Pseudo-quackery in Chronic Pain Care
A field with a large gray zone between overt quackery and evidence-based care in musculoskeletal medicine
updated Dec 20, 2017 (first published 2010)
by
Paul Ingraham, Vancouver, Canada bio
Not all quackery is obvious — not even to skeptics. Subtler snake oil is actually a more serious problem in musculoskeletal health care, because it’s harder to spot and much more common, even mainstream. Such “mild” quackery probably generates just as much false hope and wasted time, energy, money — and even harm.1
Rank, obvious quackery
If you want your quackery strong, like a stiff shot of whiskey, you can find plenty of it: the care of aches, pains and injuries is rife with alternative treatments that are experimental at best, and probably too good to be true.
- A homeopathic Arnica montana ointment, with barely any actual arnica in it, is one of the most popular remedies in the world.2
- Reiki “masters” wave their hands over injuries and diseases, almost literally trying to wish them away.3
- A sizeable sect of chiropractors sell the idea that adjusting the upper cervical spine can cure not only low back pain, but all disease.4 And they accuse physicians of arrogance!
These are some of the superstars of scientifically dubious treatments in alternative health care, and they’re relatively easy to spot and avoid. Many people are doubtful about these treatments, and many chronic pain patients in particular know all too well how little they have been helped by this category of care.5 You don’t have to be a card-carrying skeptic to know that some promises sound too good to be true.
But what if quackery isn’t so obvious?
Some surprising medical advice: “The last thing you need is therapy”
When my wife was severely injured in car accident in 2010 — fracturing her skull and brain, spine, pelvis, arm, and foot — her physiatrist (a doctor specializing in injury rehabilitation) gave her some surprising advice:
Don’t bother with any physical therapy. That’s the last thing you need. You mainly just need rest, and general activity when you can handle it. Maybe in a while go a couple times and get a little coaching and course corrections, but mostly it’s a waste of time and money.
Harsh! But not without justification — this is the cost of some serious and well-document backwardness in physical therapy.6 Many or even most mainstream rehabilitation options and treatments are based on some really antiquated ideas, and offer surprisingly little evidence-based bang for the buck-per-minute. It isn’t “quackery,”
per se, but it certainly falls far short of good, modern care with proven benefits.
Sneaky quackery
Many common treatments exist in that disconcertingly large, messy gray zone between overt quackery and proven, uncontroversial medicine. Probably the best examples are
ultrasound and
transcutaneous electrical stimulation (TENS): mainstream and extremely popular, but bombarding injuries and pain with sound waves and electric current is nowhere near as evidence-based a treatment as most people assume.
Many of these treatment are considered legitimate and mainstream even though they really aren’t any more useful than snake oil — or are just barely so. The gray zone is large because there is precious little that we can actually do to help people in pain or to facilitate healing. Not much “works.” Pain and rehabilitation science is still distressingly, exasperatingly primitive.7Things are getting better,8 but much of what we have learned has been alarmingly slow to influence clinicians. As Zusman wrote, “for reasons somewhat difficult to comprehend the message does not seem to be getting through.”9
Not much works? Citation needed! I won’t make the case in detail here (
many other articles delve into the disappointing science), but if I had to pick just a couple key citations:
Even “simple” overuse injuries continue to present surprising scientific difficulties. For instance, it turns out that tendons are
not just boring ol’ gristle after all, but impressively clever “bio-rope” with physiologic complexity undreamed of 25 years ago12 — and the only thing that’s clear is that we don’t understand the biology well enough to treat tendons effectively.
For lack of well-tested treatment methods, physical therapists, chiropractors, and massage therapists routinely sell treatments that would be considered experimental in most other fields of medicine. But patients generally have no idea when they have entered this gray zone of therapeutic guesswork, because pseudo-quackery treatments aren’t ridiculous on their face, and some of them are even interesting and promising. So what makes them dubious?
- debatable plausibility
- absence of (good) evidence
- overconfident prescription despite the lack of evidence
by
Dave Coverly, www.speedbump.com
Shruggers: ideas of average quality
A lot of treatment ideas are not very plausible, but plausibility is hard to nail down. One person’s plausibility is another’s eye-roller. I know of a lot of
allegedly plausible treatment ideas that have some merit — I wouldn’t say that they are out to lunch — but neither do they really impress me. I call them “shruggers” — ideas worth testing, but mostly pointless to debate except out of intellectual curiosity. A shrugger always has at least a couple fairly obvious problems with it.
