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Choose Cheaper, Safer Treatments

All other things being equal, always choose the cheapest and safest treatment option for your pain problem

updated (first published 2009)ARCHIVEDArchived pages are rarely or never updated. Most featured articles on PainScience.com are updated regularly over the years, but not archived pages.
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

It might seem obvious that we should choose cheaper, safer health care options whenever possible, but unfortunately it’s not: people strongly equate cost and risk with the potency of treatments and therapies. If it costs more, if it’s more uncomfortable, it must be better… right? And so they often skip safer, cheaper options.

A steep price tag is one of the clearest warning signs of quackery, but every expensive therapy — no matter how legitimate — should be avoided if there’s a cheaper option that’s just as likely to help. Risk is harder to detect, but painfully intense therapies are often the riskier ones, and easy enough to avoid.

If two kinds of therapy or treatment both have roughly the same chance of helping your pain, always choose the cheaper, safer one.

Some examples

People often pay for a large course of treatment — a $1500 series of Rolfing treatments, for instance — with an alternative health care professional before determining whether or not the therapy is effective/relevant . There might be therapeutic situations that require several appointments with minimal or erratic progress before it starts to “work,” but that’s rare. If a therapy is ever going to be successful, there should usually be some signs of it early on. Yet many people buy therapy without the benefit of those signs.

And massage therapists often recommend painfully intense treatments before less painful treatments have been tried. I’m not saying that very strong massage is never appropriate — sometimes it is. But it is something to try later, when gentler treatments have failed, when clear reasons for greater intensity are emerging. It’s a decision that patient and therapist should make together, because it can be extremely unpleasant for some patients, and because painful treatment is definitely not safe — there are real risks.

Shockwave ultrasound is a trendy therapy, an allegedly advanced version of vanilla ultrasound, which may or may not be effective for treating different kinds of injuries. The evidence is incomplete and mixed. It’s promised for plantar fasciitis, not so much for shin splints. The average patient can begin to be on top of this stuff… but they can certainly see the painful price tag, and the painful intensity of this therapy is something you’ll probably be warned about in advance. It shouldn’t be anyone’s first choice.

Why isn’t any of this as obvious as it should be?

I tested this tip out on someone who was trying to choose between two surgical options, with a $1500 difference at stake. There didn’t seem to be any way to know which one would be safer and more effective.

“All other things being equal,” I said, “choose the cheaper one.” And she said, to my surprise:

“Why?”

She really didn’t know. In her case, she had been assuming that an expensive therapy “had to be” better. It was clear to me that price tag was no real indication of the quality of the treatment she was considering — that, in fact, there was no possible way to be confident that one was any better than the other, and therefore no reason to pay more for one of them. Your options are “equal” when their quality is unknowable — when you have no firm reason to believe that one is better than the other.

It’s probably shocking how often people judge the quality of therapy primarily by its price. “You get what you pay for” is a reliable principle for refrigerators or hiking boots … but not health care.

When I worked as a massage therapist, people often said to me, “Wow, you’re busy and expensive: you must be good!”

“Maybe,” I say. “Then again, I might also just be charming and a good businessman. You really have no way of knowing.”

I like to get people thinking.

Informed consent

In alternative health care, where nearly all practitioners are freelancers, it’s extremely rare for them to say, “You don’t need my services.” Few of them are good at offering candid or detailed risk/benefit analysis to patients. Many can’t even define “informed consent” — the art and ethical necessity of fully disclosing all risks, including financial risks, before proceeding with treatment.

When patients don’t hear their full range of options, they don’t know it. And by golly if they don’t end up paying more. Funny how that works.

This is one of the shames of alternative health care. Doctors are mostly much, much better at doing informed consent than therapists. They are pretty diligent about saying things like, “You could do this or that, but this is expensive, and that’s risky, so how about this?”

But therapists have this amazing way of always recommending their own services, with barely a nod to the “alternatives.” Ironic, isn’t it? “Alternative” therapy isn’t actually good at recommending alternatives!

It’s a serious ethical shortcoming.

One more good example: dry needling

Dry-needling of trigger points — literally stabbing painful spots in muscles with acupuncture needles — is an amazingly popular therapy around the world these days, usually offered by physical therapists. The idea behind it is weak speculation, the evidence for it is equally weak — it either fails fair scientific tests or it shows only minor benefits. I explore the evidence in great detail in my trigger points book. For our purposes here, my opinion without references will suffice: I’m not impressed by it.

And there are rather obvious risks. And it ain’t cheap either.

I might be a worthwhile option for patients with serious chronic pain who are particularly desperate and understand that they are pursuing an experimental therapy. But for people new to muscle pain? People who might well get relief from much cheaper, much easier therapy? Not so much.

But, of course, I routinely encounter people who started their therapy journey with IMS, because an IMS therapist couldn’t bring themselves to say something like this:

“You know, this stuff costs and arm and a leg, and it hurts to boot. Why don’t you try a combination of heat, gentle stretch and self-massage on these three trigger points first? It’s free, easy and it might do the trick. If that doesn’t work, then you can come back and pay me almost $2/minute and we’ll see what we can do.”

“Dry needling” of muscular trigger points is very acupuncture-ish, but quite different in principle. It’s more expensive & just as unproven & inherently painful. It’s the perfect example of a therapy you don’t want until you’ve eliminated cheaper, gentler options. (And maybe not even then.)

Education as an antidote

All of this is why I write tutorials, of course. I came to believe that my massage therapy services were costly overkill for about 70% of my clients. The majority of people in pain can be helped substantially with cheap self-education. Most of them don’t need therapy — they just need some good quality information.

Tutorial vs. Therapy
An Interesting Tutorial A Few Sessions of Therapy
Effectivenessmight do the trick might do the trick
Cost $20 $500

Interesting equation!


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.

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