Why Pain Relief Is So Difficult in Modern Medicine, While High School Biology Is Enough to Prove Otherwise

North Americans spend $24 billion a year on pain relief while chronic pain is on the rise. However, for pain management in general, modern medicine provides no solutions (Marni Jackson, 2002).

Pain relief: The No. 1 Goal of Medicine

The goals of medicine can be summarized as below:

• Relief of pain and suffering.
• Cure of disease.
• Care of the infirm and disabled.
• Prevention of disease.
• Avoidance of premature death (Mark J. Hanson et al, 1999).

For the patient seeking medical help, the relief of pain is paramount, and they hope it to be as quickly as possible and to be long-lasting. Unfortunately, pain management is the most remarkable field in medicine where modern medicine miserably fails.

Modern Medicine’s Miserable Failure

In 2009, Australian researchers Machado and others published the results of their meta-analysis which estimated the effectiveness of pain relief (on a 1-100 scale) of different therapies for non-specific low back pain (LBP) as reported in placebo-controlled randomized trials (Machado et al, 2009).

A total of 76 trials reporting on 34 different therapies were included. The analysis found that for most of the therapies the pain reduction was small or moderate at the best: after weeks even months of treatment, 47% were merely 10% better than placebo, 38% were 10% to 20% better, and only 15% were > 20% better.

In summary of this review:

• In terms of “superiority to placebo”, physiotherapy, traction, behavioural and anti-depressants are no better than NSAIDs and magnets, and are barely better than placebo.
• Exercise and SMT (spinal manipulation therapy) are essentially no better than placebo either (1.7% and 1.4% above placebo respectively).
• Acupuncture and TENS are marginally (19% and 16%) better than placebo with low reliability (due to very large variations).

From Machado et al's meta-analysis of literature, what we are left with is a conclusion that for treatment of LBP, we do not have any healing modalities which are remarkably and reliably superior to placebo even after weeks to months of treatment. Being no better or barely better than placebo usually means the treatments failed.

The same scenario is not limited to LBP but applies to all other pain-related health conditions tested by placebo-controlled trials conducted in the last half century. Dr Andrew Leaver, Senior Lecturer in Physiotherapy at the University of Sydney, Australia, provided his view on the effectiveness of physiotherapy, chiropractic and osteopathy (Olivia Willis, 2017):

"We don't have robust clinical trials that prove the efficacy of every single thing that we do, but neither does any profession – a lot of medicine is not backed up by robust randomized controlled trials."

In 2018, the British Journal of Sports Medicine published an editorial titled: "Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?" The editorial strongly voiced: “Current approach to musculoskeletal pain Is failing ...

In 2019, the International Journal of Rehabilitation Research published a systematic review authored by 8 PT researchers (Momosaki R et al, 2019). The review was based on the Cochrane Database of Systematic Reviews from 2008 through 2017 in the field of physiotherapy. The Cochrane reviewers found 283 CRs in the field of physiotherapy, and among which only 16 (5.7%) were conclusive. Almost all reviews recognized the need for additional studies.

The Sharp Contrast Is …

In physical science, we can send a man to the moon. In molecular biology and biochemistry, we are almost able to clone a human. But in musculoskeletal medicine, we are still unable to reduce a patient's muscle or joint pain more than a placebo does, even when the pain is merely a penny-sized spot (for example, lateral elbow pain).

But Pain Can Be Shut Down in Seconds: High School Knowledge

The high school biology knowledge related to brain and nervous system is enough to teach us clinicians that any sensation perceived by brain is basically a flip of action (electric) potential in neurons. It follows that any medical interventions must be useless in reducing the pain unless it can trigger a flip of action potential in the neural network.

It is so obvious that pain can be, and must be, shut down in seconds (the speed of action potential transmission in neurons) simply by flipping a switch somewhere in the body. Now a question is: Why the pain management in modern medicine has miserably failed?

The reason is simple: Too many useless pet theories, fallacies or delusions in pain and musculoskeletal medicine flooded our closed minds. Few of us clinicians, if any, tried to widen our minds to the human body tissues beyond muscle, fascia or spinal joints. Many of us totally ignored the fact that without nervous system, all musculoskeletal tissue is nothing but chunks of dead flesh. We have been isolating ourselves in echo chambers made of pet theories, fallacies or delusions.

Pet Theories, fallacies & Delusions in Modern Medicine

There are many pet theories, fallacies and delusions in modern medicine particularly in musculoskeletal field in terms of how to explain the phenomenon called “pain” and how to design the resultant interventions:

• “… musculoskeletal clinicians have invented treatments for conditions that may not exist or be readily detected (such as trigger points, sacral torsions), and they have developed and perpetuated treatment paradigms (such as ‘correcting’ upper body posture and muscle imbalances) that do not conform to current research evidence” (Jeremy Lewis et al, 2018).
• "The biomechanical model (BMM) for “the effectiveness of manual therapy in the treatment of pain makes many unproven assumptions, has many obvious demonstrated flaws and lacks prior biologic plausibility and thus, should seriously be questioned” (Frédéric Wellens, 2010).

A few famous pet theories, fallacies or delusions related to pain include: trigger point theory, weak muscle theory, tight muscle theory, bad posture theory, subluxation theory, … None of these dogmas sustained robust scientific testing.

