A radical shift away from the biomedical bubble

The front cover of the July issue of The Lancet:

Some people have been calling for and working towards that radical shift for decades. Dr. Patch Adams comes to mind.

Sadly, alternative medicine has mainly only paid lip service to “social, behavioural, and environmental determinants of health,” while being much more truly defined by and deeply invested in snake oil and pseudoscience. What a tragic missed opportunity! Alt-med could easily have inspired/shamed mainstream medicine into that important “radical shift”, but instead it’s done nothing but drive ever deeper into left field.

The biomedical model definitely isn’t all wrong, and indeed much about it is so right we should actually double-down on it (e.g. vaccination!). We definitely do not need a “radical shift” away from those strengths. Of course.

However, the biomedical model has been a terrible failure for a lot of patients — especially pain patients — and there certainly a need for a radical shift away from those weaknesses. And when a pendulum needs to be swung, it’s often necessary to push away from where it’s been, to vigorously reject the past.

I have a highly relevant little-known article, one of my own favourites, that explores the strengths and weaknesses of both alt-med and mainstream medicine: Alternative Medicine’s Choice: Alternative to What?

And one more “see also”: physical therapist Sigurd Mikkelsen put together a great little compilation of related points.

Taking out the trash: purging predatory journals from my bibliography

Recently I shared a study on social media (Ghorbanpour et al). It seemed to be an unusually low quality paper, and soon after I posted it I was informed that it was published in a suspected “predatory journal” — a fraudulent journal that will publish anything for pay (literally anything, even gibberish). They are scams, ripping off academics who are desperate to publish or perish. I just blogged about predatory journals a few weeks ago:

The scientific literature is severely polluted with actual non-science, with an insane number of papers that were published under entirely false pretenses, the fruit of fraud.

Although I’ve been aware of this debacle for several years, I have not paid close enough attention to be aware of how to identify predatory journals. I assumed I didn’t have to worry about it. But the journal in this case was on a list of sixty suspected predatory journals in the rehabilitation field specifically, put together by Manca et al. That’s my turf! If that list is trustworthy (which seems likely), it’s a depressing but invaluable resource for me. Since then I’ve learned about other lists (see PredatoryJournals.com and BeallsList.weebly.com).

My next job was to audit my own bibliographic database for those bogus journals. The bibliographic database for PainScience.com contains 2450 papers. How many are the spawn of predatory journals? How heavily have I relied on their unreliable conclusions? Not a comfortable chore! But an unavoidable one.

Here’s what I found lurking in my bibliography

  • 14 journals on Manca’s list appear to be indexed by PubMed (making it much more likely that they’d be in my database)
  • 11 papers in my bibliography are in one of those journals. Not too bad…
  • 9 of those paper are from one journal! The Journal of Physical Therapy Science.
  • 8 of were rated by me, all mediocre at best.
  • 4 had proper summaries (meaning I invested significant time in understanding and explaining the paper). I’d specifically noted that one of them was poorly written.

Obviously I was well aware that these were shabby papers. Which isn’t really surprising, because these days — for many reasons — most papers are “guilty until proven innocent.” I deal with bad papers all the time. I just didn’t know that these papers were not really published.

And how were those bad sources cited?

My real concern was that I might discover that I’d used some worthless studies to support a personal bias. Was I using non-science to make any important points?

Nope! I mostly passed this test. Here’s how they were used:

  • Both Iqbal and Kim are cited on two pages as examples of “a handful of very weak studies” that support deep cervical flexor training for neck pain. I checked the only other reference I have for that, Gupta. It wasn’t on Manca’s list, but the journal’s website looked super sketchy, and I was quickly able to find it on another list of suspected predatory journals. So all three are worthless, and there is literally no real science supporting DCF training. I am Jack’s complete lack of surprise.
  • Both Hyong and Yoo are also double-cited, along with a three others, to support the claim that “just the right exercises do indeed preferentially engage the [vastus medialis muscle]”. Collectively I characterized those studies as “all admittedly small, but also all quite straightforward and probably adequate.” But not those two! So a bit wrong there, but not horribly.
  • Cheng is just barely cited (at the end of a footnote for another citation) as having conclusions “similar to” Gross, which is in turn presented as mostly inconclusive “garbage in, garbage out” review of studies of exercise for neck pain. So no real harm done there.
  • Both Ravichandran and Amin are in a list of 17 studies of massage for trigger points. The low quality of Amin is made clear even in summary: “no control, mixed results, poorly written paper.” Ravichandran is presented as just a “small negative RCT.”

That last one is the most interesting of the batch: I actually read Ravichandran et al quite carefully just a few months ago, and wrote a thorough summary of it, in which I slammed the authors for spinning their data to make the results look more positive than they were. I think it’s “one of the few clearly negative trials” of massage for trigger points, which rubs my bias the wrong way: I want to believe that massage helps trigger points! So I’m actually smugly pleased to see this paper discredited.

So that’s a dozen citations to papers that are completely useless, but — phew — I didn’t rely on any of them heavily for anything that mattered.

The remaining papers, which I had not yet gotten around to citing, and now never will:

All of these will remain in my bibliography, but their quality will be prominently questioned, and all will have the 1-star ratings that I apply only to “bad example” papers. I’ll remove most of the citations to them, as examples of the lack of support for a claim.

No doubt there’s more

I did my initial search for predatory journals in my own database before I discovered other lists of predatory journals, so I have more auditing to do, and I fully expect to find more of these festering pustules in my bibliography. However, based on these preliminary results, I suspect I won’t be too horrified by what I find.

And I will now be systematically checking the origins of every significant new citation. PainScience.com will never knowingly cite anything from a predatory journal ever again, except as a bad example.

Could these papers have some value?

Is it overkill to disqualify them entirely? It is theoretically possible for a good paper to end up in a predatory journal, but there’s know way for us to separate those from the rest. I think publication in a predatory journal almost completely undermines the credibility of a paper. Even in legit journals, with flawed but earnest peer review, we have an appalling problem with underpowered crappy little trials, the p-hacking epidemic, and so on. Peer review is deeply flawed, and in some journals it’s not much a lot better than the rubber stamp at a predatory journal, but in any half decent journal it’s a lot better than nothing.

Without it, I think the value of a paper and the credibility of its authors drops to near-zero. They might have good intentions, but they certainly don’t have good judgement. It casts doubt on the value of all their research, wherever and whenever it is published — it’s a serious stain on their record.

Zero-G and spines

microblog

Astronauts get more intervertebral disc herniations when they come down to Earth, probably because the darn things swell up in zero-G. We’re used to thinking about disc herniation as something that happens because of gravity… not because it’s absent! I’m sure most of us probably assume that taking the pressure off is nice for spines (and maybe it is while you’re still floating around).

But apparently discs get a bit poofy and unstable if you don’t keep the pressure on ‘em.

And… every time herniations come up, it’s important to emphasize that they are an over-rated problem. Of course they occur, and make some people miserable, but their severity and clinical importance has also been blown way out of proportion for decades.

This is the MICROBLOG: small posts about interesting stuff that comes up while I’m updating & upgrading dozens of featured articles on PainScience.com. Follow along on Twitter, Facebook, or RSS. Sorry, no email subscription option at this time, but it’s in the works.

Why is musculoskeletal medicine such a mess?

Jonas Salk at the University of Pittsburgh where he developed the first polio vaccine.

We are living in a golden age of pain science and musculoskeletal medicine … sorta

The 20th Century was such a scientific and technological earthquake that we all now have a tendency to assume that the human species has advanced knowledge about basically everything, but we really don’t. In many ways, the state of our knowledge of anything relatively subtle or complex in medicine is still surprisingly primitive. Even sports medicine — with so much potential funding (and potential relevance to occupational injuries) — has been bizarrely slow to build its evidence base.1 The performance of elite athletes is worth trillions to our economy, and obsessively optimized, and yet science remains almost completely silent on the best treatment options for the most common injuries affecting those high value patients, things like muscle strain.2

For most of history, medicine had bigger, scarier fish to fry than treating mere aches and pains and injuries. And it still does. But just a few decades ago, doctors and researchers were necessarily preoccupied with much more pressing public health issues … and rewarding new treatments.

Insulin and penicillin were still changing the world, as were a string of new vaccines — diptheria, pertussis, tuberculosis, tetanus, flu, yellow fever, typhus, polio, measles, mumps! Surgery and anesthesia were finally coming into their own, with error rates plummeting.3 The first organ transplants were saving people who would be be doomed without them. Dialysis! Pacemakers! Laser treatments for eyes! MRI and CT scan! Arthroscopy!

Medicine was still creating huge leaps in the length and quality of our lives.4 It was an era of low-hanging medical fruit.

When you look at the big picture, it’s easy to see that we’ve been rather busy making an amazing amount of progress in many, many other ways. Our World In Data provides many terrific examples. So many of my worst cynical impulses are contradicted by Max Roser’s charts & data. Refreshing! As Bill Clinton said, “Follow the trendlines not the headlines.” Chart Source: Max Roser & OurWorldinData.org, CC BY-SA license.

Meanwhile, musculoskeletal medicine is a bit of a backwater

Chronic pain and stubborn “minor” injuries (like repetitive strain injury) were barely noticed by medical science until about the 1980s, and they remain a bit of a backwater to this day, both scientifically5 and clinically. Musculoskeletal medicine is still a cocky teenager, just starting to come of age and figure out that it doesn’t know everything.

