Do most painful conditions resolve spontaneously? (Member Post)

The rule of healing (is that lots of things do it)

It’s widely accepted in medicine healing happens, so well that it would be hard to stop it in most cases. It’s axiomatic that medicine is an art of “amusing the patient while nature cures the disease.” Failures to heal seem to be the exception that proves the rule that healing works extremely well. The existence of the rare phenomenon of fracture non-union is a horrifying exception to the rule that most fractures heal just fine.

But finding references for all that… tricky! It feels like trying to find a reference to support “exercise is good for fitness.” We certainly do have a lot of evidence for that, but it’s a sprawling web of specifics and nuances, not easy to clearly support with even just a handful of citations, never mind just one.

There probably is a strong consilience of evidence that a great many conditions do resolve on their own: lots of individual examples, all of which add up to good support for the general rule, if you are very familiar with the literature. Sticking to musculoskeletal and pain medicine, here are some examples:

• Wound healing has an extremely well-established progression … and it ends. Wounds heal. And a great many common painful problems are wounds of one sort or another.
• Most spinal intervertebral herniations spontaneously de-herniate. An example of a particular kind of "wound" that heals better than most people think.
• The average duration of an acute episode of back pain is pretty well-pinned down. We know that most cases resolve, rather than becoming chronic, and that most chronic cases are only chronic for several months (not years).
• A startling number of sports injuries recover well without surgical aid that used to be considered essential.

And so on. You get the idea: there are many individual examples.

But I must avoiding citing “lots of evidence, but none in particular.” A lot of bad ideas are defended that way!

And this is definitely not a slam dunk.

Chronicity is far too common to ignore

The most obvious problem with the most-conditions-resolve claim is all the awkward and tragic counter-examples. Almost all the frustrating painful conditions are frustrating because they are chronic — they don’t resolve spontaneously by definition. It’s right in the name! You can make this point with a list of chronic conditions, and that list is obviously enormous.

Here are some categories and selected interesting examples:

• Frozen shoulder has always been widely thought of as a self-limiting condition. Sure, it’s disabling for way too long — up to 2 or 3 years — but the conventional wisdom is clear that it will end. But this is probably a myth! We now have evidence that frozen shoulder is not self-limiting — that, in fact, there is no typical recovery time, and a substantial percentage of cases take much longer to resolve than they should according to the conventional wisdom, if they ever do. This is all because frozen shoulder is probably actually more of a joint “disease” than an “injury,” making it one of the best examples of pathology-driven pain…
• There are many painful “forever” pathologies that can cause all kinds of musculoskeletal complaints, like autoimmune diseases, or the hypermobility spectrum disorders, or long-term damage caused by infections, or a cyst that is impinging a nerve, and so on and on. There are a lot of ways of to hurt, and many of them don’t go away. (One of the most interesting examples I’ve come across in my career is new evidence that what’s making people sick after Lyme disease is the persistence of molecule pooped out by the bacteria that the immune system simply cannot clear.)
• There are also plenty of chronic pathologies where pain is the major symptom, or even the only: migraine, irritable bowel syndrome, fibromyalgia, complex regional pain syndrome, trigeminal neuralgia, and so on.
• Many painful problems that probably will resolve when they occur in younger people are a completely different story later in life … and there are many painful problems seen mostly in older people that are probably mostly just going to get worse. While many of these come and go for years — like episodes of spinal stenosis symptoms, which can easily give the impression that they “resolve” — they tend to get inexorably worse over the long term. Bog standard arthritis also follows this pattern.
• Although many overuse injuries do resolve within about six months, they are truly notorious for their stubborness and relapses, and it’s common for them to drag on for years. Some of that chronicity is probably explained by perpetually poor load management (never resting adequately), intersecting with genetics and other systemic vulnerabilities. And poor load management isn’t always a careless or reckless failure: many people live with largely unavoidable physical stresses, especially ergonomic occupational hazards. While the persistence of such injuries isn’t a mystery, it still counts as an example of injuries that do not just get better on their own.

So clearly many conditions just do not resolve spontaneously!

A “huge” mistake? What’s the evidence that this mistake was “huge”? That might be overstating it a bit.

“Most” conditions are self-limiting?

It’s not looking good for my claim. My too-obvious-for-a-citation statement seems to be on thin ice. The “Sagan Standard” is that “extraordinary claims require extraordinary evidence.” I didn’t think I needed to apply the Sagan standard to this claim, but … maybe I did.

The statement was too broad, and I think one word in particular — “most” — was doing too much heavy lifting. It’s a butt-covering word, imprecise enough to be true as long as even a slight majority of common conditions do resolve. But do they?

I suspect it very much depends on how/who you measure. Proving that a majority of conditions are self-limiting would require advanced statistical comparison of the natural histories of dozens of conditions … and in many cases that data either just doesn’t exist or is of dubious quality. So don’t hold your breath. We’re probably never going to know.

“Most” might be accurate, but I suspect it isn’t. Yet again, my assumptions have gotten me into hot water when checked. Dammit.

In my defence…

Going forward, I will knock off trying to reassure people that “most” conditions resolve on their own. Unfortunately, “many” or “some” is much less reassuring than “most”! Using "most" was an exaggeration in service of reassuring my readers.

And why do they need reassurance? Because, for many reasons, people are too pessimistic about what to expect from their injuries and pains. And why is that?

• Pain is highly corrosive to hope. The longer it goes on, the worse it gets.

• Much less obviously to many people: healthcare professionals are often not reassuring. They have a tendency to make many kinds of painful problems sound worse than they are. They often imply (if they don’t just state it outright) that bodies are more fragile and vulnerable than they are. They do this for many reasons, despite the best of intentions. But the biggest reason is that so many of them sell solutions.

And can I support those claims? 🙂 Not easily, not simply! Nevertheless, I do strongly suspect that there is a great need to reassure people as much as possible that many conditions are much more self-limiting than they may have been led to believe. For much more detailed exploration of this theme, see Your Back Is Not Out of Alignment.