218- Sham Surgery Beats the Real Thing

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. And if this sounds different, there was no intro and the audio sounds a little bit suspect. Your ears are not deceiving you. I suffered an epic hard drive meltdown. I've been without my computer for the last four days. I'm not gonna get it back for another five days. So I am kind of filming this with my mobile rig on location. But I wanted to make sure I got this episode out. Just as last week I was traveling to Denver, Colorado for a medical conferen. Get there, everything's hunky dory. I do a bunch of work on the plane, I'm jazzed, open up my computer when I get there and I have the blue blinking folder of death staring at me. Couple hours with AppleCare, then no solution. Fly back, have 12 hours at home before I'm heading to Orlando for a chiropractic conference. Couple hours with AppleCare, then no luck, bring it to an Apple store and, and needless to say, no luck there. So I am kinda hamstrung throughout this week. But we're still gonna have fun on today's episode. And today's episode actually is a super important one because we are talking about a paper titled Sham Surgical Procedures for Pain Intervention result in significant Improvements in Pain Systematic Review and meta analysis. This is an interesting paper and you heard that correctly. Sham Surgical procedures for pain Result in Significant improvements. And we're gonna talk all about that and more on today's episode. As always, the evidence based chiropractor is sponsored by Rock Tape. So if you have not checked out Mohawk, I'm gonna give you two places to go to check it out. One is the evidence based chiropractor YouTube page YouTube.com the evidencebased chiropractor. You can check out a variety of rock tape products including Mohawk where I kind of unbox them, do some demos and talk all about them. But Mohawk is probably my favorite, so be sure to check that out. Also, you can visit rocktape.com mohawk Pick it up for 175 bucks. That includes the tool, the case, the attachments, everything you want. You can also check out all of the educational courses@rocktape.com Mohawk but as I said at the top, today's episode we're talking sham surgical procedures for pain intervention. And the the results, they did a systematic review and meta analyses. This is brand new, it was just accepted as a manuscript and you can find a direct link also in the show notes. But the gist of it is this. These researchers found we're going to break it down, but I'm going to give you the conclusion. To start, they found, quote, sham surgery is associated with large improvement in pain and other subjective patient reported outcomes, but with relatively small effects on objective outcomes. Sham surgeries are overwhelmingly safe. The magnitude of this effect should be used when planning future sham controlled surgical trials. So that's a lot to take in right there, right now. We've discussed on this specific podcast, earlier episodes we've talked about the research showcasing manipulation versus microdiscectomy. And the fact is, a couple years post surgery or post intervention from manipulation, the results of a manipulation were at least, they said, just as good as getting a microdiscectomy surgical procedure. And furthermore, those individuals who did not in those trials who failed, quote, unquote, manipulation then actually had a very high likelihood of then having a great surgical outcome. There's other papers that touch on those things as well that say to me, there's not very few people that don't have red flags that should not be at least visiting your office for a trial course of care before having surgery. We know half a million fusions are done each and every year, and that number is rising. And I'm going to estimate that double that is done in microdiscectomies, foraminotomies, laminotomies, et cetera, laminectomies. And that's a lot of individuals. How many of those individuals are experiencing chiropractic or being referred to a chiropractor before getting those surgeries? Probably not that high a percentage from what we see. Typically they can, quote, unquote, exhaust conservative care with medications or physical therapy alone. Even though the research points to what we do with an adjustment or manipulation, chiropractic care, as being something that not only has exceptionally high efficacy, but exceptionally low risk and low harms. And if they happen to fail, what we do, they they're actually great surgical candidates based on the fact that they went through the course of care. A lot to dive into right there. But the gist of it is the placebo effect and other non specific effects complicate the interpretation of a surgically's therapeutic effect. Now, a lot of times we get this as chiropractors, right? Hey, you're placebo. It's just because you're touching the patient, which, by the way, there's nothing wrong with that. But that does not only extend to chiropractic. Placebo is a part of every healing process and arguably It's a real big part of the surgical process. They say, in other words, the clinical effect of the surgery may not be better than the sham placebo effect. That is a quote from this paper. That's powerful stuff. Right? When we start thinking about this. Now, I wanna be clear. This paper is not spine surgery specific. Now, they did look at a majority of surgeries that were minimally invasive by nature. So those be spine. Those could be extremity and or other. But the gist of it is, gosh, is surgery a permanent fix? Probably not. Do many patients come into your practice and then go into a surgeon's office hoping for a, quote, unquote, permanent fix? Because chiropractic gave them some relief, but not 100% relief. Yeah, quite frankly, that happens all day, every day, which is why I'd encourage you. And what we do at the eminent space chiropractor is to bridge the gap and build those relationships. So you have fluid communication. Just in a group on Facebook earlier this week, there was a doc talking about, man, I have patients that come in and then they go to, you know, the orthopedist or the primary care, and they kind of. I get railroaded out of taking care of my patient. And my response to that is, that is exactly the case on why you need to be bridging the gap and getting out there so that you can play offense and defense in your practice. You can help direct patients to the doctors that are actually doing the right thing. And coincidentally, those are gonna be people who are also friendly to who you are and what you do, and it's what's best for the patient. Why let them go out and find for themselves just a random doctor who might talk down about what you're doing, even though what you're