In my decade working for patients in pain as a Registered Massage Therapist, I learned a few important lessons:
- “Success rates” are not something individual clinicians can actually know, it wouldn’t constitute validation of methodology even if we could.1
- I must base my clinical choices on good scientific evidence and a plausible rationale whenever possible.
- And yet there is painfully little good scientific evidence on which to base my work, and a smart-sounding rationale only gets you so far. Even the simplest things are unsolved mysteries, or hotly debated.2
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.3
The necessity of humility and conservative “diagnosis”4 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 impressive therapist
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?
Pain involves too many biomechanical and biological variables for mere mortals to work out
Even the most rudimentary understanding of pain science makes it extremely clear that all pain is multifactorial, especially chronic pain. 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, subtle, and singular causes are usually doomed.
Especially the singular.
Acute and chronic back pain is essentially all caused by an anterior innominate rotation [pelvis outta whack].
“Essentially all” back pain. Acute and chronic. One cause, his cause, the cause — the cause that he alone truly understands, of course. And so, he has a branded method. Of course he does! There are zillions of these little crankery-based fiefdoms in musculoskeletal medicine, defined by amateurism and ignorance.
A confession about one of my own pet pain theories
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 when trying to demonstrate it on the spot 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.
Lions, tigers, and bias, oh my!
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!
Another example: the leg-length debacle
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.5 (Not that minor differences can even be reliably diagnosed in the first place.6)
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!
The necessity of conservative diagnosis
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!
About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter.
Exhibit A: “I’M PURE SCIENCE”
Over the years, I have received many pain-cure pitches from delusional cranks who believe that they have a lock on a cure for “all” or “most” chronic pain. Some of them, rather than being pissed at me for my anti-quackery activism, are so delusional that think I’ll be impressed by their theory. They might hope that they can woo me (pun intended), and many are obviously hoping to recruit me to become an evangelist for their nonsense. Some are more condescending, and probably don’t think I’m likely to see the light, but it can’t hurt to try, right? They all remind me of kooky inventors who are convinced that they have a perpetual motion machine.
The following is surely the apotheosis of this phenomenon. This is a transcribed voice mail, presented it to you here for your amusement and amazement, in the form of a free verse poem. The emphasis is mostly mine for dramatic effect, but not entirely — he was definitely hitting some of these words as hard as the capitals imply. Behold the dazzling ego!
found you on the net by accident
I would love to have a discussion with you about TRUE pain healing science
which is non-medical
which apparently you have not been made aware of
I am an expert in it, I’ve written a book on it, I’ve done the work
I’ve healed migraines, dozens, actually hundreds of them
in less than 20 minutes!
very, very, very easy to do WHEN you understand the TRUE science
not the medical science, which is nonsense
but true quantum science, quantum physics, biophysics, epigenetics!
that kind of thing, you know
I’d love to have a talk with you to help you understand how REAL science is helping people to heal pain
not just cope with it
and I am the expert on it
and I do this work around the world
I’m not a flake, I’m not some kind of weirdo
I’M PURE SCIENCE
and I’d love to share this with you
and maybe I’ll enlighten you a bit on how things really work on this planet
when you look at the ADVANCED science
What a truly classic example of a “science crank”! See Therapy Babble.
Exhibit B: “I have been humble for 2 decades now” — a classic case of therapist arrogance
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.
Is a stable cuboid bone “the answer” to all pain? Don’t bet on it!
There are so many things about his thought process that are disturbing that I hardly know where to begin, but here are the highlights:
- “I have been humble for 2 decades now” is not an expression of humility. No one gets bragging rights for being humble!
- Unsurprisingly, he attributes his miraculous healing abilities to a single biomechanical factor … and a small one at that, the cuboid bone, a sugar-cube sized lump of bone in the foot which he can therapeutically “hold in place,” implying both that it could be significantly and disastrously loose before his treatment (it can’t), and that he has the magic hands to somehow ensure that it remains firmly in place after his treatment (he can’t). Man, this really is structuralism as its most outrageous!
- In the attempt to seem humble, this guy claims that he doesn’t have all the answers and that he hasn’t cured anything … but then in the same paragraph he goes ahead and claims that his method depends on a single biomechanical factor, directly implies he can cure, that he’s “an old warrior who has finally won”, that he wants to “save” people, and that he can reduce or eliminate scoliosis — a condition that I have never seen successfully treated in my career, despite the efforts of many who claimed they could.
