Intermittent cervical traction for neck pain: meta-analysis of recent RCTs.

Yang et al. Spine; July 2017.


These RCTs suggest significantly lower post-traction pain scores vs. patients getting placebo interventions. Short-term benefits are noted however significant differences on longer term follow up did not differ dramatically. It is noted further, less biased studies are necessary to draw firm conclusions of long-term benefits.

It’s important to note that ‘encouragement, ergonomic & postural advice and sensible exercise/fitness suggestions’ are all part of an evidenced-based treatment protocol.

Passive modalities and treatments are meant to stimulate healing and reduce pain-expression and the ensuing discouragement, it is vital to have non-traumatic interventions that can give good short-term relief.

Temporary, short-term relief may be all some conditions will manifest early on….that traction/decompression can improve pain quickly goes a long way to encourage and improve patient compliance so fitness and ergonomic consideration can be added in and compliance improved.


Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers’ Compensation Setting

Tye, Erik Y. BA*,†; Anderson, Joshua MD‡ et al Spine July 2017


Objective. The aim of this study was to compare outcomes in Workers’ compensation (WC) subjects receiving decompression alone versus decompression and fusion for the indication of degenerative spinal stenosis (DLS) without deformity or instability.

Summary of Background Data. The use of a fusion procedure during lumbar decompression for DLS alone remains controversial. We hypothesize that WC subjects receiving fusion and decompression will return to work less and incur greater medical costs than subjects receiving decompression alone.

Methods. Three hundred sixty-four Ohio WC subjects were identified  subjects who received an adjunctive fusion cost of the Ohio BWC on average, $46,115 more in costs accrued over 3 years after their index surgery compared with subjects who received a decompression alone.

Conclusion. Overall, fusion with decompression had a significantly negative impact on clinical outcomes in WC subjects with DLS. These results demonstrate the high risk of postoperative morbidity associated with fusion procedures and underscore the need to strongly reevaluate the use of fusion for DLS without instability in the WC population.


Evidence for a role of nerve injury in painful intervertebral disc degeneration: A cross-sectional proteomic analysis of human cerebrospinal fluid.

Kim TKY et al Spine 2017


Intervertebral disc degeneration (DD) is a cause of low back pain (LBP) in some individuals. However, while >30% of adults have DD, LBP only develops in a subset of individuals. To gain insight into the mechanisms underlying non-painful versus painful DD, human cerebrospinal fluid (CSF) protein expression was examined.


Cerebrospinal fluid was examined for differential protein expression in healthy controls, pain-free adults with asymptomatic intervertebral disc degeneration, and low back pain patients with painful intervertebral disc degeneration. While disc degeneration was related to inflammation regardless of pain status, painful degeneration was associated with markers linked to nerve injury.

Sedentary lifestyle as a risk factor for low back pain: A Systematic Review.

Chen SM, Liu MF, Int Arch Occup Environ Health. 2009 Jul;82(7)

OBJECTIVES: To review systematically studies examining the association between sedentary lifestyle and low back pain (LBP) using a comprehensive definition of sedentary behaviour including prolonged sitting both at work and during leisure time.

METHODS: Journal articles published between 1998 and 2006 were obtained by searching computerized bibliographical databases. Quality assessment of studies employing a cohort or case-control design was performed to assess the strength of the evidence.

RESULTS: One high-quality cohort study reported a positive association, between LBP and sitting at work only; all other studies reported no significant associations. Hence, there was limited evidence to demonstrate that sedentary behaviour is a risk factor for developing LBP.

CONCLUSIONS: The present review confirms that sedentary lifestyle by itself is not associated with LBP.

Acupuncture Effects

Review: Steve Novella MD PhD 2015

All of this evidence is in stark contrast to what most people believe about acupuncture. People actually think science supports acupuncture. That simply isn’t the case. Which isn’t really surprising, because we’re talking about a healing system that rests on a belief in auras: an alleged “energy” in and around the body that no one can or has ever actually detected.

Conclusion: Once again we see that the best acupuncture clinical trials show that it does not matter where or if you place the needles. Since these are the two interventions specific to acpuncture, we can conclude (confidently, at this point) that acupuncture does not work and that any perceived benefit from acupucture is due to placebo or nonspecific effects.
The acupuncture industry needs to be called on their continued promotion of a medical modality which has already been shown to be ineffective by clinical research. The mainstream media needs to be criticized for uncritically accepting the propaganda of the acupuncture industry.

Some ‘non-nerve compromise’ conditions may benefit in prone flexion.

We created the Neural-flex to afford multiple ‘X’-axis positional iterations. This is because after 50 years of ‘facilitated motion’ research flexion and extension motions/pivoting at the waist can make improvements to disc migration patterns better than neutral positions.
The premise of pre-positioning patients in extension (or flexion) is not new and has been borne out over several decades of ongoing clinical research.

Some patients have confounding s/s and fail to ‘easily-classify’ as directly flexion or extension. Unlike supine positioning which comes in just one ‘variety’ (flexion or hyper-flexion) prone positioning can be a multiplayer: neutral, slight-torso extension, hyper-extension, extension torso & lower-body and lower-body flexion (5-35 degrees).
Neutral is likely the most common with extension (5-25 degrees) next. Hyper-extension and dual (upper & lower) extension less common and more likely needed in patients under 40. Flexion is a transitional-position allowing traction in otherwise difficult to treat conditions i.e. nerve compromise, stenosis etc.

However some 60+ year old patients (prone tolerant) and those demonstrating extension-motion pain reduced with form-closure but otherwise modest compression findings.

