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Posts tagged ‘Physical therapy’

Why do ¨alternative¨ therapies seem to work?

Whenever we feel sick, or have pain, we tend to go to the doctor or to a therapist of some kind. The thing is that most of us usually don´t  like going to the doctor or therapist and we wait a long time before we finally decide to go. And then when we finally decided to go, the symptoms usually improve. This makes us think that the doctor we decided to go to or the therapy we decided to do worked. I mean it´s quite simple, A leads to B, or doesn´t it? Let´s take a closer look at that.

When we think that just because two things happen together,  then one must have been the cause of the other is called a LOGICAL FALLACY and this is something we do a lot.

Let me give you an example: When the rooster crows, the sun rises.  Therefore, the rooster causes the sun to rise.

We do this more than we can imagine, and especially in my field (physical therapy) I see it a lot, I have also done it. Patients would come to me, I would treat them and they would get better, so I would naturally think ¨I´m the best¨ and ¨he got better because of me and my new wonderful technique that I applied on him¨ . We tend to base clinical convictions on personal experience and this, my friends, is a mistake. We have to base our treatments on randomized, placebo-controlled trials.  Any treatment that doesn´t base itself on that is ¨bogus¨. This is the foundation of modern healthcare.

And which treatments usually don´t base themselves on that……¨alternative medicine¨( But sometimes ¨alternative medicine¨ works, why is that? Well, here are just a couple of reasons why sometimes it ¨works¨.

  1. The natural history of a disease- Many diseases are self-limiting. If the condition is not chronic or fatal, the body´s own recuperative processes usually restores the sufferer to health.
  2. Regression to the mean- Many diseases are cyclical, meaning they get worse or better temporarily, but always move back to an average severity(1). Back pain, arthritis, allergies, and multiple sclerosis are cyclical, meaning sometimes they get worse and sometimes they get better. Usually, we go to the therapist or doctor when we have the most pain, so it´s bound to get better no matter what the therapist does to you.
  3. Placebo effect – ineffective treatment that can nevertheless be consoling. But the placebo effect is not restricted only to fake treatments, it also plays a role in the impact of real medicine. For example, although a patient will derive benefit from taking aspirin largely due to the pill´s biochemical effects, there can also be an added bonus as a result of the patient´s confidence in the aspirin itself or in the doctor who prescribes it (2). That is why sometimes the doctor´s reputation, the cost of the treatment, its novelty, a gentle touch, a nurse´s smile, a diploma-covered wall, could all increase the placebo effect(3-5).
  4. Confirmation bias- We desire treatment success because illness is unpleasant. Recently there was a study (6 ) that measured objectively and subjectively the effectiveness of active albuterol against placebo (the patients were given a fake active albuterol), sham acupuncture or no intervention.  Active albuterol is used for those who have asthma, it’s a bronchodilator. Subjectively ALL experienced an improvement (they used a visual analog from 0 to 10, in which 0 means no improvement and 10 means complete resolution). With albuterol the subjective improvement was of  50%,  with placebo it was 45%, sham acupuncture 46% and the no-intervention control group getting a 21%. So, all improved subjectively but there was a big difference between placebo-sham acupuncture and the no intervention group, even though all 3 were INEFFECTIVE for the disease, crazy right?! Well, objectively (which means we can measure it), they made each of the 4 groups blow to measure lung function. And not surprisingly, the albuterol group improved the best, in fact, the real albuterol did 3 times better than all the other three groups. But, what was amazing is that all 3 ¨fake¨ groups improved a little, even thought NOTHING was being done to them. And also, objectively there was a HUGE difference between the real treatment and the fake treatment although subjectively there was barely any difference!!!! I hope you all understood the importance of this.

Alternative medicine is called alternative because it really doesn´t work. If it worked it would be called MEDICINE. Physical therapists out there reading this, let´s try to base our treatments on randomized, placebo-controlled trials and not on our own clinical or personal experience.

Here is a nice video that talks about alternative medicine. It´s 45 minutes but very interesting.


  1. Streiner DL. Regression toward the mean: Its etiology, diagnosis, and treatment. Can J Psychiatry. 2001;46:72–76
  2. Ernst E, Simon S. Trick or Treatment ? Alternative medicine on trial. Transworld Publishers.London,UK.2008
  3. Benedetti F, Mayberg HS, Wager TD, Stohler CS, Zubieta JK. Neurobiological mechanisms of the placebo effect. J Neurosci. 2005;25:10390–10402.
  4. Ernst E, Resch KL. Concept of true and perceived placebo effects. BMJ . 1995;311:551–553.
  5. Evans D.  Placebo: Mind over matter in modern medicine. Oxford University Press; 2004
  6. Michael E. Wechsler, John M. Kelley, Ingrid O.E. Boyd, Stefanie Dutile, Gautham Marigowda, Irving Kirsch, Elliot Israel, Ted J. Kaptchuk. Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in AsthmaN Engl J Med. Author manuscript; available in PMC 2012 January 14.Published in final edited form as: N Engl J Med. 2011 July 14; 365(2): 119–126

Massage- what does it really do?

