Evidence doesn’t support spinal cord stimulators for chronic back pain – and they could cause harm
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In an episode of ABC’s Four Corners this week, the use of spinal cord stimulators for chronic back pain was brought into question.
Spinal cord stimulators are devices implanted surgically which deliver electric impulses directly to the spinal cord. They’ve been used to treat people with chronic pain since the 1960s.
Their design has changed significantly over time. Early models required an external generator and invasive surgery to implant them. Current devices are fully implantable, rechargeable and can deliver a variety of electrical signals.
However, despite their long history, rigorous experimental research to test the effectiveness of spinal cord stimulators has only been conducted this century. The findings don’t support their use for treating chronic pain. In fact, data points to a significant risk of harm.
What does the evidence say?
One of the first studies used to support the effectiveness of spinal cord stimulators was published in 2005. This study looked at patients who didn’t get relief from initial spinal surgery and compared implantation of a spinal cord stimulator to a repeat of the spinal surgery.
Although it found spinal cord stimulation was the more effective intervention for chronic back pain, the fact this study compared the device to something that had already failed once is an obvious limitation.
Later studies provided more useful evidence. They compared spinal cord stimulation to non-surgical treatments or placebo devices (for example, deactivated spinal cord stimulators).
A 2023 Cochrane review of the published comparative studies found nearly all studies were restricted to short-term outcomes (weeks). And while some studies appeared to show better pain relief with active spinal cord stimulation, the benefits were small, and the evidence was uncertain.
Only one high-quality study compared spinal cord stimulation to placebo up to six months, and it showed no benefit. The review concluded the data doesn’t support the use of spinal cord stimulation for people with back pain.
What about the harms?
The experimental studies often had small numbers of participants, making any estimate of the harms of spinal cord stimulation difficult. So we need to look to other sources.
A review of adverse events reported to Australia’s Therapeutic Goods Administration found the harms can be serious. Of the 520 events reported between 2012 and 2019, 79% were considered “severe” and 13% were “life threatening”.
We don’t know exactly how many spinal cord stimulators were implanted during this period, however this surgery is done reasonably widely in Australia, particularly in the private and workers compensation sectors. In 2023, health insurance data showed more than 1,300 spinal cord stimulator procedures were carried out around the country.
In the review, around half the reported harms were due to a malfunction of the device itself (for example, fracture of the electrical lead, or the lead moved to the wrong spot in the body). The other half involved declines in people’s health such as unexplained increased pain, infection, and tears in the lining around the spinal cord.
More than 80% of the harms required at least one surgery to correct the problem. The same study reported four out of every ten spinal cord stimulators implanted were being removed.
High costs
The cost here is considerable, with the devices alone costing tens of thousands of dollars. Adding associated hospital and medical costs, the total cost for a single procedure averages more than $A50,000. With many patients undergoing multiple repeat procedures, it’s not unusual for costs to be measured in hundreds of thousands of dollars.
Rebates from Medicare, private health funds and other insurance schemes may go towards this total, along with out-of-pocket contributions.
Insurers are uncertain of the effectiveness of spinal cord stimulators, but because their implantation is listed on the Medicare Benefits Schedule and the devices are approved for reimbursement by the government, insurers are forced to fund their use.
Industry influence
If the evidence suggests no sustained benefit over placebo, the harms are significant and the cost is high, why are spinal cord stimulators being used so commonly in Australia? In New Zealand, for example, the devices are rarely used.
Doctors who implant spinal cord stimulators in Australia are well remunerated and funding arrangements are different in New Zealand. But the main reason behind the lack of use in New Zealand is because pain specialists there are not convinced of their effectiveness.
In Australia and elsewhere, the use of spinal cord stimulators is heavily promoted by the pain specialists who implant them, and the device manufacturers, often in unison. The tactics used by the spinal cord stimulator device industry to protect profits have been compared to tactics used by the tobacco industry.
A 2023 paper describes these tactics which include flooding the scientific literature with industry-funded research, undermining unfavourable independent research, and attacking the credibility of those who raise concerns about the devices.
It’s not all bad news
Many who suffer from chronic pain may feel disillusioned after watching the Four Corners report. But it’s not all bad news. Australia happens to be home to some of the world’s top back pain researchers who are working on safe, effective therapies.
