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Reviews of Pain Professions

An opinionated guide to the most popular sources of professional help for injuries and chronic pain

Paul Ingrahamupdated

If you’re in pain, what type of doctor or therapist should you should see? Who helps people with chronic pain? This is the top question asked by PainScience.com readers, and the hardest to answer.

The industry is a mess, the medicine of aches, pains, and injuries is surprisingly primitive,1 rife with quackery, and even more rife with pseudo quackery — superficially mainstream treatments that don’t work at all, or not very well.2

Photo of a woman receiving massage therapy, lying face down, back bare and a towel across her hips, with a pair of hands on either side of her lumbar spine.

Everyone loves to love massage therapy, but is it medically useful?

And yet there are many amazing clinicians out there, and finding the right one can be critical for patients trying to cope with an undiagnosed chronic pain problem, or a diagnosed one that resists all treatment. Below you’ll find descriptions and reviews of many potentially relevant professions: all the ones that my readers have asked about for twenty years, and some that I wish they would ask about.

Warning! Nothing is sacred here. These are highly subjective thumbnail sketches with a strong pro-science bias, plus some deliberate snark, roasting, and generalizing. I have high standards for what constitutes evidence-based medicine, and I see major issues with all professions, and major issues on both sides of the mainstream/alternative divide. And every profession also has its good/bad apples, of course — but some undoubtedly more than others, and that matters.

Who are these reviews for?

If you have an undiagnosed pain that has been steadily worsening for more than a few weeks, please see a doctor, or see one of PainSci’s when-to-worry guides about neck pain or back pain. Otherwise, this guide is most relevant to:

I am mostly reviewing professions, not “modalities”

A treatment modality is a specific method or technique. Some professions are dedicated to a single modality, like acupuncture, massage therapy, or orthopedic surgery. And some modalities are more about branding and profit than evidence-based medicine.3

Other professions are more about using “whatever works,” and they pick and choose modalities for the occasion, like physical therapy. And a few professions — most notably chiropractic — are mostly known for one approach to pain, but wish they weren’t: many chiropractors use a variety of modalities and are actively seeking to widen their scope of practice in both practical and legal ways.

Table of Contents


Coming eventually: orthopaedists, personal trainers, occupational therapists, and some thoughts on multidisciplinary care.

Acupuncture

Acupuncture is the not-so-ancient4 Chinese method of using fine metal needles to improve health by stimulating the flow of “qi” in the body. It emerged from Chinese folk medicine and politics: a mish-mash of superstition and common sense, poetry and metaphor, and propaganda (seriously). And it’s the poster child of alternative medicine: charismatically exotic but less absurd than homeopathy, and heavily researched, people assume there “must be something to it,” including many skeptics until surprisingly recently. But acupuncture gets its support only from junky science, while all the good tests show that it’s no better than a placebo, for pain or anything else. This has been conceded even by many acupuncture researchers (although they bizarrely try to spin it as good news). Even NCCAM admits that acupuncture “works no better than a sham treatment at easing symptoms like pain and fatigue.”

We shouldn’t be surprised: acupuncture’s popularity comes from easily debunked myths and cultural baggage, and it’s blatantly based on “vitalism,” a naive belief in an undetectable energy system in biology (like the Force in Star Wars). Chinese medicine was never “wise” to begin with: it was just typical pre-scientific medicine, a patchwork of superstition, habit, and guess work. Acupuncture is not and never has been used for anaesthesia (not even journalist James Reston, contrary to legend and by his own account); its use for that purpose was grossly exaggerated for political reasons during China’s Cultural Revolution.

Finally, acupuncture isn’t even entirely safe: aseptic technique (disinfectant, gloves) is often poor, and infections can and do happen.

Acupuncture’s glory days are over. It is confidently supported only by ideologues and the uninformed. More study is not needed. All of this is explored more thoroughly in the article Does Acupuncture Work for Pain? A review of modern acupuncture evidence and myths, focused on treatment of back pain & other common chronic pains.

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Chiropractic

Chiropractic is popular and some practitioners are excellent, but the profession is obviously riddled with controversies and quackery from the subtle to the overt, and there lots of bad apples (way too many to dismiss as a trivial minority). And the bad apples jump on every bullshit bandwagon in alternative medicine, like claims that that spinal adjustment can prevent COVID infection by “boosting” immunity. Wow, who knew? The biggest concerns about the profession are:

The profession is strongly divided between progressives and traditionalists, and it’s hard for patients to tell them apart. Remember that patients are always at a disadvantage trying to identify bad apples, because the bad ones are working hard to seem fresher and more nutritious than they actually are.

