Or see the help page for answers to common customer questions
Of course, I don't want to be too reassuring. Several folks pointed out that not all herniated discs retreat back to their home between the vertebra. Indeed, probably most don't. So, how about some real data, some hard numbers on how herniations change over time? I give you: Kjaer 2016, “the first study to investigate changes in the size of lumbar disc herniations” over a long period. See the bibliography item for full details, but the upshot was: 65% did not change, 17.5% resolved, 5% fluctuated (weird), and only 12.5% got worse. Those numbers are not awesome numbers — obviously herniations do not all magically go away — but I do think they are different and much less discouraging numbers than most people have in their heads, I think.
Not that herniation severity correlates well with pain or predicts recovery in the first place.
Of course, I have now cited Kjaer et al in my low back pain tutorial.
“Lumbar disk herniation has an uncertain natural history.” UNDERSTATEMENT.
Check out these before/after pictures of a disk herniation that solved itself. Look closely where the arrow is pointing. Read the single paragraph description of the case. No scalpels were involved in this recovery. Now, did your concern level about disc herniations just drop 3 notches? Good, mission accomplished. File under “back pain rarely as bad as it feels.”
Recently I published the first new feature article for PainScience.com in quite a while: Zapped! Does TENS work for pain? The peculiar popularity of being gently zapped with electrical stimulation therapy. I’ve now added an interesting new section to it about pulsed electromagnetic field therapy (PEMF). It’s amazingly positive, and inspired by some fresh science…
PEMF is clearly kin to TENS, part of the electrotherapy family. And yet it’s a different beast, much more exotic, with a more mysterious mechanism of action. PEMF is hypothesized to directly stimulate cellular repair, and not for nothing: it seems to really do that, and the effect is almost magical, speeding up bone fracture healing, and even restoring it in cases where healing has failed completely.
The scientific reviews of PEMF used for this purpose are unstintingly positive.1 Shi Hf, Xiong J, Chen Yx, et al. Early application of pulsed electromagnetic field in the treatment of postoperative delayed union of long-bone fractures: a prospective randomized controlled study. BMC Musculoskelet Disord. 2013;14:35. PubMed #23331333. PainSci #53405. “Fracture patients treated with an early application of PEMF achieved a significantly increased rate of union and an overall reduced suffering time compared with patients that receive PEMF after the 6 months or more of delayed union, as described by others.” 2 Assiotis A, Sachinis NP, Chalidis BE. Pulsed electromagnetic fields for the treatment of tibial delayed unions and nonunions. A prospective clinical study and review of the literature. J Orthop Surg Res. 2012;7:24. PubMed #22681718. PainSci #53378. “PEMF stimulation is an effective non-invasive method for addressing non-infected tibial union abnormalities. Its success is not associated with specific fracture or patient related variables and it couldn't be clearly considered a time-dependent phenomenon.” When does this happen in musculoskeletal medicine? Never, that’s when!
So PEMF has been used on fractures for a long time now, but only recently have PEMF devices gotten small and cheap enough for consumers and less critical medical applications. Can they work on more ordinary problems? Like arthritis? Something TENS can only treat effectively with just the right settings and variables, that no one can seem to confirm? Apparently so…
Although the evidence for this isn’t unanimous, some of the best and most recent PEMF trials are unambiguously positive.3 Bagnato GL, Miceli G, Marino N, Sciortino D, Bagnato GF. Pulsed electromagnetic fields in knee osteoarthritis: a double blind, placebo-controlled, randomized clinical trial. Rheumatology (Oxford). 2016 Apr;55(4):755–62. PubMed #26705327. PainSci #53404.
This was a scientifically rigorous test of wearable pulsed electromagnetic fields (PEMF) for older patients with osteoarthritis of the knee: moderate to severe cases with X-ray evidence and pain of at least 4/10 for more than six months, despite maximum tolerated medication. Sixty patients wore either a real PEMF device for 12 hours per day, or a fake; neither they nor the researchers knew who got real PEMF (double-blind). PEMF is particularly easy to test properly, because it causes no sensation, making it much easier to compare to an active placebo.
