147- What's Wrong with Placebo?

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langme. This is a great episode for new docs as well as seasoned or tenured docs as well. We are talking placebo. What is so bad about placebo anyway is the title of this episode. We're gonna dive into the research that substantiates chiropractic care as clinically more beneficial. That was an awkward way to put that. But better than placebo. We're also going to talk a little bit about spinal fusions and why they may be the most rampant placebo driven intervention that's cost the most money than we can possibly imagine. So we're gonna dive into a lot of stats and a lot of good conversation points that you can bring to your patients this week in practice for sure. But before we get started, we are getting close. October 26, 27 and 28. The event is the 27th and 28th is Rock Stock 2018 in Miami Beach, Florida. We couple weeks out. I'm going to be down there filming having a great time with their crew. The speaker lineup is outrageous. If you have not got your tickets for Rock Stock, be sure to do so. Miami beach in just a couple weeks time. October 27 and 28 and I'll be there filming and hanging out. So if you're going to come shoot me an email Jeff at the Evidence based Chiropractor let me know and we can make sure to spend some time together and hang out. But as I said at the top, we are talking placebo today. So what is placebo? Well, by textbook definition a placebo is a substance or treatment of no intended therapeutic value. It's an interesting way to put it right? No, no intended therapeutic value. Because what we've seen time and time again is that placebo can provide a lot of value and this is where things become interesting and ironic. I'm gonna jump around a little bit but I think it's really important to understand the context of placebo. One thing with this is if you check out my YouTube page, the evidence based Chiropractor, you will see an unbelie amount of comments from the general public. I highly doubt too many of these people are double PhDs or anything like that. Although there might be a few out there that are commenting hey, chiropractic is a sham. It's all a placebo. And there's quite a few of them with that. And, you know, number one, I kind of sit there and smile when I see that. And I say, what's wrong with that to begin with? You know, if a patient comes in and they are going to have a negative approach to care, in other words, they do not want to get better. They, I don't care what intervention you do, chiropractic surgery, medication, you can do anything you want, and you're gonna be hard pressed to find result. So the mind is the most powerful healing object or director that we've ever known. Everything that we do with our care or any other practitioner does with their care obviously interacts with the person's central nervous system. And a positive approach to care has been proven time and time again to be unbelievably powerful in the outcomes. So, you know, number one, I don't think placebo is a bad thing to start. I'm gonna lay that foundation and just say, yeah, I want people to know and hope and desire that they're going to have an effect, right? If you're receiving a placebo, then you obviously are going after something, right? You want to find improvement in some kind, some alteration. And chiropractic is most of the time gonna be pain relief and increased function. If somebody believes that my care is going to work, I don't think they need to for it to work, but that it helps the outcome when they do. So that's one thing I'll say right off the bat is I don't think there's as much of a problem with placebo as is initially. A lot of people come out with. Now, with that also being said, let's dive a little bit deeper because I don't want to misconstrue things. There is no question that what we do through adjustments or manipulations far exceeds what a placebo can do on its own. And that's been showcased in 2013 in Spine Journal, a randomized trial. They published an article in Spinal High Velocity Low Amplitude Manipulation in Acute Non Specific Low Back Pain. The title of that's interesting because it doesn't actually describe very well what the research paper did. And what they did in this research paper is they looked at manipulation and diclofenac. Diclofenac is one of the most commonly prescribed NSAIDs out there. We're talking hundreds of millions of prescriptions per year. And what they found is this. This is powerful. This is a Take home message, quote, this is the first time that spinal manipulation was investigated in a double blinded, randomized, controlled design showing clear superiority compared with placebo and nsaid. In this study, manipulation wiped the floor with Diclofenac. And you would not believe how many neurologists, how many orthopedic guys are prescribing diclofenac like it's going out of style, yet rarely referring to a chiropractor. But again, I'm gonna read that quote one more time. This is the first time that a spinal that spinal manipulation was investigated in a double blinded, randomized control design, showing clear superiority compared with placebo and nsaid. I'm gonna go one step farther with that. They also found, quote, final evaluation showed manipulation being significantly better than NSAID in clinical, superior to placebo. So it was. Yeah, it's clinical. It sounds kind of weird. It shouldn't be clinically as far as I'm concerned. But at any rate, clinically superior to placebo and significantly better than NSAI said. So anytime anybody is already coming with, oh, chiropractor, you're touching a patient, of course they're gonna feel better. Well, I hope the patient does want to feel better. And for new docs out there, you'll be shocked at the amount of patients you see actually paying money and coming into your practice that don't want to get better. That's an eye opener and a topic for a different podcast, but certainly, you know, placebo in chiropractic, does it help outcomes? As I said at the beginning, I think anytime somebody's coming in for, for relief, for functional improvement, and they want to believe that the intervention's going to help, that's a positive thing in the right direction. It's not true. Placebo, but that's