Reading Guide for Skeptics
A tour of PainScience.com for readers who have doubts and concerns about the validity and efficacy of popular treatments for injuries and chronic pain
You can skip down to the recommended articles for skeptics.
Skeptics, critical thinkers and scientists will feel at home on PainScience.com. I have good skeptical credentials. In particular, I am a rare example of alternative medicine apostate: I actually quit my alt-med day job, exasperated with pseudo-science. I have renounced many flaky beliefs, and today I am the Assistant Editor for Science-Based Medicine, which gives me daily access to some of the smartest health science writers in the world. PainScience.com has the honour of being recommended on QuackWatch. I have been militantly skeptical enough to get legally harassed for it, which earned me a number of amazing new skeptical friends and allies. And although I have many articles I’m proud of, one in particular is the most detailed critical analysis of the world’s best-selling homeopathic products (homeopathic arnica creams), which ranks at or near the top of most relevant web searches.
PainScience.com is one of the few skeptical resources focussed on pain and injury treatments. Are they dubious? Dangerous? Distracting? This popular Venn is one of my skeptical greatest hits. See The 3 D’s of Quackery.
Quitting massage for science
Massage therapy has the potential to be a science-based profession, making reasonable claims and providing a service of modest but genuine value to many patients. Alas, so far, it has fallen well short of that potential in many ways, and many “leaders” of the profession routinely endorse egregious quackery1 and generally drag massage down into the mud of alt-med’s many manufactroversies. That has given me a lot to write about! Massage itself is not quackery … but it is badly polluted with it.
Ordinary massage and the legitimate practice of massage therapy should not be categorized as quackery. Massage can help people relax, relieve aching muscles, and temporarily lift a person’s mood. However, many therapists make claims that go far beyond what massage can accomplish. And even worse, massage therapy schools, publications, and professional groups are an integral part of the deception.
Massage Therapy: Riddled with quackery
Massage therapists can spot logical fallacies and care about EBM are not unheard of, but we are quite rare — too small a minority, in my opinion. For a long time I struggled with whether or not I should stay in the profession as an advocate for reform, or just move on and don my “science journalist” hat permanently. I closed my massage therapy practice in 2010 and have not looked back.
Pseudo-science is common in all health care for common painful problems
As a skeptical writer, I’m working almost by myself in my niche. Exercise science is drowning in skeptics. Nutrition? Plenty of skeptics there! Medicine in general? There’s probably more skeptical writing in that category than any other. But a rigorously skeptical and science-based perspective on treatment common painful problems is rare. For example, my tutorial about iliotibial band syndrome (runner’s knee) is the only detailed skeptical review of that problem in existence. My popular mythbusting YouTube videos on that topic stand nearly alone — hundreds of competing videos make little or no attempt to critically consider any of the popular treatment claims (like foam rolling).
It’s badly needed. Finding good care for injuries and stubborn pain problems can be surprisingly difficult for patients. There are many intellectually immature and pre-scientific ideas2 in musculoskeletal health care, and not just in alternative medicine. There are many intellectually immature and pre-scientific ideas in musculoskeletal health care — treatments that aren’t on the skeptical radar, but should be. Many of those ideas are baked into the clinical reasoning of all kinds of professionals. That’s why I wrote about “pseudo-quackery” in conventional care for SkepticNorth.com — treatments and therapies that aren’t on the skeptical radar, but should be.
Physician Richard Deyo of Seattle has spent his career publishing trying to educate his medical colleagues and slay several myths about low back pain that, zombie-like, just won’t die.3 In 2001, the infamous Philadephia Panel published a series of articles that were deeply critical of common practices in mainstream physical therapy.4 And many professionals, lacking training in formal logic and science, routinely confuse correlation with causation,5 with significant consequences. And so on.
I found it impossible not to notice these glaring issues during my training and ever since. I also find writing about them irresistable!
Should we keep an open mind about astrology, perpetual motion, alchemy, alien abduction and sightings of Elvis Presley? No, and I am happy to confess that my mind has closed to homeopathy in the same way.