At the centre of all the controversy is a service that many people are happy to pay for, including myself once in a while: a spinal joint “popping.” No matter what it actually does or does not achieve medically, it often freels like like scratching an itch you can’t reach. Whatever the nature of this phenomenon, I believe it’s the main source of chiropractic’s economic viability.

For a more thorough review of chiropractic, see The Chiropractic Controversies: An introduction to chiropractic controversies like aggressive billing, treating kids, and neck manipulation risks.

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Physiotherapy (AKA physical therapy)

Physiotherapists are the most mainstream of the non-physician professionals,5 and they throw everything but the kitchen sink at injuries and stubborn regional pains. They enjoy considerable mainstream legitimacy, because training and certification standards for physiotherapists are generally high around the world. Ideally, a physiotherapist will act as a competent guide to a wide array of evidence-based treatment and self-treatment options, a troubleshooter and rehabilitation coach.

Unfortunately, too many physiotherapists indulge in a wide variety of classic pseudo-quackeries, especially the “passive” and “electrical” modalities like ultrasound, transcutaneous electrical nerve stimulation (TENS), and laser therapy, but also notoriously over-hyped treatments like dry needling, spinal manipulative therapy, and taping.

Physios are also big suckers for structuralism, which 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. There are times when it seems like all physios know how to do is pathologize biomechanical “quirks” and offer ways to expensively “correct” them.

And their business model of setting patients up with a passive therapy and then running around the clinic attending to other patients is still surprisingly common and widely resented (it’s a complaint I have heard countless times).

It’s not for nothing that someone (a physiotherapist, actually) has written a book called “The End of Physiotherapy.”6

But obviously there’s great diversity in the profession, and better physiotherapists are more science-based, more willing to take more time with patients, and will lean more heavily on exercise and load management advice rather than dubious electrotherapies and so on.

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Medical Doctors (in general practice)

Despite many imperfections in the practice of modern medicine, doctors still collectively set the standard for health care, and a good family doctor is a superlative generalist. All doctors are overwhelmingly better qualified on average than any of the alternative medicine professionals, and that includes the chiropractors and naturopaths that constantly boast that their training is just as good (it really isn’t7).

Unfortunately, even a lot of superlative generalists will let patients down when it comes to musculoskeletal and pain medicine. Most family docs are simply not qualified to treat most common musculoskeletal conditions, and there is ample evidence of these inadequacies.8 These shortcomings are all the more tragic because so many people trust their doctors’ expertise and ask them for help with so many of these problems.9 Their ignorance can even be quite destructive when it comes to treating aches and pains.

I am not a doctor basher. Medicine is a vast field, and it is not fair or reasonable to expect even the best generalist to be well-prepared for every kind of patient. If I had to know how to sew up large gashes in people, I doubt I’d be so well-informed about runner’s knee or frozen shoulder. The problem is that general practitioners usually don’t appreciate the startling complexity of chronic pain and seemingly “simple” musculoskeletal conditions, and so they don’t even know when they are out of their depth, and don’t refer when they should.

I have seen cases as absurd as a professional violinist with the most predictable shoulder muscle strain imaginable misdiagnosed as a cancerous tumour, a man with a fresh knee injury told to put heat on it and resulting in disastrous swelling, and countless examples of ordinary muscular back pain escalated into disastrously scary “disc herniation” diagnoses.

Unless you are bleeding, take your GP’s advice about muscuskeletal problems with a huge grain of salt.

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Medical Doctors (Physiatrists and Physical Medicine & Rehabilitation specialists)

A physiatrist is basically a physical therapist with a medical degree. This is the only profession reviewed here that I find it a bit difficult to “roast.” Perfect? Hardly! They suffer from most of the same issues physios have: just as blinkered by structuralism, and perhaps even more over-invested in common pseudo-quackeries like ultrasound.

But physiatry gets an A+ if I grade on a curve — and I have to grade on a curve, because otherwise every profession here would be getting a D, E, or F. They should probably be most people’s first choice for most common stubborn painful problems. You just have to find one, and that may not be easy. Which is quite a downside.

