Pseudo-Quackery in Physical Therapy

Unfortunately, not all quackery is obvious — not even to skeptics. Pseudo-quackery is medicine that isn’t much better than pure snake oil, but has successfully disguised itself as much more legitimate and evidence-based than it actually is, and is often hidden in plain sight in mainstream healthcare. Thanks to its good quality camouflage, pseudo-quackery is much more widely used, and generates more false hope and wasted time, energy, money, and even harm.1

Treatments like this are more formally known as “low-value medical practices.”2 and they are extremely common — practically standard — in the treatment of pain and injury. Classic examples span the full breadth of well-known interventions like ultrasound and shockwave therapy, “corrective” exercise, spinal manipulation, transcutaneous electrical nerve stimulation (TENS), stem cell therapies, and even surgeries like knee debridement and spinal fusion.

All kinds of healthcare suffer from this to some degree, of course — wherever there is quackery, there will be even more quackery that is tamer and sneakier — but I believe it’s particularly prevalent in the world of physical therapy et cetera, especially manual therapy.3 These areas of healthcare have always been a bit of a backwater, and nonsense thrives in the shadows, fills knowledge gaps in our knowledge — and there are still many of those.

Obvious quackery

If you want your quackery strong, like a stiff drink of bleach, you can find plenty of that! The care of aches, pains and injuries is rife with alternative treatments that are downright dangerous or delusional, not even plausible or consistent with established science, and often rooted in conspirituality, crankery, and vitalism. The claims are obviously “extraordinary.” Some of the most obvious quackery often foisted on patients:

• A homeopathic Arnica montana ointment, with barely any actual arnica in it, is one of the most popular remedies in the world in any category.4
• Reiki “masters” wave their hands over injuries and diseases, almost literally trying to wish them away.5
• A sizeable sect of chiropractors sell the idea that adjusting the upper cervical spine can cure not only low back pain, but all disease.6 And they accuse physicians of arrogance!

And much more, of course: superstitions and spiritualism, magnet and crystal cures, detox scams, psychic/faith healing, germ theory denialism, anti-vax and plandemic zealotry, quantum anything, Wi-Fi and 5G hysteria, and supplement-selling pyramid schemes! Sheesh! These are all blatantly dubious treatments, relatively easy for any educated person to spot and avoid. Most people are doubtful about these, and chronic pain patients in particular often know all too little they’ve been helped by this category of care (if not harmed).7

You don’t have to be a card-carrying skeptic to suspect that some promises are empty.

Sneaky quackery

Some quackery is just too subtle, specialized, or well-disguised to detect with a standard-issue bullshit detector. The average skeptic is quick to criticize of chiropractic, but probably does not know how far similar pseudoscientific rot has spread into physical therapy. They underestimate the seriousness of the problems in my domain. But I have spent all my time in this world since the late 1990s, I now take it for granted that the entire subdomain of physical medicine is a shambles and falls far short of being evidence-based.

But the most deceptive pseudoscience simply does not look like pseudoscience, and so I often have to advise skeptics that, ackshually, what their physio told them is utter bollocks. Physiotherapy, despite being the main ambassadors for mainstream physical medicine, is a distressingly good case study of how the whole point of pseudoscience is to disguise itself as science. The most deceptive pseudoscience does not SMELL like pseudoscience. Although physical therapy isn't synonymous with pseudo-quackery — many good practitioners can and do steer clear of it, of course — the overlap is strong, and physical therapy is exactly where most of them have become commercially successful and widely accepted.

Many treatments live in a large and messy grey zone between overt quackery and good medicine. For any one patient, most aren’t nearly as absurd and/or dangerous as many “snake oils,” but they are perceived as much more valuable and “normal.” For instance, bombarding injuries and pain with pressure waves and electricity is nowhere near as legitimate and modern as most people assume! The truth is that they are only slightly less absurd than homeopathy or crystal healing: much more plausible, but no more effective, or not much.

Pseudo-quackery examples: the master list

• foam rolling8
• vibration therapy in general, but especially massage “guns” (coarse, as opposed to vibrating cells and molecules)9
• prolotherapy10
• ultrasound and shockwave therapy11
• “corrective” therapeutic exercise, especially core strengthening (e.g. glutes that supposedly aren’t “activating”)12
• therapy taping13
• transcutaneous electrical nerve stimulation (TENS)14
• spinal decompression15
• therapeutic Botox16
• trigger point therapy in general,17 but especially dry needling18
• Regenerative medicine. Every other therapy in the rehab business bills itself as “regenerative,” but two popular examples dominate this category:
• blood therapies, mainly platelet-rich plasma19
• stem cell therapy20
• laser therapy21
• functional movement screens22
• intrathecal pumps
• posturology23
• spinal manipulative therapy24
• opioids for musculoskeletal pain25
• brain blaming and various “neuromodulation” treatments26
• neurodynamic stretching27
• orthotics28
• digital motion X-ray29
• far infrared radiation (mainly used in saunas)30
• muscle relaxants
• NMDA receptor antagonists for back pain
• orthopedic surgeries31

How to spot a pseudo-quackery

The sneaky quackeries share common traits in varying proportions:

