Sunday, January 12, 2014

A look through SBM

Today is another one of those horrible days for pain, still in a moderate flair up and am rather not pleased by any of this. Soon I will have health care all sorted out and go back to the doctor and hopefully move forward with all of this. -sigh- One can hope. 

So I decided to take a look through the fantastic blog over at Science Based Medicine for the various things people have suggested I try for my chronic pain. So many of them are bunk that its just sad. Anyway, here goes: 


Hypnotherapy is a hard one as there is no good clinical definition for what it is. Nearly every practitioner you ask will have a different definition and a different method of doing it. This makes it hard to evaluate realistically in research but what research is out there isn't exactly compelling. 
I'll leave it up to Steven Novella for a better way of putting this: 

"My personal current summary of the clinical research is that there is a suggestion of a positive effect from the specific operational elements of hypnosis (specifically increased suggestibility) for the treatment of subjective symptoms, like pain and nausea, that are amenable to suggestibility. However, the research has not yet adequately isolated this variable and therefore more research of better methodological quality is necessary to definitively answer this question.

Acupuncture: Part 1 and part 2

To be honest, the first linked article's title alone sums up my views on acupuncture for back pain: "Acupuncture Does Not Work for Back Pain." I have looked at study after study testing acupuncture for back pain and to be honest, I have stopped looking. NONE of them have compelling evidence and most in fact tell me that it doesn't matter where you stick the needles or if you even use needles at all (Heck I saw a study that got just as good of an "effect" from poking people with toothpicks. No joke.). As Dr. Novella puts it "the only reasonable scientific conclusion to draw from this is that acupuncture does not work." For more on the situation with acupuncture research check out the article in part 1. 

Part 2 has one main line that I wanted to pull out (though the whole thing is worth reading if you aren't familiar with the shenannagans that get pulled in acupuncture research):
"The data on education for back pain indicates that it is as effective as medical interventions for acute and subacute low back pain, and effective but not as effective as medical intervention for chronic low back pain. " - Dr Novella (emphasis mine)
This is another common things I get - Here, try this book on managing back pain! There IS a difference between chronic pain and acute pain. And things that work for one don't necessarily work for the other.


I am sick of this one as much as I am sick of acupuncture recommendations. It doesn't work, it has no plausible mechanism, no evidence of efficacy, nearly no safety evaluations and I am just plain tired of it. Subluxations are made up and don't exist thus we can't find them and adjust joints to correct for them. I know this seems harsh but when you hear the same thing over and over again you just want to explode. It's not my job to educate people, I have enough stuff to deal with already rather than having to say 'thanks but I'll stick with what my doctor recommends' 50 times a week (sometimes it feels like 50 times a day). My link is to an article by a former chiropractor about the field, check it out, and look through SBM for info about chiropractic to see all the bs that is within.


Oh yoga. I like doing yoga, it's a nice, relaxing stretch and light exercise. When my balance isn't off too  much I actually do a 30 min yoga routine designed to help work my core muscles and stretch my back and legs. It is quite effective as a low impact stretching set for those of us that have to be very careful about how we stretch and move. So what is the downside? The whole host of woo that goes with it. The "chi" "qi" "shared energy" "symbiotic earth mother energy" "shared spirit" and more are all names for woo. There are claims galore, quoting from the article: 
"during one bent over pose they say you are squeezing the pancreas/liver this apparently pushes toxin out and they also say you can taste the toxins coming out in your mouth (taste described as chloriney), during reverse back bending pose they say if you look back as far as you can you can stretch your optic nerve, in one pose where you bend your arms awkwardly they say that you build up blood pressure and when this pressure is released the blood will move so intensely through you arteries it will blast away plaque build up, near the end they have a breathing exercise which they claim is pushing out all the toxins the stretching has apparently pushed into your lungs, throughout they talk about the increasing of bone density and of joint strength, finally that stretching your lower back calms you because personal stress building up in your lower back muscles/tissues."
These aren't even the tip of the iceberg in the claims but they are a good sample. Before I move on I like Dr. Novella's response to this pile of woo: 
" I certainly hope that yoga practitioners are not squeezing their liver or pancreas, or that they are stretching their optic nerve. Nerves don’t like to be stretched – that causes damage. It also would not be safe to perform a maneuver that backs up your blood flow and then releases it in a powerful blast. This has a much greater chance of causing a brain hemorrhage than scouring plaque off your arteries. In other words, the yoga instructor better hope that everything they are claiming is a lie, or else they are likely to find themselves liable for very real medical harm." 


I have been told to take every bloody multivitamin under the sun. I did take a single daily multivitamin with my night time medications for a while. What happened? I started throwing up my medication every night. I went to my doctor and she recommended I stop the multivitamin. Why? Because many people that take them don't need to anyway and its the most likely cause of my nausea. Since I hadn't been on the high level pain pills at the time we didn't have a more likely cause hanging over my head. Ya know what, until this last week the nausea has been gone and I haven't puked up my meds again. 

The linked article looks at routine use of multivitamins, something many people do, to see if its effective and safe. Not all supplements are useless - prenaitals, specific supplements for a specific deficit, vitamin B12 in anemics, vitamin D for breast feeding babies, etc. SPECIFIC vitamins for a SPECIFIC reason can be effective and safe. I have a calcium deficiency, I can opt to eat more calcium rich food (which is what I have chosen) or take a supplement. Someone without a calcium deficiency is just peeing out the extra calcium, where is the point in that? 

The conclusion cited from the Annuls of  Internal Medicine on multivitamins?