Mike Baum,6 The dangers of complementary therapy, Breast Cancer Res. 2007; 9(Suppl 2): S10
How to build bridges and trust with people who don’t agree with you yet
At TAM8, Phil Plait, the Bad Astronomer, implored skeptics not to be dicks. This was surprisingly controversial! Whatever my opinion, I have no choice, however: Saganic super-civility is clearly a key component of my success in persuading readers of this website.
This website has a surprisingly good track record of actually changing minds — a challenge that fascinates the skeptical community (particularly after Phil Plait’s infamous Don’t Be a Dick speech at TAM8). Despite the fact that I “debunk” and criticize a great many bad products, services and ideas in the world of therapy for pain — every one of which is someone’s cherished belief, the basis for entire careers or revenue streams, or the subject of a passionate healing anecdote — I am happy to say that I get a great deal of heartening email of the “thanks for bringing me around” variety. Many of my readers believed in something dubious … and then stopped believing in it after reading about it here.
This situation has also improved: I used to get a lot more hate mail than I do now. Over the years, apparently, my style has become less provocative and more effective. Here are my impressions of what strategies I use on PainScience.com to successfully build bridges and trust with people who don’t (yet) agree with you:
- Humour, humour, and also humour. Funny, that!
- Candid self-deprecation is very disarming. I’m terrible at it, but I do my best.
- In particular, go out of your way to show that you know you can be wrong.
- Rigorous, thorough, substantive referencing!
- Story-telling and anecdotes that challenge the hype. Antimonials rock.
- Always, always get agreement on easy, smaller points first. Once someone is nodding, they tend to keep nodding.
- Make it about the money. Time and again it’s the consumer advocacy angle that turns on the light bulb. No one wants to be perceived as a sucker.
There’s a fine line between engaging readers with humour, and pissing them off with sass. And of course the line is in different places for different people on different topics. So you can only please some of the people some of the time — but make it as fun as possible for the ones you reach.
Greatest hits! Some articles have attracted more attention — and gotten me into more trouble — than other articles. The following eight stand out:
- PS Does Epsom Salt Work? — The science of Epsom salt bathing for recovery from muscle pain, soreness, or injury. Hardly the most controversial article I’ve written, this is nevertheless the single most popular article on PainScience.com, attracting thousands of readers per month. This seems odd to me. I really have no idea why so many people are searching for information on Epsom salts, but they do, and they land here. They also send me an extraordinary amount of hate mail — that’s right, mail that is hateful, about Epsom salts — potently demonstrating that people do not like to have their beliefs challenged, even when their beliefs are about things as trivial as bath salts.
- PS Quackery Red Flags — Beware the 3 D's of quackery: Dubious, Dangerous and Distracting treatments for aches and pains (or anything else). A short article built around a highly condensed caveat emptor infographic, a Venn diagram — shareable and social media friendly. Grab the full-size image and pass it around.
- PS Placebo Power Hype — The placebo effect is fascinating, but its “power” isn’t all it’s cracked up to be. This article is one of the few of its kind about this topic on the internet: the most annoying trend in alternative medicine: the exaggeration of “the power of placebo” as a justification for therapy that can’t beat a placebo. Therapies that perform no better than placebo are now predictably spun as being “as good as placebo,” as though placebo is the new gold standard to meet. Oh my.
- PS Does Arnica Cream Work for Pain? — A detailed review of popular homeopathic (diluted) herbal creams like Traumeel, used for muscle pain, joint pain, sports injuries, bruising, and post-surgical inflammation. Traumeel has the distinction of being the most popular of all homeopathic products … and this has routinely been by far the most prominent skeptical article about homeopathic arnica creams (although a recent article by skeptical pharmacist Scott Gavura has been competing with it quite effectively).
- PS Quite a Stretch — Stretching science shows that a stretching habit isn’t doing much of what people hope This is PainScience.com’s original “controversial” article. Stretching was the one of the issues that got me writing. Again using hate mail as a measure of success, I knocked this one out of the park. However, the cranks have an extraordinarily consistent habit of accusing me of holding an opinion I do not actually hold — that stretching is “useless.” Not only do I not say this, but I go out of my way to contradict it. The problem is that the haters rarely read past the first screenful of the article before firing up their flame throwers. Haters are funny that way. Don’t miss the much newer and very popular A Stretching Experiment.