• Superficially scientific plausibibility. There’s story about how it works that isn’t completely ridiculous — more than a vague scientific vibe, something that isn’t obviously at odds with existing science, as we routinely see with more blatant quackery.
• It’s perpetually “promising.” There’s almost always “evidence,” but it’s never good evidence, while the good evidence is almost invariably negative or underwhelming. But more robust scientific validation is just around the corner, we pinkie swear! Obvious quackery either hasn’t been studied because it’s just too stupid for serious people to take that seriously, or — if someone has bothered, usually as a debunking exercise, like the famous test of therapeutic touch by Rosa et al.32 — it’s just a slam-dunk negative.
• There’s substantial related investment, and infrastructure: complex and expensive equipment, training and certifications, conferences, entire journals devoted to the topic, and so on — all of which contributes strongly to the impression that “there must be something to it.” Although more obvious quackery aspires to this and sometimes achieves it to some degree, it rarely achieves it to any significant degree.
• The supreme overconfidence of being on Team Mainstream. All of the above doesn’t just impress patients: it is embraced hardest of all by professionals, driving the kind of relaxed overconfidence that can only come with the safety of numbers. For all their bluster, snake oil salesman know full well that they are marginalized, out in left field, and their sales pitches are full of clever ways of evading and overwhelming skepticism. The pseudo-quack knows that they don’t even have to justify themselves. It’s a subtle difference that becomes glaring with familiarity. It is particularly obvious by how shocked and triggered they get when their claims are challenged: they don’t expect that. There are people who have been doing this stuff in clinical practice for decades and they literally do not know that there are people like me who think it’s well-disguised garbage, and they get very discombobulated and head-explodey when they finally encounter it. It’s a distinctive form of incredulous outrage!

“A promising treatment is often in fact merely the larval stage of a disappointing one. At least a third of influential trials suggesting benefit may either ultimately be contradicted or turn out to have exaggerated effectiveness.”

Bastian, 2006, J R Soc Med

How can do so many bad treatments thrive for so long?

The pseudo-quackersy persist for all the same reasons as the more obvious quackery — they offer easy answers for hard problems — but the higher superficial credibility of those "answers" makes them very successful and durable in the marketplace. Science sells!

For lack of evidence-based treatment methods, manual therapists routinely fall back on things that aren’t, and would be considered experimental in other areas of medicine … but they present them earnestly and overconfidently, in the language of scientific medicine. The use of technology adds substantially to the aura of sophistication. The category is filled with opportunistic and “innovative” treatment products and services. Patients mostly have no clue when they have entered this grey zone of therapeutic guess work, because pseudo-quackery treatments aren’t ridiculous on their face. They are what serious-seeming professionals are actually recommending.

But those professionals mostly just don’t know how to actually help people with these problems. Not much is known to work,33 just a few specific things for very specific patients. Even “simple” overuse injuries continue to present surprising scientific difficulties. For instance, it turns out that tendons are not just boring ol’ gristle after all, but impressively clever “bio-rope” with biological complexity undreamed of 25 years ago34 — and the only thing that’s clear is that we don’t understand that biology well enough to help distressed tendons. But the entire industry is still basically working with simplistic mental models that don’t come anywhere close to coming to terms with the biological complexity of the problem.

There are now mountains of evidence about what does not work — substantial evidence of absence for practically every widely used form of physical and manual therapy35 — but the bad news has been alarmingly slow to influence clinicians. As Zusman wrote, “for reasons somewhat difficult to comprehend the message does not seem to be getting through.”36 Even the “progressive” ideas in the field, like Cognitive Functional Therapy and doing physical medicine the “biopsychosocial way,” aren’t exactly based on good science either.3738394041 The bad old ways may just get swapped out for fashionable new ones that aren’t much better!

by Dave Coverly, www.speedbump.com

Some surprising medical advice: “The last thing you need is physical therapy”

When my wife was severely injured in a car accident in 2010 — fracturing her skull and brain, spine, pelvis, arm, and foot — her physiatrist (a doctor specializing in injury rehabilitation) gave her some surprising advice:

Don’t bother with any physical therapy. That’s the last thing you need. You mainly just need rest, and general activity when you can handle it. Maybe in a while go a couple times and get a little coaching and some course correction, but mostly it’s a waste of time and money.

Harsh! But not without justification — this is the cost of some serious and well-documented backwardness in physical therapy.42 Many or even most seemingly mainstream rehabilitation options and treatments are based on some antiquated ideas, and offer surprisingly little evidence-based bang for the buck-per-minute. It isn’t quite “quackery” — not like homeopathy — but it falls far short of evidence-based medicine.

Patients love to love physical therapy,43 but that may be in part because physical therapists use all of the pseudo-quackeries discussed in this article: treatments that are defined by seeming more legitimate than they actually are.

Embrace the uncertainty!

It is said by some that health care would be paralyzed if we could dispense only proven treatments — as alt-med evangelists and critics of evidence-based medicine delight in pointing out.44 Unproven therapies are particularly unavoidable in my former profession: as a massage therapist, I literally could not move a muscle in my office without doing something unproven. What’s an ethical practitioner to do?

