Not all quackery is obvious — not even to skeptics. Subtler snake oil is actually a more serious problem in musculoskeletal health care, because it’s harder to spot and much more common, even mainstream. Such “mild” quackery probably generates just as much false hope and wasted time, energy, money — and even harm.1
Rank, obvious quackery
If you want your quackery strong, like a stiff shot of whiskey, you can find plenty of it: the care of aches, pains and injuries is rife with alternative treatments that are experimental at best, and probably too good to be true.
- A homeopathic Arnica montana ointment, with barely any actual arnica in it, is one of the most popular remedies in the world.2
- Reiki “masters” wave their hands over injuries and diseases, almost literally trying to wish them away.3
- A sizeable sect of chiropractors sell the idea that adjusting the upper cervical spine can cure not only low back pain, but all disease.4 And they accuse physicians of arrogance!
These are some of the superstars of scientifically dubious treatments in alternative health care, and they’re relatively easy to spot and avoid. Many people are doubtful about these treatments, and many chronic pain patients in particular know all too well how little they have been helped by this category of care.5 You don’t have to be a card-carrying skeptic to know that some promises sound too good to be true.
But what if quackery isn’t so obvious?
Some surprising medical advice: “The last thing you need is therapy”
When my wife was severely injured in 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 course corrections, 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.6 Many or even most mainstream rehabilitation options and treatments are based on some really antiquated ideas, and offer surprisingly little evidence-based bang for the buck-per-minute. It isn’t “quackery,” per se, but it certainly falls far short of good, modern care with proven benefits.
Many common treatments exist in that disconcertingly large, messy gray zone between overt quackery and proven, uncontroversial medicine. Probably the best examples are ultrasound and transcutaneous electrical nerve stimulation (TENS): mainstream and extremely popular, but bombarding injuries and pain with sound waves and electric current is nowhere near as evidence-based a treatment as most people assume.
Many of these treatments are considered legitimate and mainstream even though they really aren’t any more useful than snake oil — or are just barely so. The gray zone is large because there is precious little that we can actually do to help people in pain or to facilitate healing. Not much “works.” Pain and rehabilitation science is still distressingly, exasperatingly primitive.7 Things are getting better,8 but much of what we have learned 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.”9
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 physiologic complexity undreamed of 25 years ago12 — and the only thing that’s clear is that we don’t understand the biology well enough to treat tendons effectively.
For lack of well-tested treatment methods, physical therapists, chiropractors, and massage therapists routinely sell treatments that would be considered experimental in most other fields of medicine. But patients generally have no idea when they have entered this gray zone of therapeutic guess work, because pseudo-quackery treatments aren’t ridiculous on their face, and some of them are even interesting and promising. So what makes them dubious?
- debatable plausibility
- absence of (good) evidence
- overconfident prescription despite the lack of evidence
Shruggers: ideas of average quality
A lot of treatment ideas are not very plausible, but plausibility is hard to nail down. One person’s plausibility is another’s eye-roller. I know of a lot of allegedly plausible treatment ideas that aren’t completely out to lunch, but they don’t exactly impress me either. I call them “shruggers” — ideas worth testing, but mostly pointless to debate except out of intellectual curiosity. A shrugger always has at least a couple fairly obvious problems with it.
Manual therapists (and doctors too) have a lot of shruggers: untested, or barely tested, or badly tested. Here’s a bunch of examples that I think fall into this category. Some readers will think several of these are obvious quackery, while others will be outraged that I’m suggesting they are candidates. This only emphasizes the point: they are in the gray zone. I’ve added more detailed explanatory footnotes to several of the more informative examples, highlighted.
- foam rolling
- ultrasound, especially extracorporeal shockwave therapy14
- transcutaneous electrical nerve stimulation (TENS)16
- education therapy
- spinal decompression17
- trigger point therapy in general,18 but especially dry needling19
- platelet rich plasma injection20
- low-level laser therapy21
- Functional Movement Screening22
- intrathecal pumps
- spinal manipulation therapy23
- opioid medications24
- digital motion x-ray26
- muscle relaxants
- NMDA receptor antagonists for back pain
Not much evidence + plenty of confidence = sure, why not?