Most doctors are straight up unqualified to treat chronic pain and non-traumatic injuries.6 PM&R (Physical Medicine & Rehabilitation, A.K.A. physiatry) is one of the youngest and most obscure medical specialities, and the only one that tackles most “aches and pains” head on. (Rheumatologists and orthopedists in theory deal with all forms of therapy for any kind of musculoskeletal problems, but in practice these specialities have been dominated by serious diseases and injuries, and by profitable elective surgeries that “make sense” to the surgeons who make money doing them but are amazingly unstudied to this day — or, for the few that have been properly tested, proven ineffective78 or dangerous!9)

Perhaps we do have the medical “luxury” of paying more attention to relatively minor pain problems that were overshadowed by the more critical medical issues of the past. But of course those problems aren’t really so minor — just less major than things that kill you outright.

Despite a century of rapid progress, there are still many common medical myths that simply won’t die: doctors and patients alike still believe things that we should drink at least eight glasses of water a day or that we only use 10% our brains.10 And that’s still a problem even where the light of science is shining most brightly. It’s far worse in musculoskeletal medicine: for every mainstream medical myth, there are three about aches and pains and injuries. Myths and snake oil have thrived in the relative darkness of this neglected sub-category of medicine.

Chronic pain is a pretty scary fish to fry too

Non-lethal chronic pain accounts for a stupendous amount of human suffering. The economic costs of even mild to moderate problems — your garden variety back pain, frozen shoulder, patellofemoral pain, carpal tunnel syndrome, and so on — are quite hair-raising. Virtually all of the research that does on any of these things starts out with an accounting of its horribleness.

For most of history, medicine had bigger, scarier fish to fry than treating aches & pains. Not that pain isn’t scary too…

More severe chronic pain problems — a horrible neck pain that just won’t quit, or dreaded afflictions like fibromyalgia and complex regional pain syndrome (CRPS) — are truly awful. Indeed, CRPS can be so horrendous and untreatable11 that many victims take their own lives to escape the pain. And yet patients with chronic pain often feel abandoned and disbelieved.12

The general neglect of pain science was most unfortunate. Turns out it’s both more important and more difficult — weirder even — than anyone imagined half a century ago. We can put a man on the moon, but we can’t fix most chronic pain.

Part of the problem is that pain is usually “complex” while rocket science is merely “complicated.” Science has made similarly weak progress in solving other complex problems like autoimmune, metabolic and mood disorders. Evidence based treatments in areas involving complexity are barely better than folk wisdom. Which opens the door to alt med quackery

Todd Hargrove, paraphrasing (by tweet) key concepts in his excellent article, “Is Movement Therapy Rocket Science?

A sad legacy: primitive musculoskeletal medicine is still the rule

Musculoskeletal health care is still rather primitive, not only because of its late arrival but because it has been too free to “wing it” for too long. For many topics, the bleeding edge consists not of good science, but the speculations of desperate patients and opportunistic cure purveyors. Vast numbers of professionals still work almost exclusively with obsolete conventional wisdom — ideas that predate the increasingly golden age of research in musculoskeletal health care that is finally underway. Ideas that can still be found in the textbooks, making progressive professionals who know better roll their eyes.

One of my readers wrote to me in the grips of justifiable outrage about a string of egregiously incompetent healthcare professionals he’d encountered while trying to recover from an injury. It was all routine nonsense from my perspective — unfortunately, I’m accustomed to such stories — but he was in a state of disbelief that so-called professionals could possibly be so amateurish. “Why is there so much ignorance in musculoskeletal medicine?” he asked.

So many factors! A sampling…

  • Professional pride and tribalism, ideological momentum, screwed up incentives.13
  • The love of “advanced” and technological treatment methods, which has generated so much pseudo-quackery.14
  • Near universal ignorance of the history of science, critical thinking skills, and the cognitive distortions and limitations that bind us all… like emotional reasoning, confirmation bias, the human weakness for oversimplification and “common sense,” and looking only “where the light is.”
  • The obscurity and difficulty of newer and better ideas, especially the major neurological and biological factors that we’re still learning about (but neglecting these is rapidly getting unforgivable).

The largest source of trouble, however, is undoubtedly “structuralism,” the most pernicious type of oversimplification in the field: a great many problems are still treated as though they were “mechanical” in nature, ignoring extensive evidence to the contrary. Particularly in chiropractic and massage therapy, there is an amateurish industry-wide obsessive preoccupation with “alignment” and other structural factors — like leg-length differences.15

There’s also a litany of even more embarrassing ideas and distractions in those professions — really archaic alt-med stuff, all kinds of vitalism and worse.16 Acupuncture, the darling of alt-med, a therapy even many skeptics gave a pass to for a long time, is completely washed up and now the sole domain of cranks, flakes, and the naive.17

Modern medicine has also generally failed patients, with benign neglect, useless surgeries (cited above), and the unmitigated disaster of the opioid crisis.18

People with severe unexplained body pain bounce around the medical system like they are in a pinball machine, serially misdiagnosed and mistreated, often never finding a single doctor or therapist who recognizes the problem, or — having at least recognized it — has a clue what to do about it.

There is a groan that unites men and women, rich and poor, in any nation. These [muscle] pains are “explained” in every culture, but the universal fact of this persistence must mean that no adequate therapy exists.

~ Professor Patrick D. Wall, FRS, DM, FRCP, in the Foreword to Muscle Pain: Understanding its nature, diagnosis and treatment

Some “getting the word out” reading

What’s new in this article?

AugustRevised to properly answered a reader question: “Why is there such ignorance in musculoskeletal medicine?” It was good cynical fun trying to explain.

2017Cited Grant et al and Ramos et al on the state of evidence-based sports medicine.

2016Minor edit: added a particularly good turn of phrase to the conclusion (“the speculations of desperate patients and opportunistic cure purveyors”).

2016Minor edit: mentioned physiatry and PM&R (a strange oversight, overdue for correction).

2016Added more medical and scientific context and some new citations, particularly about orthopedic surgeries and opioids. Some general editing. Removed a small section of dubious value.

2016New introductory paragraph, for additional historical context.

2007Publication.

Notes

  1. Grant HM, Tjoumakaris FP, Maltenfort MG, Freedman KB. Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time? Am J Sports Med. 2014 Apr;42(7):1738–1742. PubMed #24758781.

    Things may be getting better: “The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.” Fantastic news, if true! On the other hand, maybe I should be careful what I wish for, since my entire career is based on making some sense out of the hopeless mess that is sports and musculoskeletal medicine…

    BACK TO TEXT

  2. Ramos GA, Arliani GG, Astur DC, et al. Rehabilitation of hamstring muscle injuries: a literature review. Rev Bras Ortop. 2017;52(1):11–16. PubMed #28194375. PainSci #52750.

    Yet another “garbage in, garbage out“ review of hopelessly inadequate evidence, not enough for conclusions about any of the most popular treatments for one of the most common athletic injuries. A high profile injury with a clear nature, nothing subtle or weird or obscure. It’s 2017, and that’s all we’ve got? I’m starting to wonder if this is ever going to be fixed.

    BACK TO TEXT

  3. The story of anaesthesia is incredible: fatal errors were horrifying at first, largely due to lack of standardization of equipment, and then reduced to nearly zero in one the most impressive quality control initiatives in any human endeavour. The story is marvelously told in Atul Gawande’s fantastic book, Complications. BACK TO TEXT
  4. Visualizing the History of Improving Health around the World (http://ourworldindata.org/VisualHistoryOf/Health.html#/title-slide) BACK TO TEXT
  5. Don’t get me wrong: there’s a lot of research. If you do a PubMed search for most pain problems, you’ll find quite a lot. But it’s a big world, and that research is dwarfed by the scale of Big Medical Science (which has been pumping out almost unbelievable amounts of research for decades). It’s a trickle of surprisingly recent, tiny, and many amateurish studies. BACK TO TEXT
  6. Doctors are unqualified to care properly for most common pain and injury problems, especially the stubborn ones, and this has been proven by other doctors: Stockard et al found that 82% of graduates lacked “basic competency” in this area. For more information, see The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones. BACK TO TEXT
  7. Louw A, Diener I, Fernández-de-Las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016 Jul. PubMed #27402957. PainSci #53458.

    This review of a half dozen good quality tests of four popular orthopedic (“carpentry”) surgeries found that none of them were more effective than a placebo. It’s an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.

    Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing the test. This review introduction is excellent, and does a great job of explaining the problem. As of 2016, this is the best academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and more readably — in the excellent book, Surgery: The ultimate placebo, by Ian Harris.

    The surgeries that failed their tests were:

    • vertebroplasty for osteoporotic compression fractures (stabilizing crushed verebtrae)
    • intradiscal electrothermal therapy (burninating nerve fibres)
    • arthroscopic debridement for osteoarthritis (“polishing” rough arthritic joint surfaces)
    • open debridement of common extensor tendons for tennis elbow (scraping the tendon)

    BACK TO TEXT

  8. Even where the need for surgical intervention seems obvious, such as stabilizing a badly fractured spine, things aren’t so simple. See Spinal Fracture Bracing: My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace. BACK TO TEXT
  9. Cohen D. How safe are metal-on-metal hip implants? BMJ. 2012;344:e1410. PubMed #22374741. PainSci #53447.

    A scholarly analysis of the safety of MoM implants:

    Hundreds of thousands of patients around the world may have been exposed to toxic substances after being implanted with poorly regulated and potentially dangerous hip devices, a BMJ/ BBC Newsnight investigation reveals this week. Despite the fact that these risks have been known and well documented for decades, patients have been kept in the dark about their participation in what has effectively been a large uncontrolled experiment.

    Cobalt-chromium implants have been used successfully in orthopaedics for years—for example, in knee operations and fracture repair. They are known to release metal ions, but some metal-on-metal prostheses do so on a much greater scale than previously thought. These ions can seep into local tissue causing reactions that destroy muscle and bone and leaving some patients with long term disability.

