Patients with stubborn pain problems often want to know the odds that a proposed therapy will work. Who wants to waste time or money on another therapeutic approach without a sense of whether or not it’s going to work?
Is there a 20% chance that massage therapy will resolve your hip pain?
But the margin of error on that estimate is so large that the estimate is meaningless: 20% +/- 75%?
In other words, it is simply unknown. Therapy may go very well, or it may be futile, or the results may be somewhere in the middle. I have seen many examples of every possible outcome. Hunches about the potential of therapy are essentially useless: they are wrong enough often enough that it’s really not worth paying much attention to them. Excellent results sometimes come from cases that seemed hopeless, and sometimes we hit a wall when for some reason it seemed like an easy challenge.
“Success rates” are meaningless
Therapists are fond of advertising — literally or informally — that they have a high “success rate” with their overall style, or a specific technique or method. Most people know better than to believe a highly inflated number, but we need to be skeptical even of more modest claims, like, “I find about 70% of people get better with this approach.”
That is not something individual clinicians can actually know. Clinical outcomes are subject to a dazzling number of confounding factors — so many that estimates are basically meaningless. Most importantly, clinicians have a badly skewed sample: patients tell them about perceived successes much more than failures.
Even if it was knowable, a high success rate still wouldn’t constitute validation of methodology. Again, the confounding factors: there are many ways that people can actually get better that have nothing to do with the alleged “active ingredient” in the therapy.
Battle of the (charming) experts
The uncertainty comes from many variables, of course. But one of the most obvious is simply that experts constantly disagree, about pretty much everything and anythng. No matter how sensible an idea sounds, you can pretty much count on finding a dissenting expert opinion that sounds sensible!
There is simply too much diversity of expert (and ignorant) opinion on virtually every imaginable aspect of health care for patients to know whether or not a therapy will work without just trying it.
I have seen literally thousands of examples in my career of patients who tried a therapy that failed because they were persuaded by reasonable-sounding recommendations from charismatic, well-intentioned professionals who just happened to be — in my expert opinion! — dead wrong.
No offense, gentle reader, but most patients do not have the knowledge to reliably evaluate the opinions of health care professionals. You can mostly only judge their character — the general quality of their logic, their interpersonal skills, etc. — and that isn’t really a good way of judging.
When people hear how busy my practice is, they often say, “Wow, you must be really good.” And I always reply, because I love to make this point about integrity in health care, “Actually, I may just be charming.” That always gets a laugh, so apparently it’s a very charming thing to say.
I know many other popular therapists who are not — in my opinion! — particularly good at their jobs, but they are definitely appealing and persuasive people with great interpersonal skills!
All or nothing?
It may be difficult to estimate the odds, but one thing is for sure: therapy is not generally an all-or-nothing proposition … especially an “all” proposition. The majority of “successful” physical therapy for pain problems more than a year old results in some degree of imperfect but desirable “improvement” — not unqualified victory.
“Nothing” is certainly more common than “all.” The sad truth is that the effectiveness of physical therapy in general tends to lean towards the negative. Far more therapies fail or produce only weak results than those that work well.
For instance, consider the question asked above: Will acupuncture help 1 in 5 cases of back pain? There actually is a good answer to that question, and the answer is: no. Acupuncture for low back pain has just recently been proven by superb scientific research to be essentially totally useless for low back pain, no better than randomly sticking needles into your skin.1 Acupuncture for other kinds of pain is not in much better shape.2
Unfortunately, just because there is an answer doesn’t mean you can know the answer. There really is no way for patients to reliably identify bogus therapies. Some patients, some of the time, successfully call bullshit — but just as often, bogus therapies sound good and fool smart people, both the prescriber and the patient.
And of course bogus therapies often usually result in complete failure, except perhaps for mild placebo effects.
So, what to do?
Don’t estimate! Or estimate with a huge margin of error!
It is not really possible to choose a therapy with any confidence about its effectiveness, unless you study it very thoroughly. And you can’t really take anyone’s word about it either. About the best you can hope for — and the best I offer most patients — is that success is plausible.
The only way to find out for sure if a therapy will work for you is to try it. That is the nature of the problem. Which is why I always encourage patients to be shoppers — give your time and money to professionals who seem to think clearly and give good service. Give them a reasonable chance (a few appointments, perhaps) to “fix” you and then, if you aren’t seeing clear progress, move on and try something else!
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.
Here are some other articles that may help you choose a therapy or a therapist:
- PS The Not-So-Humble Healer — Cocky theories about the cause of pain are waaaay too common in massage, chiropractic, and physical therapy
- PS Battle of the Experts — A guide for patients caught between conflicting diagnoses and prescriptions
- PS Choose the Therapist, Not the Therapy — When you’re in pain, you want to know “what works,” but what you should look for is an honest therapist of any kind
- PS Does Massage Therapy Work? — A review of the science of massage therapy … such as it is
- Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for Chronic Low Back Pain: Randomized, Multicenter, Blinded, Parallel-Group Trial With 3 Groups. Arch Intern Med. 2007;167:1892–1898. PainSci #56004. ❐ BACK TO TEXT
- See Does Acupuncture Work for Pain?. BACK TO TEXT