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, amazingly unregulated,2 and with shockingly few reputable sources of information about them. Make no mistake: selling false hope is big business.
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
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.
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 “opportunity cost”11 is regarded by anti-quackery activists as the main non-obvious reason why alternative medicine is not “harmless.”
Classic examples of distractions from proper care
Strengthening is common distraction,12 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.13 Stretching is another time-consuming and mostly useless approach to fixing pain problems.14 Chiropractors are legendary for selling long, expensive treatment plans.15
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.
- Acupuncture isn’t particularly dangerous,16 but it sure dials up the other two Ds to full power: it’s expensive, time-consuming, and scientifically bankrupt. Despite a great deal of wishful thinking and sloppy research to the contrary, acupuncture has been slam-dunk disproved.17
- The athletic habit of taking NSAIDs (i.e. ibuprofen, Advil) to prevent soreness is another good 2D hybrid. Dubious? In spades — sorry sporty folk, but it does not work.18 Dangerous? Minor but undeniable — they aren’t known as a “gut burners” for nothing. Distracting? Not really. It’s cheap, fast and doesn’t really get in the way of anything else.
- Ultrasound is an interesting example. It seems out of place on a chart about “quackery” — isn’t it high-tech and mainstream? Not many treatments are dangerous and distracting without also being pretty dubious, but a specific form of ultrasound — shockwave therapy — might fit the bill. Dubious? It’s hardly proven medicine, but it is biologically plausible, and has shown some promise in early trials. Unfortunately, it’s also plausible that it could worsen some conditions. And it calls for a bunch of expensive appointments. And it hurts.19
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
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.
- Testing treatments: better research for better healthcare (book), by Imogen Evans, Hazel Thornton, and Paul Glasziou (book review). This excellent book is currently available for free from www.TestingTreatments.org. It’s a superb exploration why research matters, and how it’s done.
- Science-Based Medicine: Exploring issues and controversies in the relationship between science and medicine (sciencebasedmedicine.org). Science-Based Medicine is now the single best source of critical thinking about health care available anywhere. Founded by Yale neurologist Dr. Steve Novella of the Skeptic’s Guide to the Universe, it’s written by several physicians who are alarmed by the soaring popularity of dangerous and pointless alternative health care. The title of the blog expresses the elegant idea that the value of ideas in health care ideas must not only be based on evidence, but must also be reasonably consistent with a well-established body of scientific knowledge of how the human body works.
- QuackWatch: Your Guide to Quackery, Health Fraud, and Intelligent Decisions (QuackWatch.org). Quackwatch fights health-related frauds, myths, fads, fallacies, and misconduct. Its primary focus is on health consumer information that is difficult or impossible to get elsewhere. Dr. Stephen Barrett, the founder of QuackWatch and author of most of the articles, is one of the great figures of anti-quackery activism. For many years now, I’ve been watching his work and the controversies and legal battles that swirl around QuackWatch, and I have been consistently impressed by Dr. Barrett’s integrity and intelligence — and unimpressed by the tactics and quality of his critics. He is also providing a vital service and a sorely neglected perspective on health care.
- What’s the Harm? (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.
- Science versus Experience in Musculoskeletal Medicine — The conflict between science and clinical experience and pragmatism in the management of aches, pains, and injuries
- 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.
- 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].
- 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.
- 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 Gel Work for Pain? A detailed review of popular homeopathic (diluted) herbal creams and gels like Traumeel, used for muscle pain, joint pain, sports injuries, bruising, and post-surgical inflammation..
- 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.
- 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.
- Toxic contamination of barely regulated “natural” supplements is a huge problem. Marketplace 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.
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.
- 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.
- 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.
- “In microeconomic theory, the opportunity cost, or alternative cost, of making a particular choice is the value of the most valuable choice out of those that were not taken. In other words, opportunity that will require sacrifices.”
- 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).
- “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..
- 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 science has shown that this extremely popular form of exercise has almost no measurable benefits.
- See The Chiropractic Controversies: An introduction to chiropractic controversies like aggressive billing, treating kids, and neck manipulation risks.
- 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?
- 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.
- 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.
- See Does Ultrasound Therapy Work? Many concerns about the widespread usage of therapeutic ultrasound, especially extracorporeal shockwave therapy (ESWT).