professional environments. These days? Just $165 from London Drugs. (All microphones are kind of phallic, but this one, sheesh…!)

Amazing search results

Videos will always outrank articles on Google, all other things being equal. Or so I’ve heard. This is one of the best reasons to publish videos — Google promotes them. In less than an hour of publishing this one, Google put it on the first page of results searching for “it band myths.” That’s astounding. Jaw-dropping. The results weren’t as good for less specific searches, but still … the fact that it appeared at all, and within the hour, is quite remarkable.

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Protandim is a currently popular nutritional supplement or “nutraceutical” that supposedly helps people with pain and, well, almost literally anything else. It is backed by some physiological plausibility — it’s an antioxidant — but that’s about it. In a new article for ScienceBasedMedicine.org this morning, Pursued by Protandim Proselytizers, Dr. Harriet Hall once again summarizes the (lack) of evidence that Protandim helps people. There’s still only one human trial of this stuff … and still none that have anything to do with pain.

Note that there have been no human clinical studies since the one in 2006. The newer studies are just more animal and laboratory studies, so they do nothing to change my previous conclusion. If I were a mouse being artificially induced to develop skin cancer in a lab study, I might seriously consider taking Protandim. But so far, the only study in humans measured increased antioxidant levels by a blood test but did not even attempt to assess whether those increases corresponded to any measurable clinical benefit, for cancer or for anything else.

Dr. Hall also shares some of her contents of her mail bag about this stuff. It’s illuminating, and good for a chuckle. Note that Dr. Hall also has an article about antioxidants in the current (Volume 16 Number 4) print issue of Skeptic Magazine, “Complexities of Antioxidants.” See also my main article on nutraceuticals for more information on similar products, likecreatine, chondroitin sulfate, glucosamine, and several more: Do “Nutraceuticals” Help Arthritis and other Aches and Pains?

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“Effects of massage on pain, mood status, relaxation, and sleep in Taiwanese patients with metastatic bone pain: A randomized clinical trial”
Jane et al. Pain. Volume 152, Number 10, p2432-42. Oct 2011.

Does massage therapy help patients with the grinding, deep pain of bone cancer? This Korean study in the journal Pain — nicely randomized, controlled, and a little bigger than small with 72 patients involved — compared the efficacy of massage therapy to “social attention.” That’s a good comparison, because it is likely that being cared for and attended to is one of the most important factors in the perceived (and actual) value of massage therapy. To know if massage itself is the “active ingredient” in massaging cancer patients, it’s got to do better than that. This comparison is rarely done in massage studies, and it should be done more often.

Researchers looked for effects on “pain, mood, muscle relaxation, and sleep quality,” and the results were encouraging across the board. Compared to people who were “just” given social attention

the reduction in pain with massage was both statistically and clinically significant, and the massage-related effects on relaxation were sustained for at least 16–18 hours post intervention.

Every little bit counts

It’s unlikely that the effects were sustained for long after that. Short-lived relief is a common problem with massage, and it is not all that impressive with problems like chronic low back pain, where treatment results need to last to be meaningful. With the severe pain of a serious and possibly fatal disease, however, any real relief is a genuinely big deal to the patient. As an example, such a massage could literally give a patient one of the only and most pleasant moments of their treatment process — or even of the remaining days of life.

Something to write home about

Another interesting note here is that the benefits were both “statistically and clinically significant.” As I’ve explained here before, it’s unfortunate how often we see positive experimental results reported as “significant” when it means only statistically significant but clinically insignificant — meaning the experiment showed a real but trivially minor effect. (See: Trivial but statistically significant: A lot of research makes evidence seem more “significant” than it is.) In this case, the benefits were probably both real and worth writing about. Unfortunately, even when benefits are reported as both significant and meaninfully large, they may still be wrong, which is why we always need so much research to confirm even the simplest things.

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Dr. Grumpy

Three recent-ish migraine items from cantakerous neurologist blogger, Dr. Grumpy:

• News flash: nasuea makes migraines worse! And other news of the obvious.
• If only I could have more migraines …
• As rude as it sounds: “I went down on Saturday. I had to do it in front of my kids, too.”

And a delightful patient quote of the day, which I will share in full here:

The pain went down through my legs. Not all my legs, I mean, but just the ones on the bottom of my body.

And if you think that’s weird, you should see my inbox. (And that is why I shy away from email diagnosis and consultations, despite being more or less constantly asked to diagnose and consult. Readers send me “descriptions” of their pain problems, routinely with the considerate disclaimer that they “don’t expect a diagnosis,” when what they really mean is, “I realize I can’t hold you to it, but I want a diagnosis anyway.” Many of them are articulate and give perfectly nice descriptions. Many more are sworn enemies of articulate, and my chance of having a clue what they are talking about based on their email is approximately zero percent. And so it goes.)

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Reebok is being forced to issue refunds for its “toning” shoes, because the American Federal Trade Commission decided that their advertising claims were just a little bit too absurd. Stay classy, Reebok! And well done, FTC! The all gives me a lovely dose of schadenfreude at Reebok’s expense.

So what’s this all about? Well, there’s a bazillion news stories about it right now, but I found a beefier article on AceFitness.org that covers the science rather well … just how I’d do it if I took the time (and if I was leading a team of PhD authors): Will Toning Shoes Really Give You a Better Body?

No.

And there’s the other reason I didn’t do it — because the whole thing goofy, and deserves curt dismissal. As Alex Hutchinson of Sweat Science put it:

The problem is that it’s very hard to write a science-of-exercise column on something so devoid of science. Or to look at it another way, it’s very easy, but the column ends up being two sentences long …

Still, I’m glad John Pocari and colleagues went to the trouble to debunk toning shoes. What a tremendous and richly deserved smackdown!

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