New approaches such as sensorimotor retraining, which includes reassurance and encouragement to increase patients’ activity levels, cognitive functional therapy, which targets unhelpful pain-related thinking and behaviour, and old approaches such as exercise, have recently shown benefits in robust clinical research.
If we were to remove funding for expensive, harmful and ineffective treatments, more funding could be directed towards effective ones.
Ian Harris, Professor of Orthopaedic Surgery, UNSW Sydney; Adrian C Traeger, Research Fellow, Institute for Musculoskeletal Health, University of Sydney, and Caitlin Jones, Postdoctoral Research Associate in Musculoskeletal Health, University of Sydney
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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5 Ways To Make Your Smoothie Blood Sugar Friendly (Avoid the Spike!)
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At 10almonds, we are often saying “eat whole fruit; don’t drink your calories”. Whole fruit is great for blood sugars; fruit juices and many smoothies on the other hand, not so much. Especially juices, being near-completely or perhaps even completely stripped of fiber, but even smoothies have had a lot of the fiber broken down and are still a liquid, meaning they are very quickly and easily digestible, and thus their sugars (whatever carbs are in there) can just zip straight into your veins.
However, there are ways to mitigate this…
Slow it down
The theme here is “give the digestive process something else to do”; some things are more quickly and easily digestible than others, and if it’s working on breaking down some of the slower things, it’s not waving sugars straight on through; they have to wait their turn.
To that end, recommendations include:
- Full-fat Greek yogurt which provides both protein and fat, helping to slow down the absorption of sugar. Always choose unsweetened versions to avoid added sugars, though!
- Coconut milk (canned) which is low in sugar and carbs, high in fat. This helps reduce blood sugar spikes, as she found through personal experimentation too.
- Avocado which is rich in healthy fats that help stabilize blood sugar. As a bonus, it blends well into smoothies without affecting the taste much.
- Coconut oil which contains medium-chain triglycerides (MCTs) that are quickly absorbed for energy without involving glucose, promoting fat-burning and reducing blood sugar spikes.
- Collagen powder which is a protein that helps lower blood sugar spikes while also supporting muscle growth, skin, and joints.
For more on all of these, enjoy:
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Want to learn more?
You might also like to read:
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Reading As A Cognitive Exercise
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Reading, Better
It is relatively uncontroversial to say that reading is good for cognitive health, but we don’t like to make claims without science if we can help it, so let’s get started:
There was a 2021 study, which found that even when controlling for many other factors, including highest level of education, socioeconomic status, and generalized pre-morbid intelligence:
❝high reading activity, as defined by almost daily reading, was associated with lower odds of cognitive decline, compared to low reading activity❞
Source: Can reading increase cognitive reserve?
However, not all reading is the same. And this isn’t just about complexity or size of vocabulary, either. It’s about engagement.
And that level of engagement remains the key factor, no matter how quickly or slowly someone reads, as the brain tends to automatically adjust reading speed per complexity, because the brain’s “processing speed” remains the same:
Read more: Cognitive coupling during reading
Everyone’s “processing speed” is different (and is associated with generalized intelligence and executive functions), though as a general rule of thumb, the more we practice it, the faster our processing speed gets. So if you balked at the notion of “generalized intelligence” being a factor, be reassured that this association goes both ways.
So is the key to just read more?
That’s a great first step! But…
The key factor still remains: engagement.
So what does that mean?
It is not just the text that engages you. You must also engage the text!
This is akin to the difference between learning to drive by watching someone else do it, and learning by getting behind the wheel and having a go.
When it comes to reading, it should not be a purely passive thing. Sure, if you are reading a fiction book at bedtime, get lost in it, by all means. But when it comes to non-fiction reading, engage with it actively!
For example, I (your writer here, hi), when reading non-fiction:
- Read at what is generally considered an unusually fast pace, but
- Write so many notes in the margins of physical books, and
- Write so many notes using the “Notes” function on my Kindle
And this isn’t just like a studious student taking notes. Half the time I am…
- objecting to content (disagreeing with the author), or
- at least questioning it, or which is especially important, or
- noting down questions that came to my mind as a result of what I am reading.
This latter is a bit like:
- when you are reading 10almonds, sometimes you will follow our links and go off down a research rabbit-hole of your own, and that’s great!