The End of a Myth

J Anesthesia & analgesia. June (14) 2013 

A small excess of positive results after thousands of trials is most consistent with an inactive intervention. The small excess is predicted by poor study design and publication bias. Further, Simmons et al (2011) demonstrated that exploitation of “undisclosed flexibility in data collection and analysis” can produce statistically positive results even from a completely nonexistent effect. With acupuncture in particular there is documented profound bias among proponents (Vickers et al., 1998). Existing studies are also contaminated by variables other than acupuncture – such as the frequent inclusion of “electro-acupuncture” which is essentially transdermal electrical nerve stimulation masquerading as acupuncture.

The best controlled studies show a clear pattern – with acupuncture the outcome does not depend on needle location or even needle insertion. Since these variables are what define “acupuncture” the only sensible conclusion is that acupuncture does not work. Everything else is the expected noise of clinical trials, and this noise seems particularly high with acupuncture research. The most parsimonious conclusion is that with acupuncture there is no signal, only noise.

No doubt acupuncture will continue to exist on the High Streets where it can be tolerated as a voluntary self-imposed tax on the gullible…believing claims that are simply untrue.

It is clear from meta-analyses that results of acupuncture trials are variable and inconsistent, even for single conditions. After thousands of trials of acupuncture, and hundreds of systematic reviews (Ernst et al., 2011), arguments continue unabated. In 2011, Pain editorial summed up the present situation well:

“Is there really any need for more studies? Ernst et al. (2011) point out that the positive studies conclude that acupuncture relieves pain in some conditions but not in other very similar conditions. What would you think if a new pain pill was shown to relieve musculoskeletal pain in the arms but not in the legs? The most parsimonious explanation is that the positive studies are false positives. In his seminal article on why most published research findings are false, Ioannidis (2005) points out that when a popular but ineffective treatment is studied, false positive results are common for multiple reasons, including bias and low prior probability.”

Since it has proved impossible to find consistent evidence after more than 3000 trials, it is time to give up. It seems very unlikely that the money that it would cost to do another 3000 trials would be well-spent elsewhere.


More on the Placebo ‘Effects’

Kaptchuk offers some ideas about what the key factors might be in the placebo effect (i.e. in positively enhancing healing, but not from the material effects of the treatment or drug). He suggests it is the effect of hope, attention and care; and to do with the social, not just their personal, beliefs i.e.(Pygmalion effect)
In turn that suggests these points:

• It has been established that persistent stress (unlike sharp, but passing, shocks) reduces immune system function. One service which doctors can perform is to tell a patient that they will recover. This is often not at all certain to the patient and their family. One of the reasons for mental illness being frightening to most people, is they don’t believe it will pass: this is in strong contrast to flu, food poisoning, broken bones, where they know they will recover. The assurance relieves anxiety and stress, which in turn improves immune system functioning, and so recovery.
• Thus it could be that inducing a patient (and those around them) to care for themselves is sometimes a key factor, and the basis for real healing effects independent of material interventions. This thought is further supported by the consideration that today in developed countries, the leading causes of death (heart disease, cancer) are thought to be largely controlled by lifestyles that the patient, not doctor, controls: persuading patients to behave differently is the key to controlling mortality.

Placebo vs. Hawthorne Effects

The placebo and Hawthorne effects compare and contrast in these ways: 

• Both are psychological effects on the participants, causing an effect when the material intervention has no effect.
• Both are effects produced by the participants’ perceptions and reactions; but the former emphasises their response to new equipment or methods, while the latter emphasises their response simply to being studied.
• The leading suspected cause in the placebo effect is the participants’ false belief in the material efficacy of the intervention. The leading suspected cause in the Hawthorne effect is the participants’ response to being studied i.e. to the human attention.
• In both cases, the experimenter may be deceiving the participants, or may be mistakenly sincere, or neutral with respect to the effects of the technology or intervention. In general however, the experimenter appearing to the participant to believe in the efficacy of the intervention, while not essential, may be more, or more often, important to the placebo effect than to the Hawthorne effect.

Positive Thinking
Related to placebos is evidence about how positive thinking can improve heath outcomes. This area shows that healing and recovery is affected by various kinds of positive thinking. This is not mostly about a placebo effect confounding an experiment, but about better medical outcomes for physically treated patients depending on whether they additionally have positive thinking. The mediating causes are probably: effects on pain; on how well we look after ourselves; and on reduction in persistent stress.

Pulsed electromagnetic fields in knee osteoarthritis: a double blind, placebo-controlled, randomized clinical trial.

Bagnato GN et al Rheumatology (Oxford). 2016 Apr;55(4)

This was a scientifically rigorous test of wearable pulsed electromagnetic fields (PEMF) for older patients with osteoarthritis of the knee: moderate to severe cases with X-ray evidence and pain of at least 4/10 for more than six months, despite maximum tolerated medication. PEMF is particularly easy to test properly, because it causes no sensation, making it much easier to compare to an active placebo. The placebo devices do not emit a radiofrequency electromagnetic and the active device cannot be distinguished in any way from the placebo device.

Their pain and knee function were compared. PEMF won decisively: the real-PEMF patients enjoyed a 25.5% reduction in pain, compared to a 3.6% reduction for the fake-PEMF patients. Knee function improved as well, though not as much.
The authors explain that “some of the effects of this therapeutic approach might be derived from neuromodulation of the pain mechanism”: that is, it might be “just” a pain-killer, as opposed to actually helping to heal arthritic cartilage.