In my decade working for patients in pain as a Registered Massage Therapist, I learned two important lessons:
Indeed, even the simplest things are unsolved mysteries, or hotly debated.1 For the average clinician, the only defence against all this uncertainty is to muster as much scientific rigour as we can, and otherwise trust our instincts and stay humble. We often do the right thing … but not usually because we actually understand the right thing.
It seemed like massage therapy was effective. But, if that was true, I still don’t really know why, despite studying the subject constantly for many years.2It is alarmingly easy to go too far and begin making diagnostic connections that exist only in our hopes & our egos.
The necessity of humility and conservative “diagnosis”3 is the theme of everything I’ve learned. I try not to ever think of myself as a “healer.” In school, I learned that it is the job of the manual therapist (massage therapist, physiotherapist, chiropractor) to see the interconnectedness of the human body — to see causal relationships between seemingly unrelated structure and function. If we don’t have some depth of understanding about the biomechanical puzzle — something beyond “the hip bone is connected to the thigh bone” — then we must be nearly useless to the people we serve.
But it is alarmingly easy to go too far and begin making diagnostics connections that exist only in our hopes. And our egos.
The therapist who claims to understand therapeutically significant connections between parts that seem particularly unrelated is more likely to impress his patients. And to have an ego problem.
It is always reassuring — for both therapist and client — when skilful assessment seems to yield evidence that, hey, “everything really is connected!” — as though we weren’t entirely sure of it. In fact, both practitioners and patients tend to judge the quality of a treatment on the basis of how many degrees of separation the therapist seems to be able to perceive between symptom and cause.
We all like diagnoses that connect the dots. The more dots we connect, the more we like it!
But it’s a trap.
Unfortunately, there is a problem of sharply diminishing returns as the number of dots (variables) increases. This results in …
The Law of Fancy Diagnosis
The more clever a therapist tries to be about a diagnosis, the less likely it is to be meaningful.
A classic extreme example of the Law of Fancy Diagnosis at work is a chiropractic modality based on the reasoning that most or all symptoms in the body originate with only the joints of the upper cervical spine — a panacea, firmly in the “too good to be true” category. But many practitioners of this modality are so gung ho that they actually will not treat other spinal joints, let alone any other part of the body. I don’t think much of this, and I think such practitioners survive largely on the basis of the emotional authority of such a fancy-sounding premise for therapy.
I have treated many refugees from such therapy, who failed to get relief from their symptoms. Those who claim relief are probably enjoying a nice placebo effect, or would have healed just fine in any case.
Why does the attempt to make elaborate connections usually result in useless therapy?
The number of variables wedged between the symptoms and the deepest causes of even the simplest musculoskeletal conditions is simply shocking.
While it is reassuring on the one hand to occasionally see clear signs of the interconnectedness of anatomy and physiology, it is on the other hand downright alarming to recognize that everything really is connected — and paralyzingly complex, like looking at the night sky and being completely freaked out by the number of stars. Manual therapy is a bewildering and miraculous game of pick-up sticks where everything we do affects everything else, and no health care professional can seriously hope to make “common” sense of it. There is no certainty about anything in this business.
Therefore, elaborate attempts to connect pain with distant or subtle causes are usually doomed. They never impress in the end.
I have dared to get pretty fancy with my own theories about the connections between upper body pain and respiratory dysfunction (see The Respiration Connection). I have told my clients, with unjustified confidence, that they must learn to breathe with their diaphragm to cure their headaches. I think it might have even worked once. This attractive idea relies on several steps of logic, each of which depends on others — things that can be pretty hard to nail down. For instance …
People almost certainly do not breathe the same way under all conditions. Someone who has significant difficulty with diaphragmatic recruitment in my office may have no problem with it at all when she is jogging — or the other way around. How would I know? And where does that leave my attempt to diagnose respiratory dysfunction as a cause of headaches?
I’ve lost sleep over that one.
People are ridiculously complex, and a diagnosis that relies on any more than a couple steps of logic is problematic even for a therapist with machine-like objectivity — which, of course, no therapist has. But it gets worse when the therapist is a real person with emotional biases and vested interests.
If any of the many variables that a diagnostic theory depends on is subject to biased perception — if the practitioner must guess about anything, if she must feel for a joint position as subtle as a grain of sand in a towel, if her reputation is at stake, and if this procedure is in itself is two degrees of causal separation from the symptoms in another region of the body (admittedly related but by no means related significantly) — then forgive me if I am quite skeptical about the whole thing.
And I am more skeptical still when treatment will supposedly require weeks or months of expensive therapy and diligent therapeutic exercises … all of which is based on the assumption that the original diagnosis was accurate!