    Harris tells the (chilling) story of metal-on-metal hip implants in Surgery: The ultimate placebo, one of the best-ever (and freshest) examples of surgical overconfidence.

    BACK TO TEXT

  10. Vreeman RC, Carroll AE. Medical myths. BMJ. 2007 Dec;335(7633):1288–9. PubMed #18156231. PainSci #52815. BACK TO TEXT
  11. O’Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with complex regional pain syndrome. Cochrane Database Syst Rev. 2013;4:CD009416. PubMed #23633371. PainSci #54535. BACK TO TEXT
  12. Toye F, Seers K, Allcock N, et al. Patients’ experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. The British Journal of General Practice. 2013 Dec;63(617):829–41. PubMed #24351499.

    This paper reviewed qualitative research on musculoskeletal pain to shed light on what it’s like to have chronic pain. Several worrisome themes were clear. Chronic musculoskeletal pain often forces patients into the awkward position of having to prove the legitimacy of their condition: “if I appear ‘too sick’ or ‘not sick enough’ then no one will believe me.” Many end up doubting themselves and questioning their own identity and wondering who is “the real me.” Many lose hope and feel lost (or lost by) the health care system.

    BACK TO TEXT

  13. Certification rackets are rampant: professionals routinely invest deeply in getting specific certifications of extremely dubious value. Freelancer healthcare professionals are inherently biased towards whatever is emotionally appealing to their customers. Insurance is the source of bizarre incentives: patients will seek out a specific bogus therapy, and professionals will provide it, simple because insurance will pay for it (insurance-based medicine). The profit motive is strong! Consider that orthorpedic surgeries are fantastically profitable for American orthopaedic surgeons, and there are many lesser examples. All of this stuff pulls clinicians towards “faith” in their methods. BACK TO TEXT
  14. Not all quackery is obvious — not even to skeptics. “Pseudo-quackery” appears to be mainstream, advanced, technological, “science-y,” or otherwise legit — quackery without any sign of being way out in left field. It has enough superficial plausibility to persist in the absence of evidence against it. This subtler type of snake oil is a more serious problem in musculoskeletal health care, because it hides right in the mainstream. For instance, it’s nearly synonymous with the early history of physical therapy, and remains alarmingly prevalent in that profession. So pseudo-quackery is extremely common, and generates more false hopes and wasted time, energy, money, and harm than more overt quackery, which is relatively marginalized. See Pseudo-quackery in Chronic Pain Care: A field with a large gray zone between overt quackery and evidence-based care in musculoskeletal medicine. BACK TO TEXT
  15. PS Ingraham. Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. PainScience.com. 16378 words. BACK TO TEXT
  16. Both massage and chiropractic are guilty of believing and promoting an astonishing array of pseudoscientific ideas and therapies. See The Chiropractic Controversies, Does Massage Therapy Work? and 💩 Massage Therapists Say. BACK TO TEXT
  17. Acupuncture has a good reputation it does not deserve. Although heavily researched, its support comes only from heavily biased junk science, while it fails all the good quality scientific tests. It does not work for pain or anything else and we shouldn’t be surprised: it’s based on mysticism and myths. It’s surprisingly modern rather than ancient and wise, for instance, and cannot actually be used for anesthesia. More study is not needed. For more information, see Does Acupuncture Work for Pain? A review of modern acupuncture evidence and myths, focused on treatment of back pain & other common chronic pains. BACK TO TEXT
  18. PS Ingraham. Opioids for Chronic Aches & Pains: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids for musculoskeletal problems like neck and back pain. PainScience.com. 4113 words. BACK TO TEXT

Big neck pain book edit

The first version of this document was created in 2002. It was upgraded and expanded several times before I started keeping track of updates put it up for sale in September of 2007. It was revised and expanded to book-length in the summer 2009, and continues to be updated as new scientific information becomes available, and in response to reader requests and suggestions.

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 108 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

AugustComplete book edit: Top-to-bottom edit of the book, the first ever. Described in more detail in a blog post.

AugustMinor update: Added the revelation that literally all of the very weak studies supporting DCF training are probably fraudulent. [Section: “Core” neck strength: training the deep cervical flexors.]

JulyNew section: A new standard chapter for most PainScience.com tutorials summarizing several key concepts about placebo. [Section: Some important things to keep in mind about placebos.]

JuneNew section: No notes. Just a new section. [Section: “Core” neck strength: training the deep cervical flexors.]

JuneRevised: Substantial miscellaneous modernization. In particular, much more useful information on the critical distinction between “poor posture” and “postural stress.” [Section: Ergonomics are probably more important than posture.]

JuneScience update: Added several references about the long term risks of joint popping, a paragraph about the short-term risks, and a citation about what causes joint popping. [Section: Popping your neck joints: bad habit, or self-treatment?]

JuneRevision: Clarified the important distinction between hazard and risk. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

MayScience update: Added information about dry needling, a cousin of acupuncture, and a neglected sub-topic. Note that information about dry needling has always been available in the companion book about trigger points, but its presence here in the neck pain book is long overdue. [Section: The fascinating case of acupuncture.]

MayRevision: Substantial improvements, harmonizing with the ergonomics revision. Much stronger focus on the scientific case for microbreaking despite the lack of evidence that stagnacy is a problem in the first place. Added a practical tip, and a comic. [Section: Microbreaking.]

AprilUpgrade: Added much more detail about the crisis in orthopedic surgeries — very important context — and more detail to the descriptions of surgical options. [Section: Surgical options.]

FebruaryMajor improvements: Extensive new material about the relationship between neuropathy and neck pain, focused on clues that neuropathy is a factor in a case of chronic neck pain. [Section: How can I tell if there’s a pinched nerve?]

FebruaryMinor improvement: Added a footnote about the long-term risks of poor neck posture and text neck. [Section: Does abnormal curvature hurt? Not much! The neck posture myth.]

FebruaryRe-write: I threw 90% of this section away and started over with a much stronger focus on the interesting question of whether or not “cervicogenic headache” is even a thing. It’s a like-new section, now with much more useful diagnostic clues. [Section: Connections between neck pain, headaches, and migraines.]

JanuaryMinor science update: Added some references about the reliability of subluxation diagnosis. [Section: Subluxation: can your neck be “out”?]

2017Science update: Cited Chumbley et al on traction for neck pain in… fighter jet pilots! [Section: Pull my neck! The potential of traction.]

2017New section: No notes. Just a new section. [Section: Kill it with fire! Treatment by nerve destruction.]

2017Change of position: After reviewing the same scientific papers previously cited more carefully, I decided that they were much less promising than I originally thought. The section has flip-flopped from optimism to pessimism about nerve blocks without a single change in what’s actually cited, just a change in the level of diligence in interpreting the science. I’ve also added more detail and references. [Section: Diagnostic numbing of facet joints.]

2017Science update: Brought some more science to this discussion, especially Sandler et al on a link between stretching and back pain, and Tunwattanapong et al with modestly good news. Plus a bunch of editing. [Section: Will stretching help neck pain?]

2017Upgraded: Added much more information about massage “endangerment sites,” discussion of the potential relevance of neuritis, extensive clarifications and editing. [Section: Can you damage neck nerves by self-massaging?]

2017Science update: Finally added some basic information about “text neck” — mostly that it’s not actually a thing, and a good example of bogus information about neck pain. [Section: Neck pain myths busted here!]

2017Science update: Finally brought a little science to support the claim that trigger points complicate injury. More needed, but it’s a start. [Section: From the frying pan of injury pain to the fire of trigger point pain.]

2017Revision: This section was aging poorly. Reviewing it recently, it seemed too much like I was defensively explaining a pet theory (and I suppose I was). So I’ve done some thorough revision to bring it up to my current standards: less overconfidence, more science. [Section: The case for myofascial trigger points as a major neck pain villain.]

2017Upgraded: Added some more detailed safety advice and discussion of vibrating massage tools. Removed and de-emphasized a couple tools. Better images. Thorough editing the whole section. [Section: The role of massage tools in neck massage.]

2017New tip: Added a weird bonus strengthening tip based on Smith et al, which showed that clenching leg muscles reduced pain everywhere in patients with chronic neck pain. [Section: Build your neck muscle strength and endurance.]

2017Science upgrade: More evidence on how much (or little) pain is caused by cervical disc herniations, plus other miscellaneous citations and clarifications. Removed the claim that herniations actually decrease with age — the reference for that was no longer persuasive. [Section: Is it a herniated disc? Does it matter? The herniation myth.]

2017Revision: Added an example of SMT injury and a footnote about fearmongering, and then found myself editing the whole section. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2017Minor update: Widespread minor improvements to complete the integration of central sensitization into the book. The neck pain book is now fully sensitive about sensitization!

2017Minor update: Integrated discussion of central sensitization, reframing the “confidence cure” as treatment for central sensitization. [Section: Relaxation and the confidence cure.]

2017Science update: Light editing, plus a new paragraph and citation to Morikawa et al, an odd little study showing that neck massage is relaxing, or possibly more. [Section: Introduction to treating your own neck trigger points.]

2017Edited: Several minor miscellaneous clarifications and elaborations, and some additional references. [Section: Pain killers and muscle relaxants.]

2017Revised: Thoroughly revised section and, unfortunately, a reversal from optimism to pessimism about the efficacy of nerve blocks. [Section: Needles for neck pain: nerve blocks for facet joints and related treatments.]

2017Expanded: Added important red flag information about artery tears with pain as the only symptom. [Section: “What if there’s something really wrong with my neck?” Safety information!]

2017Revision: Modernization and expansion; added more information about surgical options in particular. [Section: Surgical options.]

2017New section: Tips and a checklist for trying to estimate how much your neck pain might be about sensitization. [Section: How can you tell if you’re sensitized?]