Here are simple instructions for converting pseudo-quackery into ethical therapy in just moments:

1. Look patient in the eye.
2. Take a deep breath.
3. Recite the mystical incantation, “I don’t know if this will help you.”

I could protect my patients from my own ignorance only by proactively and candidly emphasizing it. Anything less would have been unethical.

Unfortunately, just saying “I don’t know” seems to be a dying art amongst self-employed therapy mongers. The almighty dollar is the main problem. Most manual therapists are freelancers, and their rent only gets paid when patients return for more. This is all it takes for many practitioners to recommend unproven treatments with just a bit too much enthusiasm. Even just a little bit of normal human ego can do it.

Process versus product

Most of the pseudo-quackeries are “products” or “services” that are intended to deliver a benefit more or less indepently of the clinical context. “Magic bullets.” That is, it shouldn’t matter all that much who is delivering them or why. Almost all of them are supposedly good for practically anything that ails you, no clinical reasoning or subtlety required.

But good health care is a process that is greater than the sum of its parts, rather than just a “service” or “product.”45 Dr. Jason Silvernail:

Published trials of an impairment-based manual therapy approach where the treatment is provided by highly-trained clinicians using manual therapy in the context of a systematic, hypothesis-based clinical reasoning process have consistently shown large effect sizes in validated outcome measures relative to other interventions.

In other words, what works is probably complex and subtle and the result of good coaching and consulting — not the dumb one-size-fits-most application of whatever electrotherapy the therapist happens to have invested in.

It’s dangerous because it’s not very dangerous

Pseudo-quackery can be mild-mannered and humdrum. No big deal, really. But that’s exactly why it goes largely unexamined.

It is routinely perpetrated by average professionals suffering from a little confirmation bias and a lack of familiarity with the scientific literature. In no case are these people true quacks in the sense a hardened skeptic would use the word — they’re just ordinary professionals who can’t read journals all day long and have bills to pay. Their confidence in unproven therapies runs the full gamut from apathetic assumption to premature enthusiasm to crass entrepreneurial boosterism.

And yet if it isn’t the job of a therapist to be openly humble in the face of profound ignorance of what truly works, then I don’t know what is.

Despite its ho-hum personality, pseudo-quackery is a clear and present danger, particularly to chronic pain patients. Even skeptical patients routinely spend thousands of dollars on false hopes in the grey zone, often spending years in the “therapy grinder,” hammering away expensively at a condition that there was never really much hope of treating in the first place.

Chronic pain patients often feel desperate, and it’s not wrong to cautiously try an experimental treatment method. But very few methods are anywhere near as promising as their marketing makes them seem. Be cynical. Be careful. And beware of professionals who haven’t gotten the memo: humility in treating chronic pain is not just a nicety, but an ethical necessity.

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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., or subscribe:

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Notes

1. A basic premise of this article is that quackery is never harmless. See What’s the Harm? and Quackery Red Flags: Beware the 3 D’s of quackery: Dubious, Dangerous and Distracting treatments for aches and pains (or anything else).
2. Herrera-Perez D, Haslam A, Crain T, et al. Meta-Research: A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals. eLIFE. 2019 Jun 11;8(e45183). PainSci Bibliography 52236 ❐ “Low-value medical practices are medical practices that are either ineffective or that cost more than other options but only offer similar effectiveness.”
3. My title says “physical therapy,” but that’s a simple shorthand for a many overlapping kinds of healthcare categories and professionals that try to help people with pain and recovery from injury. “Physical medicine” is the best overall label for this group, and it basically means “physical therapy et cetera,” and includes naturopaths, occupational therapists, rheumatologists, and many more: they are all reviewed on another page. But “manual therapy” dominates. “Manual therapy” refers mainly to massage, spinal adjustment, and other costly methods of using hands/tools to “fix” tissue, mainly treatments that are done to passive patients. Although mostly the domain of massage therapists and chiropractors, physical therapists also use many manual methods. Unfortunately, it is mostly a pseudoscientific dumpster fire based more on authority, tradition, and marketing than good research. And yet some practitioners are responsible, and the power of compassionate touch to comfort and inspire should never be underestimated. For more information, see Manual Therapy: What is it, and does it work? The science of "fixing" tissue with hands-on treatments like massage and spinal manipulation.
4. Homeopathic (diluted) arnica creams for pain, such as Traumeel, are quite popular. They contain only trace amounts of the best-known ingredient, arnica. They may contain other herbs as well, some of them less extremely diluted. Scientific evidence so far strongly suggests that effects of such creams are minor at best. For more information, see Does Arnica Gel Work for Pain? A detailed review of popular homeopathic (diluted) herbal creams and gels like Traumeel, used for muscle pain, joint pain, sports injuries, bruising, and post-surgical inflammation.
5. Therapeutic touch is hands-off aura massage, actual touch not included. It is the main example of so-called “energy medicine” and a close cousin of Japanese reiki. It is naked quackery. Auras do not exist and cannot be felt, let alone manipulated therapeutically. For more information, see Use the Force! The myth of healing energy in massage and bodywork: Reiki, therapeutic touch, and other “energy medicine” methods are culturally rich but scientifically bankrupt.
6. “Upper cervical” (NUCCA) chiropractors believe that nearly all problems not only originate solely in the top-most spinal joint, but that they have the skill to reliably correct all of these problems by manipulating that joint. This is hard for many people to swallow, but there is still clearly a market for the service — many patients are charmed by such an elegant-seeming explanation for everything that’s ever gone wrong with them. I’ve mentioned NUCCA in many places around PainScience.com, but have never focused on it. The most relevant articles are The Chiropractic Controversies, What Happened To My Barber?, and Does Spinal Manipulation Work?.
7. Kamen P. All in My Head: An epic quest to cure an unrelenting, totally unreasonable, and only slightly enlightening headache. Da Capo Lifelong; 2005. p. 177–194.

