I’m on holiday for a couple weeks at the moment, so updates will be slow for a couple weeks. But of course I never truly stop working entirely …

A recent email exchange with a reader inspired this small piece, which is really more about critical thinking and cognitive distortion than Epsom salts. In this case, the reader was well aware that the apparent benefits of Epsom salts baths might well be explained by the baths not the salts. Most mail I get on the topic is just the opposite: Epsom salts routinely get credit they probably don’t deserve. Here’s how it goes:

1. Patient has a problem and tries non-salty hot baths or soaking. However, because it’s just a bath and expectations are low, this effort is never particular diligent. This is key to the setup: the patient has never actually given non-salty soaking a good try, at least not compared to what they will do when …
2. Patient gets the idea to try Epsom salts! This seems much more promising.
3. Thus inspired, the patient proceeds to soak quite diligently — much more diligently than ever before.
4. When some benefit is then observed, patient attributes this to the salt — of course. Maybe it is, but maybe it’s just the unusual regularity of the nice soaking. The point is that we obviously can’t know … but the patient is now officially biased.
5. If the benefits are at all notable, this person will usually start proclaiming to anyone who will listen that they “know” that Epsom salts work.
6. When challenged (“It might be just the hot bath, eh?”), they will almost certainly object and claim (correctly!) that they have tried simple hot soaking without results. They have indeed. But it was never actually tried well enough to really know.

Tricksy, the human mind is.

David Moorcroft was about as flexible as a 2×4, but it didn’t keep him from winning a lot of races.

Reader Jennifer M. found this great passage from an excellent 1983 Sports Illustrated article about David Moorcroft, a British middle and long distance runner and 5,000 metres world record holder. It’s a splendid addition to my stretching article:

Stacked in a corner of Anderson’s [Moorcroft’s coach] office are bundles of scientific papers. “I’ve tried to interpret the findings of the best physiologists and translate them into sound practices,” says Anderson. “That’s made me a radical. We’ve turned some coaching sacred cows on their ear.”

For one, Anderson dismisses the stretching that most runners do. “It’s rubbish,” he says. “The received idea that by touching your toes you lengthen the fibers in your hamstrings is wrong. Soft tissue stretching like that is a learned skill and doesn’t carry over into running. Dave requires a flexibility, a joint mobility, but running fast is the right kind of stretching for him.”

The world-record holder mutely demonstrates his suppleness by reaching toward his toes. His fingertips get down to about midshin.

‘What Made Him Go So Wonderfully Mad?’ So Inquired a friend of David Moorcroft after the Briton broke the world 5,000 record in an amazing performance, Moore (sportsillustrated.cnn.com)

This was 1983, mind you: those “bundles of scientific papers” that led Anderson to his “radical” stretching beliefs were 27+ years old.

Jennifer added that this reminded her of her father, “who remained competitive at the 800m until into his 60s, but could never come close to touching his toes.”

Tech/publishing note: interesting that Sports Illustrated has so much back catalog content online. Also, Apple’s Safari web browser did a groovy job of stitching all the separate pages of that article into one highly readable presentation, using their nifty reader feature.

‘What Made Him Go So Wonderfully Mad?’ So Inquired a friend of David Moorcroft after the Briton broke the world 5,000 record in an amazing performance

Dr. Tim Taylor, a chronic pain specialist from Virginia, has contributed an important new chapter to my book about muscle pain, Save Yourself from Trigger Points & Myofascial Pain Syndrome! This is SaveYourself.ca’s first major collaboration, and a really good one to start with — it’s fantastic to have expert assistance in creating such valuable information for my readers.

Dr. Taylor has written about the medical factors that can make muscle pain stubborn, particularly the harmful effects of statin drugs (i.e. Lipitor) and a variety of nutritional and hormone deficiencies. For instance, sun-deprived readers please take note: it is now well-established by research that most people are not getting enough vitamin D (see Holick), and that this is relevant to pain (see Plotnikoff and Holick). In 2003, Plotnikoff et al wrote rather dramatically in Mayo Clinic Proceedings (emphasis mine):

…all patients with persistent, nonspecific musculoskeletal pain are at high risk for the consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for vitamin D deficiency …

Even watered down, those results should be of great interest to pain patients.

