In an important article, Wally Smith writes about ‘Pseudoevidence-based medicine.’1 He defines it ‘as the practice of medicine based on falsehoods that are disseminated as truth. Falsehoods may result from corrupted evidence – evidence that has been suppressed, contrived from purposely biased science, or that has been manipulated and/or falsified, then published. Or falsehoods may result from corrupted dissemination of otherwise valid evidence. These falsehoods, when consumed as truth by unwitting and well-intentioned practitioners of evidence-based medicine, then disseminated and adopted as routine practice, may well result not only in inappropriate quality standards and processes of care, but also in harms to patients.’
But I would suggest a second concept— ‘pseudo-pseudo evidence-based medicine (PP-EBM): disseminated ‘evidence’ that never reaches the level of evidence. It represents assertions, ‘facts,’ definitions and beliefs that are derived without testing or without adequate scientific basis. Like Smith’s P-EBM, PP-EBM finds its home in journals, where citations transform it from opinion to fact. It thrives in lectures, advertising, and in some guidelines from professional organizations. It transforms hypotheses into facts.
There is a lot of PP-EBM in fibromyalgia. Pharmacologic treatments are effective. Central sensitization explains or is the primary mechanism for fibromyalgia. Fibromyalgia is a disease. Fibromyalgia ‘causes’ symptoms. And so on. Feynman’s idea that ‘science is the belief in the ignorance of experts’ and Joseph Conrad ‘s that ‘Skepticism is the tonic of minds, the tonic of life, the agent of truth – the way of art and salvation’ ought to find a place with us whenever we think of fibromyalgia.
David Simons, who with Janet Travell were the authors of Myofascial Pain and Dysfunction: The Trigger Point Manual (TPM),2 was a remarkable physician. At his death in 2010, he was memorialized in a long New York Times obituary that included this: ` David G. Simons, whose ascent more than 19 miles above the Earth in an aluminum capsule suspended from a helium balloon set an altitude record in 1957 and helped put the United States on the road to manned space flight died April 5 at his home in Covington, GA’ [a record that still stands (FW)]. Janet Travell was equally famous. President Kennedy’s physician, the first woman physician at the New York Hospital, she was also the author of an illuminating autobiography. If trigger points needed a mother, she was it. In fact, the Travell and Simons drawing of trigger points and their radiations began as a poster presentation at an American Medical Association meeting that was later published as an ‘exhibit.’3
But if there ever was need for examples of PP-EBM, these authors provided it. In a book that was filled with extraordinary anatomic drawings, Travell and Simons provided figures of locations of trigger points, radiation of pain, injection and `spray and stretch’ techniques. In one 61-page chapter, the authors provided detailed information about perpetuating factors for myofascial pain (MFP) and trigger points, including 317 references. The book was an enormous success—a bible of trigger points. It found it way into academic libraries and practitioner’s offices through several editions. In a perfect example of science by citation and PP-EBM, it was repeatedly cited as an authoritative reference. Many, like me, trying to understand trigger points, read deeply in the book. But the more I read the more I doubted. The book represented opinion, not science. None of the trigger points or their treatments were validated; none were tested for reliability. There were almost no studies in the Travell-Simons book, just testaments. Most of the perpetuating factors were plain wrong, and represented outdated, overthrown junk science.
For Travel and Simons trigger points and myofascial pain could be perpetuated by nutritional inadequacies (`crucial perpetuating factors’), ‘low ‘normal’ levels of vitamins B1, B6, B1, and folic acid. Then there were vitamin C deficiencies, problems with calcium, potassium, iron, trace minerals, borderline anemias, sub-optimal thyroid function, hyperuricemia, hypoglycemia, allergies, and many other factors. If they were so wrong about simple, well-established science, how could we believe what they wrote about myofascial pain and trigger points? Funny, hard as I tried, I could never find many of the trigger points and ‘taut bands’ they wrote about. In the hands of this apostate at least, stretch and spray and injections were of dubious benefit.
In 1992, we performed a study of trigger points. A group of four myofascial pain experts, selected by Simons and including Simons, blindly examined four patients with MFP. The examiners were allowed to take as much time as they needed; they could examine but not interview the patients. As we had mixed MFP patients with those who had fibromyalgia, it was a blinded experiment. These MFP experts were no ordinary examiners. They were the best. They wrote the book, they did the lectures. But, in the end, they could not find or agree on the trigger points. It was a disaster. The examiners were distraught. After the results were in, they protested and wanted to change the protocol and purposes of the study (post hoc). It wasn’t fair, they said. Glenn McCain, one of the rheumatologists, exploded in outrage. It was intolerable, he said, to alter study results. He was so angry that the opposition stopped. Subsequent delays and disagreements over the methods, results and discussion continued and almost prevented publication. But time took over; people forgot, and the study—a little toned down—came out in the Journal of Rheumatology.4 If we believed in trigger points and The Trigger Point Manual before, we were a lot less secure in our beliefs now.
Janet Travell came to Wichita, Kansas in the 1980s, by which time she was in her 80s. She had been invited by the Wichita dental community, and a patient demonstration was scheduled. I was in full-time practice of rheumatology, and I attended together with medical people from my clinic. Dr. Travell was perched on a high seat, and patients were brought to her. I remember it this way. ‘What is your trouble, my dear?’ The patient explained that she had thoracic and low back pain. ‘And what did you do.’ She went to see many doctors, but the pain persisted. ‘Then they sent me to Dr. Wolfe.’ Now I recognized her. This was going to be bad. ‘And what did he say, my dear?’ ‘He said there was nothing he could do for me.’ That was something I never said to patients, but she had read me right. The patient had terribly severe S-curve scoliosis and there wasn’t much I really could do. ‘We’ll see, my dear,’ Dr. Travell said. She took out her bottle of ‘Flouri-methane’. The patient’s blouse was removed. Dr. Travel stretched her out in front of the audience and sprayed. I knew I was lost. Dr. Travel would cure her. ‘Did that help?’ ‘No.’ Three more positions and stretches and sprays followed. Still, ‘no.’ The skirt was removed. The audience of male dentists drew closer. Travell sprayed and stretched again and again. But it didn’t work. It didn’t work. ‘Do you have any allergies, my dear?’ ‘Yes, I do.’ ‘Dr. Travell spoke almost sadly, ‘Oh, then we won’t be able to help you until your allergies are cured.’ So there it was all the time, perpetuating factors. There are always perpetuating factors—ready when you need them.
I was reminded of Peter Medawar’s Advice to a Young Scientist,5 quoted in James Wilson’s Conduct, Misconduct, and Cargo Cult Science,6 ‘I cannot give any scientist of any age better advice than this: the intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not.’ PP-EBM is a reversal of that advice. It pervades our specialty.
1. Smith, W.R. Pseudoevidence-based medicine: what it is, and what to do about it. Clinical Governance: An International Journal 12, 42-52 (2007).
2. Travell, J.G. & Simons, D.G. Myofascial pain and dysfunction: The trigger point manual (Williams & Willkins, Baltimore, 1983).
3. Travell, J.G. & Rinzler, S.H. The myofascial genesis of pain. Postgrad.Med. 11, 425-434 (1952).
4. Wolfe, F. et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol 19, 944-51 (1992).
5. Medawar, P.B. Advice to a young scientist (Basic Books, 1981).
6. Wilson, J.R. in Proceedings of the 29th conference on Winter simulation 1405-1413 (IEEE Computer Society, 1997).