Physiatry/PM&R is a relatively new and obscure speciality (compared to, say, neurology) and the branch of medicine most relevant and valuable to patients suffering from musculoskeletal pain. Practitioners are qualified to screen patients for more ominous causes of pain — something many non-physician health professionals often fail at, for lack of training — and are often quite knowledgeable about a variety of musculoskeletal and pain problems that they’ve taken a particular interest in.

Like all other medical specialists, PM&R docs can’t know everything, and if there’s a concern for the average patient here it’s that their problems may not be “interesting” enough for these doctors. Many of them will be preoccupied with care for quite severe conditions, and less informed about “minor” or less obvious chronic pain problems like, say, plantar fasciitis (which isn’t minor at all if it has kept you from walking more than a block for two years). Many of these physicians care for some extremely ill and gravely injured people, and some of them will tend to be dismissive of patients who don’t have what they think of as a “serious” problem. I have seen patients fall through that crack: hurting badly enough to be miserable, but not badly enough to be of interest to a physiatrist.

“Medical” or “rehabilitative” massage therapy

Massage therapy is my own former profession (2000–2010, RIP). “Medical” massage is hyperbole: it’s an informal and pretentious marketing term with no specific meaning. But it can be a somewhat useful label for a style of massage and a class of therapists with better-than-average training (more than a year), and those who aspire to be more like physical therapists who just happen to be very “handsy” with their modality choices.

Unfortunately, more training doesn’t necessarily count for much, because “a little knowledge is a dangerous thing.” The profession of massage therapy still mostly sells itself as an “alternative” medicine and is full of amateurism at best and rank quackery at worst. There are many myths about massage therapy that remain prevalent.10 Many patients complain of sessions that are too brutally intense, too unfocused, or too weird. I left the profession because it was so embarrassingly unprofessional and anti-scientific.11

And yet… massage itself is awesome. It’s important to know the myths and nonsense, but there is also a great deal to be said in defence of massage, chiefly that it can be a delicious and relaxing sensory experience that is inherently valuable. Touch is profound for primates, and massage probably facilitates wellness in ways that are hard to deconstruct, test, and/or even define. More concretely, massage is also probably the best way to treat “trigger points” (muscle knots), which is one of the most plausible ways that massage can help people with chronic pain.12

It’s hard to find a good medical massage therapist, especially one who can also just deliver a great massage (I do have some tips). But if you can, it’s worth it.

For more information about massage therapy, see Does Massage Therapy Work? A review of the science of massage therapy … such as it is.

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Bodywork and non-medical massage therapy

In contrast to the small minority of “medical” massage therapists, almost all the massage therapists in the world are poorly trained and either uncertified or dubiously certified, and notoriously flaky — like Phoebe from Friends, a cynical . Fancier massage therapists mostly look down on them as mere “bodyworkers” or night-school-trained “masseuses.”

Most ordinary massage therapists do aspire to be paramedical professionals, but it’s largely delusional (especially for those who work in that grey zone verging on the sex trade, which continues to confuse and alienate the public). Most work in spas, resorts and on cruise ships, doing treatments that are notoriously fluffy, with virtually no therapeutic value other than the comfort/luxury of a quiet hour of touching (although many patients find skin-deep massage to be more annoying than anything else).

If pseudoscientific thinking is common amongst medical massage therapists, it comes standard with bodyworkers, and a lot of it is so intellectually stunted that it doesn’t even qualify as sloppy science: it’s just straight up magical thinking. Every other one of them embraces aura massage, psychic healing, and astrology. It’s impossible to overstate how cringe-inducing it all is for anyone remotely rational. I feel like I have “heard it all,” but massage therapists keep surprising me with the extremes of their militant ignorance.13

And yet … and yet …

And yet people do seek them out, because people understandably love massage — and it has a potent reputation for helping aching, stiff bodies. Is that reputation deserved? Both yes and no. “It’s complicated.”

And, in all sincerity, some of the best massages I have ever had were done by massage therapists with minimal training. The ostensibly more credible medical massage therapists often actually get in their own way of just giving a good massage, because they are preoccupied with playing at being like physiotherapists. And some “flakes” are actually emotionally mature — and maybe that actually matters more than training. Bodyworkers get so much hands-on experience that some become skillful at easing soft tissue pain in spite of their lack of training, even if they misunderstand or overintrepret why they are effective. (They are probably mainly effective largely because “muscle knots” are a clinically important phenomenon, and because of the neurological potency of pleasurable touch. Massage therapy gets a stamp of approval even from medical back pain experts.14) And never underestimate the therapeutic value of “just” a good relaxation massage!