2017Correction: An evidence-based correction regarding computer display position. [Section: Ergonomics are probably more important than posture.]

2017Big upgrade: Continued to beef up the science of psychological risk factors, and also added much more about other kinds of risk factors. The section almost doubled in size. [Section: A recipe for persistent neck pain — what are the risk factors?]

2017Science update: Two key new citations to support the idea that the state of muscle tissue is a big factor in neck pain. [Section: The most important tissue issue in most neck pain: muscle.]

2017Science update: A paragraph about genetic vulnerability to persistent neuropathic pain. [Section: Is it a pinched nerve? Rarely! The nerve pinch myth.]

2017New section: Substantial new section about sensitization, an important perspective on chronic neck pain. [Section: Neck pain as the tip of the sensitization iceberg.]

2017Science update: Solid little science update based on Nakashima et al, showing huge numbers of intervertebral disc bulges in healthy people. [Section: Is it a herniated disc? Does it matter? The herniation myth.]

2017Upgraded: Several good red flag clarifications and a couple interesting new references about spinal cord compression. [Section: “What if there’s something really wrong with my neck?” Safety information!]

2016Science update: Significant revision and some important new citations more firmly establishing the link between psychological and lifestyle factors and poor recovery from neck pain. Previously this section relied too much on similar evidence about other problems: it is now more neck-centric. [Section: A recipe for persistent neck pain — what are the risk factors?]

2016Science update: Added some useful new indirect evidence about SMT for migraine (Chaibi et al). [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2016Edited: Added some important footnotes and clarifications. [Section: The most important tissue issue in most neck pain: muscle.]

2016Edited: Thorough revision and modernization. Although I revised this section a mere five years ago, it needed it again! [Section: Estimating the importance of trigger points in your own case.]

2016New section: More than a thousand new words on the topic of neck cracking. [Section: Popping your neck joints: bad habit, or self-treatment?]

2016Science update: Revised the introduction to treatments for clarity and completeness, added new references, and a new short paragraph about risks and harms. [Section: Treatment: What can you do for a crick in the neck?]

2016Major update: Broadened scope of section to include all pain killers. Added a summary of opioids, and a guide to experimenting with the over-the-counter ones; added more science; merged and edited previously separate sections on rebound pain and muscle relaxants. [Section: Pain killers and muscle relaxants.]

2016Correction: Removed overconfident statements about the clinical significance of the effects of psychoactive drugs, plus related minor updates. [Section: Estimating the importance of trigger points in your own case.]

2016Minor update: Some editing and new caveats. [Section: Diagnostic numbing of facet joints.]

2016Update: Added new intro to section about distorted body image. [Section: Subluxation: can your neck be “out”?]

2016Science update: Added citation about the efficacy of ibuprofen for headache. [Section: Pain killers and muscle relaxants.]

2016Science update: Added some particularly good science to shore up the personal anecdote added in January. [Section: Could it be arthritis? Is your spine degenerating? Probably not, no.]

2016Improved: Added a new key point about how to recognize the pain of a nerve root pinch. [Section: How can I tell if there’s a pinched nerve?]

2016Science update: New footnote supporting the use of education (like this tutorial!) to treat chronic pain. [Section: Introduction.]

2016Minor update: Added a good personal ancedote…because my spine is degenerating! Also, a footnote about surprisingly painless joint damage. [Section: Could it be arthritis? Is your spine degenerating? Probably not, no.]

2015Science update: Added some hard evidence on the minor (non-lethal) risks of SMT from Carlesso 2010. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2015Science update: Added an interesting reference to Carlesso 2013 with some discussion of the implications. [Section: Neck pain versus back pain: some similarities and differences.]

2015Science update: Added a humility citation, conceding the absence of scientific evidence that massage helps neck pain. Also, modernization summary of trigger point therapy. [Section: Introduction to treating your own neck trigger points.]

2015Science update: Added a little more information about the nature of uncovertebral joints. [Section: Why does a crick feel the way it does?]

2015Upgraded: More and clearer red flag details, especially about spinal cord trouble (myelopathy). [Section: “What if there’s something really wrong with my neck?” Safety information!]

2015Major update: Completely rewritten and greatly expanded, with much more science, emphasizing strength as a worthwhile treatment option. [Section: Build your neck muscle strength and endurance.]

2015Revised: Editing and some new science about changing head posture. [Section: Will strength improve neck posture/curvature?]

2015Minor update: More data on neck pain recovery rates [Section: Prognosis: What’s the worst case scenario for neck pain?]

2015Minor addition: Added a patient anecdote about a strange muscle spasm experience…which I know all too well. [Section: Is it a spasm? Nope, probably not that either: the muscle spasm myths (plural).]

2015Minor update: Added an expert quote. [Section: Does abnormal curvature hurt? Not much! The neck posture myth.]

2015Science update: Added brief example of nerve pinch by vertebral artery twistiness. [Section: How can I tell if there’s a pinched nerve?]

2015Science update: Added three good references and a diagram about how much “wiggle” room nerve roots have. [Section: Is it a pinched nerve? Rarely! The nerve pinch myth.]

2015Expanded: Added about 350 words about neck circle safety. [Section: Mobilizations or “wiggle therapy”.]

2014Science update: Added a new good-news study about massage for neck pain. [Section: The case for myofascial trigger points as a major neck pain villain.]

2014Minor update: Upgraded references on neck pain recovery rates. [Section: Prognosis: What’s the worst case scenario for neck pain?]

2014Science update: Added some important acknowledgements that the science of trigger points is a bit half-baked, and linked out to much more information for the curious. [Section: The case for myofascial trigger points as a major neck pain villain.]

2014More content: Explanation of the difference between a subluxation and an MID. [Section: Subluxation: can your neck be “out”?]

2014Science update: Added citation to a key 2012 study of the effectiveness of adjustment for neck pain. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2014New: A new section, but also a summary of an existing free article. [Section: Digital Motion X-Ray.]

2013Minor update: Added a (fascinating) footnote about the myth of anaesthetic paralysis. [Section: Reality checks: some popular treatments that are particularly silly.]

2013Minor yoga update: Added a reference and paragraph about the risks of yoga, which are minor but real, especially for neck pain. [Section: Will stretching help neck pain?]

2013Minor science update: Added a tiny, flawed study about yoga for neck pain (for what little it’s worth). [Section: Will stretching help neck pain?]

2013New evidence: Rare good news: the first good quality scientific test showing that reducing fear is actually good medicine. The section got a decent editing as well. [Section: Relaxation and the confidence cure.]

2013New section: No notes. Just a new section. [Section: A massage success story.]

2012Science update: Added evidence that the stakes are high with chronic pain: it may even shorten lives. [Section: Neck pain myths busted here!]

2012Science update: Added a key reference about the effectiveness of massage for back pain, with the (safe) assumption that it probably applies to neck pain as well. [Section: The case for myofascial trigger points as a major neck pain villain.]

2012Science update: A new study shows that massage therapists cannot reliably find the side of pain by feel — good evidence that no gross spasm (or other structural factor) is usually involved. [Section: Is it a spasm? Nope, probably not that either: the muscle spasm myths (plural).]

2012Minor update: Added some creative problem-solving for hot climates. [Section: Accidental icing: avoid drafts at night.]

2011Minor update: Added a minor but odd note about “sensory annoyances” like hats and collars. [Section: Ergonomics are probably more important than posture.]

2011Minor update: Added some unusual research about the risks heavy metal “head-banging” — a fun example, for perspective. [Section: Is it a strain? Probably not! The muscle strain myth.]

2011More content: Added scientific cases studies, examples, pictures and video of true dislocation and abnormal anatomy to help drive home the point that even significant spinal joint dysfunction can be surprisingly harmless … never mind subtle joint problems. [Section: Subluxation: can your neck be “out”?]

2011Minor science update: Cited a study about yoga and stretching for back pain. [Section: Will stretching help neck pain?]

2011New section: This section is a summary of an important concept that’s been available in a free article since late 2008, but also needed to be emphasized here. Now it is. [Section: From the frying pan of injury pain to the fire of trigger point pain.]

2011Minor update: Added a reference about the poor overall quality of online information about common injuries. See Starman et al. [Section: Neck pain myths busted here!]

2011Added a fun thing: I can’t believe I didn’t know about inflatable neck extenders until now! [Section: Pull my neck! The potential of traction.]

2011New section: More information about an important characteristic of muscle-dominated neck pain. [Section: “Out of nowhere”: seemingly random episodes of neck pain.]

2011Major update: Totally renovated section: re-written, reformatted, expanded, upgraded. A few new checklist items were added, most were expanded, and all were clarified. A separate and handier “quick” checklist was added to the existing “slow” checklist. [Section: Estimating the importance of trigger points in your own case.]

2011Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

2011Upgraded: New artwork from PainScience.com artist Gary Lyons, plus some important new references. [Section: Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints.]

2010Updated: Updated with an important story about a disastrous example of neck stretching that backfired. Not just for customers: this particular section is a short version of a new free article. [Section: Will stretching help neck pain?]

2010Minor update: Some good new science cited in the introduction, about the overall effectiveness of manual therapies. See D’Sylva et al. [Section: Neck pain myths busted here!]

2010Major Update: Rewriting and expansion of the Special Supplement on spinal manipulative therapy. [Section: Subluxation: can your neck be “out”?]

2010Update: New science confirms that helmets do not cause neck injuries — they just keep your head safe. However, minor injury remains likely and problematic. [Section: Is it a strain? Probably not! The muscle strain myth.]

2010New cover: At last! E-book finally has a “cover.”

2010Science update: Updated with a summary of a bizarre experiment with muscle relaxants that had quite surprising results. [Section: Reality checks: some popular treatments that are particularly silly.]