Everyone always wants a damn massage, and they always ask me, especially my family. Even though I studied physical therapy and massage is only a tiny little piece of what we do, everyone associates physical therapy with massage. So, of course, I get asked all the time for a massage. The worst thing about it is that no one ever gives me a massage, so I don´t even know what it feels like anymore, but I do know the benefits of a massage. So what does a massage really do? Lets find out.

Massage reduces depression and massage reduces anxiety, and it does this because it is relaxing (1-2). It is also said to reduce blood pressure (3) and help people to sleep, even when under stress. Massage also helps patients with sub-acute or chronic lower back pain, but not with acute back pain!(5). And that´s about it, folks. Scientifically, those are the only things that massage has been proven to do, nothing else! (It may help with other diseases but it´s usually due to one of these factors I just mentioned) But, what about all those other things we always hear massage is good for? Like, for example, it helps with circulation, it detoxifies and so on. Well, they are basically myths!! So let´s start talking about those myths.

Circulation – massage helps with circulation but very, very, very, VERY little!! If you want to improve your circulation go for a walk, it´s cheaper and MUCH more effective in increasing circulation (6-7,10).

Detoxifies or gets lactic acid out – Massage doesn´t do either of these, in fact it could do the opposite! When we give a massage we produce a mildly toxic state know as rhadomyolysis(8-10).

Massage helps with muscle soreness – Like I stated in my last post (, almost nothing helps with muscle soreness and that includes massage.

Massage helps you recover after an exercise – Actually it doesn´t!! This may surprise more than one (including me), but the evidence says that ¨massage significantly impairs lactic acid and hydrogen ion removal from muscles after strenuous exercise by mechanically impeding blood flow¨(9-10).

Massage releases ¨fascia¨-  First let me explain what fascia is. Fascia is the connective tissue that wraps around all of our muscles and is heavily interconnected with muscular function. Fascia is also very, very, strong. In a study done in 2008, Chauldhry found that forces outside the physiological range would be required to produce just 1% compression and 1% shear of the fascia lata and plantar fascia. In another study done in 2012, Simmons and Martinez found that the relatively low level of forces used by manual therapists is not enough to cause significant deformation of collagen in the fascia. In other words, massage does not release or change fascia, fascia is too tough for that to happen! What may happen, and this is still a hypothesis, is that myofascial release is thought to stimulate intra-fascial mechanoreceptors, which cause alterations in the afferent imput to the central nervous system, leading to a reduction in the activation of specific groups of motor units. So, in plain English what this means is that whenever we touch a patient we are giving information to the central nervous system, and how the central nervous system perceives this information will affect the fascia.

And the last myth about massage is when the therapist giving you the massage tells you ¨You are really tight¨. I have also done this lots of times, but research tells me I was wrong. First, tissue texture correlates poorly with pain(11)  and second we, therapists, are bad at detecting the painful side just by feel (12). So, next time you get a therapist and he tells you how tight you are…..just play along with it…..because we all do it 🙂

In conclusion: a massage is GREAT and probably helps us with a lot of our physical problems, including stress, anxiety and may even help with pain.  There are also things that massage doesn´t do and that I mentioned in this blog, but the good thing with a massage is that you can almost never go wrong. Even if the therapist tells you that he will ¨detoxify¨ you (which he won´t), you probably will come out feeling great!! So go out and get yourself a massage but please don´t ask me 😉

  1. Hernandez-Reif et al. High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywokr & Movement Therapies.199
  2. Cady et al. Massage therapy as a work place intervention for reduction of stress.Perceptual & Motor Skills 1997.
  3. Shulman et al. The effectiveness of massage therapy intervention on reducing anxiety in the work place. Journal of Applied Behavioral Science.1996
  4. Moyer. Affective massage therapy.. Int J Ther Massage Bodywork 2008.
  5. Furlan et al. Massage for low-back pain. Cochrane Database of Systematic Reviews.2008
  6. Hovind et al. Effect of massage on blood flow in skeletal muscle.  Scandinavian Journal of Rehabilitation Medicine 1974.
  7. Ramos-González et al. Comparative study on the effectiveness of myofascial release manual therapy and physical therapy for venous insufficiency in postmenopausal women.  Complementary Therapies in Medicine,2012.
  8. Wiltshire et al. Massage Impairs Post Exercise Muscle Blood Flow and “Lactic Acid” Removal. Medicine & Science in Sports & Exercise.2009
  9. Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors Sports Med. 2003;33(2):145-64.
  11. Andersen et al. Increased trapezius pain sensitivity is not associated with increased tissue hardness. Journal of Pain 2010. PubMed     
  12. Maigen et al. Lower back pain and neck pain: is it possible to identify the painful side by palpation only? Ann Phys Rehabil Med.2012

Pain part 2 – Does bad posture cause pain?