Manual therapists (and doctors too) have a lot of shruggers: untested, or barely tested, or badly tested. Here’s a bunch of examples that I think fall into this category. Some readers will think several of these are obvious quackery, while others will be outraged that I’m suggesting they are candidates. This only emphasizes the point: they are in the gray zone. I’ve added more detailed explanatory footnotes to several of the more informative examples, highlighted.
- foam rolling
- prolotherapy13
- ultrasound, especially extracorporeal shockwave therapy14
- taping15
- transcutaneous electrical nerve stimulation (TENS)16
- education therapy
- spinal decompression17
- BOTOX
- trigger point therapy in general,18 but especially dry needling19
- platelet rich plasma injection20
- low-level laser therapy21
- Functional Movement Screening22
- intrathecal pumps
- spinal manipulation therapy23
- opioid medications24
- orthotics25
- vibration
- digital motion x-ray26
- muscle relaxants
- NMDA receptor antagonists for back pain
Not much evidence + plenty of confidence = sure, why not?
If a pseudo-quackery treatment was properly
proven to be effective one day, then it would no longer be any kind of quackery. If it were proven to be bogus (“evidence of absence”) then it would be demoted to full quackery. But an unstudied shrugger? What’s that?
“Good enough,” apparently.
Pseudo-quackery gets pimped out to patients for many years or even decades, with confidence ranging from “not much” to “extreme.” But it most cases it will be pushed as a “promising” treatment, with varying degrees of informed consent, but offering usually just slight nod to the lack of evidence. And in quite a few cases, it will be sold as real medicine, exactly as though it was already proven, not a word of doubt expressed. In quite a few cases, experimental medicine will be sold as real medicine, just exactly as though it was already proven, not a word of doubt expressed.This is especially the case with the more expensive electro-therapies, where a freelance professional has spent as much as hundreds of thousands of dollars on a piece of “medical” equipment, and
must sell treatments
hard to pay for it. Shockwave ultrasound and spinal decompression machines are superb examples.
Absence of evidence alone does not pseudo-quackery make, of course. Some of these things probably
are medicine, and they will eventually be proven. But the degree to which we just can’t say is a bit shocking. The stock introduction to scientific reviews of virtually all treatments is “there is insufficient evidence to draw conclusions.” This does not apply only to the stuff in left field: we’re talking about the bread and butter treatments of mainstream physical therapy — interventions that consumers and insurers spend billions on every year — as well as stranger and newfangled stuff.
Embrace the uncertainty!
It is said by some that health care would be paralyzed if we could dispense only proven treatments — as alt-med evangelists and critics of evidence-based medicine delight in pointing out.27 Unproven therapies are particularly unavoidable in my former profession: as a massage therapist, I literally could not move a muscle in my office without doing something unproven. What’s an ethical practitioner to do?
Here are simple instructions for converting pseudo-quackery into ethical therapy in just moments:
- Look patient in the eye.
- Take a deep breath.
- Recite the mystical incantation, “I don’t know if this will help you.”
I could protect my patients from my own ignorance only by proactively and candidly emphasizing it. Anything less would have been unethical.
Unfortunately, just saying “I don’t know” seems to be a dying art amongst self-employed therapy mongers. The almighty dollar is the main problem. Most manual therapists are freelancers, and their rent only gets paid when patients return for more. This is all it takes for many practitioners to recommend unproven treatments with just a bit too much enthusiasm. Even just a little bit of normal human ego can do it.
It’s dangerous because it’s not very dangerous
Pseudo-quackery can be mild-mannered and humdrum. No big deal, really. But that’s exactly why it goes largely unexamined.
It is routinely perpetrated by average professionals suffering from a little confirmation bias and a lack of familiarity with the scientific literature. In no case are these people true quacks in the sense a hardened skeptic would use the word — they’re just ordinary professionals who can’t read journals all day long and have bills to pay. Even skeptical patients routinely spend thousands of dollars on false hopes in the gray zone, often spending years in the “therapy grinder.”Their confidence in unproven therapies spans from apathetic assumptions to premature enthusiasm to over-the-top marketing zeal.
And yet if it isn’t the job of a therapist to be openly humble in the face of our awesome ignorance of what really works, then I don’t know what is.
Despite its ho-hum personality, pseudo-quackery is a clear and present danger, particularly to chronic pain patients. Even skeptical patients routinely spend thousands of dollars on false hopes in the gray zone, often spending years in the “therapy grinder,” hammering away expensively at a condition that there was never really much hope of treating in the first place.
Chronic pain patients often feel desperate, and it’s not wrong to cautiously try an experimental treatment method. But very few methods are anywhere near as promising as their marketing makes them seem. Be cynical. Be careful. And beware of professionals who haven’t gotten the memo: humility in treating chronic pain is not just a nicety, but an ethical necessity.
