Placebo interventions for all clinical conditions

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Cochrane database Jan. 2010

Placebo effects are often claimed to substantially improve patient-reported and observer-reported outcomes across many clinical conditions, but most reports are from biased research without controls.

This Cochrane database systematic review looked at over 200 trials and discussed the effect and the findings. Many CAM practioners and adherents of alternative ‘medicine’ become, by default promoters of the value of placebo effects after such interventions. This is due to the increasing awareness that substantial, curative benefits from most CAM procedures are simply not forthcoming in well-done studies. Over the last several years Placebo effects have been relegated to the status of mundane… as opposed to miraculous. 

The conclusions of this review suggest:

“Placebo interventions do not appear to have important clinical effects in general”. “In certain settings patient-reported outcomes of pain and nausea can be influenced. The effect on pain varies considerably and it’s difficult to distinguish it from biased reporting. Variations in placebo effect can be partly explained by how trials are conducted and how patients are informed”.

Antibiotic treatment in patients with cLBP

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Eur Spine J. Apr;22(4). 2013.

As has been reported for the last few years, infectionary-processes may account for a substantial percent of cLBP. For instances Stirling et al found 53% of patients were infected with P. Acnes in nuclear tissue removed under sterile conditions. In a cross comparison of patients with herniation vs. scoliosis, fractures and tumors over 37% of herniation patients were infected with P. Acnes.

The authors conclude IF skin contamination accounted for the bacterial presence the percentage of patients would be similar.

It is thought that these anaerobic mouth and skin commensal organisms gain access to the disc during normal bacteremias as a result of neo-vascularisation associated with disc degeneration or herniation. Local inflammation in the adjacent bone may be a secondary effect due to cytokine and propionic acid production i.e. the infection is in the disc and the Modic change is a “side effect” manifest in the bone. P. Acnes cannot live in the highly vascularized/aerobic bone and is not present.

Adding force during decompression (part 2)

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If you have ever been tractioned you’ll have recognized that (depending on your size) even small, incremental additions of force can be quickly perceived. Since we have a variable-extension spring-retraction on the Kdt NF we can make subtle adjustments to the ‘retraction-force’ of the sliding lumbar section and allow the perception of the pull (via table motion) to be enhanced. It is highly recommended that novice-decompression clinicians follow: ’40 pound max/females, 50 pound max/males for the first 1 or 2 sessions to avoid untoward effects…not that they are extremely common but the annoyance of such effects can ruin your day. The spring can be fully tightened prior to treatment and then ‘backed-off’ to allow the patient to better sense the pull and their ‘lower body participation’ (caudal motion) with the pull. When adding force typically the spring should be fully ‘off’ and 5 pound increments then dialed in on the motor. Of course excess caution is never a bad clinical attribute and even though many bigger, male patients will be able to well-tolerate 15-20 additional pounds sticking to the 5 pound rule makes the most sense. As was described in a previous blog; degenerative discs typically show marked thinning of the posterior annular fibers and excessive strain could theoretically “sprain” them.

Adding force during decompression (part 1)

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Much discussion centers on the importance of the traction force (tension). Our experience after more than 2 decades of use perhaps seems counterintuitive however we’ve found the amount-of-force is only marginally connected to improved outcome but substantially connected to increased pain or iatrogenic (negative) outcomes. Not that there is a direct analogy to the SAID principle however like overtraining, over-stretching or burdening the spinal structures with tensions they cannot easily adapt to is not clinically sound.

When we lie down and eliminate Y-axis compression disc-osmosis begins (in those discs still hydrostatic). Adding a modest axial-tension enhances that effect. In perfectly healthy structures its likely very large forces can be quickly adapted to and no injury results, however virtually every “patient” will have desiccation and degenerative changes, especially in the posterior annulus. This compromised tissue has a poorer adaptation to rotation and axial stretch. A 1/3rd bodyweight (or less in some cases) is still the best starting point. We add 5-10 pounds only after the first 2-3 sessions where full tolerance has been proven but subjective indicators are not changing. You can add the force after the 2nd pull (on most traction units you can do this on-the-fly). The rest force (20-25 pounds needs not be altered…and this remains true irrespective of the pull-force).