- PS Does Chiropractic Work? — An introduction to chiropractic controversies like aggressive billing, spinal adjustment as a panacea, treating kids, neck manipulation risks, and more. Irony: this is not a particularly good article. It has been de-clawed and edited to within an inch of its life for legal reasons. Try to guess what reasons those are! I’ll give you three guesses and the first two don’t count. If you cannot instantly guess, you can’t really call yourself a skeptic yet (but keep working it, baby). In its current, tame form — just a mild-mannered summary of the issues — it doesn’t generate much hate mail. But back in the day, before I knew better than to poke certain beasts, it sure did!
- PS Alternative to What? — “Alternative” health care professionals need to decide what they are really the alternative to. This article contains the highest concentration of criticism of CAM found anywhere on the webite, and also talks about what alternative medicine could have been in an alternate universe — what it could and should have been, as opposed to being an not-so-complementary anti-scientific substitute for medical care.
- PS Does Massage Therapy Work? — A review of the science of massage therapy … such as it is. Massage consists of a mess of overlapping, vague claims that range from the utterly absurd to the plausible but messy. There is no question that massage interacts with human nervous systems in interesting ways (but hopelessly understudied), so the debate is going to stay lively for a long time. This is the most concentrated and heavily referenced critical analysis of the topic I’m aware of. A closely related and particularly skeptical article (which earned me many new enemies in alt-med this year) really picks apart one of the hype-iest claims in massage history: “massage reduces inflammation.” Um, no.
And here’s a bunch more …
- PS Why “Science”-Based Instead of “Evidence”-Based? — The rationale for making medicine more science-based.
- PS Ioannidis: Making Medical Science Look Bad Since 2005 — A famous and excellent scientific paper … with an alarmingly misleading title. (One of the nerdiest articles on the site … with one of the strongest skeptical points.)
- PS Bogus Citations — 11 classic ways to self-servingly screw up references to science, like “the sneaky reach” or “the uncheckable”. Fine link bait, this one! Share it!
- PS Smarter and Funnier — Publication standards for PainScience.com and why you can trust the information published here. I try to make PainScience.com about 800% better than most health care information on the web. Here’s why, and how.
- PS Does Acupuncture Work for Pain? — A review of modern acupuncture evidence and myths, particularly with regards to treating low back pain and other common pain problems.
- PS Does Fascia Matter? — A detailed critical analysis of the clinical relevance of fascia science and fascia properties. Fascination with fascia looks quite silly by the end of this article.
- PS The Functional Movement Screen (FMS) — The benefits of the popular screening system for athletes might be over-sold by some professionals Publishing this one was one of my first experiences with “going viral” — not on a mainstream scale, but certainly sweeping through Therapy World like a wild poopstorm.
- PS Extraordinary Health Claims — A guide to critical thinking, skepticism, and smart Internet reading about health care.
- PS Your Back Is Not Out of Alignment — Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. This is my thesis, the “big idea” of my career, my pet issue …
- PS Choose Cheaper Treatments — All other things being equal, always choose the cheapest and most comfortable treatment option for your pain problem — a vital basic consumer advocacy principle.
- PS The Not-So-Humble Healer — Cocky theories about the cause of pain are waaaay too common in massage, chiropractic, and physical therapy. Criticizes alt-med practitioners for not actually being humble, and includes a great story about an encounter I had with a therapist with an amusingly specific theory about the origin of “all pain” …
- PS Battle of the Experts — A guide for patients caught between conflicting diagnoses and prescriptions. What are health care consumers to do when experts disagree? Disqualifying some of the “experts” as poor sources is a good start!
- PS Water Fever and the Fear of Chronic Dehydration — Do we really need eight glasses of water per day? A profile of one of the most irritating and persistent bits of unscientific health advice under the sun.
