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There’s an exasperating contradiction in modern chronic pain management. The entire point of cognitive-behavioural therapy for pain is that pain can be managed — or why bother? — and yet much of the modern literature focusses on the notion of reducing “suffering” rather than pain, based on the premise that pain is unavoidable. Dr. Lorimer Moseley:
I found this situation quite confusing — ‘pain can be modified by our beliefs and behaviours’ seems inconsistent with ‘pain cannot be relieved by modifying beliefs and behaviours’. I also think that this approach of ‘conceding that we can do nothing for pain’ seems inconsistent with what we now know about the underlying biological mechanisms of pain — that pain is fundamentally dependent on meaning.
And the meaning of pain can often be changed. Not that it’s easy! But it is possible, and that is the point of trying to help people understand that their pain doesn’t necessarily mean they are in any danger.
People assume that insurance companies are so savvy and parsimonious that they would never cover health services that weren’t effective. This premise is often used as a substitute for scientific evidence by alternative medicine advocates: surely such infamously tight-fisted corporations wouldn’t pay up if it wasn’t worthwhile, right? That’s almost better than science! Follow the money!
But insurance companies do not have secret methods of determining the efficacy of unproven treatments, out of the reach of science. The industry has a long history of insuring the treatments people want; they get sucked in by the same hype that their clients are sucked in by. Remember, insurance companies may be infamously tight-fisted, but they also have to sell insurance. They want to attract new customers, and placate existing ones. They will only drop coverage of a treatment when the absence of evidence and/or evidence of absence reaches a critical mass, or if cost ineffectiveness starts to become a glaring problem.
We may think intuitively that there is a downstream positive impact for people who use these benefits [mainly massage therapy, but also chiropractic and physiotherapy]—it makes them feel better, so arguably their usage of other benefits [health care services] should be lower than other plan members. But in our study, when we looked at those who use massage and chiropractic and compared their drug costs to others who didn’t use them, we found their drug costs are, in actual fact, higher.
This is completely at odds with what most people probably assume: an insurance company saying that they have data that strongly suggests that massage therapy and chiropractic may not worth paying for, because those patients do not have reduced health care costs later on (not their drug costs, anyway).
And yet they’ve been paying for it anyway. Why? Probably because they’d have a major marketing and PR problem if they refused to pay for massage therapy and chiropractic! These are popular services. If only popularity actually meant something…
The point of this post is not whether or not the insurance company is correct. It is not about whether massage therapy and chiropractic are actually cost-effective in the long run. We don’t know. They don’t know. The quoted position of an insurance company is not good evidence of that one way or the other. It’s worth noting, but it could easily be quite misleading… and, in fact, I suspect it is!
The point of this post is that an insurance company was having some surprising self-doubt about the value of paying out this particular benefit. People like to assume insurance companies “know” because they have a finely tuned sense of value. The only evidence I’ve presented here is evidence that they do not know. They pay for services mainly because people want them. And, contrary to what most people would expect, here’s a company that actually fears that perhaps they should not be paying for massage and chiropractic... but is still doing it anyway, at least for now. I think that’s inherently interesting.
But it doesn’t tell us whether or not massage therapy and chiropractic patients actually do end up spending more on drugs in the long run.
I’ve been learning a lot more about pain-killing drugs lately, but mostly the kind you can get without a prescription. The opioids are another whole world of risks and benefits. I stumbled on this good summary of how pain-killers can backfire and cause pain instead of treating it, which seems like a particularly important thing to understand:
Yes, the drugs used to treat pain can also cause pain. If you have been using opioid drugs for years and the pain keeps getting worse and worse, this vicious pain cycle could be a result of opioid-induced hyperalgesia. Because the opioids turn your natural pain relieving system off, your body is left without enough chemicals in the system as the drug wears off every four to six hours. This cycle causes a frequent roller coaster of up’s and down’s that sensitizes the nervous system to the point that you feel more pain. Not only do you feel more pain, you feel anxious, restless and have trouble sleeping. If this sounds familiar, then it is time to find an exit strategy off the opioid roller-coaster that you are on.
For four more pain-causing drugs, see “Top 5 Drugs That Can Cause Pain,” by Christina Lasich, MD.
So apparently this bit of conventional wisdom about weight training is bogus: “Eating protein soon after a workout will help build muscle.”
For years I believed it in that way that we believe things that matter to us…but don’t matter quite enough to have ever done a myth check. Better late than never!
And, yes, the headline (“Workout nutrition is a scam”) is a bit hyperbolic and clickbaity. The actual article is very specific — protein timing for bodybuilding — and it’s well written.
This article about placebo is about how placebo allegedly works even when people know that it’s a placebo — placebo without deception. This is based on a well-known 2010 study of placebo for irritable bowel syndrome. The article is about that researcher’s plans to study open-label placebos for cancer next. And that’s really all the article has to offer: it’s basically a press release for the research sequel to the original placebo-hyping blockbuster. There is no new research, yet. It was just an advertisement for the idea.