For more information about massage therapy, see Does Massage Therapy Work? A review of the science of massage therapy … such as it is.

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Naturopathy

A naturopath is the general practitioner of alternative medicine, an opposite-of-mainstream “doctor,” and a dumping ground for every conceivable kind of crank theory of disease and snake oil remedy.15 Naturopathic apostate Britt Hermes accurately describes it as “a system of indoctrination based on discredited ideas about health and medicine, full of anti-science rhetoric and ineffective and sometimes dangerous practices.”16 Tell us what you really think, Britt! Many of them push supplements hard — which is important in a follow-the-money way, because it’s a major source of revenue for many practices — but the supplement industry is hopelessly corrupt (insanely profitable and unregulated, it pumps out adulterated and contaminated products).

One of the main justifications for naturopathy is the idea that they have an “open mind” about a variety of chronic health and pain problems and treatments about which medical doctors are often ignorant and excessively dismissive. But inserting crank theories into the holes in medical knowledge is not the antidote to our medical helplessness.17

What is good about naturopathy isn’t unique, and what’s unique to it is mostly just anti-medical. At its best (or least harmful), it is mainly “lifestyle” medicine, but you don’t need a naturopath for that. Contrary to popular cynicism, every good doctor is not just aware of the importance of exercise and nutrition and sleep, but fights a constant losing battle trying to persuade their patients to get at least a little bit in more into shape and drink a little less booze.

Do I think there are some genuinely good naturopaths? Sure, there are always “good apples”: some naturopaths are in that profession just to practice healthcare in a way that makes up for some of the legitimate shortcomings of medicine… but they are so rare that I don’t think any patient should try to find them. If one falls into your lap, great, fine — proceed with caution, and don’t be surprised if your “good” naturopath turns out to be a supplements distributor for a multi-level marketing scheme.

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Psychiatry, psychology, and counselling

Chronic pain often goes hand-in-hand with depression, anxiety, stress, sleep deprivation, and addictions — all of the systemic vulnerabilities that are probably an underestimated part of the pain puzzle.18 And while “all in your head” is perhaps the most irritating idea in all of medicine, of course psychosomatic illness/pain does actually exist.

To the extent that mental health care professionals can help with those issues, they are undoubtedly providing valuable adjunctive therapies. They almost certainly reduce suffering and disability. But to what extent do they reduce pain itself? The evidence so far — decades of research — is thoroughly negative. 🙁 For a review of the evidence, see Cognitive Behavioural Therapy for Chronic Pain.

Where there is mecical uncertainty, there is quackery — and psychiatrists, psychologists, and counsellors are not immune to the siren call of suspiciously easy answers to hard problems. They have indulged in some of the most horrendous of all snake oils in both the past and present. “Conversion therapy” is the great shame of the field, and it is still shockingly prevalent. Also notable: hypnosis and EMDR (which is basically CBT with finger waving).

I personally know both a psychiatrist and a psychologist who are two of the smartest and most rational people I have ever known. But, alas, they aren’t all like that. And as with every profession reviewed here… how are patients supposed to tell? For the most part, they simply cannot.

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Homeopathy

Homeopathy is a 200-year-old medical philosophy that has been thoroughly debunked, and survives today thanks to wishful thinking, ignorance, and because it is too useless to be very dangerous. It is one of the most profitable, absurd, and oily of all snake oils.

Most people have no idea just how strange homeopathy is. The deal-breaker for many consumers is the discovery that it’s not just an “herbal” or “natural” remedy, but a “magical” one, based on a principle that reeks of flaky physics and old-timey snake oil flamboyance — much farther out in left field than herbs. Some people, of course, are quite happy citing quantum physics to explain alternative medicine, but you really have to be a card-carrying new age nut to go there. For most people, that crosses a line.

But they have to find out first! Fortunately, doctors, scientists and skeptics are unanimously and harshly critical of homeopathy, and have published many good quality critical reviews. For instance, see my own article about homeopathic arnica (extremely well-known as the now-defunct brand of Traumeel) — the most popular of all homeopathic products, intended to treat inflammatory pain.

Most professions with a lot of problems still have their good apples, even if they’re hard to find. Homeopathy is not one of those professions. There are no more good homeopaths than there are good faith healers. If a person has devoted their career to treating people with homeopathy, they have lost their way. They may be compassionate and well-intentioned, but they are not well-informed or rational. There simply is no such thing as a “good homeopath.”

