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.

The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review.

Wertli MM et al 

Spine J. May 2014

Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP).

The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP.

The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP), researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive.

Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.

Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature.

Seffinger MA et al Spine Oct 2004

To determine the quality of the research and assess the interexaminer and intraexaminer reliability of spinal palpatory diagnostic procedures.

Conflicting data have been reported over the past 35 years regarding the reliability of spinal palpatory tests.

The authors used 13 electronic databases and manually searched the literature from January 1, 1966 to October 1, 2001. Forty-nine (6%) of 797 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus or a content expert reconciled discrepancies.

A higher percentage of the pain provocation studies (64%) demonstrated acceptable reliability, followed by motion studies (58%), landmark (33%), and soft tissue studies (0%). Regional range of motion is more reliable than segmental range of motion, and intraexaminer reliability is better than interexaminer reliability. Overall, examiners’ discipline, experience level, consensus on procedure used, training just before the study, or use of symptomatic subjects do not improve reliability.

The quality of the research on intra reliability and intra reliability of spinal palpatory diagnostic procedures needs to be improved. Pain provocation tests are most reliable. Soft tissue paraspinal palpatory diagnostic tests are not reliable.

Braces and orthoses for treating osteoarthritis of the knee.

Cochrane Database Syst Rev. 2015 Mar 16;(3)

Duivenvoorden T, Brouwer RW, et al

Individuals with osteoarthritis (OA) of the knee can be treated with a knee brace or a foot/ankle orthosis. The main purpose of these aids is to reduce pain, improve physical function and, possibly, slow disease progression. This is the second update of the original review published in Issue 1, 2005, and first updated in 2007.

To assess the benefits and harms of braces and foot/ankle orthoses in the treatment of patients with OA of the knee.

Evidence was inconclusive for the benefits of bracing for pain, stiffness, function and quality of life in the treatment of patients with knee OA. On the basis of one laterally wedged insole versus no treatment study, we conclude that evidence of an effect on pain in patients with varus knee OA is lacking. Moderate-quality evidence shows lack of an effect on improvement in pain, stiffness and function between patients treated with a laterally wedged insole and those treated with a neutral insole. Low-quality evidence shows lack of an effect on improvement in pain, stiffness and function between patients treated with a valgus knee brace and those treated with a laterally wedged insole. The optimal choice for an orthosis remains unclear, and long-term implications are lacking.

Note: It’s interesting how committed we can be to certain ‘ideas, concepts and procedures’ when in fact there is (and perhaps never was) any real scientific backing for them(?)….