PainScience.com Sensible advice for aches, pains & injuries
 
 
Picture of red flags, symbolizing the red flags that indicate quackery.

Quackery Red Flags

Beware the 3 D's of quackery: Dubious, Dangerous and Distracting treatments for aches and pains (or anything else)

updated
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com

I have been studying and weighing the pros and cons of treatments for many years now — every imaginable way of helping all kinds of pain problems and chronic injuries. Always, the most important question to ask is, Does it work? But that can be hard to answer … and there are some other reasonable questions. The choice boils down to the same handful of priorities over and over again: even if it isn’t proven, does it at least make sense? Is it safe? Cheap? Reasonably convenient?

Many unproven treatments get a pass this way: they might not work any miracles, but they are still effective, safe, and/or cheap enough to be “worth a shot.”

And then there’s the ones that probably aren’t …

Treatment trouble illustrated

Many treatments are quite dubious (implausible), or particularly distracting (time consuming, costly), or somewhat dangerous … or even all of the above. This Venn diagram illustrates the intersection of these considerations.

Pain is often a tough problem, and there are no perfect treatments for it. The diagram aims to illustrate the concerns that we should juggle — not just knock everything.

The worst possible treatment would score strongly on all three Ds. Fortunately no common pain treatments are quite that bad, but my examples all have problems — at least two Ds, to some degree — that are often denied or ignored by the people selling and using them. And yet many of them are widely available, popular, packaged and promoted attractively and aggressively.1 And many of them come from giant, greedy industries. Supplements, for instance, are nearly as big an industry as pharmaceuticals, and amazingly unregulated.2 Make no mistake: selling false hope is big business.

About footnotes. There are 18 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942. ← That symbol means a link will open in a new window.
Try one!

Dubious!
Implausible & disproven, or just really underwhelming

Dubious treatments require your mind to be so open that your brains fall out. Some may be hopelessly at odds with solid science or even logic. Or they may be too good to be true, supposedly good for “all pain” and other delusions of grandeur. Many started out as “a good idea at the time,” but have simply not panned out — either don’t work at all, or not well enough to take seriously.3

Classic examples of implausible treatment

The most implausible therapies are detox scams and homeopathy,4 and the ultimate in disproven therapies are a lot of popular supplements5 and acupuncture (more about needles below).

Dangerous!
Risks of harm to body & mind

When people innocently ask “what’s the harm?” there are usually answers they’ve never thought about.6 “Natural” is not always good, and often it isn’t even safe.7 By definition, anything that actually has any effect can also have too much of an effect, and some treatments are just inherently more hazardous. Bizarrely, history is actually packed with examples of popular but extremely dangerous treatments.8 There are also serious underestimated risks in the delicate business of treating chronic pain — pain-wracked nervous systems may respond very poorly to “intense” therapies and fear and worry.9

Classic examples of harmful quackery

A variety of unusually intense manual therapies, such as high velocity spinal adjustments or really strong massage, like old-school Rolfing and other “deep” styles. Many medications involve well-known and significant risks, of course.

Distracting!
Proper care neglected due to time & money spent elsewhere

Distraction is another kind of danger, but I set it apart because it’s the one people tend to forget about, and it encompasses a wide range of non-medical hazards, particularly the hazard to your wallet and your schedule. People will tell me they’ve “tried everything,” but when we break it down it turns out they’ve really only made an investment in, say, five things — three of them were expensive, dangerous and/or dubious, while the fourth actually interfered with the only good choice of the bunch, leaving the patient broke, frustrated, in more pain than ever, and believing that their problem is too difficult to treat. This is a bad situation — and tragically common. “Distraction” can be serious, even lethal.10

Classic examples of distractions from proper care

Strengthening is common distraction,11 one of the more common forms of the wild goose chase to achieve postural and structural correctness — often taking a great deal of time and money that could have been much better spent.12 Stretching is another time-consuming and mostly useless approach to fixing pain problems.13 Chiropractors are legendary for selling long, expensive treatment plans.14

Vintage “electric bath”

A triple threat: dangerous, distracting & dubious! Source: olden times.

About the (imperfect) examples in the diagram

Each example represents a particularly strong combination of two of the three D’s. It’s not an exact science.

Not all of the examples are condemned as entirely useless — such treatments would belong at the heart of the diagram! I deliberately chose not to include examples that probably do belong there, because the diagram is not the answer, but the importance of the question.


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

Related Reading

Notes

  1. This is a simple, relentless fact of human nature and commerce: if scams were obvious, they wouldn’t work. The successful ones survive and thrive by being appealing and seductive … not by looking silly and pathetic. BACK TO TEXT
  2. Quackwatch.org [Internet]. Barrett S. How the Dietary Supplement Health and Education Act (DSHEA) of 1994 Weakened the FDA; 2012 Mar 6 [cited 12 Apr 13]. BACK TO TEXT
  3. It is common for dubious therapies to claim scientific support based on scientific studies that technically had statistically significant (real) “positive” results — but when you look at the data you find evidence of an effect so trivial that the therapy is damned with faint praise. It fails to impress. See The “Impress Me” Test: Most controversial therapies are fighting over scraps of “positive” evidence that damn them with faint praise. BACK TO TEXT
  4. Homeopathic (diluted) arnica creams for pain, such as Traumeel, are quite popular. They contain only trace amounts of the best-known ingredient, arnica. They may contain other herbs as well, some of them less extremely diluted. Scientific evidence so far strongly suggests that effects of such creams are minor at best. For more information, see Does Arnica Cream Work for Pain? A detailed review of popular homeopathic (diluted) herbal creams like Traumeel, used for muscle pain, joint pain, sports injuries, bruising, and post-surgical inflammation.. BACK TO TEXT
  5. See Can Supplements Help Arthritis and Other Aches and Pains? Debunkery and analysis of supplements and food-like medicines (nutraceuticals), especially glucosamine, chondroitin, and creatine, mostly as they relate to pain. BACK TO TEXT
  6. What’s the Harm? (http://WhatsTheHarm.net/)

