Jonas Salk at the University of Pittsburgh where he developed the first polio vaccine.

We are living in a golden age of pain science and musculoskeletal medicine … sorta

The 20th Century was such a scientific and technological earthquake that we all now have a tendency to assume that the human species has advanced knowledge about basically everything, but we really don’t. In many ways, the state of our knowledge of anything relatively subtle or complex in medicine is still surprisingly primitive. Even sports medicine — with so much potential funding (and potential relevance to occupational injuries) — has been bizarrely slow to build its evidence base.1 The performance of elite athletes is worth trillions to our economy, and obsessively optimized, and yet science remains almost completely silent on the best treatment options for the most common injuries affecting those high value patients, things like muscle strain.2

For most of history, medicine had bigger, scarier fish to fry than treating mere aches and pains and injuries. And it still does. But just a few decades ago, doctors and researchers were necessarily preoccupied with much more pressing public health issues … and rewarding new treatments.

Insulin and penicillin were still changing the world, as were a string of new vaccines — diptheria, pertussis, tuberculosis, tetanus, flu, yellow fever, typhus, polio, measles, mumps! Surgery and anesthesia were finally coming into their own, with error rates plummeting.3 The first organ transplants were saving people who would be be doomed without them. Dialysis! Pacemakers! Laser treatments for eyes! MRI and CT scan! Arthroscopy!

Medicine was still creating huge leaps in the length and quality of our lives.4 It was an era of low-hanging medical fruit.

When you look at the big picture, it’s easy to see that we’ve been rather busy making an amazing amount of progress in many, many other ways. Our World In Data provides many terrific examples. So many of my worst cynical impulses are contradicted by Max Roser’s charts & data. Refreshing! As Bill Clinton said, “Follow the trendlines not the headlines.” Chart Source: Max Roser & OurWorldinData.org, CC BY-SA license.

Meanwhile, musculoskeletal medicine is a bit of a backwater

Chronic pain and stubborn “minor” injuries (like repetitive strain injury) were barely noticed by medical science until about the 1980s, and they remain a bit of a backwater to this day, both scientifically5 and clinically. Musculoskeletal medicine is still a cocky teenager, just starting to come of age and figure out that it doesn’t know everything.

Most doctors are straight up unqualified to treat chronic pain and non-traumatic injuries.6 PM&R (Physical Medicine & Rehabilitation, A.K.A. physiatry) is one of the youngest and most obscure medical specialities, and the only one that tackles most “aches and pains” head on. (Rheumatologists and orthopedists in theory deal with all forms of therapy for any kind of musculoskeletal problems, but in practice these specialities have been dominated by serious diseases and injuries, and by profitable elective surgeries that “make sense” to the surgeons who make money doing them but are amazingly unstudied to this day — or, for the few that have been properly tested, proven ineffective78 or dangerous!9)

Perhaps we do have the medical “luxury” of paying more attention to relatively minor pain problems that were overshadowed by the more critical medical issues of the past. But of course those problems aren’t really so minor — just less major than things that kill you outright.

Despite a century of rapid progress, there are still many common medical myths that simply won’t die: doctors and patients alike still believe things that we should drink at least eight glasses of water a day or that we only use 10% our brains.10 And that’s still a problem even where the light of science is shining most brightly. It’s far worse in musculoskeletal medicine: for every mainstream medical myth, there are three about aches and pains and injuries. Myths and snake oil have thrived in the relative darkness of this neglected sub-category of medicine.

Chronic pain is a pretty scary fish to fry too

Non-lethal chronic pain accounts for a stupendous amount of human suffering. The economic costs of even mild to moderate problems — your garden variety back pain, frozen shoulder, patellofemoral pain, carpal tunnel syndrome, and so on — are quite hair-raising. Virtually all of the research that does on any of these things starts out with an accounting of its horribleness.

For most of history, medicine had bigger, scarier fish to fry than treating aches & pains. Not that pain isn’t scary too…

More severe chronic pain problems — a horrible neck pain that just won’t quit, or dreaded afflictions like fibromyalgia and complex regional pain syndrome (CRPS) — are truly awful. Indeed, CRPS can be so horrendous and untreatable11 that many victims take their own lives to escape the pain. And yet patients with chronic pain often feel abandoned and disbelieved.12

The general neglect of pain science was most unfortunate. Turns out it’s both more important and more difficult — weirder even — than anyone imagined half a century ago. We can put a man on the moon, but we can’t fix most chronic pain.

Part of the problem is that pain is usually “complex” while rocket science is merely “complicated.” Science has made similarly weak progress in solving other complex problems like autoimmune, metabolic and mood disorders. Evidence based treatments in areas involving complexity are barely better than folk wisdom. Which opens the door to alt med quackery

Todd Hargrove, paraphrasing (by tweet) key concepts in his excellent article, “Is Movement Therapy Rocket Science?

A sad legacy: primitive musculoskeletal medicine is still the rule

Musculoskeletal health care is still rather primitive, not only because of its late arrival but because it has been too free to “wing it” for too long. For many topics, the bleeding edge consists not of good science, but the speculations of desperate patients and opportunistic cure purveyors. Vast numbers of professionals still work almost exclusively with obsolete conventional wisdom — ideas that predate the increasingly golden age of research in musculoskeletal health care that is finally underway. Ideas that can still be found in the textbooks, making progressive professionals who know better roll their eyes.