Clueless!

As a Registered Massage Therapist, I was clueless about this for a decade. So tragic! Imagine your physiotherapist, massage therapist or chiropractor working away on your tissues for more than a buck a minute, in vain, blissfully unaware that the real reason you hurt is that you’re D deficient! Or taking Lipitor. Or some other non-obvious medical complication that your doctor is probably also clueless about.

Many therapists will protest that they “know” about the importance of nutritional deficiencies and drug side effects: however, I would bet that, in almost every case, that “knowledge” is mostly just a vague faith that “nutrition is important” and “drugs are bad” — not the same as having a specific knowledge of which drugs cause myalgia, which nutrient and hormones deficiencies matter and why, and what to do about them beyond taking a multi. There is serious medical expertise needed here.

I’ve actually avoided studying and writing about these medical issues, because Dammit, Jim, I’m Not a Doctor! — it’s just generally unwise for me to write about squishy medical stuff, and I’ve got my hands rather full with orthopedics. And so this vital information was previously missing from my book, and I did not have the time or the academic or clinical expertise to fix it. I was painfully aware of it, but there was no easy cure.

Fortunately, Dr. Taylor came to me … starting out as one of my customers.

An important customer

Dr. Taylor was pleased with my book, but he knew that something important was missing. He knew all too well how important medical factors can be in a chronic pain case: he’s lived through that discovery. Dr. Taylor has suffered and recovered from serious muscle pain himself, and it changed his career. Dr. Taylor and his wife Dr. Anna Bittner started a clinic dedicated to chronic pain management, particularly myofascial pain syndrome.

“After many months without success, and being told my pain was imagined, I found internationally recognized experts who treated me with excellent results, and Anna’s fibromyalgia also improved substantially,” Dr. Taylor explains. “I developed a passion for helping other people in pain and offering them the same techniques that had relieved my own pain. This is the most satisfying thing I have ever done as a doctor.”

Dr. Taylor thought my book was worthy of upgrading, and offered to do it.

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Dr. Tim Taylor, Richmond, Virginia. After their own successful recoveries from chronic pain, Dr. Taylor and his wife Dr. Anna Bittner started their own clinic, Pain Relief Home.

Who knew collaboration could go this smoothly? I sure didn’t!

I often get offers from would-be collaborators, but no proposal has ever amounted to anything. A thousand things can go wrong with collaborations! It’s like herding cats. Make three points about a document and they will probably misinterpret the first, disagree with the second, and ignore the third.

Not Tim.

Dr. Taylor didn’t just volunteer to contribute, he did it fast and well. Content was delivered weeks before expected. Every email was answered within hours. He was thorough and accurate and reasonable and polite and a productivity machine.

“Show me the evidence” usually doesn’t get such a good answer

At one point I thought we might have had a deal-breaker. SaveYourself.ca is all about the science. This has been a sticking point with some contributors over the years — many have lots of ideas, but not much evidence.

I’d asked Dr. taylor to provide more specific scientific evidence for several points, a fairly tall order. I wasn’t sure what would happen. On the one hand, I thought the evidence probably existed. But, based on past experience, the predictable response was excuses, a 3-week delay, useless references …

Tim provided a good list of specific references the next morning.

A book that’s always up-to-date

This is exactly why I don’t really want to publish a print book. Electronic wins hands-down in this situation. This update is available to my readers now — the most important one-time upgrade in the history of the trigger points book. Anyone who has a current subscription can read it today.

And of course it’s also available very cheaply to past customers. Normally you’d have to buy a new, full-price edition of a book to get an upgrade like this — here it’s just a small renewal fee, even if it’s been years since your original purchase. That’s just better.

Start reading …

Odd! Just a couple days after posting about a not-yet-published study of trigger point squishing — quite a rare subject for research — I came across (via @massagetherapy) an almost identical study that is published. They also reported news that makes massage therapists smile:

…using ischemic compression on shoulder trigger points may reduce the symptoms of patients experiencing chronic shoulder pain.