The other day we saw that pain is very complex and that in most cases it´s produced in the brain. So, if it´s really produced in the brain, does posture or movement really matter? We have all gone to the physical therapist or doctor and have heard that ¨your back pain comes because you have too much of a curve in your back¨, or ¨your back pain or shoulder pain comes because of your forward head posture¨ or ¨your knee pain comes because you have too much of a pronation on your foot¨. Hell, I´ve done it, I´ve been saying that to my patients for years because that is what was taught to me.

Up to last year I had a client, XG, who always came to me because he had back pain. I would always tell him that his back pain was coming because of his posture. He had a forward head (still does) and a big lordosis (inward curve) in the lower back .I tried to correct his posture, I gave him exercises to do at home, I stretched him, I did everything you could imagine but his posture hasn´t really changed but guess what, his pain has, it´s gone!!

So what I´m basically trying to say is that there is no consensus on supporting a biomechanical (and posture) model of pain (1-10). Because:

• Postural and structural asymmetries cannot predict back pain and are unlikely to be its cause (1).

• Local and global changes in spinal biomechanics are not demonstrably the cause of back pain (1).

• A postural structural biomechanical model is not suitable for understanding the causes of back pain (1).

This is so because postural structural asymmetries and imperfections are normal!! The body has surplus capacity to tolerate such variation without loss of normal function. That is why there is little scientific evidence to show that posture will cause pain (2-5). If posture was a factor of pain how come you see thousands of people around with bad posture with no pain and thousands more with ideal posture in a lot of pain? That just shows that there is much more to pain than just posture.

This is not meant to deny that there is a correlation between pain and certain postures, but that this association is neither sufficient nor conclusive to justify our efforts to dictate people’s posture and movement. But what we do know for sure is that there is no ‘ideal’ posture, and any posture if maintained for too long will result in dysfunction, and maybe pain. The key is movement.

To end this article and the topic of posture and pain, and to confuse people even more, I will say that there actually is potential harm in  “addressing” the unsubstantiated claims of bad posture. Things just as: focus on “bad” movement or “bad” positioning have the potential to sensitize the individual into believing that a benign (wrong) positioning is in fact something that represents a threat. And as we saw yesterday in the video, pain is the response to threat, either real or perceived, and how we view our environment and ourselves within that environment can positively or negatively affect that threat response. So by addressing things that don’t have evidence to support them (bad posture), we are actually increasing the chance that an individual might have the very real experience of pain. We are creating a self-fulfilling prophecy. That is real harm – and it is evidenced (2-5).

I will finish by quoting some of Lorimer’s famous quotes and with a link to a video that demonstrates the tricks the mind can play on us.

Favorite Lorimer Quotes

  • “Pain is very complex.”
  • “We can’t treat every pain patient with a simple solution.”
  • “The best way to get rid of chronic pain is to chop the person’s head off.”
  • “As soon as you interact with the patient, you are in their brain.”
  • “Always do more today than you did yesterday.”

P.S In my last post I said that you can have an injury without having pain. Some of you didn´t believe me, which is normal, so references 7-12 demonstrate just that.

Also, those that have been following me may be asking themselves why I still  haven´t talked about how to deal with pain. The simple answer is that I first wanted you guys to really understand what pain is and change the way you think about it. With these 2 posts maybe you haven´t really understood it yet, but I probably made you look at pain from a different perspective. Now that we have this different perspective, in my next post I will finally talk about how to ¨deal¨ with it. Hope you liked the article, until next time.


1. Lederman E. The fall of the postural-structural-biomechanical model in

manual and physical therapies: exemplified by lower back pain. J Bodyw Mov

Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011

2. Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May

3.Moseley, G. Lorimer. Reconceptualising pain according to modern pain
science. Physical Therapy Reviews 2007; 12: 169–178.

4.G Lorimer Moseley. Teaching people about pain: why do we keep
beating around the bush? Pain Manage. (2012) 2(1), 1–3.

5.Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.

6. Moseley GL. Pain, brain imaging and physiotherapy–opportunity is
knocking. Man Ther. 2008 Dec;13(6):475-7.
7.Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people
without back pain. N Engl J Med.1994 Jul 14;331(2):69-73.

8. Sher JS et al. Abnormal findings on magnetic resonance images of
asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5.

9.Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset
and descriptor patterns related to different injuries. Pain. 1982

10. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magneticresonance
scans of the lumbar spine in asymptomatic subjects. A prospective
investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.

11. Kleinstück F, Dvorak J, Mannion AF. Are “structural abnormalities” on
magnetic resonance imaging a contraindication to the successful conservative
treatment of chronic nonspecific low back pain? Spine (Phila Pa 1976). 2006
Sep 1;31(19):2250-7.

12. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S,
Einhorn TA, Felson DT. The clinical importance of meniscal tears
demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J
Bone Joint Surg Am. 2003 Jan;85-A(1):4-9.

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