   In this chapter of All in My Head: An epic quest to cure an unrelenting, totally unreasonable, and only slightly enlightening headache, Kamen tells the story of her experiences with a wide variety of alternative therapies for her chronic headache. The result is one of the funniest and most insightful explorations of alternative health care ever put to paper.

8. Foam rollers are so popular that they have taken on a life of their own, as if they are not “just” a delivery system for massage — different or even better than massage. But foam rolling is in fact just a delivery system for massage, for whatever that is worth … which apparently isn’t much, because the science of foam rolling is a big fat nothing burger. Read more.
9. Ingraham. Vibration Therapies, from Massage Guns to Jacuzzis: What are the medical benefits of vibrating massage and other kinds of tissue jiggling? PainScience.com. 5690 words.
10. Prolotherapy (a portmanteau of “proliferative therapy”) is a classic example of a provocation therapy, intended to “toughen up” ligaments and tendons that are, supposedly, causing trouble because they are weak. Which is very weak sauce. This therapy is a particularly perfect example of a pseudo-quackery, because it was popularized by a physician in modern times; it had a very plausible and specific biological rationale that is still persuasive to the uninformed today; and it can only be provided by doctors (because injections). But it has also has many hallmarks of alternative medicine and snake oil, and the rationale stopped sounding biologically plausible to most experts at least thirty years ago! I cover it in a bit more detail Tissue Provocation Therapies in Musculoskeletal Medicine, and there’s a full-throated critical analysis in my low back pain tutorial — the main condition it was originally intended to treat.
11. See Does Ultrasound or Shockwave Therapy Work? Garden variety ultrasound is bad enough, but ESWT in particular is textbook pseudo-quackery: popular, expensive, over-hyped, and definitely being sold to patients for conditions it has little hope of treating … and yet on the other hand, it almost certainly is good for something, and proponents can still easily say “more study needed.”
12. Tedious and specific “corrective” or “therapeutic” exercises are a tired cliché of rehab and physical therapy, both strengthening and stretching. It’s what everyone (athletes and non-athletes alike) imagines their training montage will look like if they are ever hurt. This style of rehab is largely based on the flawed and even harmful assumption that there is something in-correct about injured patients — fragile, weak, uneven, imbalanced, etc — which must be fixed by sufficiently expert and precise exercise prescription. This kind of thinking has been called “The Corrective Exercise Trap” — a trap for pros and patients. Don’t get me wrong — strength is great stuff, and resistance training has great value. But the delusion of precision is generally as bankrupt as the idea of a workout that “targets” belly fat! You can read much more about this in my main strength training article.
13. Ingraham. The Dubious Science of Kinesiology Tape: The origin story and science of therapy tapes like Kinesio Tape, KT Tape, Spider-Tech, RockTape. PainScience.com. 5608 words. Therapy taping (Kinesio Tape® and its newer competitors) has been hot since the 2012 Olympics, with both fans and suppliers making big claims about pain and injury treatment and performance enhancement. Thanks to all the attention, we have more science than usual for this sort of thing — all showing trivial effects at best, and completely negative results for many specific claims, like increasing circulation.
14. Ingraham. Zapped! Do TENS and friends work for pain? The peculiar popularity of being gently zapped with various kinds of electrical stimulation therapy. PainScience.com. 12156 words. Humans love stimulants! We have always enjoyed zapping ourselves and each other, just a little bit, or even quite a lot. In the 20th century, and still today, by far the most popular (and tame) form of electrotherapy or neuromodulation is transcutaneous electrical nerve stimulation (TENS). Although pleasant and mildly analgesic for some people, TENS is roughly in the same league as the comfort of a heating pad, and does not remotely deserve to be a staple of physical therapy. Other kinds of electrical stimulation are somewhat interesting, and more promising, like deeper stimulation — zapping the brain and spinal cord have some genuine potential.
15. Spinal decompression is a fine example of a treatment that is deep in the grey zone, verging on quackery. Certainly the way chiropractors sell it (aggressively, for a lot of money), it is largely snake oil. What keeps it in the grey zone: a kernel of therapeutic truth probably lurks somewhere in there. Used judiciously and with fully informed consent, it could be rescued from quackery and take a modest but respectable place in the neck and back pain toolkit.
16. Botox has its uses, but it’s also a very complicated mixture of risks and benefits for different conditions, and unfortunately its often marketed for virtually any painful problem that might be related to spasm — which is often unwise. For more information about therapeutic Botox, see Cramps, Spasms, Tremors & Twitches.
17. Trigger point therapy is a perfectly useful treatment idea that may well be validated by proper testing in time, but it is kept in the grey zone largely by an attitude problem: dogmatic belief in its value, chronic over-selling, and poor clinical reasoning based on flawed theories about what trigger points are. Oh, and did I mention? Hopelessly inadequate and confusing evidence so far. See Trigger Point Doubts.
18. Dry needling is the “stabbing” of putative trigger points with acupuncture needles: a practice that has been widely embraced by physical therapists. The risks are much greater than they are with any other form of treatment for trigger points, with no greater justification.
19. You can inject your own blood into an injury to “increase circulation” in an almost brutal way, delivering everything that blood has to offer at high concentrations right where healing needs to happen. This is the injection of “autologous whole blood” (AWB), or the parts of blood: for platelet-rich plasma (PRP) the blood is processed to make a concentrated mixture dominated by platelets, a blood ingredient that releases more growth factors. Either way, the hope is that a bloody injection will stimulate healing where it is otherwise failing — one of the simplest kinds of “regenerative” medicine, especially for stubborn, slow-motion injuries like tendinitis. PRP is popular and profitable, but the evidence for its efficacy is simply abysmal. See Does Platelet-Rich Plasma Injection Work? An interesting treatment idea for arthritis, tendinopathy, muscle strain and more.
20. Stem cell therapies are based on “generic” cells or their biochemistry. Stem cells are biologically fascinating, and they could have unusual properties and might well be a healing stimulant. But in terms of understanding and translating that biology into useful medicine, it’s an extreme case of caveat emptor: stem cell therapy clinics have sprung up everywhere and they are way ahead of the science. This medical tech is just not safe and proven yet, and many of the clinics selling it are just cashing in on hype and hope. See Salamander Science and Regenerative Medicine: Why does PainScience.com have a salamander mascot? Their regenerative superpower is an inspiring, profound example of what is possible in biology and healing.