These studies look so much alike that if you put them both in the same cute little sailor suits you wouldn’t be able to tell them apart. They’re both rather simple and small, they both studied “ischemic pressure” — pressing and holding a trigger point or “muscle knot” until it’s a bit oxygen-starved — and they both produced an unambiguously thumbs-up of a result.

Indeed, this research showed an impressive treatment effect: a score measuring shoulder discomfort went down a whopping 75% in those treated, compared to a mere 30% reduction in people who received treatment in a nearby location. That’s a humongous difference and a great demonstration of a principle I’m always pimping on SaveYourself.ca: therapies should have no problem demonstrating their benefits in a fair test. The results should impress.

And these results impress.

Mostly.

Caveats!

These glowingly positive results will tend to perpetuate assumptions about the nature of trigger points. Even considered together, these two studies cannot be said to actually “prove” anything. They are still too small and their results might not be due to the actual treatment.

One obvious problem, for instance, is that both experiments compared treatment in the right place to treatment in the wrong place. This flings the door wide open for a major confounding factor: patients with shoulder pain would be well aware the sham treatment is a sham, probably dramatically decreasing their satisfaction and expectation of benefit. Meanwhile, people getting treatment in the “right” place will likely feel much better about the treatment and have much higher hopes: rich soil for a placebo effect.

Unfortunately, it is quite plausible that both of these studies simply showed that poking people’s trigger points gives great placebo.

This science stuff is tricky!

Still, we’ll file it all under “promising.” If the effect was a placebo, it was an awfully potent one.

An upcoming issue of Journal of Bodywork & Movement Therapies will include a new study of trigger point squishing. I was lucky to get a look at a final draft, thanks to connections at The Pressure Positive Company, the massage tool manufacturer that supplied the tools.

This experiment has the simple elegance of a good science-fair project. Dr. Dawn Gulick of the Widener University Physical Therapy Department simply compared the sensitivity of trigger points both with and without a simple treatment of pressure — squishing them, that is. That’s an experiment I’ve always wanted to do myself.

In life, and in a massage therapy office, it seems obvious that sore spots in muscles often get less sore when you apply pressure to them, but this apparent phenomenon is strikingly unconfirmed by any research. And we do need it confirmed, because what seems “obvious” to the fallible human mind is often surprisingly wrong. It’s also important to study it because, even if the treatment works, it may not work for the reason that seems obvious. For instance, what if it’s not actually the pressure that’s doing the job, but simply the touch? Or even the social interaction with the patient? You need some careful testing to suss out that kind of thing.

This experiment tested a specific method of squishing: pressing a trigger point firmly and long enough to starve it of some oxygen (ischemic pressure), repeatedly, for several days. This has long been one of the preferred methods of treatment, and it is specifically recommended in my own trigger point e-book as a best-bet protocol, but I have no real idea if that’s really the best way to get rid of a trigger point.

Dr. Gulick et al. measured trigger point sensitivity before and after treatment in 28 people with two trigger points in the upper back. Their conclusion:

There was a significant difference between the pre- and post-test sensitivities of the treated and non-treated trigger points. The results of this study confirm that the protocol of six repetitions of 30-second ischemic compression with the Backnobber II rendered every other day for a week was effective in reducing trigger point irritability.

Excellent!

This is small-scale science, and hardly the last word on this subject — remember, all knowledge is provisional — but the results are encouraging and certainly consistent with my professional experience.

How much does the effect of a medication depend on what you are told about it? Quite a bit, apparently!

This strange and fascinating study in Psychosomatic Medicine showed that a muscle relaxant actually increases tension when the patient is told (lied to) that it is actually a stimulant. The false information is so potent — or the drug is so weak — that its intended effect is actually reversed.

It’s like a Jedi mind trick. These aren’t the drugs you’re looking for.

But the reverse was not true: even when told that they were taking a muscle relaxant (and they were), subjects did not actually relax any more than people taking a placebo … and in some cases less!