a positive thing in the right direction. And research showcases that. Hey, even with that as fact, chiropractic manipulation, spinal manipulation, chiropractic adjustment outperforms. It's clinically superior to placebo and significantly better than nsaid. So let's take a look at the other side of the coin. Cause one thing I was speaking of just a couple weeks ago when I was teaching at Life University was about the fact, you know, maybe 15, 20 years ago, a hundred. So that's chiropractic. So I'm sorry, I'm gonna switch gears and talk a little bit on spinal fusions right now. Hundred thousand, some odd spinal fusions performed maybe 20 years ago. Half a million performed five years ago. So, you know, that's a 500 you know, it's five times more. And I got interested in that because there's a few very, very, you know, you know, damning quotes, so to speak, that a few very prominent surgical groups have come out with. I'm gonna read one to start the context, and then we'll talk a little bit farther about it as well. Number one is that it's all about finding the pain generator, right? If you're doing a surgical intervention, you really need to know what's causing the pain because you're making a mechanical change to it in theory. So here's a quote for you. Quote, lumbar spine fusion surgery only works for specific indications and can only work if we can identify what the specific pain generator for the patient is. Probably 80 to 90% of the time, the pain generator can't be identified. Eighty to 90% of the time, the pain generator can't be identified. Yet that is an absolute key to having a spinal fusion work. So I dug a little bit deeper on this. Cause I said that sounds pretty outrageous. And I found a surgeon by the name of Ian Harris who wrote a book called Surgery the Ultimate Placebo. In it, he puts together some very, very interesting things. In it, Dr. Harris talks about there's the fact that there's very little evidence that spine fusion surgery works for back pain, that it's obviously unbelievably expensive, and the complications often require more surgery, an increase in mortality, and don't even result in the spine being fused quite often. This is from Dr. Harris himself, who performed many spine fusions. You know, he also talks about the increased rate, and he talks about the fact that at $100,000 a pop, we're talking about, you know, big, big, big, big money. We're talking About B money, $50 billion a year type money, which is pretty outrageous. And then he goes on to talk about the fact that regardless of what intervention that you do in his world, in the medical side of things, if it's a medication or an injection, what they seen in the literature, this is from Dr. Harris, is that about two thirds of the time, there's a positive outcome. So it works in about 2/3 of patients. So I'm going to read A quote from Dr. Harris here on a paper he wrote which I think really frames this. He wrote, quote, I once attended a course by an internationally renowned spine surgeon. Yes, I used to be a spine surgeon, and I used to do spinal fusions, who explained that nearly all treatments for back pain resulted in improvements in about 2/3 of patients. I asked him why he did spinal fusions for back pain if it was no more effective than the alternatives. He said, because it works in about two thirds of the patients. So while I'm kind of chuckling here, I mean, obviously there's been many, many people, tens of thousands, hundreds of thousands, if you add them up in totality, potentially millions who have undergone spinal fusions and have not got the result they've desired. And it's cost and taxed our healthcare system to the tune of hundreds of billions of dollars. And with all of that, I'm just really framing things in a way that I hope you can take away some really key points. Number one is that placebo by itself is not the worst thing on planet Earth. Patients wanting to get better is important. Now, there's ethical concerns. You don't tell somebody you're gonna do something and not do it unless you're in a research study and the patient's aware. There's hardcore ethics behind that. But the bottom line is I want all my patients to have a positive expectation of care. That's a really good way to frame it. Second thing is, as far as chiropractic is concerned, many people talk about the fact, oh, it's, you know, better at placebo. Placebo, number one, that's not the worst thing in the world. But number two, research has showcased in a dumbo blinded, randomized controlled trial by spine, top tier research that chiropractic adjustments are clinically superior to placebo. Now, if we go to the other side of the equation, we say 100,000 spinal fusions 20 years ago, 500,000 just a couple years back, and we have spine surgeons coming out saying this is no better. A spinal fusion very rarely is any better than a placebo. And it starts to become a really compelling case. And for me, what's compelling about it is these are the opportunities to talk with your patients. Hop on Facebook, talk a little bit about this. You don't need to disparage any other healthcare profession, but talk about what you know. Do a little bit of research. Take what you've learned in this podcast, use it for table, talk with your patients, use it when you're talking out in the community. And certainly have this in mind. Now, you're not gonna go into another doctor's office and try to rail against what they do every day, but have this in mind as you frame conversations with other healthcare providers in your community. The evidence, the research stand behind what you do as a chiropractor. Be proud of that, know that, Be proud of that. And showcase that to not only patients, but other healthcare providers in your community. If you want help with any of that, obviously check out what we have going@the evidencebasedchiropractor.com we help docs bridge the gap and build relationships with other healthcare providers in their community, medical doctors and other. We do it better than anybody else. We've probably done it longer than anybody else. So check out what we are up to at the evidence basedchiropractor.com and I hope you have a great week in practice and I will talk to you soon.

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