21. “Cold” or low-level laser therapy (LLLT) is the best-known specific type of photobiomodulation therapy (PBMT), just one of many riffs on that tune, but the most famous and one, and the most clearly a pseudo-quackery. Not all PBMT is about true laser light (coherent, monochromatic, directional). Sometimes it’s just red or (more penetrating) infrared light, and sometimes a mix. Lasers seem to attract cranks and quacks, and laser therapy is strongly associated with much more than its fair share of bullshit and fraud. PBMT is superb at putting on scientific airs based on many seeds of truth in “biophysics,” but the evidence reviews are a train wreck. Laser therapy either doesn’t work at all, or it requires a perfectly storm of variables to work even a little. It’s face plausibility is high, but tends to fall apart when you start to think about it: why would organisms evolve a highly adaptive response to an artificial stimulus? They probably didn’t! Read more:

    Ingraham. Cold Laser Therapy Reviewed: A critical analysis of treating pain and injury with frickin’ laser beams. PainScience.com. 4504 words.

22. The Functional Movement Screen (FMS) is a pseudo-diagnostic physical test of coordination and strength, especially “core” strength, invented in 1997 and now used (and abused) by manual therapists healthcare professionals. It was originally conceived of as a trouble-detection system, which is baked into the name: it’s just a “screen,” in theory. In practice, it also unwisely used like diagnostic tool to “explain” injury (“well there’s your problem,” pointing to a slight deficit “revealed” by the FMS). Although it’s at least somewhat reliable (practitioners can generally produce the same results), it has failed many tests of its validity, its ability to predict or even detect injury. Multiple scientific reviews since the mid-2010s have concluded that it is not useful. It’s extremely unlikely that anyone can figure out who is going to get injured, or what’s wrong with people who already have been injured, just by watching them move. The FMS is both a product of, and a contributor to, the common but dubious belief that injury is a function of subtle movement dysfunctions. See The Functional Movement Screen (FMS) Reviewed: The powers of the popular screening system for athletic injury risk may be over-hyped.
23. “Posturology” is the cheesy, popular term for the mostly made-up “discipline” of studying the relationship between posture and pain, and even between posture and diseases. In other words, it is the clinical application of the belief that posture is a significant factor in many common painful problems (especially back pain). While there may be kernels of truth in posturology, it is overwhelmingly sloppy and amateur, with many claims that are flatly contradicted by the evidence. And yet it is firmly in the mainstream, a staple of physical therapy: 65% of physical therapists believe that educating their patients about posture is “very important”, and another 28% rank it just below that — “despite a lack of strong evidence that any specific posture is linked to better health outcomes” (see Korakakis et al.).
24. Ingraham. Does Spinal Manipulation Work? Spinal manipulation, adjustment, and popping of the spinal joints and the subluxation theory of disease, back pain and neck pain. PainScience.com. 18266 words.
25. Ingraham. Opioids for Chronic Aches & Pains: The nuclear option: Oxycontin, codeine and other opioids for musculoskeletal problems like neck and back pain. PainScience.com. 6216 words.