- Like every intellectually lazy professional, he dismisses the importance of “technical explanations.” They are good “for conversing with doctors” … something I think we can safely bet he doesn’t actually ever do.
- He cites a single reference as “confirmation” for a wildly optimistic, extravagant claim of therapeutic efficacy. Wow, that must be some reference! That brings oversimplification of a complex subject to new lows!
And a final dig I can’t resist …
- He is allegedly a complementary medicine professional … but he can’t spell it. How sad. Also, he can’t punctuate. As my father always said, “Bad writing doesn’t necessarily mean you’re stupid, but it sure makes you look stupid.”7
This is why so many doctors so reasonably object to alternative medicine: because it is, so often, so disappointingly ego-driven.
- For a much more thorough exploration of the problems with structuralism, and lots of relevant scientific evidence, see Your Back Is Not Out of Alignment — Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain
- Healer Syndrome — The problem with health care professionals, especially in alternative medicine, who want to be known as “healers”
- Therapy Babble — Hyperbolic, messy, pseudoscientific ideas about manual therapy for pain and injury rehab are all too common
- 💩 Massage Therapists Say — A compilation of more than 50 examples of the bizarre nonsense spoken by massage therapists with delusions of medical knowledge
- This article is one of my only attempts to persuade clients of a “dot-connecting” theory about a common upper body pain problem: The Respiration Connection — How dysfunctional breathing might be a root cause of a variety of common upper body pain problems and injuries
- Complete Guide to Low Back Pain — An extremely detailed guide to the myths, controversies, and treatment options for low back pain
What’s new in this article?
2018 — Added an example of misguided “singular” explanations for chronic pain.
2018 — Added new appendix: “Exhibit B: ‘I’M PURE SCIENCE’”
2016 — General editing and modernizing. Added several links to relevant articles that have been written since.
2004 — Publication.
- Clinical outcomes are subject to a dazzling number of confounding factors. For instance (one significant example among dozens) clinicians have a badly skewed sample: patients tell professionals about perceived successes much more than failures.
- The usefulness of stretching, the nature of DOMS, the cause and effect of joint cracking, the best practices for treating back pain, whether or not we really need “8 glasses of water per day” or even whether it matters in the least to drink water after a massage.
- Ingraham. Does Massage Therapy Work? A review of the science of massage therapy … such as it is. ❐ PainScience.com. 22262 words.
- Educated guessing, officially. Non-doctors are not legally permitted to “diagnose” in any jurisdiction that I know of — it is out of the massage therapist’s legal scope of practice. (The below applies to other manual therapists as well.) While some massage therapists may in fact be more educated about musculoskeletal problems than physicians (who really aren’t), they are certainly much less educated about some of the other medical problems that may be mistaken for musculoskeletal problems, and thus are technically forbidden from giving an “official” explanation for symptoms: a diagnosis. However, in my experience, this doesn’t even remotely prevent most massage therapists from going right ahead and speculating confidently and extensively about the causes of pain, and even many other conditions they have even less business diagnosing (“Shortness of breath” is a great example: a condition with many possible medical causes, but many a massage therapist will diagnose (or “treat as if”) it as a muscular respiratory dysfunction). I have hardly ever been in a massage therapist’s office without being told what’s wrong with me. Sometimes there’s some weak lip service paid to the possibility of other causes, and medical referrals are — fortunately — pretty common for many obviously non-musculoskeletal complaints. Not quite as common as I’d like, but pretty common.
- Grundy PF, Roberts CJ. Does unequal leg length cause back pain? A case-control study. Lancet. 1984 Aug 4;2(8397):256–8. PubMed #6146810 ❐
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.
- Cooperstein R, Lucente M. Comparison of supine and prone methods of leg length inequality assessment. J Chiropr Med. 2017 Jun;16(2):103–110. PubMed #28559750 ❐ PainSci #52779 ❐
Assessments of leg length are common, both with the patient lying down or standing. Either could be reliable, but in this test they did not agree with each other. Two chiropractors with more than 30 years experience each assessed the same few dozen patients, and agreement between their results when they felt confident in them was “perfectly nil.“ Despite the widespread and confident use of each method, this test clearly suggests that at least one of them is unreliable, but it’s also entirely possible that both of them are.
- I reserve the right to critisize others even though I also mak mistaks the sometimes. Not everyone’s a writer, but writing with many glaring errors is much worse than just lacking a knack — and it exposes a lack of mental rigour and maturity. There is such a thing as a minimum literacy required for one’s ideas to be taken srsly.