doing is, in the research, the best option for care for musculoskeletal issues, neuromusculoskeletal issues that don't have red flags. It's absolutely crazy, but you gotta take the effort and get out there and do it. So in this paper, they identified our articles and they were screened based on the fact that it had to be a randomized controlled clinical trial, and it was comparing surgery to a corresponding sham placebo group. So that was basically kind of what they were looking at. And what they found, again, was the gist of it is primary outcomes. In this meta analysis, they looked at what was the improvement in pain on a 0 to 10 analog scale. Number two, what was the improvement in any subjective outcome? And number three, improvement in any objective outcome. Now, what they found was that specifically on the subjective side of things, individuals with sham procedures did exceptionally well. Now, the other interesting part of this is the complication rate. We know that from a spine surgery perspective, the complication rate, which can be tallied in a few different ways, to be fair, complications depending upon the hospital system, depending upon the state, depending upon even the country at times can be classified one way or the other. Was it a complication or was it a side effect? Was it a minor adverse event or was it a major complication? There are some definitives, but there's a lot of gray in that. And we've seen in surgical procedures, specifically around spine, that there can be a complication rate up to 20% or more. Now, in this study, they found the minor complication rate for Sham surgeries was 3.8% and the major complication rate was. Was 0.2% with no fatalities in the sham group. That's really important as well. Now, think about the 3.8. From a minor complication or from a major complication, the 0.2%. We don't put it exactly in terms like that for what we do within chiropractic, but I can tell you we're a heck of a lot lower. Now, if you want to classify some transient ache or pain as a minor complication, yeah, Maybe we're about 3.8%, but I know that our major complication rate is. Is definitely below 0.2%. So important to keep in mind, even with the sham surgeries doing well, it's obviously still a surgery, and there's still complications and challenges well beyond what we do in our practices. Now, they also cite another paper that found, quote, improvement in the placebo arm was seen in 75% of the sham trials, and that in about 50% of the trials, the. There was no difference in the outcomes between the sham arm and the surgical arm. Think about that. They're citing a paper that says half the time, 50% of the time, there's no difference in the outcomes between if somebody has a sham surgery or has an actual surgery. That's insane. And think about the fact that they found 75% of the time in these placebo randomized controlled trials, there was improvement in the placebo arm. So again, when somebody's saying about chiropractic, well, it's all placebo. Hey, I'll take all the placebo credit in the world, but quite frankly, we're probably lower on the placebo effect scale than surgeries in many cases. And that makes sense, right? You Think about the financial toll, the time toll, the mental stress and energy that goes into a surgical procedure. Yeah. People are really, you know, hell bent on making sure that they have a great outcome. So. So that amount of belief in the surgery being the fix absolutely can contribute to the placebo effect. Now, again, they noted that most of the studies and procedures in this were minimally invasive. And the bottom line is, they said, quote, in conclusion, sham surgery is associated with a large improvement in pain and other subjective patient reported outcomes and a markedly lower effect on measurable objective outcomes. So objective outcomes, Sham surgery doesn't do too much. That's to be expected if there is specifically in the spine, if there's a structural issue. Right. I'm give away throwback here, a limitation of matter. There is a disc herniation that is far beyond what we can do naturally. The body's unable to heal itself with conservative care, it's unable to get over the hump. Well, then, yeah, if that is cut out, chopped off, so to speak, that can result. It's a structural issue. If you have severe spinal cord stenosis, a huge disc pressing in that spinal cord, those people respond exceptionally well. But that's rare. So many people have surgeries done, microdiscs, laminectomies, foraminotomies, et cetera, that are on minor disc bulges or minor herniations that might still heal. If somebody only has a course of NSAIDs and some physical therapy, that is enough to check the boxes that they've, quote, unquote, failed conservative care, even if they've never visited a chiropractic clinic. I don't think that should be the case. But I know that if we're gonna wait around for the legislature to change that, we're gonna be waiting a long time. So that is where it breaks down to you getting out there, bridging the gap and building relationships. We know what we do has such high efficacy, it has such low risk, it's cost effective, there's unbelievably high patient satisfaction. And basically, what we do with manipulation adjustments are recommended across multiple university platforms, organizations, et cetera. And we have seen in the literature that we can perform just as well as surgical intervention. And those that happen to fail, what we do, are actually great surgical candidates. All that comes together to say you need to be reaching out. If you want help doing that, visit us@the evidencebasedchiropractor.com, we've had a ton of new members. Come on. I think that's people getting motivated. In 2020 to bridge the gap and build relationships. You can see that there is opportunity there and that opportunity is going to go away over time as more docs in your community start reaching out to the other MDs in your community. If you want to be one of the first, if you want to get in bridge the gap, build a relationship, start talking the truth about healthcare in your community and getting other people to do what's right and guide and direct them. It is all about relationships. So visit us at the evidence basedchiropractor.com I hope this was a semi unique, unique episode here. No intro, no outro. Next week, Knock on wood. Next week I'll be back on my full rig. Everything will be normal. We'll have the intro, we'll have the outro. Most importantly, I'll have my computer back. So if you have any questions or concerns, I do have my phone throughout the whole week so you can hit me up jeff the evidence basedchiropractor.com Otherwise, I hope you have a fantastic week in practice and I will talk to you soon.