And there’s more. This study contains many odd gems, such as the bizarre fact that quite a lot more muscle relaxant was found in the blood of people who had been told that the muscle relaxant was a muscle relaxant. It appears that they literally soaked up more of the stuff from the GI tract when they believed that it was a relaxant! And yet it still didn’t actually relax them any more than a placebo.

Weeeeeird …

“Basically they are the Amway for people who think a metal tube full of ‘granulated minerals and crystals’ can fix your bad back, make crappy wine taste better, reduce the acidity of lemons, energize your food, etc. I went to a ‘wanding party’ in Westchester, and it was very weird indeed.”

Weird multi-level marketing company sells $300 cure-all wand

I narrowly escaped a breast biopsy because of trigger points in the pectoralis major. I’d had bad chest pain for a month. I was on the table, permit signed, draped. The doctor wasn’t sure: she said she wanted another mammogram. I left confused, relieved … but still hurting.

Then I lucked out: my regular internist was puzzled, but thought it might be “soft tissue.” That made me go to a physical therapist. The physical therapist pulled out the big red books [see citekey: href="http://SaveYourself.ca/bibliography.php?tra"> tra, type: bookMyofascial Pain and Dysfunction] on trigger points, and we read together about pectoralis major trigger points. Treatment was a complete success. A month-old severe pain that I had been treating with ice packs in my bra and Lortab — gone!

Janice Kregor, competitive swimmer, retired pediatrician and medical school instructor

Indeed she was lucky. Her physicians acted with admirable caution and humility, and she ended up working with a physiotherapist who was not only familiar with trigger points, but had good information on her shelf and knew what to do with it. Many patients in the same predicament would have been biopsied and continued to suffer unexplained pain.

Alexa Ray Joel, somehow still with us after trying to kill herself with an unbelievably teensy dosage of arnica and other herbs.

I could not make this up. Truth really is stranger than fiction — and funnier, too!

Back in December, Billy Joel’s daughter Alexa Ray tried to kill herself, probably because she heard “Piano Man” one too many times. She did a poor job of it. She tried to kill herself homeopathically. And not just any homeopathy — she took Traumeel.

That’s my turf. Traumeel is relevant to muscle pain.

Traumeel is (mostly) an extremely diluted preparation of the herb arnica and allegedly good for “aches and pains.” It contains ingredients that would be modestly toxic (probably not lethal) … if they weren’t diluted to the point of absurdity. Alexa Ray’s plea for help led to about .00000000000000001% of her death. The crazy math of it is quite familiar to skeptics around the world, who all blew milk out their noses and slapped their thighs crimson when they heard this precious news item.

You could get more arnica montana by licking the plant — once. Hell, a hundredth of a lick would probably be a higher dose. Alexa Ray’s suicide method was less dangerous than inhaling new car smell. It would be (much) easier (and more fun) to kill yourself with light beer. Death by Nerf bat would have been considerably more efficient.

Last year I wrote a comprehensive analysis of Traumeel that rose to the top of the Google charts, and there it remains — usually second in the listings only to traumeel.com itself. It is a polite article. It is a careful article. One does not want to step directly on the toes of those who profit from Traumeel. My aspersions are … diluted. The article does not ever say that Traumeel does not do anything, it just implies it.

And so does Alexa Ray’s failure to kill herself.

You can’t kill yourself with Traumeel, no matter how hard you try. I promise. Alexa tried, and she is with us still. So is debunking magician James Randi, despite numerous homeopathic overdoses (of another homeopathy remedy, Calms Fortes).

This isn’t a safety feature of homeopathy. What’s more likely: that homeopathy doesn’t work at all? Or that homeopathy is potent medicine but not potent enough to hurt you in overdose? Just how wishful can thinking get?

The only thing this pathetic Joelian incident demonstrates is that the ingredients of Traumeel are so diluted that … that it … that it doesn’t … no, I’m not going to say it. You know how the sentence ends. I will just close with this:

“A leading toxicologist said it would be nearly impossible to overdose on the homeopathic medicine Traumeel,” reported the Daily News.

Um … “nearly”?