- sometimes you will disagree with something and write to tell us, and that’s great too (when this happens, one or the other or all of us will learn something, and yes, we have published corrections before now)!
- sometimes what you read here will prompt a further question, and you’ll send that to us, and guess what, also great! We love questions.
Now, if your enjoyment of 10almonds is entirely passive, don’t let us stop you (we know our readers like quick-and-easy knowledge, and that’s good too), it’s just, the more you actively engage with it, the more you’ll get out of it.
This, by the way, was also a lifelong habit of Leonardo da Vinci, which you can read about here:
How to Think Like Leonardo da Vinci: Seven Steps to Genius Every Day – by Michael J. Gelb
a very good book that we reviewed last year
How you read (i.e. what medium) matters too!
Are you reading this on a desktop/laptop, or a mobile device? That difference could matter more than the difference between paper and digital, according to this study from 2020 that found…
❝The cumulation of evidence from this and previous studies suggests that reading on a tablet affords different interactions between the reader and the text than reading on a computer screen.
Reading on a tablet might be more similar to reading on paper, and this may impact the attentional processes during reading❞
What if my mind wanders easily?
You can either go with it, or train to improve focus.
Going with it: just make sure you have more engaging reading to get distracted by. It’s all good.
Training focus: this is trickier, but worthwhile, as executive function (you will remember from earlier) was an important factor too, and training focus is training executive function.
As for one way to do that…
If you’d like a primer for getting going with that, then you may enjoy our previous main feature:
No-Frills, Evidence-Based Mindfulness
Enjoy!
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Kava vs Anxiety
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Kava, sometimes also called “kava kava” but we’re just going to call it kava once for the sake of brevity, is a heart-shaped herb that
bestows the powers of the Black Pantheris popularly enjoyed for its anxiolytic (anxiety-reducing) effects. Despite the similarity of the name in many languages, it is unrelated to coffee (except insofar as they are both plants), and its botanical name is Piper methysticum.Does it work?
Yes! At least in the short-term; more on that later.
Firstly, you may be wondering how it works; it works by its potentiation of GABA receptors in the brain. GABA (or gamma-aminobutyric acid, to give it its full name), as you may recall, is a neurotransmitter that is associated with feelings of calm; we wrote about it here:
So, what does “potentiation of GABA receptors” mean? It means… Scientists don’t for 100% sure know how it works yet, but it does make GABA receptors fire more. It’s possible that to some degree GABA fits the “molecular lock” of the receptors and causes them to say “GABA is here”; it’s also possible that they just make them more sensitive to the real GABA that is there, or there could be another explanation as yet undiscovered. Either way, it means that taking kava has a similar effect to having increased GABA levels in the brain:
As for how much to use, 20–300mg appears to be an effective dose, and most sources recommend 80–250mg:
Kava as a Clinical Nutrient: Promises and Challenges
This review of clinical trials found that it was more effective than placebo in only 3 of 7 trials; specifically, it was beneficial in the short-term and not in the long-term. For these reasons, the researchers concluded:
❝Kava Kava appears to be a short-term treatment for anxiety, but not a replacement for prolonged anti-anxiety use. Although not witnessed in this review, liver toxicity is especially possible if taken longer than 8 weeks.❞
Another review of clinical trials found better results over the course of 11 clinical trials, though again, short-term treatment only was considered to be where the “safe and effective” claim can be placed:
❝Compared with placebo, kava extract appears to be an effective symptomatic treatment option for anxiety. The data available from the reviewed studies suggest that kava is relatively safe for short-term treatment (1 to 24 weeks), although more information is required. Further rigorous investigations, particularly into the long-term safety profile of kava are warrant❞
Source: Kava extract for treating anxiety
Is it safe?
Nope! It has been associated with liver damage:
The likely main mechanism of toxicity is that it simply monopolizes the liver’s metabolic abilities, meaning that while it’s metabolizing the kava, it’s not metabolizing other things (such as alcohol or other medications), which will then build up, and potentially overwhelm the liver:
Constituents in kava extracts potentially involved in hepatotoxicity: a review
However, traditionally-prepared kava has not had the same effect as modern extracts; at first it seemed the difference was the traditional aqueous extracts vs modern acetonic/ethanolic extracts, but eventually that was found not to be the case, as toxicity occurred with industrial aqueous extracts too. The conclusion so far is that it is about the quality of the source ingredients, and the problems inherent to mass-production:
Meanwhile, short-term use doesn’t seem to have this problem, if you’re not drinking alcohol or taking medications that affect the liver:
Mechanisms/risk factors – kava-associated hepatotoxicity ← you’ll need to scroll down to 4.2.4 to read about this
Want to try it?