For more information, see Homeopathy Schmomeopathy: Homeopathy is not a natural or herbal remedy: it’s a magical idea with no possible basis in reality.

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Rheumatology

Rheumatology is the medical specialty devoted to arthritis, particularly the inflammatory arthritides (autoimmune diseases). These physicians are appropriately preoccupied with those serious and complicated problems, and many of them sub-specialize in just one, which is both a strength and a weakness. On the one hand, it isn’t fair or reasonable to expect an arthritis specialist to “get” pain caused by non-arthritis conditions.

On the other hand, many patients with increased rates of puzzling regional pains, or unexplained widespread pain, will eventually be diagnosed — probably by a rheumatologist — with an autoimmune disease like rheumatoid arthritis or lupus. So rheumatologists have an important role to play, and there’s no excuse for them being incurious and dismissive about symptoms they cannot explain.

And yet a lot of patients see exactly that attitude.

The dark side of specialization is being blinkered and passing the buck, because — for the busy medical specialist — declaring that your troubles are out of their scope of practice is safer and easier than the risk and hassle of trying to figure you out. As a bleak example, this problem has been formalized in Canada, where rheumatologists have been told by their professional organization that fibromyalgia is out of their scope of practice — they aren’t technically allowed to help fibromyalgia patients! But this policy should enfuriate patients and experts alike, because “fibromyalgia” isn’t even a disease: it’s just a label for unexplained chronic widespread pain. So the policy is essentially synonymous with endorsing the dismissal of “difficult” patients — which includes some patients who are actually suffering from the early stages of inflammatory arthritides! But symptoms too subtle to easily diagnose rarely get serious attention, even though they can make people miserable.

All of this applies to any specialist, but it’s most pronounced with rheumatologists and neurologists, the two types of medical specialists that are the most preoccupied with treating serious diseases while also being the most qualified to troubleshoot tricky pain cases. It’s a frustrating dilemma that results in many patients falling through the cracks.

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Neurology

Neurology seems straightforward enough on its surface: a medical specialty for diseases of the nervous system, many of which are famous, like Parkinson’s disease, multiple sclerosis, Alzheimer’s, plus all the mechanical neuropathies: all the many consequences of pinching various types of nerve tissue. If you aren’t moving or feeling things right, off you go to a neurologist.

But for every well-known neurological problem, there are a dozen subtler ones, and neurologists are downright besieged with medically unexplained symptoms that might be neurological in character…. and they will lose interest in patients that can’t be readily diagnosed. And there are a lot of those. A neurologist once told me:

About half of the patients I see have no diagnosable neurological condition. There’s something wrong with them, but I have no idea what, and I never will. So I focus on the ones I can help.

Fair enough! We want specialists to specialize. But many of those hard-to-diagnose patients will eventually be diagnosed with a neurological problem! And so neurologists shouldn’t be incurious about patients they “can’t help,” but the sad truth is that they often are. The dark side of specializing is being blinkered and passing the buck, because — for the busy medical specialist — declaring that your troubles are out of their scope of practice is far safer and easier than the risk and hassle of trying to figure you out.

All of this applies to any specialist, but it’s most pronounced with rheumatologists and neurologists, the two types of medical specialists that are the most preoccupied with treating serious diseases while also being the most qualified to troubleshoot tricky pain cases. It’s a frustrating dilemma that results in many patients falling through the cracks.

What a patient wants is one of those rare neurologists who is actually more of a generalist, who has taken an interest in tougher cases and a wider view of neurology. But while these doctors do exist, they are frustratingly rare. Just as with finding one of the “good apples” in one of the “bad professions,” I am not sure how I feel about telling patients to try to find one of these doctors — it is too difficult to be practical.

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Podiatrists, orthotists, pedorthists, and other makers and suppliers of orthotics

Feet take a lot of abuse and are often the site of chronic pain. How fortunate that there are foot specialists and people who make orthotics, right? Well, it’s complicated…

Orthotics are certainly not the only prescription option for healthcare professionals with foot expertise, but it is obviously a major one. And yet the value of orthotics has generally been inflated for decades, because it’s something that can be sold. In truth, orthotics have only a modest role to play in the treatment of most foot problems. And yet there are many unscrupulous and shoddy suppliers of these products who will prescribe orthotics for almost any problem, or none at all. Even reputable suppliers lean towards overprescription. And it is effectively impossible for consumers to know if they actually need any of these products, or where to get an expert prescription and a quality product.