I don’t like the idea.
Ironically, Kaptchuk’s 2010 evidence of placebo without deception was itself deceptive (or at least disingenuous), because patients were still given a clear reason to have faith in what they were given. In this way, the 2010 study was well-crafted to produce a placebo effect, just by raising expectations with a different kind of deception. And Kaptchuk will do the same with the next study, with completely predictable results. And it will be a big deal, mark my words… because cancer. And because everyone loves the “power” of placebo!
I explain the problem with the 2010 study in more detail in my placebo article.
“Efficacy” is how well a treatment works in ideal circumstances, such as in a carefully contrived scientic test. Unfortunately, real life is rarely ideal! (You may have noticed.) “Effectiveness” is how well the same thing works in typical clinical settings and patients’ lives. Which is what matters to most patients.
A classic example of efficacy versus effectiveness is strong calorie restriction for losing weight: anyone who substantially restricts calorie intake over long periods will lose weight, but it’s a serious error to assume that it’s just a matter of discipline. Low calorie diets are so difficult to sustain for so many reasons, many of them out of our control, that most people will gain back any weight they do manage to lose. They are efficacious, but also notoriously ineffective.
A recent editorial in the British Journal of Sports Medicine explains that exercise (in a physical therapy context) is well-known to be efficacious, but may not be effective. That is, it works well when tested in the lab, but not so much for real patients. Again, effectiveness is what matters to patients! If effectiveness is low, only a few lucky and/or disciplined people can realistically expect to benefit.
For example, I recently shared a perfect example of this problem: Ylinen et al found fairly good evidence that strengthening is probably efficacious for many people with chronic neck pain… but maybe only if they stick to it for as long as a year. That takes a lot of discipline, and many people will fail at it. (And some will fail even if they stick to it, because not all cases respond to strengthening.) So even if it does work in a scientific test, can we say “it works”? It’s ambiguous.
I think there’s a large gray zone here: some exercise therapies are much more difficult and impractical than others. When they are truly efficacious, they are an opportunity for determined patients with frustrating chronic pain: an intervention that might really work, but onlyif you’re up to a substantial challenge! Many people aren’t…but you can be some will be. And for those patients only, “it works.”
See Kenny Venere’s more detailed discussion of effectiveness and efficacy.
I love it when The Onion does health stuff: “Area Man's Knee Making Weird Sound.”
COLORADO SPRINGS, CO—Noting that it began happening just a few days ago, local 31-year-old Anthony Forster told reporters Monday that his left knee has been making a really strange sound lately. “It’s like a little clicking noise—can you hear it?” said Forster, as he repeatedly flexed his knee back and forth in an effort to demonstrate the unusual sound. “You have to get really close and listen for it. It usually happens when I bend my knee all the way back and—there, did you hear that? It was doing it worse before, but you can still hear it.” At press time, sources confirmed a small blood clot just above Forster’s knee had broken loose and was traveling through his bloodstream to his brain, where it is expected to cause a massive stroke, killing him instantly.
Nice touch with the hypochrondiac flourish at the end.
The evidence we have for longer term training is nothing but good news: lasting improvements in strength, pain, and disability. It still hasn’t been replicated, but it’s excellent preliminary data. For more information, see Ylinen et al, or a much more detailed new discussion in my neck pain book.
(By the way, this is yet another in a series of many updates about exercise efficacy. They just keep happening.)
The good news is that the prognosis for most painful problems is good without any help. In fact, as things get better, you can usually count on getting better faster. You can’t rush it, but healing speeds up on its own. I recently rewrote and modernized my article on this topic:
Impossible mission? I set out to summarize basic tips about over-the-counter pain medications as concisely as possible — a blurb I can re-use in many places on PainScience.com. It has to be brief and readable and yet hit all the highlights that most people need to understand, most of the time. And of course it has to be safe and accurate advice, with a certain amount of legal paranoia. For instance, I’d like to be able to say that combining different types of OTC analgesics is quite safe, because I think it is, but I’m not absolutely sure and I would have to be. So it’s a very tricky paragraph to write. Here’s the result (so far, revised once after some reader suggestions):
Over-the-counter (OTC) pain medications are fairly safe and work in different ways, so do experiment cautiously. There are four kinds: acetominophen/paracetamol (Tylenol, Panadol), plus three non-steroidal anti-inflammatories (NSAIDs): aspirin (Bayer, Bufferin), ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn). Don’t take any of them chronically — risks go up over time, and they can even backfire and cause pain (rebound headaches). So respect dosage limits, especially for acetominophen, which hurts livers, and beware the hidden dosages in cold meds. NSAIDs are safer, but they irritate the gut, even taken with food, and especially with booze. Voltaren® Gel is an ointment NSAID, and great for treating superficial pain with minimal dosing.
And I’d really like to include this, but I just can’t make it fit into 140 words!
Athletes, please don’t take “Vitamin I” to prevent soreness — it doesn’t work!