If the potential for hepatotoxicity doesn’t put you off, here’s an example product on Amazon ← we do not recommend it, but we are not the boss of you, and maybe you’re confident about your liver and want to use it only very short-term?
Take care!
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Apricots vs Peaches – Which is Healthier?
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Our Verdict
When comparing apricots to peaches, we picked the apricots.
Why?
Both are great! But there’s a clear winner:
In terms of macros, apricots have more fiber and, which is less important because the numbers are small, more protein. Apricots do also have more carbs, and/but carbs from whole fruit are not a problem for most people (especially because of the fiber), unless undertaking a very carb-controlled diet.
When it comes to vitamins, apricots sweep with more of vitamins A, B1, B2, B5, B6, B9, C, E, & K. Peaches meanwhile boast more vitamin B3, and that only marginally, as well as more choline.
In the category of minerals, apricots sweep again with more calcium, copper, iron, magnesium, manganese, phosphorus, potassium, and zinc. Peaches are not higher in any minerals.
Finally, if we consider polyphenols, apricots sweep yet again. The flavonols that peaches have, apricots have more of, and apricots have a long list of flavonols that peaches don’t.
Outside of flavonols, there is one (1) phenolic acid that peaches have more of (it’s 3-Caffeoylquinic acid), and it’s only slightly more, and it’s mostly in the skin which isn’t included if you buy your fruit ready-chopped. So in those cases, apricots would have the higher 3-Caffeoylquinic acid content anyway.
All in all, with their higher content of fiber, vitamins, minerals, and polyphenols, apricots easily win the day.
Enjoy both, though! Diversity is healthy!
Want to learn more?
You might like to read:
- Dried Apricots vs Dried Prunes – Which is Healthier?
- Which Sugars Are Healthier, And Which Are Just The Same? ← we know we link this one a lot, but we think it’s important for everyone to know how fruit is good and juice isn’t (and why, less that seem bizarrely arbitrary)
Take care!
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Ginger Does A Lot More Than You Think
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Ginger’s benefits go deep!
You are doubtlessly already familiar with what ginger is, so let’s skip right into the science.
The most relevant active compound in the ginger root is called gingerol, and people enjoy it not just for its taste, but also a stack of health reasons, such as:
- For weight loss
- Against nausea
- Against inflammation
- For cardiovascular health
- Against neurodegeneration
Quite a collection! So, what does the science say?
For weight loss
This one’s quite straightforward. It not only helps overall weight loss, but also specifically improves waist-hip ratio, which is a much more important indicator of health than BMI.
Against nausea & pain
Ginger has proven its effectiveness in many high quality clinical trials, against general nausea, post-surgery nausea, chemotherapy-induced nausea, and pregnancy-related nausea.
Source: Ginger on Human Health: A Comprehensive Systematic Review of 109 Randomized Controlled Trials
However! While it very clearly has been shown to be beneficial in the majority of cases, there are some small studies that suggest it may not be safe to take close to the time of giving birth, or in people with a history of pregnancy loss, or unusual vaginal bleeding, or clotting disorders.
See specifically: Ginger for nausea and vomiting of pregnancy
As a side note on the topic of “trouble down there”, ginger has also been found to be as effective as Novafen (a combination drug of acetaminophen (Tylenol), caffeine, and ibuprofen), in the task of relieving menstrual pain:
See: Effect of Ginger and Novafen on menstrual pain: A cross-over trial
Against inflammation & pain
Ginger has well-established anti-inflammatory (and, incidentally, which affects many of the same systems, antioxidant) effects. Let’s take a look at that first:
Read: Effect of Ginger on Inflammatory Diseases
Attentive readers will note that this means that ginger is not merely some nebulous anti-inflammatory agent. Rather, it also specifically helps alleviate delineable inflammatory diseases, ranging from colitis to Crohn’s, arthritis to lupus.