Even seemingly simple connections defy easy understanding. Most therapists believe, for instance, that there is an important connection between leg length difference and back pain. This is one of the sacred cows of physical therapy. And it seems like a sensible cow.
I could retire if I had a buck for every client who has ever told me that they’ve been diagnosed with a leg-length difference that accounts for their symptoms. Therapists and clients alike love this diagnosis for its seemingly obvious biomechanics. The more subtle the leg-length difference, the higher the regard for the diagnosis (which says a lot).
Too bad it’s wrong! A 1984 study in the British medical journal, Lancet, concluded that there “no association was found” between leg-length differences and chronic back pain.4
It seems obvious that these dots would be connected. They aren’t. People also once thought it was obvious that a heavier object falls faster than a lighter one. It doesn’t, of course. You have to check these things!
For all of these reasons, by the end of my career I was avoiding too-clever-by-half theories based on issues with biomechanics and posture. I did not make much of leg length differences, or torsions of the pelvis, or any other alignment bogeymen. Even if these things are important, I stopped pretending to be able to understand them well enough to justify thorough assessment and elaborate treatment. It just wasn’t good bang for my clients’ buck.
I prefer to believe that people are not particularly fragile, and that therapy can be used to “encourage” normalization of function regardless of whatever biomechanical dysfunction may or may not be involved. I prefer to believe that it is not always realistic to diagnose the deepest, rootiest cause of every problem, and that treating “just the symptoms” may actually be a perfectly reasonable thing to do when the root causes are a needle in a haystack … especially when searching through the hay costs $100/hour!
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.
I received a note from a reader — allegedly a colleague and kindred spirit. He briefly expressed his appreciation for my writing, and then asked:
Would you like to know what actually causes trigger points? I have been at this for twenty years and have the answers that we all search for.
Clearly, this is someone who fancies himself a “healer” with special knowledge. His delusions of grandeur are betrayed not only by his belief that he has “the answers that we all search for,” but by his teasing lack of detail. If he really has special knowledge, why would he ask me if I want to know? Why wouldn’t I? Why be guarded or vague? Just share! Can you imagine a scientist writing to another scientist and saying, “Would you like to know how things really work?”
I decided to bite, just to see what he would say, and his reply was vain and vague, with hand-waving references to an “amazing” therapeutic protocol that can work marvels with pain patients, and all of it depending on something — he doesn’t say what — in the feet. This is classic wind up for a doozy of a structural theory to explain all pain. For structuralists, “it all” always hinges on one critical biomechanical factor.
I pointed out that his lack of humility, lack of detail, and lack of scientific evidence was all fairly off-putting. And this was his reply, pitch perfect for a delusional “healer.” I have reproduced it here word for word, because it is just such a gloriously irritating example of this kind of thinking, which is absolutely rampant in alternative health care:
I appreciate what you are saying, I have been humble for 2 decades now, in fact this has been my ministry for 20 years. As I have said I don’t have all the answers and I don’t have a panacea for anything, neither have I cured anything, I’ve worked with many alternative types of medicine and have used these methods to end my own bout with cancer. What makes my method work is a complimentary adjustment top to bottom. What makes the adjustment stay is the cuboid [a small foot bone] being held in place. If you have the skills needed to reduce or eliminate the scoliosis then you can appreciate that just to get proper treatments in some areas, you have to fight. I am entirely guilty of being an old warrior, who finally has won. I don’t need to argue any more, I demonstrate. I have no desire to change the way things are, only to save as many as I can. Technical explanations are good for conversing with doctors, but my mission is to communicate with the average joe who has been through the “mill” and has lost hope, these are my flock. To check out my “ extraordinary claims” You will find confirmation in Dr. Warren Hammers book entitled; Soft tissue examination and treatment by manual methods pg 425.
There are so many things about his thought process that are disturbing that I hardly know where to begin, but here are the highlights:
And a final dig I can’t resist…
This is why so many doctors so reasonably object to alternative medicine: because it is, so often, so disappointingly ego-driven.
— General editing and modernizing. Added several links to relevant articles that have been written since.
This classic, elegant experiment found no connection between leg length and back pain. Like most of the really good science experiments, it has that MythBusters attitude: “why don’t we just check that assumption?” Researchers measured leg lengths, looking for differences in “lower limb length and other disproportion at or around the sacroiliac joints” and found no association with low back pain. “Chronic back pain is thus unlikely to be part of the short-leg syndrome.” Other studies since have backed this up, but this simple old paper remains a favourite.BACK TO TEXT