    Alternative health care has an undeserved reputation for being harmless and wholesome. In fact alternative medicines and treatments are just as full of hazards and risks as medical care, yet with virtually no proof of efficacy or regulation. While many other skeptical websites focus on the question of efficacy, WhatsTheHarm.net is devoted to cataloguing the costs of alternative health care: the many lives ruined and even lost.

    BACK TO TEXT
  7. Toxic contamination of barely regulated “natural” supplements is a huge problem. Marketplace recently exposed high levels of fecal contamination in the popular cold remedy, Cold FX: see What FX? Several studies have found outrageous levels of heavy metals in such products. Saper et al (2004) and Saper et al (2008) are good examples. See also Garvey et al and Bogusz et al. BACK TO TEXT
  8. The colorful history of medicine and quackery is overflowing with people who “swore by” treatments that were bizarre and dangerous. Bloodletting was popular almost until the 20th century, despite being relentlessly harmful. Some of the most lethal “cures” in history were inspired by the discovery of radiation. People happily drank metals like mercury and silver. Even drinking urine had near fad status for a while! They tried to purge disease with sulfuric acid, and stimulate their vitality (and virility) with powerful electric shocks. Women were sold Lysol as a douche … and women actually went along with it for a while. Voluntary lobotomy may be the craziest of them all: it was a popular treatment for all kinds of psychiatric disorders, and at least fifty thousand people volunteered to have their brains lanced.

    All of these terrible treatments, and many more obscure examples, had many fans and enthusiastic testimonials. People paid for them, believed in them, loved them, swore by them — that is how misleading testimonials can be. People believe what they want to believe.

    BACK TO TEXT
  9. Since many dubious therapies are based on trumped up pathologization tactics, all too many pain patients end up believing that they are a “really bad case” — all the more so when hard-sold therapy fails. This can make them heart-breakingly harder to treat. For more about the role of the mind in chronic pain, see Pain is Weird: Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it. BACK TO TEXT
  10. The classic example of literally lethal distraction is that cancer patients sometimes pursue poor alternative therapies while their cancer continues to grow, as in the much-publicized example of Steve Jobs. It’s unclear whether Jobs’s delay really increased his risk, given that he had an unusual and slow cancer. But certainly other patients have died horribly because they wasted their time on quack cancer cures that never had any promise. BACK TO TEXT
  11. Weakness is rarely the cause of musculoskeletal trouble, but overuse sure is! Well-planned rest is an extremely important recovery strategy that is almost always given short shrift in favour of time-consuming efforts to get stronger, often with a “no pain, no gain” sensibility that does more harm than good. See The Art of Rest: The finer points of resting strategy when recovering from injury and chronic pain (hint: it’s a bit trickier than you might think).. BACK TO TEXT
  12. “Structuralism” is the excessive focus on causes of pain like crookedness and biomechanical problems. It’s an old and inadequate view of how pain works, but it persists because it offers comforting, marketable simplicity that is the mainstay of entire styles of therapy. For more information, see Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.. BACK TO TEXT
  13. Stretching is just generally over-rated. It certainly does feel good, but it’s ineffective for pretty much everything it is normally used for. See Quite a Stretch: Stretching Hype Debunked: Stretching science shows that a stretching habit isn’t doing much of what people hope. BACK TO TEXT
  14. See Does Chiropractic Work? An introduction to chiropractic controversies like aggressive billing, spinal adjustment as a panacea, treating kids, neck manipulation risks, and more. BACK TO TEXT
  15. And yet not risk free. There are cases of infections and punctured hearts and lungs, for instance. Admittedly, these are rare complications — but why take any risk if there’s no hope of therapy? BACK TO TEXT
  16. It does not do anything a placebo can’t do. This has been acknowledged even by its own most credentialled proponents, as in the prominent case of the 2010 New England Journal of Medicine paper (Berman et al). For more about that, and a thorough tour of the evidence, see Does Acupuncture Work for Pain? A review of modern acupuncture evidence and myths, focused on treatment of back pain & other common chronic pains. BACK TO TEXT
  17. Nieman DC, Henson DA, Dumke CL, et al. Ibuprofen use, endotoxemia, inflammation, and plasma cytokines during ultramarathon competition. Brain Behav Immun. 2006 Nov;20(6):578–84. PubMed #16554145.

    This experiment tested the effect of ibuprofen on hard-core marathoners. There were 29 ultra-marathoners on high doses of ibuprofen and 25 controls that completed the race without meds. There was no measurable difference in muscle damage or soreness between the two groups. Lead researcher David Niemen: “There is absolutely no reason for runners to be using ibuprofen.”

    For some good mainstream journalism about this research see Convincing the Public to Accept New Medical Guidelines, by Aschwanden. For a good plain language tour of the topic in a major medical journal, see Warden.

    BACK TO TEXT
  18. See Does Therapeutic Ultrasound Work? Many concerns about the widespread usage of therapeutic ultrasound, especially extracorporeal shockwave therapy (ESWT). BACK TO TEXT