We’ll be honest (we always are!), the benefits in this case are not necessarily life-changing, but they are a statistically significant improvement, and if you are living with one of those conditions, chances are you’ll be glad of even things described in scientific literature as “modestly efficacious”.
What does “modestly efficacious” look like? Here are the numbers from a review of 593 patients’ results in clinical trials (against placebo):
❝Following ginger intake, a statistically significant pain reduction SMD = −0.30 ([95% CI: [(−0.50, −0.09)], P = 0.005]) with a low degree of inconsistency among trials (I2 = 27%), and a statistically significant reduction in disability SMD = −0.22 ([95% CI: ([−0.39, −0.04)]; P = 0.01; I2 = 0%]) were seen, both in favor of ginger.❞
To de-mathify that:
- Ginger reduced pain by 30%
- Ginger reduced disability by 22%
Read the source: Efficacy and safety of ginger in osteoarthritis patients: a meta-analysis of randomized placebo-controlled trials
Because (in part) of the same signalling pathways, it also has benefits against cancer (and you’ll remember, it also reduces the symptoms of chemotherapy).
See for example: Ginger’s Role in Prevention and Treatment of Gastrointestinal Cancer
For cardiovascular health
In this case, its benefits are mostly twofold:
- It significantly reduces triglycerides and LDL cholesterol, while increasing HDL cholesterol
- It significantly reduces fasting blood sugar levels and HbA1c levels (both risk factors for CVD)
Against neurodegeneration
This is in large part because it reduces inflammation, which we discussed earlier.
But, not everything passes the blood-brain barrier, so it’s worth noting when something (like gingerol) does also have an effect on brain health as well as the rest of the body.
You do not want inflammation in your brain; that is Bad™ and strongly associated with Alzheimer’s and Parkinson’s.
As well as reducing neuroinflammation, ginger has other relevant mechanisms too:
❝Its bioactive compounds may improve neurological symptoms and pathological conditions by modulating cell death or cell survival signaling molecules.
The cognitive enhancing effects of ginger might be partly explained via alteration of both the monoamine and the cholinergic systems in various brain areas.
Moreover, ginger decreases the production of inflammatory related factors❞
Check it out in full, as this is quite interesting:
Role of Ginger in the Prevention of Neurodegenerative Diseases
How much to take?
In most studies, doses of 1–3 grams/day were used.
Where to get it?
Your local supermarket, as a first port-of-call. Especially given the dose you want, it may be nicer for you to have a touch of sliced ginger root in your cooking, rather than taking 2–6 capsules per day to get the same dose.
Obviously, this depends on your culinary preferences, and ginger certainly doesn’t go with everything!
If you do want it as a supplement, here is an example product on Amazon, for your convenience.
Enjoy!
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Hanging Exercises For Complete Beginners & Older Adults
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Hanging (not the kind with a gallows) is great for the heath, improving not just strength and mobility, but also—critically—looking after spinal health too. Amanda Raynor explains in this video how this exercise is accessible to anyone (unless you have no arms, in which case, sorry, this one is just not for you—though hanging by your legs will also give similar spinal benefits!).
Hanging out
Hanging can be done at home or at a park, with minimal equipment (a bar, a sturdy tree branch, etc).
Note: the greater the diameter of the bar, the more it will work your grip strength, and/but the harder it will be. So, it’s recommend to start with a narrow-diameter bar first.
Getting started:
- Start with a “dead hang”: grip the bar with hands shoulder-width apart, thumb wrapped around.
- Aim to hang without pulling up; build endurance gradually (10–30 seconds is fine at first).
- Work up to holding for 60 seconds in three sets as a fitness goal.
Progression:
- If unable to hang at all initially, use a chair or stool to support some body weight.
- Gradually reduce foot support to increase duration of free hanging.
- Start with 10 seconds, progressing by small increments (e.g: 15, 20, 25 seconds) until reaching 60 seconds.
Advanced variations:
- Move the body while hanging (e.g., circles, knee lifts).
- Experiment with different grips (overhand, underhand) for varied muscle engagement.
- Try scapular pulls or one-arm hangs for additional challenge and strength-building.
For more on all of this plus visual demonstrations, enjoy:
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