2010Minor update: Update with another recent study showing that strength training doesn’t work. [Section: Will strength improve neck posture/curvature?]

2010Major update: Completely overhauled and substantially expanded, and polished several relevant bibliographic records. [Section: Will strength improve neck posture/curvature?]

2010Rewritten: Completely overhauled and substantially expanded, and polished several relevant bibliographic records. [Section: Does abnormal curvature hurt? Not much! The neck posture myth.]

2010Science update: Added an interesting reference about how muscle relaxants are surprisingly ineffective. [Section: Reality checks: some popular treatments that are particularly silly.]

2009Minor update: Shored up substantiation of the relationship between migraines and trigger points. See Fernández-de-Las-Peñas et al, and another paper by Fernández-de-Las-Peñas et al, and also Calandre et al. [Section: The case for myofascial trigger points as a major neck pain villain.]

2009New section: First new section since the huge update in the fall, a short-but-useful section. [Section: A poke in the disc! Cervical provocation discography as a method of diagnosis.]

2009Huge upgrade: Over the past several months, the neck pain tutorial has more than quadrupled the amount of information it offers, and it is now book-length at more than 40,000 words. Almost every single section was overhauled, and many new sections were added. Dozens of references to more recent scientific research were integrated and their significance explained, including several good new studies less than six months old.

One final lumpy update

A globus hystericus story, with a side of science

SUMMARY

full article 6500 words

What’s going on in there?: A 19<sup>th</sup> century etching/lithograph of a human throat dissection during an autopsy.

What’s going on in there?

A 19th century etching/lithograph of a human throat dissection during an autopsy.

It was just the right sort of day for a stress-triggered medical problem: moving day. The lump in my throat was like a thick booger I couldn’t swallow. Or a medium-sized pill lodged in my esophagus. Or a finger pressing firmly on my trachea. As moving day wore on, it grew under my Adam’s apple until I noticed I was clearing my throat as often as I swallowed. I kept trying to spit it up, and getting nothing.

It was fucking frustrating. Painless,1 but deeply unsettling.

This sensation, in the absence of any physical obstruction in the throat, is called globus pharyngeus, or — if you’re in a more judgemental mood — the old-timey term globus hystericus, which bluntly suggests a psychosomatic cause. Globus feels like something in your throat, but it’s all in your head. Apparently.

My initial battle with globus felt like the longest month of my life, peaking with some terrifying swallowing awkwardness that made eating difficult. I then continued to suffer seriously for about eight months, and then occasional milder episodes ever since — another year and counting. For a sensory phantom, globus is a serious bully.

This is an unusually personal article, an exploration of a medical problem that relates to pain indirectly. I’ve rarely used the PainScience.com platform in this way, but globus belongs here: it can hurt, it’s quite musculoskeletal in character, it’s often associated with neck pain, and it involves some truly neat biology and science. I think this article will help some people. There aren’t many detailed articles about globus available, and certainly none like this one.

My globus story has a happy ending (sort of)

My globus was clearly a complication of a larger medical drama that had started months before, in the summer of 2014. I’d had months of odd throat pain leading up to the onset of globus, and that pain lasted until the middle of summer 2015… when I finally found and literally removed the cause, after 10 months of serious misery. My globus got much better over a few weeks after that, and then erratic episodes harassed me for another couple years.

You can skip down to the discovery of the weird cause of my throat pain in 2015, or a summary of the slower happy ending by 2018 … or just read through the story as I experienced it and save the good news for last.

My globus story is here to help you, the globus sufferer searching the Internet for clues to the nature of your misery. If this article reassures you, or anything else, please drop me a line and tell me about it. It’s is also just pure emotional venting for me. I need to write about this. I’ve been through throat hell, and I just need to talk about it.

Day 1: There’s something growing in there!

By late on moving day — a Saturday — I was starting to really worry. It felt so much like there was something in my throat that I kept shining a flashlight down my gullet. I saw a harmless and irrelevant nodule on my uvula,2 but that’s what I fixated on at first, even though it was much higher in the throat than my globus sensation. This is the problem with trying to diagnose yourself, kids.

Remember, I’d been having months of other odd throat symptoms. So it didn’t take much to get my imagination revved up. Basically, when you have a lump in your throat that won’t go away, most people think cancer. A Wikipedia page on cricopharyngeal spasm (more on this below) says:

These spasms are frequently misunderstood by the patient to be cancer.

I sure as shit did.

Day 2: The least relaxing Sunday ever

I woke up Sunday morning to find the lump gone. Bliss! I felt like cheering. I kept swallowing experimentally and grinning madly. Callooh, callay, it’s gone! Phew! This was also my first helpful hint that it probably wasn’t cancer. As a general rule, tumours don’t

  1. appear in an afternoon
  2. leave you alone just because it’s time for breakfast.

Alas, I was also about to be hammered by the discovery that globus typically worsens as the day goes on. By midday, it started to niggle, and within a couple more hours I had to concede that The Lump was back. I found it emotionally impossible to keep in mind that it wasn’t acting much like a tumour. I spent the rest of the day in a state of extreme anxiety and frustration. A couple times, I was squirming on the edge of panic, fighting the impulse to whimper and scream, like I was waking up from a nightmare about swallowing something too large.3

Oddly, my symptoms backed off almost completely later in the evening. As I relaxed. Another clue!

Day 3: This T-shirt trying to kill me!

On the third day, I got woozy: I had head rushes every other time I stood up all day long, which greatly exacerbated my fear of seriousness illness. Of course, I was also exhausted and strung out.4 But in my mind, it was all “okay, I guess I’m probably dying now or something.”

And then there was the T-shirt. We all know how dangerous they can be.

As the globus set in for the afternoon, it had a more dire quality to it than before. It had merely been irritating and worrisome. When I put on a fresh T-shirt with a fairly high and tight collar, I felt like I was being strangled. I lightly touched my trachea and discovered that even a tiny amount of pressure felt extremely threatening.

That’s it! I thought. To the walk-in clinic! It was dark and raining like movie rain, but I trudged out and walked ten minutes to the clinic in my new neighbourhood… and found they had a minimum one-hour wait.

I wasn’t that scared. I’m a busy man! I went back home. Maybe in the morning.

Illustration of a T-shirt with teeth in the collar, pointing upwards, representing the feeling of extreme sensitivity to pressure on my throat.

Days 4, 5, 6…

As the days marched on, I suffered quite a bit, and learned three main things:

  • The walk-in clinic was an absurdly busy place. Spooked as I was, I would be brave-ish and wait for a scheduled appointment with my ENT specialist on Saturday.
  • I felt worse every afternoon, but better each late evening — presumably as I relaxed. Indeed, my evenings were unusually relaxing relative to the days that preceded them. It fits. Also, Lorazepam was startlingly helpful.5
  • Swallowing saliva was a bit awkward, but food was easy. In fact, it felt good and eased the symptoms for a while. And so I ate quite a bit.

Day 7: Like being force fed a chopstick

“You encouraged me to come back early if I needed to,” I said to the ENT specialist, a big, genial guy with a thick silver chain around his neck. “So I’m back early because I have a new symptom that’s freaking me out. I’ve never wanted anyone to stick a scope down my throat so badly. Please look in there and tell me what you see.”

Avoid throat scopes if you can. Laryngoscopy feels like being force fed a whole chopstick. It’s one the crappiest experiences I’ve ever had in a doctor’s office. He’d done it once before after spraying the back of my throat with a topical aneasthetic. This time he did it without the numbing, for no apparent reason: just snuck up on me, the bastard. If he ever tries that again, he’s going to end up with a me-shaped hole in his door from my cartoonish exit.

So after a week of having an incredibly distinct sensation of something lodged in my throat, what did he find?

You already know what he found

Nothing. Nothing at all. Just a nice smooth pink tube.

I could go on for paragraphs about the doctor and what we discussed, but blah blah blah. He found nothing, he diagnosed globus. He tried to reassure me that there probably is something “real” going on, but the lump sensation itself … globus. His prescription:

“Calm. The fuck. Down.”

Okay, he didn’t actually swear, but you could tell he wanted to. I more or less accepted his diagnosis.

Day 8: Wikipedia for the win

On the 8th day, I read Wikipedia. Beware of Googling your medical problems. Seriously. Watch this pretty hilarious video about how perilous it is. But I’m an expert — I sort of do this kind of reading for a living — so I dared.

Within minutes I discovered a perfect description of my globus, and I do mean perfect.

Specifically, a sub-type of globus — cricopharyngeal spasm — fit me better than my skin. Some of it was eerily accurate, like “The symptoms can be mimicked by pushing on the cartilage in the neck, just below the Adam’s apple” and “eating, in fact, often makes the tightness go away for a time.” Yeah. That’s me, to a T.

What a strange sensation, to find one’s misery captured precisely in a bulleted list. Strange…but good, because according to Wikipedia, cricopharyngeal spasm is a

harmless, if uncomfortable, self-limiting disorder and will resolve itself over a period of time.

I felt better for the first time in a week. I really did.

Day 9: These eggs are trying to kill me!

On the Monday of the second week, I made myself my favourite breakfast: a nice little omelette, hot and soft. The trick is not to overdo them, mere seconds in the pan, like Julia Child taught me. I had no globus as I prepared them. I wasn’t expecting any trouble.

And then I choked on my eggs.

Swallowing felt distinctly awkward, and I couldn’t get a bite down. I had to cough a bit of it back up.

Betrayed by an omelette! It was emotionally shattering. The most comforting thing I’d learned the day before — “eating often helps” — was destroyed in a few moments. Cancer fear rushed back in like a dark tide. Difficulty swallowing felt like confirmation of my worst fears. If I was struggling to swallow, there had to be something obstructing my throat? Amiright?6

The legacy of the fishbone

Confession: I’ve never been good at swallowing.