One of my readers wrote to me in the grips of justifiable outrage about a string of egregiously incompetent healthcare professionals he’d encountered while trying to recover from an injury. It was all routine nonsense from my perspective — unfortunately, I’m accustomed to such stories — but he was in a state of disbelief that so-called professionals could possibly be so amateurish. “Why is there so much ignorance in musculoskeletal medicine?” he asked.

So many factors! A sampling…

  • Professional pride and tribalism, ideological momentum, screwed up incentives.13
  • The love of “advanced” and technological treatment methods, which has generated so much pseudo-quackery.14
  • Near universal ignorance of the history of science, critical thinking skills, and the cognitive distortions and limitations that bind us all… like emotional reasoning, confirmation bias, the human weakness for oversimplification and “common sense,” and looking only “where the light is.”
  • The obscurity and difficulty of newer and better ideas, especially the major neurological and biological factors that we’re still learning about (but neglecting these is rapidly getting unforgivable).

The largest source of trouble, however, is undoubtedly “structuralism,” the most pernicious type of oversimplification in the field: a great many problems are still treated as though they were “mechanical” in nature, ignoring extensive evidence to the contrary. Particularly in chiropractic and massage therapy, there is an amateurish industry-wide obsessive preoccupation with “alignment” and other structural factors — like leg-length differences.15

There’s also a litany of even more embarrassing ideas and distractions in those professions — really archaic alt-med stuff, all kinds of vitalism and worse.16 Acupuncture, the darling of alt-med, a therapy even many skeptics gave a pass to for a long time, is completely washed up and now the sole domain of cranks, flakes, and the naive.17

Modern medicine has also generally failed patients, with benign neglect, useless surgeries (cited above), and the unmitigated disaster of the opioid crisis.18

People with severe unexplained body pain bounce around the medical system like they are in a pinball machine, serially misdiagnosed and mistreated, often never finding a single doctor or therapist who recognizes the problem, or — having at least recognized it — has a clue what to do about it.

There is a groan that unites men and women, rich and poor, in any nation. These [muscle] pains are “explained” in every culture, but the universal fact of this persistence must mean that no adequate therapy exists.

~ Professor Patrick D. Wall, FRS, DM, FRCP, in the Foreword to Muscle Pain: Understanding its nature, diagnosis and treatment

Some “getting the word out” reading

What’s new in this article?

AugustRevised to properly answered a reader question: “Why is there such ignorance in musculoskeletal medicine?” It was good cynical fun trying to explain.

2017Cited Grant et al and Ramos et al on the state of evidence-based sports medicine.

2016Minor edit: added a particularly good turn of phrase to the conclusion (“the speculations of desperate patients and opportunistic cure purveyors”).

2016Minor edit: mentioned physiatry and PM&R (a strange oversight, overdue for correction).

2016Added more medical and scientific context and some new citations, particularly about orthopedic surgeries and opioids. Some general editing. Removed a small section of dubious value.

2016New introductory paragraph, for additional historical context.

2007Publication.

Notes

  1. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781.

    Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine…

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  2. Ramos GA, Arliani GG, Astur DC, et al. Rehabilitation of hamstring muscle injuries: a literature review. Rev Bras Ortop. 2017;52(1):11–16. PubMed #28194375. PainSci #52750.

    Yet another “garbage in, garbage out“ review of hopelessly inadequate evidence, not enough for conclusions about any of the most popular treatments for one of the most common athletic injuries. A high profile injury with a clear nature, nothing subtle or weird or obscure. It’s 2017, and that’s all we’ve got? I’m starting to wonder if this is ever going to be fixed.

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  3. The story of anaesthesia is incredible: fatal errors were horrifying at first, largely due to lack of standardization of equipment, and then reduced to nearly zero in one the most impressive quality control initiatives in any human endeavour. The story is marvelously told in Atul Gawande’s fantastic book, Complications. BACK TO TEXT
  4. Visualizing the History of Improving Health around the World (http://ourworldindata.org/VisualHistoryOf/Health.html#/title-slide) BACK TO TEXT
  5. Don’t get me wrong: there’s a lot of research. If you do a PubMed search for most pain problems, you’ll find quite a lot. But it’s a big world, and that research is dwarfed by the scale of Big Medical Science (which has been pumping out almost unbelievable amounts of research for decades). It’s a trickle of surprisingly recent, tiny, and many amateurish studies. BACK TO TEXT
  6. Doctors are unqualified to care properly for most common pain and injury problems, especially the stubborn ones, and this has been proven by other doctors: Stockard et al found that 82% of graduates lacked “basic competency” in this area. For more information, see The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones. BACK TO TEXT
  7. Louw A, Diener I, Fernández-de-Las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016 Jul. PubMed #27402957. PainSci #53458.

    This review of a half dozen good quality tests of four popular orthopedic (“carpentry”) surgeries found that none of them were more effective than a placebo. It’s an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.

    Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing the test. This review introduction is excellent, and does a great job of explaining the problem. As of 2016, this is the best academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and more readably — in the excellent book, Surgery: The ultimate placebo, by Ian Harris.

    The surgeries that failed their tests were:

    • vertebroplasty for osteoporotic compression fractures (stabilizing crushed verebtrae)
    • intradiscal electrothermal therapy (burninating nerve fibres)
    • arthroscopic debridement for osteoarthritis (“polishing” rough arthritic joint surfaces)
    • open debridement of common extensor tendons for tennis elbow (scraping the tendon)

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  8. Even where the need for surgical intervention seems obvious, such as stabilizing a badly fractured spine, things aren’t so simple. See Spinal Fracture Bracing: My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace. BACK TO TEXT
  9. Cohen D. How safe are metal-on-metal hip implants? BMJ. 2012;344:e1410. PubMed #22374741. PainSci #53447.

    A scholarly analysis of the safety of MoM implants:

    Hundreds of thousands of patients around the world may have been exposed to toxic substances after being implanted with poorly regulated and potentially dangerous hip devices, a BMJ/ BBC Newsnight investigation reveals this week. Despite the fact that these risks have been known and well documented for decades, patients have been kept in the dark about their participation in what has effectively been a large uncontrolled experiment.

    Cobalt-chromium implants have been used successfully in orthopaedics for years—for example, in knee operations and fracture repair. They are known to release metal ions, but some metal-on-metal prostheses do so on a much greater scale than previously thought. These ions can seep into local tissue causing reactions that destroy muscle and bone and leaving some patients with long term disability.

    Harris tells the (chilling) story of metal-on-metal hip implants in Surgery: The ultimate placebo, one of the best-ever (and freshest) examples of surgical overconfidence.

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  10. Vreeman RC, Carroll AE. Medical myths. BMJ. 2007 Dec;335(7633):1288–9. PubMed #18156231. PainSci #52815. BACK TO TEXT
  11. O’Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with complex regional pain syndrome. Cochrane Database Syst Rev. 2013;4:CD009416. PubMed #23633371. PainSci #54535. BACK TO TEXT
  12. Toye F, Seers K, Allcock N, et al. Patients’ experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. The British Journal of General Practice. 2013 Dec;63(617):829–41. PubMed #24351499.

    This paper reviewed qualitative research on musculoskeletal pain to shed light on what it’s like to have chronic pain. Several worrisome themes were clear. Chronic musculoskeletal pain often forces patients into the awkward position of having to prove the legitimacy of their condition: “if I appear ‘too sick’ or ‘not sick enough’ then no one will believe me.” Many end up doubting themselves and questioning their own identity and wondering who is “the real me.” Many lose hope and feel lost (or lost by) the health care system.

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  13. Certification rackets are rampant: professionals routinely invest deeply in getting specific certifications of extremely dubious value. Freelancer healthcare professionals are inherently biased towards whatever is emotionally appealing to their customers. Insurance is the source of bizarre incentives: patients will seek out a specific bogus therapy, and professionals will provide it, simple because insurance will pay for it (insurance-based medicine). The profit motive is strong! Consider that orthorpedic surgeries are fantastically profitable for American orthopaedic surgeons, and there are many lesser examples. All of this stuff pulls clinicians towards “faith” in their methods. BACK TO TEXT
  14. Not all quackery is obvious — not even to skeptics. “Pseudo-quackery” appears to be mainstream, advanced, technological, “science-y,” or otherwise legit — quackery without any sign of being way out in left field. It has enough superficial plausibility to persist in the absence of evidence against it. This subtler type of snake oil is a more serious problem in musculoskeletal health care, because it hides right in the mainstream. For instance, it’s nearly synonymous with the early history of physical therapy, and remains alarmingly prevalent in that profession. So pseudo-quackery is extremely common, and generates more false hopes and wasted time, energy, money, and harm than more overt quackery, which is relatively marginalized. See Pseudo-quackery in Chronic Pain Care: A field with a large gray zone between overt quackery and evidence-based care in musculoskeletal medicine. BACK TO TEXT
  15. PS Ingraham. Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. PainScience.com. 16378 words. BACK TO TEXT
  16. Both massage and chiropractic are guilty of believing and promoting an astonishing array of pseudoscientific ideas and therapies. See The Chiropractic Controversies, Does Massage Therapy Work? and 💩 Massage Therapists Say. BACK TO TEXT
  17. Acupuncture has a good reputation it does not deserve. Although heavily researched, its support comes only from heavily biased junk science, while it fails all the good quality scientific tests. It does not work for pain or anything else and we shouldn’t be surprised: it’s based on mysticism and myths. It’s surprisingly modern rather than ancient and wise, for instance, and cannot actually be used for anesthesia. More study is not needed. For more information, see Does Acupuncture Work for Pain? A review of modern acupuncture evidence and myths, focused on treatment of back pain & other common chronic pains. BACK TO TEXT
  18. PS Ingraham. Opioids for Chronic Aches & Pains: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids for musculoskeletal problems like neck and back pain. PainScience.com. 4113 words. BACK TO TEXT