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 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 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.
Patients love to love physical therapy,7 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.
Many common treatments exist in that disconcertingly large, messy grey 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 grey 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.8 Things are getting better,9 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.”10
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 ago13 — 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 grey 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 grey zone. I’ve added more detailed explanatory footnotes to several of the more informative examples, highlighted.
- foam rolling
- ultrasound, especially extracorporeal shockwave therapy15
- transcutaneous electrical nerve stimulation (TENS)17
- education therapy
- spinal decompression18
- trigger point therapy in general,19 but especially dry needling20
- platelet rich plasma injection21
- low-level laser therapy22
- Functional Movement Screening23
- intrathecal pumps
- spinal manipulation therapy25
- opioid medications26
- physical vibration (coarse, as opposed to vibrating cells and molecules)29
- digital motion x-ray30
- far infrared radiation (mainly used in saunas)31
- 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 in most cases it will be pushed as a “promising” treatment, with varying degrees of informed consent, but offering usually just a 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.32 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.
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.”33 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 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 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.
Did you find this article useful? Interesting? Maybe notice how there’s not much content like this on the internet? That’s because it’s crazy hard to make it pay. Please support (very) independent science journalism with a one-time donation or RECURRING donation.
See the donation page for more information & options. Exclusive content for patrons coming mid-2021.
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.
What’s new in this article?
Five updates have been logged for this article since publication (2010). 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.
Mar 24, 2021 — Added “posturology” to the list of pseudo-quackeries.
2020 — Added a new short section, “Process versus product.”
2020 — Added far infrared radiation to the list of popular pseudo-quackeries.
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.
2010 — Publication.
- 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).
- 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.
- 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 The Myth of Healing Hands: Reiki, therapeutic touch, and other “energy medicine” methods are culturally rich but scientifically bankrupt.
- “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?.
- 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.
- 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 bizarre 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.”
- 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).
- Sort of. A lot of amazing work has been done in basic pain science the last few decades, 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, Sensitization in Chronic Pain, Pain is Weird, and 34 Surprising Causes of Pain.
- 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 …
- 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 Thomsonfrom 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.”
- 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 than those of placebos.”
- Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overview and methodology. Phys Ther. 2001;81(10):1629–1640.
“Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for low back pain”
“Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for knee pain”
“Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain”
“Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain”
- See Khan 2000 and Medzhitov 2008.
- 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 is 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, the condition it was originally intended to treat.
- 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.”
- 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. 4974 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.
- Ingraham. Zapped! Does TENS work for pain? The peculiar popularity of being gently zapped with electrical stimulation therapy. ❐ PainScience.com. 9090 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.
- 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.
- 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.
- 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.
- 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.
- Ingraham. Cold Laser Therapy Reviewed: A critical analysis of treating pain and injury with frickin’ laser beams. ❐ PainScience.com. 2806 words.
- 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.
- “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).
- 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. 17825 words.
- 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. 4751 words.
- Ingraham. Neurodynamic Stretching: Stretching and stimulating nerves to treat neuropathy… hopefully. ❐ PainScience.com. 2473 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.
- 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?.
- Ingraham. Vibration Therapies, from Massage Guns to Jacuzzis: What are the medical benefits of vibrating massage and other kinds of tissue jiggling? ❐ PainScience.com. 4983 words.
- 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.
- 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.
- 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.
- Silvernail J. Manual therapy: process or product? J Man Manip Ther. 2012 May;20(2):109–10. PubMed #23633891 ❐ PainSci #54128 ❐