I find myself playing the role of the ‘akshually’ guy with my fellow skeptics when they underestimate the pseudoscience in my professional world of aches, pains, and injury. Physical medicine. Physical therapy. This happens regularly. And so I often have to advise skeptics that what their physio has told them is utter nonsense.
Skeptics are naturally critical of chiropractic, naturopathy, and homeopathy. But few realise how far the same pseudoscientific rot has spread into the more mainstream professions. Bear with me here: physical therapy is nearly as sketchy as chiropractic. It is riddled with only somewhat less implausible ideas. It tends to avoid the extremes of alt-med, but its average sins are in the same dubious league. “Dry needling” is only hair-splittingly different from acupuncture (a ‘modern’ rationale for the same practice), but it is widely practiced by physical therapists and defended with the same tribal zeal that you see from acupuncturists when they circle their wagons.
Dry needling is the tip of an iceberg of subtler examples. From a skeptical perspective, physical therapy has the same problems as more traditional targets of skepticism. Despite being the primary ambassadors for mainstream physical medicine, physiotherapy is a distressingly good case study of how the whole point of pseudoscience is to disguise itself as science. Skeptics are prone to focusing on sillier examples that don’t actually do a good job of it, while getting fooled by a sufficiently scientific veneer on topics outside their own lanes. The most deceptive pseudoscience does not look like pseudoscience, even to skeptics.
Citations needed? But of course! I am not out on a lonely limb with this. Whole books have been written about it (The End of Physiotherapy). There is a literature about it (Zusman). And it is a field I have been writing about extensively, with deep-dive topic reviews citing a large number of relevant studies.
Massage therapy
I started out in physical medicine as a massage therapist with aspirations to be a ‘medical’ muscle manipulator. My skeptical origin story is that I read The Demon-Haunted World while I was starting my career in alternative medicine – amazing timing! When I publicly criticised pseudoscience in my profession, I was formally accused of “professional misconduct” by the alt-med zealots in charge of my licence.
Seeking allies and like minds at The Amazing Meeting in 2007 in Las Vegas, I was amazed to discover how much my fellow skeptics wanted to believe the best of my flaky profession. Skeptics tend to generously assume that the problems were limited to some New Age kooks on the edges of massage world. If only it was that contained!
The vintage New Age contingent in massage is significant, the chiro-like preoccupation with posture and alignment is almost universal, and the profession is dominated by wide-eyed childlike enthusiasm for any ‘science’ that confirms biases and beliefs. There are entire conferences about fascia, for instance, devoted to indulging in ‘mechanism masturbation‘: wishful speculation about why/how treatments might work rather than looking for evidence that they actually do. The goal is to justify the treatment goal of ‘fixing’ alleged fascial ‘distortions’, identical in spirit to chiropractic subluxations.
In 2010, I left massage therapy in a storm of controversy over my high-profile website. For a while I still looked up to physical therapy, physiatry, and orthopaedics as the evidence-based “high ground” to retreat to as I pivoted to a career based on writing about the actual science of pain and rehab.
I was doomed to be disappointed.
Out of the alternative frying pan, into the mainstream fire
It’s not hard for skeptics to mentally file massage alongside the rest of the usual alt-med suspects. It’s a tougher sell to convince them to start thinking about physical therapy, sports medicine, orthopaedics, and mainstream medical pain clinics in the same way.
The science of physical and pain medicine is thin and patchy, and there are many ‘gods’ filling many gaps. It’s especially bad in the large subcategory of manual therapy – the hands-on ‘body mechanics’, mostly massage, chiropractic, and physiotherapy. Fifteen years after leaving massage for more evidence-based pastures, I now take it for granted that this entire subdomain of medicine is a shambles and falls far short of being evidence-based. Even some of the most ‘progressive’ ideas in the field, like Cognitive Functional Therapy (not behavioural), are based on little or no science, or obviously inadequate science. The bad old ways are replaced by fashionable but flawed new ones (Taylor et al., Breedt et al.).
There are exceptions to the rule (“not all pros”), but the rule is clear to me after many years of getting burned for trying to give physical therapy the benefit of the doubt: as a profession, it excels at pseudo-quackery.
Five examples of pseudo-quackery in physical therapy
Pseudo-quackery is quackery with a good medical disguise. It’s quackery that actually passes for good medicine despite a suspicious absence of evidence. It looks mainstream, advanced, technological, sciencey, or otherwise legit. It has enough superficial plausibility to persist in the absence of evidence against it.
This is common and dangerous. It generates more false hopes and wasted time, energy, money, and harm than much more overt quackery – precisely because it is not ‘overt’, and vastly more popular than alt-med nonsense, which remains marginalised despite 30 years of hearing about its ‘growing popularity’. The real growth is in pseudo-quackery.