When I was about five, I heard a story about my great grandmother getting a fishbone stuck in her throat… and that story stuck in my mind, forever. I hate taking pills, always have. I couldn’t really handle eating fish until I was in my twenties, and I’m still annoyingly cautious with them to this day. I have been known to give up on mouthfuls of perfectly good steak and spit them out, because I just couldn’t get the bolus positioned for a swallow that felt safe. I went through a period about three years ago where I actually felt nervous of swallowing almost anything even slightly difficult, for no apparent reason. I got over it just as it was really getting to be Quite A Thing.

Yeah, I’m a freak. Just something “funny” about me!

All this is was like sensory gasoline on the bonfire of my globus. I had a bad moment with swallowing my soft eggs, and it triggered an emotional chain reaction. Everyone has bad moments swallowing, but my moment turned into a 3-day nightmare because of my swallowing idiosyncrazy.

I guess. I’ll never really know. But it’s a good working theory.

A drawing of fish bones.

Cancer fear redux

Job one on day nine — yeah, we’re still on day nine here — was to get the cancer fear under control. An ENT specialist had looked down my throat 36 hours earlier and seen nothing. It seemed implausible to me that any kind of throat cancer could possibly be missed in a careful throat exam on Saturday, yet cause swallowing trouble on Monday. But I couldn’t confirm this in an hour of furious Googling. I needed to talk to a doctor.

I signed up for an extremely new-fangled online medical consultation service. A doctor friend of mine had invested in the company a year before and encouraged me to give it a try. So I finally did, and soon enough I was video chatting with an amiable 70-year-old physician who appeared to be hanging out at home. He was quite helpful.

“A medical student couldn’t have missed that”

“A medical student couldn’t have missed that,” he said. “The most incompetent non-specialist would have seen something.”

Upper throat cancers (squamous-cell carcinomas) are quite visible to a scope by nature — they mostly grow on the exposed surfaces of the esophagus and trachea — where cells have been abused by smoke or booze for decades, especially the combination. Fit, younger non-smokers and moderate drinkers are nearly immune.7

“Nothing’s impossible, but your risk of a cancer here is absurdly low.”

Thanks, virtual doctor.

“But let me prescribe something a little unconventional for your lump,” he said. And then he prescribed homeopathy. Groan.8 But I already had what I needed. That was more or less the last of the cancer fear.

Days 10, 11, 12: Swallowing my pride

On the flipping of omelettes, Julia Child said something like, “You just have to go for it. You must have the courage of your convictions!”9 So it is with swallowing. Swallowing is not a thing you can think your way through. You must let the reflexes do their work. You have to just go for it.

Easier said than done, when you’re flustered.10

I didn’t have any more difficulty actually getting food down. Nothing got “stuck” again — maybe a little bit once or twice, like a pill going down slowly, something I’ve felt hundreds of times in my life. Acknowledging this now makes it seem like it was all much ado about nothing, but it was scary as hell to live through.

The low point was on day 12, when I was just so strung out and tired that I couldn’t get through a bowl of soup — even though I was quite hungry. But the next night, starving and pissed off, I ate about five pounds of sushi without a hitch.

No bones.

The end?

After I got over the Great Swallowing Terror o’ 2014, the lump as I had known it died down steadily and hasn’t returned in several days.

I doubt it’s the end of my throat story, and it may not even be the end of my globus — apparently it can be intermittent and variable in character for months at a time [already confirmed by the time of publishing this] — but it probably was the end of feeling bullied by it [also confirmed].

Now, about the whole “all in your head business.” I’ve left the most interesting part of the puzzle for last…

All in your head…or not?

Globus is usually considered to be likely psychosomatic in the absence of actual lumps or other physical causes. For example, although “the differential diagnosis is vast” (translation: there are many possibilities!) Finkenbine and Miele (2004) define globus in the absence of a mass as “a form of conversion disorder.”

Conversion disorder is psychiatrist-speak for a condition (Mayo Clinic) “in which you show psychological stress in physical ways. The condition was so named to describe a health problem that starts as a mental or emotional crisis — a scary or stressful incident of some kind — and converts to a physical problem.” Specifically, a physically disability — an inability to do something, like walking, seeing, or swallowing.

And so — assuming there really is no literal lump — globus is a conversion disorder. Which is a sub-type of somatoform disorder, a larger category of physical disorders caused by mental illness. Which is a good-news, bad-news kind of thing. Good news that there’s nothing physical wrong, but …

The worst diseases known to science pale in comparison to the chronic and untreatable nature of somatoform disorders.

~ Mark Reid, MD, Twitter, @MedicalAxioms, Apr 16, 2015

Oh, dear.

When globus is not all in your head

Although globus “may ‘simply’ be a local sensory abnormality just like tinnitus,” Kortquee lists several reports “of very subtle changes in anatomy that when rectified have given relief of globus.”11 In other words, globus may be a musculoskeletal problem in nature, quite humdrum, just some little glitch or anatomical abnormality, probably quite subtle — a “harmless” sensory reaction to almost any chronic irritation of the throat. Here are some examples, from Kortequee et al and other sources:

  • Gastroesophageal reflux disease (GERD), chronic heartburn basically, which can be amazingly non-obvious
  • gastric inlet patches — an area of cells in the esophagus that are behaving like the wall of the stomach (e.g. producing acid)
  • Eagle syndrome, styloid process pathology, the elongation/inflammation of a weird little bone in the back of the throat behind the tonsils
  • arterial tortuosity, impinged and/or impinging — arteries can be surprisingly hard and kinky
  • retroverted epiglottis — an abnormally curled epiglottis tip touching and indenting the tongue base
  • corniculate cartilage subluxation — a slight displacement of a tiny cartilaginous structure in the throat
  • thyroid nodules — just little lumps that grow on thyroid glands
  • cervical osteophyte — arthritic bone calluses on spinal joints in the neck
  • prominent greater cornu of the hyoid — overgrowth of a wee bit of throat bone
  • hypertonicity of the upper esophageal sphincter — “tight throat,” basically

Some of these, and others, are discussed in more detail below.

Sometimes a lump is just a lump: a cancer example

Sometimes the globus sensation is caused by a real lump of some kind — just one that’s not obvious at first. The medical literature is chock-a-block with examples of globus with sneaky physical causes that dodge diagnosis in the early stages. One chilling paper describes a bone tumour growing on the front of the spine, projecting forward into the throat (Wong 2013). A relatively smooth mass, covered by layers of tissue, such a tumour could grow for a long time in secret, slowly but surely pinching the throat shut.

Yeah, creepy as hell. And I thought a fishbone was bad.

But such a tumour would also be distinctively unrelenting. Bone tumours just don’t back off when you pop a Lorazepam, like my globus does.12 A signature feature of a psychosomatic globus sensation is its sensitivity to emotional state, potentially as unpredictable as the weather. I can imagine some minor symptomatic ups and downs on the road to diagnosing such a cancer, the downward trend would be hard to miss — steadily changing from annoying to downright unpleasant.

Drawing of an eagle, representing Eagle Syndrome, one possible cause of globus pharyngeus.

It’s a bird! Eagle syndrome

A weirder example is Eagle Syndrome: a seemingly mechanical source of throat trouble that can act pretty strangely, like globus itself.

Eagle Syndrome is an irritation around the tip of an odd little bone at the back of the throat, the styloid bone, which looks like the fang of a sabre-toothed squirrel. The styloid can get too long and start to bother the sensitive anatomy around the tip, nerves and arteries.

Except fairly often people get Eagle Syndrome symptoms — including globus — without having an abnormally long styloid at all. So that’s odd.

Nor does a long styloid necessarily cause any grief! Not even close, in fact.13 As with most musculoskeletal conditions, there seem to be X-factors that make the hazards of long styloid bones less straightforward than they seem. No one knows what those factors are, of course.

Hot tip: the gargle blaster

In the whole globus saga so far, gargling has demonstrated to me best of all that I don’t have a mass in my throat, that the globus sensation is an ephemeral phenomenon — a spasm that can melt away like ice cream on a hot day, in the right circumstances.

Initially, I could only slowly and uncertainly relax my way out of it. I took all evening: a hot bath, a lie down, some deep breathing, sex, an hour of watching The Walking Dead (so peaceful!).

But then I discovered that garling could usually put a stop to it almost immediately. Gargling seems to relax the throat by stretching and vibrating it at the same time. A warm gargle may be even more soothing. It is a very unusual sensory experience. After gargling for 1-2 minutes — that’s quite a lot, try it sometime — I can get nearly complete relief from the globus sensation for at least a half hour, often much more (hours). Not bad. And quite informative about the nature of the beast.

Maybe muscle pain? The relationship of globus pharyngeus and trigger points

How does a somatoform disorder cause pain anyway? How do you go from a mental state to a physical pain? There are several possible mechanisms, but one of the most likely is the formation of so-called “trigger points” — mysterious patches of oversensitive soft tissue, particularly muscle. They are a well-described but poorly understood phenomenon, and crop up in all kinds of other chronic pain problems. Muscle is everywhere, so it can be the delivery system for an incredible array of miseries.

Like painful globus pharyngeus, I imagine — though I have no evidence of it, only my personal experience and expertise. I’ve written a large and heavily referenced book about trigger points, so I’m familiar with the science.

