Pseudo-quackery in Chronic Pain Care: a field with a large gray zone between overt quackery and evidence-based care
If you want your quackery strong, like a stiff shot of whiskey, you can certainly get plenty of that: the care of aches, pains and injuries is rife with alternative treatments that are experimental at best, and probably too good to be true. Traumeel, a homeopathic ointment, is one of the most popular topical remedies in the world.
Reiki masters wave their hands over injuries and diseases, wishing them away. A sizeable sect of chiropractors sell the idea that adjusting the upper cervical spine can cure all disease, not to mention low back pain.
These are some of the superstars of scientifically dubious treatments in alternative health care, and they are easy to spot and avoid. A lot of average people are doubtful about these treatments, and many chronic pain patients in particular know all too well how little they have been helped by this category of care. You don’t have to be a card- carrying skeptic to know that what sounds to good to be true probably is.
Less obvious quackery, what I call pseudo-quackery, is the more insidious threat to pain patients: treatments that exist in a disconcertingly large gray zone between overt quackery and proven, uncontroversial medicine. The gray zone is especially large because there is precious little good evidence about how to help people in pain. Pain science is still distressingly, exasperatingly primitive.
Even simple overuse injuries continue to present surprising scientific difficulties. Is a tendon really inflamed? Turns out that tendons are not just boring ol’ gristle after all, but impressively clever bio- rope‚ with physiologic complexity undreamed of 25 years ago.
For lack of truly good, tested treatment methods, physiotherapists, chiropractors and massage therapists sell many treatments that would be considered highly experimental in most other fields of medicine.
But patients generally have no idea when they have entered this gray zone of therapeutic guesswork, because pseudo-quackery treatments aren’t ridiculous on their face, and some of them are even interesting and promising. So what makes them dubious?
- debatable plausibility
- absence of (good) evidence
- overconfident prescription despite the lack of evidence
One person’s plausibility is another’s eye-roller. I know of a lot of allegedly plausible treatments that have some merit but do not really impress me. I call dubious, debatable therapy concepts shruggers; an idea worth testing, but pointless to discuss, except out of intellectual curiosity. Manual therapists have a million of ‘em, all untested, or barely tested, or badly tested.
If a pseudo-quackery intervention had been proven to be effective, then it would not be any kind of quackery (d’oh). And if it were proven to be bogus (evidence of absence) then it would be full quackery. But an unstudied shrugger – maybe it works, maybe it doesn’t – is harder to define, and it can get pimped out to patients for many years, decades even, with varying degrees of overconfidence. It may be pushed as a promising treatment with the slightest nod to the lack of evidence, or (more likely) it will be sold as medicine.
Absence of evidence alone does not pseudo-quackery make, of course.
Some of these things probably are medicine, and will be proven in time. But the degree to which we just can’t say is a bit shocking. The stock introduction to scientific reviews of virtually all interventions is “there is insufficient evidence to draw conclusions.”
This is not just the fringe of the reasonable we’re talking about here. We’re talking about the bread and butter treatments of mainstream physical therapy, interventions that consumers and insurers spend billions on every year, as well as stranger and new-fangled stuff.
It is said by some that health care would be paralyzed if we dispensed only proven treatments, as many alt-med evangelists enjoy pointing out (they think it proves that interventions don’t need to be proven).
Unproven therapies were particularly unavoidable in my former profession: As a massage therapist, I literally could not move a muscle in my office without doing something unproven. What’s an ethical practitioner to do? Here are simple instructions for converting pseudo-quackery into ethical therapy in just moments:
- Look patient in the eye.
- Take a deep breath.
- Recite the mystical incantation “I don’t know if this will help you.”
I could only protect my patients from my own ignorance by proactively and candidly emphasizing it. Anything less would have been unethical.
Unfortunately, saying “I don’t know” seems to be a dying art amongst self-employed therapy mongers. The almighty dollar is the main problem. Most manual therapists are freelancers, and their rent only gets paid when patients return for more. This is all it takes for many practitioners to recommend unproven treatments with just a bit too much enthusiasm. Even just a little bit of normal human ego can do it.
Pseudo-quackery can be quite mild-mannered. It is routinely perpetrated by average professionals suffering from a little confirmation bias and a lack of familiarity with the scientific literature. In no case are they what a skeptic thinks of as quacks; they’re just ordinary professionals who can’t read journals all day long and have bills to pay. Their confidence in unproven therapies spans from apathetic assumptions to premature enthusiasm to over-the- top marketing zeal.
And yet if it isn’t the job of a therapist to be openly humble in the face of our awesome ignorance of what really works, then I don’t know what is.
Despite its ho-hum personality, pseudo-quackery is a clear and present danger, particularly to chronic pain patients. Even skeptical patients routinely spend thousands of dollars on false hopes in the gray zone, often spending years in the therapy grinder, hammering away expensively at a condition that there was never really much hope of treating in the first place.
Chronic pain patients really are desperate, and it’s not wrong to cautiously try an experimental treatment method. But very few are anywhere near as promising as their marketing makes them seem. Be cynical. Be careful. And beware of professionals who haven’t gotten the memo: humility in treating chronic pain is not just a nicety, but an ethical necessity.
Paul Ingraham is a science journalist and retired Registered Massage Therapist in downtown Vancouver. He has authored several books and hundreds of articles about science-based care for common pain problems, most notably about myofascial pain syndrome, low back pain, and knee pain. Paul blogs regularly at Save Yourself (linked above), and you can follow him on Twitter or on Facebook.