"The large body of accumulated evidence has important public health and clinical implications. Evidence is sufficient to advise against routine supplementation, and we should translate null and negative findings into action. The message is simple: Most supplements do not prevent chronic disease or death, their use is not justified, and they should be avoided. This message is especially true for the general population with no clear evidence of micronutrient deficiencies, who represent most supplement users in the United States and in other countries."
If you think you have a deficiency, talk to your GP and have it tested for. If you do then you can take the one or two things you need rather than a whole host of other things that aren't helping. 

Low Dose Naltrexone

LDN is one of those things that has fallen into the dangerous side of pseudoscience for me. Not because it does or doesn't work but because of the timing of when the major marketing push started and its resultant effect on research. The clinical trials for this are in a preliminary phase and the results have been interesting. There are only pilot studies and preliminary studies so far done. We haven't seen ANY high level clinical trials done and the preliminary studies aren't nearly conclusive enough to justify human use. 
Yet pushes LDN as an effective treatment for all kinds of things (big red flag ahead) including; 18 different types of cancer, ALS, Alzheimers, Autism, Celiacs, Chrons, Emphysema, Endometriosis, Fibromyalga, AIDS/HIV, IBS, MS, PLS, psoriasis, arthritis, Lupus, and many more. Look at that list. It's horrible. One low dose of a medication with somewhat promising results in pilot studies can not have indications for so many disparate things. Not only that but something that will help with my fibromyalga is going to help with anna's lupus and is going to help with another friend's IBS? They don't even have the same cause! Something that effects the immune response for HIV patients could very easily kill a person with lupus. It's ridiculous. To quote the article on that point: 
Further, there is an inherent contradiction in simultaneously treating diseases that are auto-immune (the immune system attacking the host), and immunodeficiency diseases (like AIDS) and claiming to treat cancer by “boosting” immune activity. Increasing immune activity actually worsens auto-immune diseases, and suppressing the immune system would worsen AIDS. This is a difficult contradiction to resolve. - Dr. Steven Novella
I want to end this one with another quote because I couldn't put it better myself: 
"LDN promoters may in fact harm research into LDN by giving it a bad name. Researchers may be reluctant to hitch their careers, or funding agencies commit resources, to a treatment that has a dubious reputation. If the research is promising it will still get done, but if anything it is likely to be slowed by the efforts of the LDN promoters. 
This is just one of the many ways in which pseudoscience poisons the system." 


I am just going to quote the articles conclusion for this one:
"This study is encouraging but far from definitive. It might justify antibiotics for patients with chronic low back pain and Modic-1 MRI changes following a herniated disc when they have failed to respond to all other treatment options. This was a well-designed study, carefully carried out, with a credible rationale, impressive results, and a cautious interpretation. This is how science should be done. The authors cautioned:
We rely on our fellow colleagues to use clear evidence-based criteria and to avoid excessive antibiotic use.
 Back pain is a frustrating problem, and patients who learn about these results may ask for a trial of antibiotics even if they don’t fit the criteria of the study. That would not be justified and might be expected to do more harm than good. Chronic low back pain is a mixed bag with various etiologies, and it must be stressed that this study addressed only one very limited sub-group of back pain patients. That said, it is a ray of hope for those patients, and I hope it will be confirmed." - Harriet Hall
I recommend reading the article if you're interested. 


I can't tell you how many times I have been told I should just take Tylenol. It drives me batty. Oh yes, because pain that makes you neigh insensible can really be helped by popping a couple of Tylenol. Never mind the fact that its not an anti-inflammatory (which is something that is rather useful when your body gets super swelled up with a flare up). Don't get me wrong, the side effects are better and it's not as addictive BUT if you have to take a lot of it (like I do) the dangers from taking too much are significantly worse. 
To quote the linked article: 
"Poisoning due to chronic ingestion, which are often unintentional, are far more difficult to manage. The early signs of liver damage are not obvious, and can mimic flu-like symptoms. Once hepatic damage has started, the antidote’s effectiveness drops. In severe cases, a liver transplant is required" 
Chronic ingestion. Oh like what I have to do with high pain levels on a regular basis? Sometimes for months at a time? The funny thing to me about people recommending tylenol is that it is usually an after thought to telling me not to take vicoden or percoset (which I currently do). Um... you know that both of those are acetaminophen based right? Clearly not. This one is complicated and frankly I am going to listen to my doctor on what pain medication to take and when. 


This isn't one random people tell me to take very often, at least not specifically. They DO tell me to take ibuprofen - usually for the anti-inflammatory effect. NSAID's are all sorts of fun to deal with regularly thanks to a very special set of side effects that go with them. I get to hear repeated warnings about ulcers, and high risk of heart attacks and strokes, blah blah blah. I see my doctor at least every other month right now and will be seeing her more after my insurance stuff goes through. I keep close tabs on that stuff. I get a lot of fear mongering around some of the medication I take and apart from the heavy pain pills, these are seen as the biggest threat. 

Other interesting stuff:


I have started to pay more attention to the advertising surrounding back pain relief in the last few years and they are horrendous. The article talks about a big offender - those silly traction machines that don't remotely work. It just makes me mad to see claims for cures in the chronic pain realm. Taking advantage of vulnerable people is something that is done by the worst kind of people. The person doing the 'treatment' may be well meaning but the person running the con is scum. 

Chronic pain as a disease in its own right:

First off, read the whole article. Harriet Hall is brilliant. She writes about a book by Melanie Thernstrom which is great. Chronic pain is dehabilitating in its own right, independent of the underlying cause. Dr. Hall writes about how the nervous system can rewire itself to the pain pathways, how muscles can atrophy causing new sources of pain to develop and more. I want to read the book Dr. Hall references now.

Causes, care and consequences:

This is just an interesting article I thought would be good to include. Check it out if you are interested in the various types and causes of back pain and what can happen because of them.

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