26. Many professionals are surprisingly keen to minimize the role of pathology and injury in pain (secondary pain), the better to overzealousy (and rather conveniently) blame it on the power of the mind/brain to “amplify” pain (primary pain, “nociplastic” pain, in which pain itself is the disease). Central sensitization is a real physiological process in which neurons fire, but the diagnosis is widely abused, lazily overdiagnosed, and carelessly conflated with psychological mechanisms.

    This is a broad category, not a specific idea, but gaslighting patients in this way has become so prevalent that this list no longer seems complete without it. For much more information, see Mind Over Pain: Pain can be profoundly warped by the brain, but does that mean we can think the pain away?

27. Ingraham. Neurodynamic Stretching: Stretching and stimulating nerves to treat neuropathy… hopefully. PainScience.com. 4023 words.

    The idea of stretching nerves to treat neuropathy is interesting, and there could be something to it. But the modality has been around for ages without the slightest bit of science to support it. It’s based entirely on educated guesses and clinical experience. It sounds impressive, which is why it’s a good example of a pseudo-quackery, but it’s quite doubtful that it’s actually effective.

28. Orthotics are a particularly good example because there are such obvious legitimate uses for them, but the overwhelming majority of orthotics prescriptions are a bad idea. The industry ranges from the completely legitimate to the merely overprescribed and dubious all the way to rank fraud. See Are Orthotics Worth It?.
29. X-ray movies are a bad idea, no question. However, they are a fine example of pseudo-quackery, because they reek of science-y plausibility, and because they could be legitimately valuable in a handful of medical scenarios. But the casual observer — and even many professionals — will simply not see the problems with it without careful consideration and study. See Digital Motion X-Ray: A Dangerous Illusion of Diagnostic Power.
30. Far infrared saunas are advertised like they beam healing rays. It’s yet another example of the optimism that some kind of energetic stimulation might make biology work better (identical in spirit to TENS, ultrasound, laser therapy, etc). far infrared radiation is the part of the infrared section of the electromagnetic spectrum with the longest wavelengths, and it is widely touted to penetrate at least a few centimetres into tissue; the citation usually given for this (if any) does not actually support the claim. Effects on biology beyond simply warming tissues are conceivable, but have never actually been documented. I explore this topic in more detail in my thermotherapy article: Heat for Pain and Rehab: A detailed guide to using heat as therapy for acute and chronic pain and recovery from injury.

31. “Not all surgery,” of course, but … it is far less evidence-based and much more grotesquely over-prescribed than most patients would ever guess, and some popular procedures for painful conditions are notoriously sketchy. Like spinal fusions and knee debridements and “lube jobs.” Even joint replacements, while sometimes definitely the lesser of evils, are much more of a gamble and less evidence-based than patients assume. Surgery seems very mainstream and cromulent, but is arguably one of the best single examples of overmedicalization. There are many perspectives on and sources for this, but there is a single particularly important citation that covers all the bases, and arguably should be read by every single person considering any orthopedic surgery: Surgery: The ultimate placebo, by Ian Harris. Start with an excerpt.

32. Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. JAMA. 1998 Apr 1;279(13):1005–10. PubMed 9533499 ❐ PainSci Bibliography 56856 ❐

    This paper is an entertaining chapter in the history of the science of alternative medicine: a child’s science fair project published in the Journal of the American Medical Association. Emily Rosa’s experiment showed that “twenty-one experienced therapeutic touch practitioners were unable to detect the investigator's ‘energy field.’ Their failure to substantiate TT's most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified.”

    Therapeutic touch practitioners could not demonstrate any ability to detect a person by feeling their aura, let alone manipulating it therapeutically. The test made them look ridiculous.

    Ms. Rosa was just nine years old when she did this experiment, and remains the youngest person to have a research paper published in a peer reviewed medical journal. (It is, of course, likely that she had some parental assistance — but I don’t know the whole story.)

33. "Not much works"? Citation needed! I won’t make the case in detail here (many other articles delve into the disappointing science), but if I had to pick just a couple key citations:

    • Cashin et al., an excellent review of many low back pain treatments with a grim “not much works” theme.
    • The infamous 2001 Philadelphia Panel on rehabilitation interventions, which showed that many popular treatments in physical therapy cannot beat a placebo, an evidence-based bummer of epic proportions.
34. See Khan 2000 and Medzhitov 2008.
35. Citation: most of the rest of this website! I’ve written well-referenced articles about dozens of examples. Many of the most prominent in the pseudo-quackery category are linked below.
36. Zusman 2011, op. cit. “This is clearly evident from, among other things, the findings of recent studies such as those by Daykin & Richardson and Ali and Thomson from the United Kingdom. … The key finding was that clinicians’ beliefs (“worldview”) concerning the cause of patients’ (chronic) pain and disability were still dominated by the outmoded, structure-oriented “biomedical” model. … It is especially troubling that a structural perspective informed clinical reasoning even for patients who presented with obvious psychosocial “overlay.”
37. Taylor AJ, Kerry R. When Chronic Pain Is Not “Chronic Pain”: Lessons From 3 Decades of Pain. J Orthop Sports Phys Ther. 2017 Aug;47(8):515–517. PubMed 28760092 ❐

    This paper tells the story of a patient who had “sciatica” for thirty-five years and was misdiagnosed many times until finally getting not only a definitive diagnosis but a cure. He had a narrowed artery (arterial stenosis causing “claudication,” the pain of impaired circulation). That’s it! Not even a difficult diagnosis in the end, really. There were some pretty glaring clues there that got ignored by a lot of people who should have known better.