The placebo devices do not emit a radiofrequency electromagnetic field but are identical to the active devices, including a light-emitting diode light showing operation. The energy from the active device is not felt by the user, and the active device cannot be distinguished in any way from the placebo device.
Their pain and knee function were compared. PEMF won decisively: the real-PEMF patients enjoyed a 25.5% reduction in pain, compared to a 3.6% reduction for the fake-PEMF patients. Knee function improved as well, though not as much. I hope everyone got a real PEMF device at the end!
That’s compelling evidence. Not that there aren’t caveats. (There are always caveats.) Although the results seem straightforwardly positive, the authors explain that “some of the effects of this therapeutic approach might be derived from neuromodulation of the pain mechanism”: that is, it might be “just” a pain-killer, as opposed to actually helping to heal arthritic cartilage. But killing pain effectively would be a pretty good second place!
The Bioelectronics Corporation manufactures PEMF devices, and provided the pulsed electromagnetic fields and placebo devices, but they did not fund the study and the authors declared no conflict of interest. These devices are widely available to consumers: see ActiPatch®.
Nice long read from writer Joletta Belton, also a knower of extremely stubborn pain: Living well with chronic pain, is it possible? Might it be necessary?
I like her description of what I have always called the “therapy grinder,” and what she describes as “the emotional roller coaster of elusive cures.” That is such an important problem in chronic pain treatment. People with serious chronic pain are often strapped into that roller coaster ride by false hope in bogus and semi-bogus treatments for too long, which greatly delays the next, necessary step in their painful journey: acceptance and surrender, which are usually more therapeutic than the therapy roller coaster/grinder.
That is a doozy of a step I’ve taken personally at least twice now, so it isn’t just theory for me anymore. And I completely agree with Joletta: “It’s not giving up or removing hope, it’s giving hope.” Surrender is not always failure, though they can look damnably similar!
I love it when someone suggests a topic they’d like me to write a book about...and I’ve already written it. Ta da! Instant book!
Usually people suggest a painful topic I have not yet written a book about, of course. Arthritis, headaches, temporomandibular joint syndrome, and adhesive capsulitis are popular suggestions. I’m not really making much progress on any of those topics, unfortunately…
I have written eight books so far, and it was always my plan to write about a dozen books in total, and then keep them updated indefinitely. Ideally, I’d like fine tune the inventory a bit: demote two or three of the books I have now (so that I don’t have to maintain them), and then write several new ones.
It was also important to me to do this because I’ve been promising it for years. Specifically, I’ve promised customers who purchase my “e-boxed set” that they will have get free access to any new books I ever write. Sounds great, right? (Technically, I never promised to actually write new books, just to deliver them for free if I do, but that’s just playing word games.)
And now I haven’t finished a new book since 2009. Because, as it turns out, keeping the first eight up-to-date is at least equal a full-time job. Really, the only way to pull it off at all is to work unusually hard and smart. And I’m getting a bit old and stupid now, so this is a bit of a situation.
Nevertheless, I am optimistic: I think it will still happen! Just not quickly.
When a test of two treatments shows them to be “equally effective” — a fairly common conclusion in medical science — people often fail to consider the possibility that they are actually equally ineffective, and that the apparent benefits were actually due to something else entirely: other treatments, the healing kiss of time, good ol’ regression to the mean, and so on. This is why it’s so important to compare treatments to a persuasive placebo.
Today I’d like to share a particularly bizarre, amusing, and depressing example of how the profession of massage therapy still has a lot of growing up and getting with the times to do. And it’s an example of what passes for science reporting at MassageToday.com, apparently. And it’s a really spot on example of “tooth fairy science”: the earnest study of imaginary things.