Certified Pedorthists (C.Ped(c)) and Certified Orthotists (CO(c)) are the professionals that I recommend. They are the most qualified to not only assess and prescribe orthotics, but they actually make them. So that’s what you want, but they can be hard to find, and there is great variability in training and certification standards from region to region.

Podiatry is a medical specialization like dentistry and optometry.20 Obviously they specialize in foot problems, but many or most do not prescribe or supply orthotics (they leave that to those specialists). In Canada and the United States (most familiar to me), podiatry is mainly preoccupied with more serious foot pathology and corrective surgery, and rarely takes much of an interest in “minor” or puzzling chronic pain problems, or the kind of expert physical assessment of the entire lower limb and gait that orthotics prescribing requires.

As with all the medical specialties, some podiatrists cultivate an interest in stranger/tougher cases, but it’s not the norm.

For more information, see Are Orthotics Worth It? A consumer’s guide to the science and controversies of custom orthotics, orthopedic shoes, and other allegedly corrective foot devices.

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Osteopaths and osteopathic physicians

Osteopathy is a profession with colourful pseudoscientific roots that have been repudiated by many practitioners, but not most of them — to the peril of patients.

To the average person, an osteopath and a chiropractor are as similar as a weasel and a ferret. Globally and historically, osteopathy has always been and still remains mainly a type of alternative medicine devoted to the manipulation of muscle and joints. There are differences, but it’s all rather tedious inside baseball to patients.

In chiropractic, both progressive and traditional factions carry on under the same “brand,” benefitting from a unified identity. But osteopathy has fissioned into two major varieties. The traditional alternative-medicine style of osteopathy still mostly dominates globally, but true physician osteopaths have cropped up in some places. Mainly in the United States over the last several decades, some osteopathic schools levelled up and became true medical schools (albeit sometimes criticized for their mediocrity).

The diversity of training standards and regulation is extreme, too much even for osteopaths themselves to keep straight, let alone their patients. For instance, in Canada, nearly all practitioners are non-physician manual medicine osteopaths (in other words, a lot more like chiropractors). In the United States, both osteopath classes co-exist in significant numbers, but the non-medicals are somewhat marginalized and cannot use the title “Doctor of Osteopathy” — to avoid confusion! — and that must really rankle when there are so many “doctors” of chiropractic (who do not have medical degrees). In the United Kingdom, there’s a similar division, but even messier.

And so on. But chiropractic-like, non-medical osteopathy dominates globally.

To make matters worse, individual osteopaths often defy their category norms: some are cranks and quacks just like mainstream physicians can be (though quite possibly at higher rates). And some of the traditional osteopaths are progressive and science-loving (just like some chiropractors). You really can’t have any idea what you’re going to get — true of any profession, of course, but it’s more true of this one.

With all that diversity, it’s well nigh impossible to point to anything that actually defines the profession — except that too many practitioners are still all tangled up in those pseudoscientific roots. Have many osteopaths gotten past that? Yes. Have they all? Not by a long shot. Can patients tell the difference? I wouldn’t bet on it. For more information, see QuackWatch’s exploration of the Dubious Aspects of Osteopathy.

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Don’t “push” for a diagnosis from a medical specialist

Undiagnosable health problems are amazingly common. In the health care business, they are called “medically unexplained symptoms” (MUS), and chronic pain is the biggest MUS subcategory by far. Many people with puzzling pain go see several healthcare professionals and get frustrated by the lack of clear answers. They often have high expectations of medical specialists as troubleshooters, at first, and are disappointed to discover that specialists seem reluctant to wear that hat. One common reaction is to push for a diagnosis, to get ornery, to demand diagnostic satisfaction.

Which usually backfires.

The problem is that specialists have great excuses and valid motives for passing the buck, and so they do — and they will do it all the quicker if you “push” them for help.

Every specialist is, by definition, an expert in the problems in their field that they can diagnose and treat, and they are very busy doing it. When you present them with a problem that isn’t on that fairly short list, something they sincerely do not know how to diagnose and treat, they can honorably recuse themselves. It makes a lot of sense from their perspective: declaring that your odd problem is out of their scope of practice is far safer and easier than the risk and hassle of trying to figure you out.

If you “push,” most specialists will quickly decide that they really want you to be someone else’s problem. They will pass the buck and sleep well that night.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

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.

What’s new in this article?