    Not only was he misdiagnosed many times over more than three decades, he was misdiagnosed fashionably: that is, each misdiagnosis neatly fit a paradigm in physical therapy, better than it fit his symptoms. This carried on right up to and including the present day fascination with psychosocial factors and sensitization (which served him no better than any of the other paradigms had).

    Interestingly, the patient’s belief that something ‘was actually wrong’ had remained with him throughout the journey. This, of course, had been explained away to him (more recently) by current research and evidence-based thinking on central sensitization and pain.

    Just fascinating. The authors thoughtfully explore the implications of this rather shameful episode (definitely aimed at pros, some jargon, but readable enough for anyone — and behind a paywall, unfortunately). The bottom line? Good diagnostic skills are never out of fashion. Or shouldn’t be, anyway!

    There are criticisms of this paper from a couple of my favourite experts and writers, pointing out in a letter to the journal that one of the “fashionable” paradigms impugned here, the biopsyschosocial model, “includes the considerations [the “bio” part] that eventually cured the patient’s pain.” I like the criticism and I like the authors’ response — I see only healthy debate here

    Accuracy disclaimer: It’s always possible that a case study like this has been misrepresented to make a point. Maybe it didn’t really go down this way. But based on my own professional, I think things like this definitely do happen (and based on my personal experience, I know they do). I am referring both to fashionable misdiagnosis in general, and to problematic overemphasis on psychosocial factors and sensitization in particular. The omission of the “bio” from the “biopsychosocial” model should not happen in theory, but it certainly does in practice.

38. Breedt E, Tichenor E, Barlott T. Diagnosing the body in physiotherapy: the passage from discipline to control. Physiother Theory Pract. 2025 Nov:1–25. PubMed 41215734 ❐

    This paper is a strong indictment of some of the fashionable trends in physical therapy. The authors argue that modern “holistic,” “patient-centred,” “pain-science informed” physiotherapy is not actually humane or liberating, even though many clinicians obviously sincerely believe it is. Instead, they suggest that it quietly extends physiotherapy’s reach into more intimate aspects of life, and that that expansion conveniently aligns with unrealistic neoliberal expectations to self-optimize, self-manage, stay productive, and keep adapting forever.

    In other words, progressive physio tends to put the burden of pain relief on the patient. Although that is obviously a major oversimplification, and it doesn’t capture the authors' entire argument, it does express a major key point.

    For patients, we could boil it down even further to just a single word: gaslighting.

    Breedt et al. think today’s “progressive” approaches encourage people to:

    • reinterpret their own pain,
    • reframe their beliefs,
    • regulate their emotional responses,
    • build self-efficacy,
    • pursue meaningful activity despite symptoms,
    • and continually upgrade themselves.

    The horror! What’s wrong with those things? They can seem (and even be) meaningfully supportive, but the authors see them as part of a broader social dysfunction where individuals are expected to manage their own suffering through self-regulation rather than relying on (for instance) healthcare providers to, you know, provide. Provide what? Clinically important diagnosis and/or treatment! Which may well be neglected! See Taylor for important documentation of a representative example of that neglect.

    Breedt et al. are critiquing an ideology that wraps around this newer style of care. Progressive physiotherapy can have a shiny, benevolent surface while still carrying hidden problems — just different ones than the old biomechanical paradigm. Out of the frying pan, into the fire. From simplistic biomechanics to simplistic biopsychosocialism. The are concerned about the social-political machinery that offloads responsibility for structurally produced harm onto individuals in the first place. Rather than refining techniques of self-regulation, they urge us to examine how our economic and political orders generate the very injuries, illnesses, and debilities people are then told to manage on their own.

    I notice a striking similarity between this thesis and that of one of my favourite books, Ron Purser’s brilliant McMindfulness. This statement in the abstract jumped out:

    “We contend that ‘holistic’ movements in physiotherapy, despite their progressive appearance, serve control societies and perpetuate state and corporate power.”

    That may sound strangely political/philosophical to many readers' ears, but it’s practically an echo of the point of Purser’s book, which is that corporations have co-opted meditation and mindfulness “as a technique for social control and self-pacification.”

39. Riley SP, Ware E, Pitre Z, Russell N, Flowers DW. Pain neuroscience education combined with any singular form of physical therapy intervention is not more effective than the single intervention itself: a systematic review. J Man Manip Ther. 2025 Nov:1–11. PubMed 41262073 ❐

    This review of pain neuroscience education (PNE) concludes that trials are a bit of a mess, with studies leaning heavily on statistical significance while paying little attention to effect size, uncertainty, or clinical meaning. Seemingly “positive” findings rest mainly on dubious methods and biased interpretation rather than strong evidence.

