The 20th Century was such a scientific and technological earthquake that we all now have a tendency to assume that the human species has advanced knowledge about basically everything, but we really don’t. In many ways, the state of our knowledge of anything relatively minor/subtle in medicine is still surprisingly primitive.
For most of history, medicine had bigger, scarier fish to fry than treating mere aches and pains. And it still does. But just a few decades ago, doctors and researchers were necessarily preoccupied with much more pressing public health issues … and rewarding new treatments.
Insulin and penicillin were still changing the world, as were a string of new vaccines — diptheria, pertussis, tuberculosis, tetanus, flu, yellow fever, typhus, polio, measles, mumps! Surgery and anesthesia were finally coming into their own, with error rates plummeting.1 The first organ transplants were saving people who would be be doomed without them. Dialysis! Pacemakers! Laser treatments for eyes! MRI and CT scan! Arthroscopy!
Medicine was still creating huge leaps in the length and quality of our lives.2 It was an era of low-hanging medical fruit.
Chronic pain and stubborn “minor” injuries (like repetitive strain injury) were barely touched by medical science until about the 1980s, and they remain a bit of a backwater to this day, both scientifically3 and clinically, as most doctors are unqualified to treat chronic pain and non-traumatic injuries.4 PM&R (Physical Medicine & Rehabilitation, A.K.A. physiatry) is one of the youngest and most obscure medical specialities, and the only one that tackles most “aches and pains” head on. (Rheumatologists and orthopedists in theory deal with all forms of therapy for any kind of musculoskeletal problems, but in practice these specialities have been dominated by serious diseases and injuries, and by profitable elective surgeries that “make sense” to the surgeons who make money doing them but are amazingly unstudied to this day — or, for the few that have been properly tested, proven ineffective56 or dangerous!7)
Pehaps we do have the medical “luxury” of paying more attention to relatively minor pain problems that were overshadowed by the more critical medical issues of the past. The science of pain is both more important and more difficult — weirder even — than anyone imagined half a century ago. But of course those problems aren’t really so minor — just less major than things that kill you outright.
Non-lethal chronic pain accounts for a stupendous amount of human suffering. The economic costs of even mild to moderate problems — your garden variety back pain, frozen shoulder, patellofemoral pain, carpal tunnel syndrome, and so on — are quite hair-raising. Virtually all of the research that does on any of these things starts out with an accounting of its horribleness.
More severe chronic pain problems — a horrible neck pain that just won’t quit, or dreaded afflictions like fibromyalgia and complex regional pain syndrome (CRPS) — are truly awful. Indeed, CRPS can be so horrendous and untreatable8 that many victims take their own lives to escape the pain. And yet patients with chronic pain often feel abandoned and even disbelieved.9
The general neglect of pain science was most unfortunate. Turns out it’s both more important and more difficult — weirder even — than anyone imagined half a century ago.
Given its late arrival, the state of musculoskeletal health care is still surprisingly primitive in general. Huge numbers of professionals still believe 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.
For instance, a great many problems are treated ineffectively and simplistically as though they were “mechanical” in nature — ignoring old evidence to the contrary! Particularly in chiropractic and massage therapy, there is an amateurish industry-wide obsessive preoccupation with “alignment” and other structural factors — like leg-length differences. And then there’s a litany of even more embarrassing ideas and distractions in those professions.10
Modern medicine has also generally failed patients, with benign neglect, useless surgeries (cited above), and the unmitigated disaster of the opioid crisis.11
People with severe unexplained body pain bounce around the medical system like they are in a pinball machine, serially misdiagnosed and mistreated, often never finding a single doctor or therapist who recognizes the problem, or — having at least recognized it — has a clue what to do about it.
There is a groan that unites men and women, rich and poor, in any nation. These [muscle] pains are “explained” in every culture, but the universal fact of this persistence must mean that no adequate therapy exists.
Professor Patrick D. Wall, FRS, DM, FRCP, in the Foreword to Muscle Pain: Understanding its nature, diagnosis and treatment
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.
— Minor update: mentioned physiatry/PM&R (a strange oversight, overdue for correction).
— Added more medical and scientific context and some new citations, particularly about orthopedic surgeries and opioids. Some general editing. Removed a small section of dubious value.
— New introductory paragraph, for additional historical context.
This review of a half dozen good quality tests of four popular orthopedic (“carpentry”) surgeries found that none of them were more effective than a placebo. It’s an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.
Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing the test. This review introduction is excellent, and does a great job of explaining the problem. As of 2016, this is the best single academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and more readably — in the excellent book, Surgery: The ultimate placebo, by Ian Harris.
The surgeries that failed their tests were:
A scholarly analysis of the safety of MoM implants:
Hundreds of thousands of patients around the world may have been exposed to toxic substances after being implanted with poorly regulated and potentially dangerous hip devices, a BMJ/ BBC Newsnight investigation reveals this week. Despite the fact that these risks have been known and well documented for decades, patients have been kept in the dark about their participation in what has effectively been a large uncontrolled experiment.
Cobalt-chromium implants have been used successfully in orthopaedics for years—for example, in knee operations and fracture repair. They are known to release metal ions, but some metal-on-metal prostheses do so on a much greater scale than previously thought. These ions can seep into local tissue causing reactions that destroy muscle and bone and leaving some patients with long term disability.
Harris tells the (chilling) story of metal-on-metal hip implants in Surgery: The ultimate placebo, one of the best-ever (and freshest) examples of surgical overconfidence.BACK TO TEXT
This paper reviewed qualitative research on musculoskeletal pain to shed light on what it’s like to have chronic pain. Several worrisome themes were clear. Chronic musculoskeletal pain often forces causes patients into the awkward position of having to prove the legitimacy of their condition: “if I appear ‘too sick’ or ‘not sick enough’ then no one will believe me.” Many end up doubting themselves and questioning their own identity and wondering who is “the real me.” Many lose hope and feel lost (or lost by) the health care system.BACK TO TEXT