Why so many terrible treatments are still being provided in physiotherapy?
by Paul Ingraham, PainScience.com founder
Healthcare for persistent pain and stubborn injuries is still rather primitive, not only because of its late arrival but because it has been too free to “wing it” for too long. The bleeding edge consists not of good science, but the speculations and experiments of both desperate patients and opportunistic cure purveyors. Vast numbers of professionals still work almost exclusively with obsolete conventional wisdom — ideas that predate the increasingly golden age of research in musculoskeletal health care that is finally underway. Ideas that can still be found in the textbooks, making progressive professionals who know better roll their eyes.
A reader wrote to me in the grips of justifiable outrage about a string of egregiously incompetent healthcare professionals he’d encountered while trying to rehab an injury. It was all routine nonsense from my perspective — unfortunately, I such stories frequently— but he was in a state of disbelief that so many so-called professionals could possibly be so amateurish. “Why is there so much ignorance in musculoskeletal medicine?” he asked.
So many factors! A sampling …
- Professional pride and tribalism, ideological momentum, screwed up incentives.
- The love of “advanced” methods and technological gadgets — like laser therapy — which has generated so much pseudo-quackery.
- Near universal ignorance of the history of science, critical thinking skills, and the cognitive distortions and limitations that blind us all … like emotional reasoning, confirmation bias, the human weakness for oversimplification and “common sense,” and looking only where the light is.
- The obscurity and difficulty of newer and better ideas, especially the major physiological factors that we’re still learning about (tip of the iceberg). Neglecting these has become unforgivable over the last twenty years.
The biggest problem is probably “structuralism”: a simplistic overemphasis on visible and measurable signs of abnormal anatomy, position, and movement, all of which ignoring extensive evidence that these things are not what drives injury and pain. Chiropractic, osteopathy, and massage therapy are especially prone to this, but it’s impossible to overstate how dominant it is. Even in physical therapy and sports medicine, we still see an amateurish industry-wide simplistic obsession with “alignment,” posture, and biomechanical imperfections and fragility. No matter how technical and fancy this gets, it all still basically boils down to blaming what we can see (structure) over anything else (like physiology). It’s all mostly barking up the wrong tree.
We have seen laudable attempts to move beyond structuralism, but unfortunately that isn’t working out very well either. Now we have legions of “progressive” professionals overemphasizing the power of the mind, demonizing and overemphasizing stress and anxiety — which are relevant, but rarely the root of the problem — and generally trying to blame patients for their pain while trying not to sound like it.
There’s also a litany of even more embarrassing ideas and distractions, especially in chiropractic and massage therapy: some really archaic alt-med stuff, all kinds of vitalism, and much worse. Acupuncture, the darling of alt-med, a therapy even many skeptics gave a pass to for a long time, is now all washed up, the domain of cranks, flakes, and the naive.
Modern medicine has also generally failed patients, with benign neglect, endless useless surgeries (cited above), and extensive pharmaceutical jiggery pokery — like the unmitigated disaster of the opioid crisis. [[Ingraham. Opioids for Chronic Aches & Pains: The nuclear option: Oxycontin, codeine and other opioids for musculoskeletal problems like neck and back pain. PainScience.com. 4924 words. ]]
And so … people with unexplained chronic pain bounce around the medical system like they are in an evil pinball machine of disappointment, serially misdiagnosed and mistreated and condescended to, often never finding a single doctor or therapist who recognizes the actual problem, or — having at least recognized it — has a clue what to do about it.
Some “getting the word out” reading
- Biology is destiny. A lot of pain is caused by obscure medical problems. For every easily diagnosed cause of pain, there are a dozen that are much trickier! See 38 Surprising Causes of Pain.
- The science is a mess. Most scientific trials in musculoskeletal medicine are junky, and a high percentage are even worse (egregious pseudoscience, fraudulent, etc). See 13 Kinds of Bogus Citations and Studying the Pain Studies. More broadly speaking, it’s shocking how primitive musculoskeletal medicine, orthopedic surgery, and pain science all still are. See A Historical Perspective On Aches ‘n’ Pains.
- Surgery is the ultimate placebo. Most orthopedic surgeries are based on tradition, authority, and the faith of surgeons, and have not been properly tested in a well-designed clinical trials. Of those that have, many could not outperform placebo, and many more will probably fail in the future. •mind blown•
- Stretching is the king of popular-but-ineffective treatments. Practically everyone thinks they should stretch, but it’s mostly a waste of time that doesn’t do anything people hope it does, other than feel good.
- The value of “clinical experience” is over-rated. It’s deeply at odds with science and evidence, and it’s a terrible way to figure out what works. “Success rates” are not something individual clinicians can actually know, and it wouldn’t constitute validation of methodology even if we could. Clinical outcomes are affected by a dazzling number of confounding factors. Most importantly, clinicians have a badly skewed sample: patients tell them about perceived successes much more than failures.
- Posture is by far the most over-rated factor in chronic pain, and a professional preoccupation with posture is amateurish. Any therapist who starts a session with a “postural scan” should be fired. See Does Posture Matter?
- The “power” of placebo is badly misunderstood and overhyped.
- The controversy over the nature of trigger points (unexplained sore spots) is a legitimate, ongoing scientific controversy. It should not be a closed topic, as argued by some critics.