If a pseudo-quackery treatment was properly proven to be effective one day, then it would no longer be any kind of quackery. If it were proven to be bogus (“evidence of absence”) then it would be demoted to full quackery. But an unstudied shrugger? What’s that?
“Good enough,” apparently.
Pseudo-quackery gets pimped out to patients for many years or even decades, with confidence ranging from “not much” to “extreme.” But it most cases it will be pushed as a “promising” treatment, with varying degrees of informed consent, but offering usually just slight nod to the lack of evidence. And in quite a few cases, it will be sold as real medicine, exactly as though it was already proven, not a word of doubt expressed. This is especially the case with the more expensive electro-therapies, where a freelance professional has spent as much as hundreds of thousands of dollars on a piece of “medical” equipment, and must sell treatments hard to pay for it. Shockwave ultrasound and spinal decompression machines are superb examples.
Absence of evidence alone does not pseudo-quackery make, of course. Some of these things probably are medicine, and they will eventually be proven. But the degree to which we just can’t say is a bit shocking. The stock introduction to scientific reviews of virtually all treatments is “there is insufficient evidence to draw conclusions.” This does not apply only to the stuff in left field: we’re talking about the bread and butter treatments of mainstream physical therapy — interventions that consumers and insurers spend billions on every year — as well as stranger and newfangled stuff.
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.27 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:
- Look patient in the eye.
- Take a deep breath.
- 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.
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 spans from apathetic assumptions to premature enthusiasm to over-the-top marketing zeal.
And yet if it isn’t the job of a therapist to be openly humble in the face of our awesome ignorance of what really 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 gray 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, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
What’s new in this article?
2017 — Cited Grant et al on the gradual improvements in the evidence-based for sports medicine.
2017 — Added citations to and quotes from Zusman 2011.
- 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). BACK TO TEXT
- 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. BACK TO TEXT
- 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 Therapeutic “Touch” Is Pseudoscience: No touch included! Auras don’t exist and can’t be felt, let alone massaged for medical benefit. BACK TO TEXT
- “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?. BACK TO TEXT
- 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.BACK TO TEXT
- Zusman M. The Modernisation of Manipulative Therapy. International Journal of Clinical Medicine. 2011 Nov;2(5):644–9. PainSci #54598. ❐
A strong indictment of the persistent use of “passive movement” in physiotherapy, 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 clunky, especially the bizarrely overuse of scare quotes and parentheticals. However, I agree completely with its substance, and share the author’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.”BACK TO TEXT
- Sort of. A lot of amazing work has been done in basic pain science the last few decades (e.g. see Woolf 2010 on central sensitization). But its implications are extremely slow to trickle down to clinical practice — because they are actively resisted by many physical therapists, because they think it undermines their role as flesh-fixers. Which it does. Pain science is clearly showing that what makes pain severe and chronic has amazingly little to do with anything that can be “fixed” or manipulated in tissues, which is directly at odds with the traditional model of doing something to patient’s bodies. See Your Back Is Not Out of Alignment and Pain is Weird. BACK TO TEXT
- Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781. ❐
Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine …BACK TO TEXT
- 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” (sic).” BACK TO TEXT
- Machado LA, Kamper SJ, Herbert RD, Maher CG, McAuley JH. Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology (Oxford). 2009 May;48(5):520–7. PubMed #19109315. ❐ PainSci #54670. ❐
This is a meticulous, sensible, and readable analysis of the very best studies of back pain treatments that have ever been done: the greatest hits of back pain science. There is a great deal of back pain science to review, but authors Machado, Kamper, Herbert, Maher and McCauley found that shockingly little of it was worth their while: just 34 acceptable studies out of a 1031 candidates, and even among those “trial quality was highly variable.” Their conclusions are derived from only the best sort of scientific experiments: not just the gold-standard of randomized and placebo-controlled tests, but carefully choosing only the “right” kind of placebos (several kinds of placebos were grounds for disqualification, because of their known potential to skew the results). They do a good job of explaining exactly how and why they picked the studies they did, and pre-emptively defending it from a couple common concerns. The results were sad and predictable, robust evidence of absence: “The average effects of treatments … are not much greater those of placebos.”BACK TO TEXT
- Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overview and methodology. Phys Ther. 2001;81(10):1629–1640.