Globus pharyngeus mostly just feels odd and “uncomfortable,” but it can also be outright painful. I’ve experienced plenty of that. What began for me as “just” a weird lump sensation eventually progressed to a constant parade of deep aches and pains throughout the area — like a headache in my throat. On numerous occasions I was able to get temporary relief from these pains simply by gently massaging my neck and throat muscles (eg14)

It’s even possible that trigger points are involved in non-painful globus. Trigger points exist in a “latent” state where they are sensitive only if provoked. They don’t cause pain in this state, but they might cause subtle muscular malfunction and sensory weirdness — which we are probably quite sensitive too in the throat. The same trouble in the back might barely register with us, or only as a “stiff back,” but even the slightest interference with the sensation of swallowing may be much more of a problem.

Is it possible to tell if it’s in your head or your throat?

No, not really: it’s virtually impossible to rule out a physical lump with high confidence at first. There are too many ways that a physical problem could defy confirmation. As time goes on without any true lump being found, your confidence could go up fairly high… but it can’t reach 100%. Probably not even 90%.

Nor can globus as a conversion disorder be confirmed in most cases — not even if you are lucky enough to experience a rapid and complete recovery.

The only way to be nearly certain that it’s not a conversion disorder is to confirm a mass. And nobody wants that. That’s mostly only possible with worst-case-scenario diagnoses.

If you suspect globus, treat it like globus as best you can, and see how it goes.

2015 UPDATE: Big news! A tonsil stone emerges

After ten months of intermittent globus pharyngeus symptoms, mostly mild but often awful, something big changed on August 5. I felt a sharp catch in the back of my throat, like I’d swallowed a burr or a scrap of rough sandpaper. I rushed to the bathroom and flushed my tonsil with a syringe full of salty water, and…

A stone came out! A hard, dark, jagged little rock popped out of my tonsil onto my tongue. I saw it happen. I scooped it out of my mouth with a Q-tip. And I have it in an envelope now.

Close-up of my tonsil stone, a grey, craggy little tonsillar calculi resting on a Q-tip.

Yeah, smaller than a Q-tip head. But sharp as a burr, hard & stuck in a fleshy crack. You do not want this.

It is not an imposing size, but you would not want this thing in your eye, your tonsil, or any delicate crevice. It’s removal spelled immediate relief. Three of my non-globus throat symptoms vanished that day — acute, maddening symptoms I’d had constantly for a year.

Imagine finally scratching the worst itch of your life.

Imagine the end of Chinese water torture.

Imagine something stuck between your teeth for a year, finally pried loose.

Tonsil stones, it turns out, are a thing. Like kidneys and gall bladders, tonsils can form nasty little calcifications. They are usually just disgusting, not painful, but sometimes they can get unpleasant — like a thorn in the lion’s paw. In this case, it was a thorn I couldn’t see or touch, just a maddening irritation deep in my throat.

What a perfect way to provoke a nice case of globus pharyngeus!

I assume, hope, and pray that the removal of the stone will resolve my globus problem. When I know, I’ll update you…

2018 UPDATE: The fate of the globus after the stone came out

Globus was not quite done with me when the stone came out

It seemed like a good bet that the globus would fade away after the stone came out, but there was also the ominous possibility that the stone was only the tip of a tonsil iceberg — where there’s one stone, there could be more. Morale was too low for optimism. I did not dare to hope. I just waited.

My globus and pharyngeal freakout did wind down and stop after the stone came out. Hallelujah! But recovery was slow and erratic. Even when there was no globus per se, my pharyngeal muscles often feel spastic, tugging and twinging and give me the impression that my throat may never be quite the same ever again.

For the rest of 2015, all of 2015, and all of 2017, I had several more wrestling matches with globus, generally easier and briefer as time went on, but some of the early bouts were as awful as anything I’d experienced. More intimidating too, because the tonsil stone was gone, so why was it still happening?

It’s likely that the tonsil was still somewhat irritated, probably by a little more “gravel,” which made recovery from the major insult slower and more erratic. I worried about that for almost two years, and continued to consider the possibility of a tonsilectomy.

And it’s likely that globus can just become a bit of a paranoid habit, a consistent over-reaction to just about any kind of throat trouble. For instance, I noticed I had more globus for weeks following each cold I got during that period. In restrospect it’s obvious that I had simply been traumatized by the stone experience. That drama made me highly vulnerable to globus, with or without tonsil stones.

Nevertheless, this case of globus hystericus was clearly not hysterical at all (at least not originally). Far from being “all in my head,” it was definitely provoked by an extraordinary irritant… and it improved a lot and then — very slowly — disappeared after the irritant was mostly or entirely removed.

As I write this update in early August 2018 (just about exactly three years after the stone came out) it has been about six months since the last trace of globus, and a year since it caused any real distress. My old globus nightmare is over. If it ever comes back now, it’ll be a new nightmare.

Appendix: Another story about a very physical lump in the throat

This is a true reader story about the difference between feeling like there’s something stuck in your throat (globus sensation) and actually having something stuck in your throat. It’s another you’re-not-paranoid-if-they’re-really-after-you story, much like my own. Bill was definitely in the “actual lump” category! If I were him, I would have stopped trying to eat poultry…

I had this thing where food, especially of the meat variety, would get stuck halfway down if it wasn’t well chewed. This went on for a long time — about fifteen years — before an emergency surgery finally put a stop to it.

My first notable incident was a Thanksgiving dinner and some turkey was the culprit. I went outside and behind the barn at my parents’ place, where my disgusting noises would not be heard. I don’t remember how long it took to dislodge, but it probably was a good half-hour or more.

I went on to have some seriously ugly episodes with it, sometimes taking a couple hours to clear my throat. I would have to do some pretty gross things to try to get the food down, such as sticking my fingers down my throat. It also would cause some serious pressure and pain and accompanied by ugly sounding heaving. It happened one time on a date. She was very forgiving (and worried).

The final reckoning was caused by some grilled chicken. My very first bite got through virtually un-chewed and immediately got stuck. This one wasn’t going to budge. I was able to get the discomfort to stay relatively tolerable for the evening. It was still there the next day and all the way into the early evening. I would have episodes of severe suffering with the pain and pressure and also occasionally coughing up globs of phlegm. I had to pull over at one point while driving to deal with phlegm coughing/dry heaving/pain episode. It was hell.

I ended up going to the emergency room that evening, twenty-four hours after it got lodged. They put me under and pushed the chunk of chicken down.

They also expanded my esophagus while they were at it. I still have the before and after pics somewhere. Apparently I had a narrow esophagus all of that time. I had an aunt who had the procedure done several times, so I guess it might be inherited. I’ve not gone back to have another expansion. I don’t think it’s narrowed all the way back and I also just make sure to chew meat very well. Only minor episodes since.

If you can get any comfort out of the “other people have bigger problems” trick, that story should do the trick!

Interestingly, Bill never suffered from any fearful swallowing awkwardness, and he never had a phantom lump — just poultry lumps! My experience was a mirror image of Bill: a relatively minor provocation created a huge sensation of throat blockage.

People are different! Bill, for instance, seems quite a lot more stoic and badass than I am. Also more stubborn. Why didn’t you talk to a doctor sooner, Bill, why?!

What’s new in this article?

Nine updates have been logged for this article since publication (2014). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

AugustProbably the final status updates to the article. I’ve received several inquiries lately from people wanting to know how am doing with the globus these days. That question is now answered in the final section.

2016Added more updates about to the story about on-going episodes of globus, more integration of the implications of my updates, miscellaneous minor editing, and a new list of possible musculoskeletal causes (from sources like Kortequee). Also added a mobile-only article summary.

2016Updated my last update: status report on globus recovery one full year “Post Stone.”

2016Added “Appendix: A story about a real lump in the throat.”

2015Good news: added another update on my own story, reporting on the successful resolution of my globus.

2015Added a section “Maybe muscle pain?” and a good photograph of my bizarre tonsil stone.

2015Added an major update: the discovery of a very likely organic cause for my globus.

2014Added a brief epilogue, and clarification of several of the all-in-your-head concepts.

2014Added information about Eagle syndrome and gargling.

2014Publication.