Obsolete Ideas and Techniques

According to Australian physiotherapist Max Zusman (? - 2014), a world reknowned physiotherapy authority, passive movement has been the king in physiotherapy treatment, but is an erronneus techique based on obsolete conceptions. He argued in 2011:

• “Despite physiotherapists’ comprehensive training in the basic sciences, manipulative (“musculoskeletal”) therapy is still dominated in the clinical setting by its original, now obsolete, structure-based “biomedical” model (Zusman M, 2011).
• “...there is no convincing evidence for any lasting alteration in tissue length, position, shape or content following passive movement. Nor would any be expected given that the forces delivered by passive movements are said to be too small and too brief to do so...
• “Regardless of how rationalised, ...positive outcomes [from passive movement] may sometimes be obtained by treatment applied “elsewhere”.
• “… where pain is the major problem to be “treated” ... passive movement “appears largely erroneous”; ... it is doubtful that passive movement can achieve any lasting physical “change”.

Everything Is Self Delusion but Rapport

Based on obsolete ideas, countless techniques were invented in muculoskeletal medicine: Massage therapy, spinal manipulation, Trigger point dry needling, IASTM, Graston, Osteopathy, craniosacral therapy, myofascial release, ART, … just to name a few. Merely for a simple nerve-pinching condition (sciatica), the therapeutic modalities could include: general exercises, neurodynamic exercise, core stability, extension exercises, isometric exercise, advice or education (advice to continue normal activity), manual therapy, and spinal manipulation (Dove L et al. 2023).

But how effective are these techniques? Any single one superior to another? There was a hot discussion among physiotherapists posted on reddit.com, where it seemed every one was frustrated and disappointed with what they do. All the candid critiques led to one conclusion: “Everything is self delusion but rapport.” (For details, read this).

Voices of Critical Thinkers: Get Rid of Fancy Complex Bullshits

Since 1990s, in many medical fields including musculoskeletal medicine, self-critiques and calls for reform have become a stronger and stronger voice. As mentioned earlier, in 2018, the British Journal of Sports Medicine in an editorial strongly voiced: "Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Current approach to musculoskeletal pain is failing …" (Lewis J et al, 2018). The leading author of the editorial is Professor Jeremy Lewis, who is also a consultant physiotherapist working in the UK-NHS.

In physiotherapy community, Adam Meakins, a sports physiotherapist working in the NHS and private practice in the UK, is one of the most followed reform advocators across all social media platforms. Meakins is particularly known for his strong views, opinions, and occasionally stronger language which has irritated many of his PT fellows.

Adam Meakins's main philosophy, in his words, is “to do the simple things really well and dont get distracted by all the fancy complex bullshit that's rarely needed”. Meakins calls the useless pet theories, fallacies or delusions in physiotherapy field “the fancy complex bullshit”. I am not a PT. But as a health care practitioner, I found Meakins' strong voices against the bullshit or stupidity which is stifling or suffocating the profession called physiotherapy applies to other health care professions in musculoskeletal field.

"Muscle Pain": A Delusion & Straw Man Fallacy

Among numerous fallacies or delusions in musculoskeletal medicine, perhaps the number one fallacy or delusion is the sensation called “muscle pain”.

Pain is a sensation the brain perceives upon receiving a signal from the nociceptive nerve endings. For brain to sense the pain as coming from a specific body part or region, the tissues of that body part or region must have nociceptive nerve endings in place. “Muscle pain” has been studied in the last over 120 years. But so far there is no highly confident evidence at all that muscle fibers themselves have nocicetive nerve endings. With absence of nociceptors, how come there is “muscle pain”? Why in musculoskeletal medicine, we kept ignoring the pain in those nociceptor-rich tissues such as skin, joints, bones, ligament, tendons, fascia and the surface of alimentary tract?

Modern medicine has been fighting against “muscle pain”, a non-existent disease, for more than 100 years. It looks like the enemy we have been fighting against was just a straw man. No wonder pain science has been going nowhere in the last century.

Now we can also see why there are so many pet theories and fallacies in musculoskeletal medicine. All those fancy complex inventions were designed to deal with a health condition which exists only in our delusion.

Final Words: for Deeper & Critical Thinking

“Most histories of medicine are strikingly odd... They provide a clear account of what people believed they were doing, but almost none at all of whether they were right.” Says the British physician Druin Burch (Tetlok PE, 2015).

References

Lewis J et al, Is it time to reframe how we care for people with non-traumatic musculoskeletal pain? Brit J. Sports Med, 2018

Marni Jackson, Pain: The Fifth Vital Sign. Random House Canada, 2002

Machado L.A.C. et al, Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials, Rheumatology 2009;48:520–527

Mark J. Hanson and Daniel Callahan, The Goals of Medicine. 1999, Georgetown University Press

Momosaki R. et al, Conclusiveness of Cochrane Reviews in physiotherapy: a systematic search and analytical review. Int J Rehabil Res. 2019 Jun;42(2):97-105.

Nicholls, D.A., Physiotherapy Otherwise, Auckland University of Technology. December 14, 2021

Olivia Willis, 2017, Physiotherpy, chiropractic, and osteopathy: What's the difference? abc.net.au

Tetlok PE, Doctors without Science. 2015. https://thewalrus.ca/doctors-without-science/

Zusman M, "The modernisation of manipulative therapy," international journal of clinical medicine, vol. 2 No. 5, 2011, pp. 644-649.

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