I wrote my first version of this article in about 2006. It was amateurish and snarky, almost childishly biased in favour of massage therapy, and I rated most professions in terms of their trigger point therapy expertise (which makes me roll my eyes these days). It provoked a lot of outrage and hate mail, and I took the page down around 2012; it seemed like it was just asking for some kind of trouble, without a lot of upside. I have been meaning to start over and do it properly ever since, and I finally did in mid 2020.

It’s still a snarky article! But it’s also a lot more balanced and informed than the original. To the extent that it is not balanced, it’s because of a clearly acknowledged pro-science bias I can feel good about.

Four updates have been logged for this article since publication (Aug 3rd, 2020). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.

I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

Dec 29, 2020 — Another thorough proofreading, and many minor clarifications.

2020 — Thorough proofreading. If anyone finds any typos after this, I will be surprised. Grateful! But surprised.

2020 — Added osteopathy. (Several sections were added all at once in early August when I rebooted this article. This is the first “post-reboot” addition.) Also added a reference about physiotherapy.

2020 — Completely rebooted, truly “like new.”

2020 — Publication.

Notes

  1. We can put a man on the moon, but we can’t fix most chronic pain. The science and treatment of pain was neglected for decades while medicine had bigger fish to fry, and it remains a backwater to this day. The seemingly simpler “mechanical” problems of musculoskeletal health care have proven to be surprisingly weird and messy. The field is dominated by obsolete conventional wisdom and the speculations of desperate patients and opportunistic cure purveyors, and ignorance is widespread thanks to professional pride and tribalism, ideological momentum, screwed up incentives, and poor critical thinking skills. But the worst single offender is probably the pernicious and nearly unanimous oversimplification of treating the body too much like a complex mechanical device (“structuralism”). See A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta.
  2. Not all quackery is obvious — not even to skeptics. “Pseudo-quackery” appears to be mainstream, advanced, technological, “science-y,” or otherwise legit — quackery without any sign of being way out in left field. It has enough superficial plausibility to persist in the absence of evidence against it. This subtler type of snake oil is a more serious problem in musculoskeletal health care, because it hides right in the mainstream. For instance, it’s nearly synonymous with the early history of physical therapy, and remains alarmingly prevalent in that profession. So pseudo-quackery is extremely common, and generates more false hopes and wasted time, energy, money, and harm than more overt quackery, which is relatively marginalized. See Pseudo-Quackery in the Treatment of Pain: The large, dangerous grey zone between evidence-based care and overt quackery in musculoskeletal and pain medicine.
  3. A “modality empire” is a proprietary method (mode) of therapy championed by a single charismatic entrepreneur (the emperor). They sell books and workshops to professionals seeking to buy credibility in the form of increasing “levels” of certification, but the quality of these certifications is completely unregulated and often dubious. There is a great deal of overlap between modality empires and quackery. Many modality empires are simply repackaging old ideas. See Modality Empires: The trouble with the toxic tradition of ego-driven, trademarked treatment methods in massage therapy, chiropractic, and physiotherapy.
  4. ScienceBasedMedicine.org [Internet]. Ramey D. Acupuncture and history: The “ancient” therapy that’s been around for several decades; 2010 Oct 18 [cited 20 Sep 10].

    Saying that acupuncture is “not actually ancient” always upsets some folks. Sure, there are ancient antecedents for acupuncture — for practically anything — but acupuncture as we know it is largely a 20th Century invention.

  5. In the United States, it’s now common for PTs to earn a Doctorate of Physical Therapy, and they technically they have every right to call themselves “doctors,” like anyone with a doctorate, of course. However, in practice, most use it freely only as a credential (on business card, website, bylines, CV, etc) while avoiding using it as title. That is, they don’t introduce themselves as “doctor,” mainly to avoid confusion with physicians — which is pragmatic and humble. And certainly patients never think of them as a type of medical doctor (which they shouldn’t, because they aren’t). Thus, they are “non-physician professionals” by nature, despite the doctorates.
  6. Nicholls D. The End of Physiotherapy. First edition ed. Routledge; 2018.