Notes

  1. Only painless at first. Later on, it became painful. I’ll return to that later in the article. BACK TO TEXT
  2. Probably just a little papilloma, very common, basically a throat wart — “A benign papillomatous tumor derived from epithelium” (Wikipedia). “These benign lesions rarely cause symptoms” (Goodstein 2012). But they can get big! A 1930 case report describes one on the uvula “so long he could hold the tip between his lips. It caused him annoyance by entering the larynx and giving rise to coughing and spasm.” (Neville 1930) Yes, that would be annoying! BACK TO TEXT
  3. I’ve actually had those nightmares. In particular, I’ve had clogging nightmares, where my plumbing fills with thick mucus, and I’m trying to pull it out of myself like rotting rope. BACK TO TEXT
  4. The globus marched on, but my head rushes stopped. If I had continued to feel that way, concern might have been justified — although even then I’m not sure how I would have known it wasn’t just more exhaustion. Context is everything. I’ve had many days in the past when I had head rushes for no apparent reason — not even stress or lost sleep — days when I just randomly felt oogy, and it never amounted to anything. How are we to judge whether such symptoms are signs of something more serious, or just biological noise? We probably can’t. BACK TO TEXT
  5. I had a small Lorazepam prescription for help with insomnia. I am a champion insomniac, and have experimented with essentially all treatment options over the years. I have occasionally dabbled in the benzos, in small precisely timed doses, and found them to be extremely useful and effective when used in moderation. I dipped into my meagre supply for the globus in desperation, and was astonished by the effect: the globus went poof. It didn’t just “help” — it nuked it for the remainder of the day. BACK TO TEXT
  6. I am not right. My logic was flawed. More on this below. BACK TO TEXT
  7. This was more or less confirmed by the National Cancer Institute: “Most head and neck cancers begin in the squamous cells that line the moist surfaces inside the head and neck. Tobacco use, alcohol use, and human papillomavirus infection are important risk factors for head and neck cancers.” BACK TO TEXT
  8. He unwittingly prescribed this to the assistant editor of ScienceBasedMedicine.org…probably the most authoritative source of homeopathy criticism and skepticism on the Internet. I politely and briefly told him what I think of homeopathy. Short of keeping my mouth shut, I was as amiable about it as possible. The inevitable lame defensive answer? “Well, I’ve been doing this 30 years…” Experience is not how these things are determined. If it was, we’d still be bleeding people. BACK TO TEXT
  9. I do a great Julia Child impression. Seriously. If this was radio, I’d demonstrate. BACK TO TEXT
  10. A physician friend, Dr. Rob of One-Minute Medical School tells me that this sort of thing can get pretty bad. This is also noted in medical papers: “The sensation may lead to difficulty swallowing or breathing and may become severe or life threatening” (Finkenbine 2004). People can get so psyched out about swallowing that they do choke, and it becomes a downward spiral of fear and failure and more fear and more failure, and next thing you know, bam, feeding tube. It happens. I believe it, after this experience. BACK TO TEXT
  11. Kortequee S, Karkos PD, Atkinson H, et al. Management of globus pharyngeus. Int J Otolaryngol. 2013;2013:946780. PubMed #23935629. PainSci #53674. BACK TO TEXT
  12. I’ve wondered about this carefully. Could good drugs make you temporarily much more tolerant of the annoying sensation of a tumour in its early stages? How would that be any different than simply feeling better for a little while? A growing mass is definitely going to keep getting worse, and it’s only going to be so helpful for so long. There will be a clear trend. But at first, I think relaxation by any means could easily cause misleading remission: feeling better without actually being better. This is the sort of thing that makes it so incredible hard to tell what’s in your head or not. BACK TO TEXT
  13. Most people with elongated styloids are fine. So what’s the difference in those who do get symptoms? “Type I (elongated) was the most frequent type on both sides (42/59); and the most frequent patterns of calcification were partially calcified on the left side (18/59) and completely calcified on the right side (16/59). Only two patients were symptomatic.” (Ilgüy 2005) BACK TO TEXT
  14. There was one particularly memorable occasion. I was being kept awake by a pain that felt like it was at the back of my throat, above the larynx. It didn’t seem like something that would yield to massage, because it seemed well out of the reach of anything but a laryngoscope. And yet in desperation I was fiddling with the muscles on the surface of my throat, over the Adam’s apple, and by chance I struck upon a classic example of “reproduction” and “referral” — that is, the vivid sensation that pressure on a trigger point is (a) equisitively sensitive and (b) feels the same as a pain in another location. That is, even though I was touching superficial throat muscles, the pain “referred” right to the deep spot that was driving me bonkers. Having been prone to trigger points all my life (which is a major reason I wrote a book about them), I’ve had hundreds of experiences with this kind of sensation, but this was definitely in the top five Most Holy Shit Worthy. I rubbed the spot gently for a couple minutes… and that particular deep throat pain, one of the worst complications in the whole story, went away and stayed away for weeks. I had to repeat the treatment about three more times over the months, and it worked equally well each time. BACK TO TEXT

Pain sensitivity in migraine: specific alterations related to stimulus parameters and location

Migraine is the second most prevalent neurological disorder [1] with prevalence of 11-23% worldwide  [2-6]. Understanding the mechanisms of migraine may be the key to identifying and developing new treatments. Quantitative sensory testing (QST) methods are established techniques to assess and measure pain sensitivity in order to gain insight into mechanisms. There are a large range of QST methodologies including evaluation of detection thresholds, responsiveness to noxious stimuli, and pain modulation capabilities. In addition, there are also a large range of modalities of stimuli, including thermal, mechanical, electrical and chemical stimuli.

In QST studies of migraine, there is substantial variation across studies.  The large variability in the findings of different QST studies may be the result of the large variability of QST parameters tested. Thus, there is a need to integrate QST results across a wide array of studies in order to identify the QST parameters that are consistently different between patients with migraine and healthy controls. This will allow both researchers and clinicians to choose the QST method most likely to predict clinical outcome in migraine in a calculated, evidence-based manner. In our recent paper, [7] we performed a meta-analysis of studies comparing QST parameters between patients with migraine and healthy controls.

A literature search identified 109 studies which were included in the qualitative comprehensive review. 65 studies were included in the meta-analysis. When possible, we performed meta-analyses based on stimulation regions: combined (combined data of multiple testing locations), local (head and neck which are testing regions that are spatially associated with migraine pain), and non-local (outside the neck or head – testing regions not associated with migraine pain) for each QST modality.

Several QST parameters were identified as significantly different between migraine patients and healthy controls. Lower heat and pressure pain thresholds were observed in migraine patients compared to healthy controls in the combined locations. Importantly, differences in pressure pain thresholds were found in local, but not non-local regions, suggesting that alterations in pressure pain sensitivity in migraine patients are more pronounced in the regions of migraine pain. In addition, migraine patients had greater pain ratings to noxious cold stimuli for the combined and non-local regions (a meta-analysis of the local regions was not performed due to the small number of studies in this category) and for electrical stimuli for the non-local region. These QST parameters may be relevant for future migraine studies.

Extensive research in migraine patients has been conducted using QST. Still, our review identified some areas where more research is needed. There is a need for more studies on inhibitory and faciliatory mechanisms. Pain modulation capabilities can be assessed using various paradigms such as conditioned pain modulation, offset analgesia, pain adaptation and temporal summation, possibly representing different inhibitory and faciliatory mechanisms. Surprisingly, some of these measures have not yet been examined in migraine patients. In addition, pediatric migraine, while highly prevalent, has only limited studies dedicated to this population [8-12]. More QST studies are needed to better understand alterations in children and adolescents with migraine.

We suggest that migraine patients, compared to healthy controls, do not show overall higher pain sensitivity but rather a more selective increased in sensitivity only for specific stimuli and locations. Thus, the current meta-analysis allows a better selection of QST measure in an evidence-based way. We recommend the use of these stimuli in future migraine studies.

About Hadas Nahman-Averbuch

Dr Nahman-Averbuch is a postdoctoral research fellow at Cincinnati Children’s Hospital. Her current research focuses on hormonal and neural changes during puberty and their effect on pain.

References

  1. Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol, 2017. 16(11): p. 877-897.
  2. Lipton, R.B. and S.D. Silberstein, Episodic and chronic migraine headache: breaking down barriers to optimal treatment and prevention. Headache, 2015. 55 Suppl 2: p. 103-22; quiz 123-6.
  3. Lipton, R.B., et al., Migraine prevalence, disease burden, and the need for preventive therapy. Neurology, 2007. 68(5): p. 343-9.
  4. Goadsby, P.J., et al., Pathophysiology of Migraine: A Disorder of Sensory Processing. Physiol Rev, 2017. 97(2): p. 553-622.
  5. Krogh, A.B., B. Larsson, and M. Linde, Prevalence and disability of headache among Norwegian adolescents: A cross-sectional school-based study. Cephalalgia, 2015. 35(13): p. 1181-91.
  6. Vetvik, K.G. and E.A. MacGregor, Sex differences in the epidemiology, clinical features, and pathophysiology of migraine. Lancet Neurol, 2017. 16(1): p. 76-87.
  7. Nahman-Averbuch, H., et al., Quantitative sensory testing in patients with migraine: a systemic review and meta-analysis. Pain, 2018.
  8. Metsahonkala, L., et al., Extracephalic tenderness and pressure pain threshold in children with headache. Eur J Pain, 2006. 10(7): p. 581-5.
  9. Zohsel, K., et al., Altered pain processing in children with migraine: an evoked potential study. Eur J Pain, 2008. 12(8): p. 1090-101.
  10. Zohsel, K., et al., Quantitative sensory testing in children with migraine: preliminary evidence for enhanced sensitivity to painful stimuli especially in girls. Pain, 2006. 123(1-2): p. 10-8.
  11. Ferracini, G.N., et al., A comparison pressure pain threshold in pericranial and extracephalic regions in children with migraine. Pain Med, 2014. 15(4): p. 702-9.
  12. de Tommaso, M., et al., Laser-evoked potential habituation and central sensitization symptoms in childhood migraine. Cephalalgia, 2016. 36(5): p. 463-73.

Your money, your life: how Google ranks webpages that matter

PainScience.com has a lot of what Google calls “YMYL” pages: “your money, your life” pages that “could potentially impact the future happiness, health, or financial stability of users.” It’s a responsibility I take seriously (hell, it’s downright oppressive at times). It’s interesting and good that Google takes it seriously too.

This information comes from their guidelines for human website reviewers. They have a small army of these reviewers, which is also interesting: they use people-generated reviews to help calibrate their algorithmically-generated rankings of webpages. They want search results to resemble what humans actually want, and not just any humans: well-trained humans with good priorities!

And so they train their human reviewers to apply more rigorous standards to YMYL pages. Sounds sensible, doesn’t it? Just what we’d hope the master of the Information Age is doing.

The reality often hasn’t lived up to the dream, though. Google has bequeathed a lot of rank to some truly shite websites over the years, and recently too. It’s not surprising, because even the human reviewers probably aren’t exactly great at evaluating the quality of health care information. Hell, even bona fide health care experts constantly disagree about what constitutes good quality information! And viciously bicker about it.

But I have good news this week: Google may actually be getting better at this.

In early August, Google rolled out significant changes to how they are interpreting YMYL pages. Many lower quality health information sites are reputedly doing rather poorly with it. And what happened here? Glad you asked! Because my most YMYL-ish pages got a substantial rank boost, sending organic traffic 40-60% higher — a nice endorsement!