See also:BACK TO TEXT
- See Khan 2000 and Medzhitov 2008. BACK TO TEXT
- Prolotherapy (a portmanteau of “proliferative therapy”) is a classic example of a provocation therapy, intend to “toughen up” ligaments and tendons that are, supposedly, causing trouble because they are weak. Which is very weak sauce. This therapy a particularly perfect example of a pseudo-quackery, because it was popularized by a physician in modern times, had a very plausible and specific biological rationale (for the time), can only be provided by doctors (because injections), and yet 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. There’s a summary of it in Tissue Provocation Therapies, and a more detailed critical analysis in my low back pain tutorial. BACK TO TEXT
- See Does Ultrasound 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.” BACK TO TEXT
- PS Ingraham. Kinesio Taping Review: A quick analysis of that colourful therapy tape that was so popular at the Olympics. Does it help? ❐ PainScience.com. 2725 words. Athletic taping is hot in the last few years with prominent new products and branding and big claims about injury prevention and performance enhancement. But even Olympic athletes can be fad and fashion victims, and the evidence so far shows only trivial effects, probably due only to altered sensation (not biology or biomechanical as usually claimed). New materials may achieve different and possibly superior benefits, but probably not much. BACK TO TEXT
- PS Ingraham. Zapped! Does TENS work for pain? The peculiar popularity of being gently zapped with electrical stimulation therapy. ❐ PainScience.com. 6835 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). Other kinds of electrical stimulation are also interesting, and more promising, like deeper stimulation — zapping the brain and spinal cord. This is an overview of all forms of neuromodulation with a strong focus on TENS for pain. BACK TO TEXT
- Spinal decompression is a fine example of a treatment that is deep in the gray 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 gray 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. BACK TO TEXT
- 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 gray 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. BACK TO TEXT
- 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. BACK TO TEXT
- Platelet-rich plasma (PRP) is plausible and still shows some faint promise for tendinopathies and arthritis, but the science so far is discouraging, the hype and costs are high, and there could be risks above and beyond the basic risks of any injection. For more information, see Does Platelet-Rich Plasma Injection Work? An interesting treatment idea for arthritis, tendinopathy, muscle strain and more. BACK TO TEXT
- PS Ingraham. Cold Laser Therapy Reviewed: A critical analysis of treating pain and injury with frickin’ laser beams. ❐ PainScience.com. 2424 words. BACK TO TEXT
- The Functional Movement Screen (FMS) is a set of seven physical tests of coordination and strength, especially “core” strength, invented in 1997 and now in widespread use around the world. It was originally proposed as a trouble-detection system, which is baked into the name: it’s a “screen.” Its use in the wild seems to over-reach this stated purpose. For more information, see The Functional Movement Screen (FMS): The benefits of the popular screening system for athletes might be over-sold by some professionals. BACK TO TEXT
- PS 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. 16636 words. BACK TO TEXT
- PS Ingraham. Opioids for Chronic Aches & Pains: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids for musculoskeletal problems like neck and back pain. ❐ PainScience.com. 4517 words. BACK TO TEXT
- 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?. BACK TO TEXT
- X-ray movies are a bad idea, no question. However, they are a fine example of a 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. BACK TO TEXT
- 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. BACK TO TEXT