    The End of Physiotherapy is the first book length critical history of the profession ever written. Prompted by the tensions and pressures now being felt by physiotherapists throughout the world, the book seeks answers in the profession’s past. Through a detailed and comprehensive analysis of the principles, practices, systems and structures developed by successive generations of practitioners, teachers and regulators, the book argues that the roots of the profession’s present problems can be found in the way it established its legitimacy and orthodox status. Drawing on a wide range of historical and contemporary sources from the United Kingdom, North America and Australasia, the book explores how neoliberal economic reforms, the burden of chronic illness and lifestyle diseases, the end of the welfare state, and people’s increasing skepticism towards orthodox healthcare, might now be posing challenges that the physiotherapy profession is ill-equipped to answer. The book explores the idea of a physiotherapy paradox, whereby the very conditions that once gave the profession its social standing now threaten to undermine it. The book challenges physiotherapists to reflect on these conditions and see the challenges now being posed as a call for the greatest reform ever undertaken by the profession: a challenge that will require physiotherapists to leave behind the very principles that once made their profession great, and carve out an entirely new professional identity.

  7. Ingraham. Chiropractor, Naturopath Training Way Less Than Doctors: Medical training is much longer and better than anything naturopaths or chiropractors normally get.  ❐ PainScience.com. 1019 words.
  8. Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al. In 2002, Freedman et al wrote: “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” In 2005 in Journal of Bone and Joint Surgery, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” In 2006, Stockard et al found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.”

    The situation has not really improved since then. For more information, see The Medical Blind Spot for Aches, Pains & Injuries.

  9. Back pain alone is one of the top reasons people see their GP, accounting for 15 million American office visits in 1990 (see Hart). Imagine what all musculoskeletal problems combined must account for …
  10. The major myths about massage therapy are:

    The complete list of dubious ideas in massage therapy is much larger. See my general massage science article.

  11. Sciencebasedmedicine.org [Internet]. Ingraham P. Why I Quit My Massage Therapy Career; 2019 February 22 [cited 19 Feb 23].

    In 2007, I was accused by my profession’s regulator of being an ‘unprofessional’ Registered Massage Therapist for criticizing pseudoscience in alternative medicine. I accepted an unusual public reprimand and made a few changes to my website, but my regulator pressed their case, effectively demanding that I quit writing altogether. I quit the profession instead.

  12. While trigger point therapy is on thin ice scientifically and should be regarded as experimental, the phenomenon of sore spots linked to aching and stiffness (sometimes very severe) is all-too-real and probably clinically relevant to a wide variety of conditions. Whether massage can help with this is a question science just has not answered yet. See The Complete Guide to Trigger Points & Myofascial Pain.
  13. 💩 Massage Therapists Say: A compilation of more than 50 examples of the bizarre nonsense spoken by massage therapists with delusions of medical knowledge.
  14. Richard Deyo is openly skeptical about most other back pain therapies, but acknowledges that “promising preliminary results of clinical trials suggest that research on massage should be assigned a high priority.” Another medical researcher (Ernst) found studies of massage therapy for back pain were poorly designed, but “ …massage seems to have some potential as a therapy for low back pain. More investigations of this subject are urgently needed.” And Patrick Wall, the imminent neurologist and pain researcher, writes a single word about massage therapy in his seminal book about pain: “delightful”!
  15. For example, I can easily name three scientifically bankrupt and nonsensical modalities that are widely used by naturopaths: applied kinesiology, various forms of detoxification, and homeopathy. That’s just the tip of the quack-berg, but those examples are so egregiously prevalent in the profession that they are damning all by themselves.
  16. ScienceBasedMedicine.org [Internet]. Hermes B. ND Confession, Part 1: Clinical training inside and out; 2015 Mar 15 [cited 15 Sep 6].
  17. The “ignorance” of doctors is often also the humility they all supposedly lack: they really don’t know why someone is sick, and they ethically refuse to have answers and cures that don’t exist.
  18. The specific cause of chronic pain may often be less important than general sensitivity and biological vulnerability to any pain. The biggest risk factors for pain chronicity are things like poor health, fitness, and socioeconomic status, inequality… and they overshadow common scapegoats like poor posture, spinal degeneration, or even repetitive strain injury. How can nothing in particular make us hurt? Because pain is weird, a generally oversensitive alarm system that can produce false alarms even at the best of times, and more of them when your system is under strain. See Vulnerability to Chronic Pain: Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems.
  19. This isn’t as flaky as it sounds. There’s a specific and testable hypothesis at the heart of it. For more information, see Chronic Pain as a Conditioned Behaviour.
  20. Most medical specialists train to be generalists first, and then go on to extensive continuing education in their chosen speciality. Podiatrists, dentists, and optometrists do not go to medical school, but train for their specialization in unique programs from the start. So in general they are have less education than MDs, but also more specialized education. Podiatrists are the most “doctor-like” of the three.