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“There is really nothing new in therapy. If you think you’ve come up with something you just haven’t read enough.”
Greg Lehman, BKin, MSc, DC, MScPT
Greg Lehman has politely but thoroughly criticized some key concepts in the “Integrated Systems Model” and “The Thoracic Ring Approach” to therapy. (Ring is just a fun way to say “rib.”)
The big idea under the microscope here is just another variation on the belief that subtle biomechanical problems can cause disproportionate havoc far away in the body — a biological butterfly effect. For instance, “a plantar fasciopathy could be influenced by the ‘faulty’ biomechanics of a thoracic rib.” Or, um, ring.
Greg excels at this kind of focussed analysis. Personally, my own investigation would have consisted of just an exasperated “citation needed.” This is all classic dot-connecting structuralism, or “the epitome of fragilistic thinking,” as Greg put it. But I’m grateful to him for getting into the nitty gritty of this specific instance, and I think several of his conclusions are pitch perfect:
This is all so pessimistic, reductionist and really simple even though it’s couched in such complexity. It implies that tiny little rib movements, and tiny increases in muscle activity (who has said that more activity in the external oblique stops the ribs from moving?) are something that a robust, incredibly adaptable system can’t tolerate. It’s the epitome of fragilistic thinking.
All of these notions suggest the patient is in need of fixing. That they body is inherently weak and can only work well when optimally aligned, with precise muscle activity and perfect motor control and that some magical therapist needs to come in and correct. The body is more self cleaning oven than mechanically tuned carburetor.
…this model is regional interdependence taken to an extreme and is very similar to old school chiropractic theories about properly aligning all joints for the body to function at its most optimal. The approach is pessimistic in its view of the body and could create a sense of therapist dependence.
Read the whole thing: “Thoracic Rings and Integrated Systems: Paleolithic or Pathfinding?”
This is a brand new featured article. It’s a fairly minor one, but it is the second proper new featured article in recent history — the last one: Zapped! Does TENS work for pain? — and there’s another major one coming very soon. I’m on a roll!)
Biology and medicine are still in their scientific adolescence, and one of the clearest demonstrations of this is the surprisingly primitive state of our understanding of how muscle cells work. You wouldn’t think so looking at a textbook full of complicated diagrams of sarcomeres and the arcane biological details of energy metabolism, but there are still profound gaps in our knowledge. The business of muscle cell contraction is all conducted on a nearly invisible (molecular) scale. But to truly understand pathology, you have to really understand how something works in the first place, and one of the best ways to do that is to see it. And, in a real sense, we have never actually seen muscle cell engines at work.
Which is why this new muscle microscope is quite a big deal:
A team of Stanford researchers has developed a microscope that can visualize and measure the force-generating contractions of these patients’ individual motor units. This action has been studied for nearly 100 years, but this is the first time it has ever been observed in the muscles of a living human.
Good job, Stanford!
This is one of those science stories I don’t really know what to do with: it’s just neat, and it’s about muscle, so it belongs on PainScience.com, and in the bibliography, even if I don’t know how I’ll be citing it.
One of the traditional complaints I get about my penchant for debunkery is that I am supposedly discouraging people from trying treatments that might work for them. But that’s not what I hear from most readers, and one of them really nailed this in a recent email: she expressed her gratitude for the assistance in prioritizing her self-treatment experiments. She thanked me for putting treatments in perspective without actually dismissing them. It was lovely to get that recognition.
I want to help people prioritize the options, not demonize them.
The gray area between overt quackery and proven medicine is huge, so patients have to prioritize. You have to develop some kind of criteria for choosing what long shot to try next! And that takes education. And sometimes it also involves taking out the trash, because there is plenty of true snake oil.
At its worst, skepticism overzealously dismisses anything and everything that isn’t considered “proven.” While that kind of simplistic absolutism is rare among experienced skeptics — people who have actually made a point of learning about science and critical thinking — it’s disconcertingly common in doctors and other frontline representatives of scientific medicine. Unfortunately, many of them are amateurish skeptics: they have the right suspicion of unsubstantiated claims, but that’s about as far as it goes. I have often been irritated by their shallow, knee-jerk skepticism and scientism.
I am definitely not cool with shaming a treatment idea just for a lack of evidence. It’s got to be worse than that: biologically absurd, predatory pricing, real risks… that kind of thing is worthy of debunking and my “negativity.”
If you haven’t seen this already, you must not have visited the Internet in the last couple days.
It’s all about a lot of my own dorkiest subject matter…but on TV! And getting a bazillion eyeballs. And it even mentions P-hacking! So that feels weird. But professional comedian-pundit John Oliver nails it, of course: basically, most science reporting these days is an oversimplification nightmare, to the point where we should probably all just start automatically rolling our eyes and tuning out as soon as we hear the magic words “A new study shows…”
The TED talks satire at the end is priceless. (“What if I were to tell you… it’s both AND neither?” )
Fresh science! Sketchy sleep increases pain sensitivity.
A major driver of chronic pain is central sensitization, basically turning up the “volume” on all pain. The phenomenon is well-known, but how it works is still a mystery, and its relationship with sleep has barely been studied. A 2016 experiment looked carefully 133 patients with knee arthritis, comparing those who slept well versus those who did not. They found, with a high degree of certainty, that:
sleep fragmentation may strongly affect the pain and CS relationship; consequently, these results underscore the importance of considering and treating sleep in patients with chronic pain.”
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!