I don’t recommend actually bothering to try to read that article. The premise of this “small pilot study” is so absurd that it’s hard to parse, so let me just drag the important part out into the light for you: they are talking about studying the effects of massage on auras, using “gas discharge visualization” [insert fart joke here]. GDV is a slight variant of Kirlian photography, or “aura photography” supposedly. Which is exactly as ridiculous as it sounds, and one of the easiest things to debunk in all the Land of Silly Beliefs.
Here’s a snippet of some of the thickest bafflegab from the MassageToday.com article, with a little square-bracketed commentary from me:
The authors theorize [fancy way of saying “wildly speculate”] that the energy emitted from a person can indicate the individual’s bioenergetic field [aura]. Thus, it should be able to be measured and quantified. The theory is that the energy photons [as opposed to what other kinds of photons?] represent the dynamic bioenergy [aura!] of the person and the image represents their energy field [aura, aura, aura]. The image is capturing the displacement of gas particles emitting from the subject, either from fingertips or a full body projection. It is theorized [by fools] that the emissions represent the level and balance of energy flow in the meridians, but it is important to note that the authors state, ‘Gas discharge visualization measures are not very well defined regarding their meaning.’
GDV measures are very well defined regarding their meaning: they have none. (Nothing important anyway. It’s basically an extremely convoluted way of detecting moisture.) Planning to the interpret the effect of massage on Kirlian photography is completely pointless. This is the most blatant kind of pseudoscience: people spewing jargon to create the appearance of technical and scientific sophistication about something fanciful, like writing a paper about how many terabytes of memory God has, or the role of neutrophils in Bigfoot’s immune system. It’s absurd and pathetic. Ravensara Travillian, PhD, NA-C, LMP:
In sorrow rather than anger, I have to ask: this is the kind of Tooth-Fairy Science that we traded the credibility and plausibility of massage therapy for?
It’s a common misconception that natural is always healthy and “biology knows best.” But biology does not always know best! Evolution is a wondrous but surprisingly awkward process that leads to many compromises, tradeoffs and sacrifices, and absurd unintended consequences like an eyeball structure that is obviously second best, an unnecessary 4-metre detour for the recurrent pharyngeal nerve in giraffes, or completely non-functional inflammation caused by our immune systems mistaking exposed mitochondria for invaders. Friendly fire!
Biology is optimized for reproduction early in life, and that only partially aligns with our interests — and less so all the time, as the human lifespan gets longer. Suffering is a natural consequence…and sometimes it makes sense to interfere with it. For instance, by taming inflammation a bit with icing for pain control — which was the specific inspiration for this post.
It takes ages to prepare these! I chipped away at this one for an hour or two per week for six months, which is the only way I get anything done any more: I rotate between many projects, inching forward on many fronts. I don’t get anything done quickly! But I get a lot done slowly.
Except nothing’s ever really done, so please put on your critical thinking caps and hit me: Do you think I got anything wrong? What’s missing, despite all the thoroughness? Plenty, I’m sure. This is a good chance to influence the final form of the article.
Recently I identified about 90 broken links to other websites scattered around PainScience.com — an accumulation of about three years worth, since I last checked them. I just spent forty-five minutes fixing… six of them. Ugh!
Why so long? I link like it matters, because it does, and if something I linked to is truly gone — not just moved — then there’s a genuine need to track down something equivalent. Sometimes it’s easy, but in many cases it requires actual research, and the quality of the information definitely depends on finding a decent replacement. Come to think of it, I actually got lucky taking only 45 minutes to replace 6 links
So I’ll chip away at the other several dozen broken links over the next several weeks, a to-do item that will pop up on my list every few days, just one of dozens of other projects that can’t be done in one sitting.
And that’s why my job is full-time! And why there must be revenue: to support the infinite maintenance that any good quality educational site inevitably requires. There are some fantastic amateur blogs about musculoskeletal medicine these days, of course, but I guess that less than 5% of them are even trying to go back and do maintenance like this. Because it’s just not economically or logistically feasible.