- PS Therapy Babble — Hyperbolic, messy, pseudoscientific theories about therapy are all too common. More curmudgeonly skeptics will enjoy this ranty little article … plus the fantastic comic strips from Cectic, and the fantastic example of the butt-reflexology hoax.
Other Recommended Resources for Skeptics
With a bit of an emphasis on skepticism about health care in particular, but also some of the classic general sources like the JREF, SGU, Skepchick and Snopes…
- Science-Based Medicine: Exploring issues and controversies in the relationship between science and medicine (http://www.ScienceBasedMedicine.org/). Science-Based Medicine is now the single best source of critical thinking about health care available anywhere. Founded by Yale neurologist Dr. Steve Novella of the Skeptic’s Guide to the Universe, it’s written by several physicians who are alarmed by the soaring popularity of dangerous and pointless alternative health care. The title of the blog expresses the elegant idea that the value of ideas in health care ideas must not only be based on evidence, but must also be reasonably consistent with a well-established body of scientific knowledge of how the human body works.
- What’s the Harm? (http://WhatsTheHarm.net/). Alternative health care has an undeserved reputation for being harmless and wholesome. In fact alternative medicines and treatments are just as full of hazards and risks as medical care, yet with virtually no proof of efficacy or regulation. While many other skeptical websites focus on the question of efficacy, WhatsTheHarm.net is devoted to cataloguing the costs of alternative health care: the many lives ruined and even lost.
QuackWatch: Your Guide to Quackery, Health Fraud, and Intelligent Decisions (http://www.QuackWatch.org/). Quackwatch fights health-related frauds, myths, fads, fallacies, and misconduct. Its primary focus is on health consumer information that is difficult or impossible to get elsewhere. Dr. Stephen Barrett, the founder of QuackWatch and author of most of the articles, is one of the great figures of anti-quackery activism. For many years now, I’ve been watching his work and the controversies and legal battles that swirl around QuackWatch, and I have been consistently impressed by Dr. Barrett’s integrity and intelligence — and unimpressed by the tactics and quality of his critics. He is also providing a vital service and a sorely neglected perspective on health care.
- Respectful Insolence (http://scienceblogs.com/insolence/). One of the oldest and best skeptical blogs on the internet, written relentlessly since forever by Orac, the no-longer-secret blogging identity of Dr. David Gorski, best known for his writings on cancer and vaccines, among much else. He’s also my boss at ScienceBasedMedicine.org; we communicate regularly in that capacity, such that I have developed immense respect for his knowledge and judgement.
- James Randi Educational Foundation: An educational resource on the paranormal, pseudoscientific and the supernatural (http://www.Randi.org/). James Randi has an international reputation as a magician and escape artist, but today he is best known as the world’s most tireless investigator and demystifier of paranormal and pseudoscientific claims. The James Randi Educational Foundation is a not-for-profit organization founded in 1996. Its aim is to promote critical thinking by reaching out to the public and media with reliable information about paranormal and supernatural ideas so widespread in our society today. The JREF also sponsors the “One Million Dollar Paranormal Challenge,” which offers a million bucks to anyone who demonstrates a paranormal ability or phenomenon. Since 1964, every single one of about 1000 challengers has either failed the preliminary test, or failed even to agree to acceptable rules for the test.
- Skeptic’s Guide to the Universe (http://www.theSkepticsGuide.org/). The SGU is by far the best of the skeptical podcasts, and has attracted an audiences of hundreds of thousands of listeners over the last few years. Led by the almost alarmingly competent and productive Yale neurologist, Dr. Steven Novella (also the Executive Editor of ScienceBasedMedicine.org), every episode is a great mix of news, humour, substantive interviews and entertaining regular features. I’ve listened to every single one.
Skepchick (http://skepchick.org). Skepchick is a group of women, led by founder Rebecca Watson, who write about science, skepticism, and pseudoscience. With intelligence, curiosity, and frequent snark, the group routinely tackles alternative health care, as well as many other topics from astronomy to astrology, psychics to psychology.