A good percentage of everything you’ve ever heard about physical therapy is in this well-disguised quackery category. Here are five major examples, just a selection out of quite a few more that I’ve been documenting for over a decade:
1. Spinal manipulative therapy (SMT)
Spinal manipulative therapy (SMT) is definitely not just a chiropractor thing. Lots of physical therapists also manipulate spines. There are some technical and cultural differences, and physios and chiros often have turf battles where they accuse each other of habitually doing SMT badly. There are reasonable arguments for more conservative SMT, and hardly any physios subscribe to chiropractic subluxation theory. But they still manipulate the spine, for unclear reasons, and they do it despite evidence damning it with faint praise at best (Rubinstein et al, Nim et al.). As typically practiced by physios, SMT isn’t quite ‘quackery’, but it certainly qualifies as pseudo-quackery: it is promoted as a sophisticated clinical power tool, a ‘magic hands’ thing, knowing exactly what to press and pull and twist and how hard and why.
2. Ultrasound and shockwave therapy
These tech-powered therapies are used for injuries like tendinitis with sound and/or pressure waves. The vague idea is to warm, vibrate, stimulate, and even irritate tissues a little to “kickstart” healing (many bad treatment ideas are based on the dubious logic of breaking some eggs to make an omelette). Ultrasound has been so popular for so long that it defines the experience of physical therapy for many patients. It remains surprisingly common despite being scorned by better physios – who often tell me “no true Scotsman physio uses ultrasound!”, shortly before another patient tells me that they just got some ultrasound from their physio. Ultrasound has been thoroughly undermined by every scientific review for decades (such as Ebadi et al., but there are many more).
And shockwave therapy? That’s the fancy modern upgrade, and probably the single best example of pseudo-quackery: although the principle is a little different, it’s a distinction without a difference from the patient perspective. It is used just like ultrasound, and it is now supplanting it, but it’s over-hyped, more expensive, often painful, and rarely or barely beneficial (not even for tendinitis, probably the biggest use case – see Alsulaimani et al.).
3. Functional Movement Screening
The branded “Functional Movement Screen” is a set of seven physical tests of coordination and strength, especially ‘core’ strength, invented in 1997 and now in widespread use around the world. It was originally proposed as a trouble-detection system, which is baked into the name: it’s a ‘screen’. But its use in the wild often seems to reach past this stated purpose into diagnostics and justification for ‘correcting’ a lot of alleged movement dysfunctions and deficiencies that are largely fanciful.
It is a strong example of a theme in physical medicine: simplistic demonisation of innocuous or incidental natural variations in anatomy and movement. Conveniently, professionals can easily sell ‘solutions’ for these ‘problems’ that sound sophisticated. FMS got popular long before it was tested – and it flopped when it finally was (Bakken et al.). And yet it remains influential.
4. Therapy taping
Therapy taping is one of the hottest fads in the business; countless physios have jumped on the profitable kinesiology-tape bandwagon. It grew out of traditional compression bandaging, got commercialised as a chiropractor’s invention in the 70s, and then exploded in popularity with the innovation of colour at the 2012 Olympics. The hype machine churned out spin-off products, with many dubious claims about therapeutic benefits, such as injury prevention and performance enhancement. Several new brands were quickly born.
All the attention inspired a lot of research, and so we now know for sure what seemed obvious to many all along: it’s all much ado about nothing. Taping certainly doesn’t increase circulation, enhance performance, promote injury recovery, reduce inflammation, or provide meaningful support (Reneker et al.). And yet it has fooled millions by seeming extremely mainstream, and with plenty of citations to ‘promising’ evidence that doesn’t stand up to scrutiny… but hardly anyone ever seems to scrutinise it.
5. TENS and friends
Transcutaneous electrical nerve stimulation is the best-known member of a large family of electrical stimulation and “neuromodulation” therapies. Since the discovery of electricity, humans have been keen on zapping themselves and each other. Although pleasant and mildly analgesic for some people, TENS is roughly in the same league as the comfort of a heating pad, and does not remotely deserve to be a staple of physical therapy. But then there are other much more dubious kinds of stim therapies, like microcurrent therapy (think ‘homeopathic TENS’). When I criticised MCT on social media recently, even I wasn’t cynical enough to expect the fierce defensive reaction from some physical therapists. While a minority of progressive pros scoff at TENS and MCT, it’s clear that legions of others still believe.
This is only about a third of my full list of major examples of pseudo-quackeries: others include trigger-point therapy, ‘corrective’ exercise, prolotherapy, foam rolling, spinal decompression, orthotics, platelet-rich plasma, knee ‘lube’ jobs, laser therapy, neurodynamics, vibration therapies, and still more. All are problematic. Some are almost complete nonsense, while a few have a larger seed of truth but are abused so much that there’s no practical difference from quackery.
Physio is full of this stuff. It may not be as ridiculous as homeopathy, but it’s not far off, and – crucially – it’s largely invisible to your standard skeptical-grade bullshit detector.
