Pseudo-quackery in Pain Management: a field with a large gray zone between overt quackery and evidence-based care

 
Today, we have a special treat.  As I mentioned in the inaugural post (which went up before we launched), Skeptic North will have an occasional Guest Blogger feature.  Today, I’m pleased to introduce you all to Paul Ingraham, who will kick off our Guest Blog series!  If anyone else is interested in being a guest-blogger for us, contact me, at skepticnorth [at] gmail [dot] com, and we’ll go from there.  In the meantime, Enjoy!

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Criticizing alternative health care is dangerous work. Like Simon Singh in the UK, I have been legally attacked for questioning scientifically unsound practices in alternative health care and my professional regulator calls it offensively unprofessional and wants to censor my large website (SaveYourself.ca). Tens of thousands of dollars in legal defense expenses are at stake & justice is expensive!

And worth every penny.

This afternoon I will discuss my case publicly for the first time, with Desiree Schell on CJSR’s Skeptically Speaking at 6pm Mountain Standard Time. See the website for a countdown to the live broadcast, or listen later by podcast. Meanwhile, here’s my first guest post for Skeptic North, introducing some of the basic scientific issues with the treatment of pain problems.

If you want your quackery strong, like a stiff shot of whiskey, you can certainly get plenty of that in my field: the care of aches, pains and injuries is rife with treatments that haven’t got even a shred of plausibility, let alone good evidence. Traumeel, a homeopathic ointment, is one of the most popular topical remedies in the world. Reiki masters wave their hands over injuries, wishing them away. A large sect of chiropractic extremists sell the idea that adjusting the upper cervical spine can cure all disease, not to mention low back pain.

These are the superstars of quackery in my field, the heavy hitters, the weirdest of the woo. But that just makes them easier to spot. A lot of average people will trash talk these treatments. You don’t have to be a card-carrying skeptic to know that what sounds too good to be true probably is.

A more insidious threat to therapy consumers is pseudo-quackery: treatments that exist in a disconcertingly large gray zone between overt quackery and truly evidence-based care. This gray zone is especially large because there is precious little good evidence about how to help people in pain. Pain science is still distressingly primitive. Even simple overuse injuries continue to present surprising scientific difficulties. Is a tendonitis really inflamed? Turns out that tendons are not just simple gristle, but impressively clever bio-rope with complexity undreamed of 25 years ago.

For lack of good interventions, large numbers of physiotherapists, chiropractors and massage therapists sell many treatments that would be considered experimental in most other fields of medicine. Patients generally have no idea when they have entered this gray zone, because pseudo-quackery treatments aren’t ridiculous on their face, and some are even interesting and promising. So what makes them dubious?

  • debatable plausibility
  • absence of (good) evidence
  • overconfident prescription

One personal plausibility is another eye-roller. I know of a lot of allegedly plausible treatments that have some merit but do not impress me. I call dubious therapy concepts shruggers an idea worth testing, but pointless to discuss, except out of intellectual curiosity. We 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 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. 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 are particularly unavoidable in my line of work: as a massage therapist, I literally can’t 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:

  1. Look patient in the eye.
  2. Take a deep breath.
  3. Recite the mystical incantation, I don’t know if this will help you.

I can only protect my patients from my own ignorance by proactively and candidly emphasizing it. Anything less would be 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 of us are freelancers, and our 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 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 real 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 to 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.

Some would argue and some have that sellingany unproven treatments (without informed consent) is quackery, period. I think that’s too wide a brush, and so I coined the idea of pseudo-quackery to describe the gray area. But why should any therapy be offered to the public until an reasonable standard of evidence is met? Where is the line? In a perfect world, would we denounce as quackery anything that isn’t proven or offered with strong disclaimers? Commence arguing commenting!

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Paul Ingraham is a science journalist and Registered Massage Therapist with a busy hands-on practice in beautiful downtown Vancouver. He has authored several books and hundreds of articles about science-based care for common pain problems like knee pain and muscle knots. All of his work is published on SaveYourself.ca.

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  • Paul Ingraham

    Paul Ingraham is a former Vancouver massage therapist who quit his job in alternative medicine due to frustrations with anti-scientific attitudes and practices, which led to a legal scuffle. He now makes his living writing about science-based treatment for common injuries and pain problems, and has published hundreds of articles and several ebooks at SaveYourself.ca (see skeptics reading guide). He is also an editor for ScienceBasedMedicine.org.