Rebecca again, founder of Skepchick.
- Snopes.com: Urban Legends Reference Pages (http://www.Snopes.com/). Barbara and David P. Mikkelson have been publishing the Urban Legends Reference Pages on Snopes.com since 1995. It is one of the most thorough collections of debunkery available anywhere. Although relatively few items concern health care specifically, it is an essential bookmark for every critical thinker.
- EBM-First.com (http://www.EBM-First.com). A well-curated and thorough directory of reading recommendations and references for a couple dozen alternative medicine topics. It’s hard to find good reading lists, but it’s not hard here! The most relevant to PainScience.com are craniosacral therapy, energy therapies and reiki, homeopathy, magnetic therapy, reflexology,
therapeutic “touch.” As you can see there’s a strong focus on alternative medicine’s flakier side.
- Skeptic: Extraordinary claims, revolutionary ideas, and the promotion of science (http://www.skeptic.com). The Skeptics Society, headed by Dr. Michael Shermer, is a scientific and educational organization for “anyone curious about controversial ideas, extraordinary claims, revolutionary ideas, and the promotion of science.” In many ways, this is the best of the skeptical websites, and the organization also publishes a pretty good podcast.
- Skeptic North (http://skepticnorth.com). I’m a Canadian skeptic, so Skeptic North is near and dear to me, the first Canada-wide blog for skeptics: a rag-tag team of skeptical misfits from coast to coast to provides you with a one-stop destination for all things “Canadian skeptic.”
- Skeptic’s Dictionary (http://skepdic.com). “Definitions, arguments, and essays on topics ranging from acupuncture to zombies, and provides a lively, commonsense trove of detailed information on things supernatural, paranormal, and pseudoscientific.” Thorough, competent, and well-maintained.
- Bad Science (http://www.badscience.net/). Blog of Ben Goldacre, best-selling author, broadcaster, medical doctor, academic, and tough critic of bad science wherever it happens, in both mainstream and alternative medicine … Could Ben be any more my kind of guy?
- What Do I Do Next? 105 ways to promote skeptical activism When people first get skeptical, they often want to know what they can do about it. This is the ultimate compilation of ideas and answers to that frequently asked question.
And a few notable blogs about aches and pains and related topics by authors who “get it”:
- BetterMovement.org: Practical Science On Movement And Pain: Practical Science On Movement and Pain (http://BetterMovement.org). Todd Hargrove is a Seattle Rolfer with a refreshingly clear, precise, and rational style. He has an uncanny ability to tackle controversial subject matter in a way that doesn’t seem to bother anyone.
- The New York Times, Well Blog (http://well.blogs.nytimes.com/author/gretchen-reynolds/). Gretchen Reynolds has written hundreds of articles for The New York Times “Well” blog… and they’re basically all good. She’s the most reliable mainstream journalist writing in this field that I’m aware of.
- Sweat Science: Fitness myths, training truths, and other surprising discoveries from the science of exercise (http://www.runnersworld.com/sweat-science). Alex Hutchinson’s science journalism on exercise is a perfect fit for PainScience.com. If I were trying to focus on exercise science as a writer, I might just give up, Alex already has it so-well covered. There are any number of exercise topics I am thrilled to leave to him, rather than tangling with them myself.
- TheSportsPhysio: Simple, practical, honest advice (https://thesportsphysio.wordpress.com). I have marketed myself as a “sassy” rationalist, but truthfully Adam Meakins is much sassier and feistier than I am. An entertaining and very skeptical physiotherapist blogger.
- GregLehman.ca (http://www.greglehman.ca/category/blog/). Greg Lehman is a Canadian physiotherapist and chiropractor with incredible mastery of the subject matter, good writing skills, and real talent for seeing all sides of an issue.
- Massage & Fitness Magazine (http://www.massagefitnessmag.com/whats-the-news). The man behind Massage & Fitness Magazine, Nick Ng, used to be grumpy about PainScience.com, but has since become a skeptic and one of the most tireless writers and advocates for rationality in the field.
This is a painfully incomplete list, but I’ll keep working on it.