    After strict screening for trial quality and research integrity, the authors found only a handful of studies worth taking seriously — and those do not show that adding PNE to a single physical therapy intervention improves pain or function. The evidence base is thin and varied, and cannot justify good-news conclusions. PNE is somewhere between absence of evidence and evidence of absence: not disproven outright, but doesn’t produce a clear positive signal even when bias is presumably warping results in favour of PNE.

    Riley et al. do not claim that PNE is useless in all contexts, but they do conclude that it cannot be defended as an effective add-on treatment for improving pain or functional outcomes. Some secondary measures — such as pain knowledge, self-efficacy, and fear of movement — show limited signals in specific cases, but these effects do not translate into meaningful clinical benefit. Overall, this is quite damning review: the literature is not just “inconclusive,” it’s unimpressive.

40. “Boot nail guy” is a notorious anecdote about someone who had severe pain because he thought he was injured. “Progressive” clinicians and researchers and influencers have leaned on this anecdote much too hard since circa 2010, always to make the point that pain is powerfully modulated by psychology. They abuse the anecdote because there are is no compelling evidence that pain is a function of fear and anxiety. See The legend of Boot Nail Guy reconsidered
41. Roberts A. The biopsychosocial model: Its use and abuse. Med Health Care Philos. 2023 Sep;26(3):367–384. PubMed 37067677 ❐ PainSci Bibliography 49695 ❐

    ABSTRACT

    
    

    The biopsychosocial model (BPSM) is increasingly influential in medical research and practice. Several philosophers and scholars of health have criticized the BPSM for lacking meaningful scientific content. This article extends those critiques by showing how the BPSM's epistemic weaknesses have led to certain problems in medical discourse. Despite its lack of content, many researchers have mistaken the BPSM for a scientific model with explanatory power. This misapprehension has placed researchers in an implicit bind. There is an expectation that applications of the BPSM will deliver insights about disease; yet the model offers no tools for producing valid (or probabilistically true) knowledge claims. I argue that many researchers have, unwittingly, responded to this predicament by developing certain patterns of specious argumentation I call "wayward BPSM discourse." The arguments of wayward discourse share a common form: They appear to deliver insights about disease gleaned through applications of the BPSM; on closer inspection, however, we find that the putative conclusions presented are actually assertions resting on question-begging arguments, appeals to authority, and conceptual errors. Through several case studies of BPSM articles and literatures, this article describes wayward discourse and its effects. Wayward discourse has introduced into medicine forms of conceptual instability that threaten to undermine various lines of research. It has also created a potentially potent vector of medicalization. Fixing these problems will likely require reimposing conceptual rigor on BPSM discourse.

42. Zusman M. The Modernisation of Manipulative Therapy. International Journal of Clinical Medicine. 2011 Nov;2(5):644–9. PainSci Bibliography 54598 ❐

    This paper strongly criticizes the persistent use of “passive movement” in physiotherapy — doing things to patients bodies — and the disappointing reasons for it: a “now obsolete, structure-based ‘bio-medical’ model” which has “been shown flawed or at least irrelevant.” Unfortunately, the language of the paper is tortuous, and the bizarre overuse of scare quotes and parentheticals is particularly odd. But I agree entirely with its substance, and share the Max Zusman’s frustration with the state of physical therapy: “The profession needs to be seen to be taking the mature stance afforded by its modern science-based training.”

    Nicholls D. The End of Physiotherapy. 1st ed ed. Routledge; 2018.
43. Hush JM, Cameron K, Mackey M. Patient Satisfaction With Musculoskeletal Physical Therapy Care: A Systematic Review. Phys Ther. 2010 Nov. PubMed 21071504 ❐

    Quite a bit of research has been done on physiotherapy and its efficacy, most of it quite discouraging. But what about the patients? Do they like it? Does it work well for them? This study attempted to calculate what the patient satisfaction level was for those who received physical therapy care.

    A review of the literature was undertaken from several databases. A search of 3,790 studies allowed for a thorough study of 15 that met the criteria.

    The researchers concluded that “patients are highly satisfied with musculoskeletal physical therapy care” and found that “the interpersonal attributes of the therapist and the process of care are key determinants of patient satisfaction.” Given that, it’s a bit odd that the authors thought it was “unexpected” that how well treatment worked was “infrequently and inconsistently associated with patient satisfaction.”

    I’ve always considered it a given that how a patient feels about a treatment has almost nothing to do with how well it worked (independently of placebo), but this study is the first time I’ve seen some good hard evidence of it. “Satisfaction is not the same thing as effectiveness” (Long).

44. They think it proves that interventions don’t need to or can’t be studied and proven. They’re wrong. They also think evidence-based medicine is dogmatically, automatically against anything that isn’t proven. They’re wrong about that too. EBM has always formally recognized the value of clinical experience and the complexity of clinical reasoning.
45. Silvernail J. Manual therapy: process or product? J Man Manip Ther. 2012 May;20(2):109–10. PubMed 23633891 ❐ PainSci Bibliography 54128 ❐