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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Moringa Oleifera Against CVD, Diabetes, Alzheimer’s & Arsenic?
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The Healthiest Drumstick
Moringa oleifera is a tree, whose leaves and pods have medicinal properties (as well as simply being very high in nutrients). It’s also called the drumstick tree in English, but equally often it’s referred to simply as Moringa. It has enjoyed use in traditional medicine for thousands of years, and its many benefits have caught scientists’ attention more recently. For an overview before we begin, see:
Now, let’s break it down…
Anti-inflammatory
It is full of antioxidants, which we’ll come to shortly, and they have abundant anti-inflammatory effects. Research into these so far has mostly beennon-human animal studies or else in vitro, hence the guarded “potential” for now:
Potential anti-inflammatory phenolic glycosides from the medicinal plant Moringa oleifera fruits
Speaking of potential though, it has been found to also reduce neuroinflammation specifically, which is good, because not every anti-inflammatory agent does that:
Antioxidant
It was hard to find studies that talked about its antioxidant powers that didn’t also add “and this, and this, and this” because of all its knock-on benefits, for example:
❝The results indicate that this plant possesses antioxidant, hypolipidaemic and antiatherosclerotic activities and has therapeutic potential for the prevention of cardiovascular diseases.
These effects were at degrees comparable to those of simvastatin.❞
~ Dr. Pilaipark Chumark et al.
Likely a lot of its benefits in these regards come from the plant’s very high quercetin content, because quercetin does that too:
Quercetin reduces blood pressure in hypertensive subjects
For more about quercetin, you might like our previous main feature:
Fight Inflammation & Protect Your Brain, With Quercetin
Antidiabetic
It also has been found to lower fasting blood sugar levels by 13.5%:
Anti-arsenic?
We put a question mark there, because studies into this have only been done with non-human animals such as mice and rats so far, largely because there are not many human volunteers willing to sign up for arsenic poisoning (and no ethics board would pass it anyway).
However, as arsenic contamination in some foods (such as rice) is a big concern, this is very promising. Here are some example studies, with mice and rats respectively:
- Protective effects of Moringa oleifera Lam. leaves against arsenic-induced toxicity in mice
- Therapeutic effects of Moringa oleifera on arsenic-induced toxicity in rats
Is it safe?
A popular food product through parts of Africa and (especially) South & West Asia, it has a very good safety profile. Generally the only health-related criticism of it is that it contains some anti-nutrients (that hinder bioavailability of its nutrients), but the nutrients outweigh the antinutrients sufficiently to render this a trifling trivium.
In short: as ever, do check with your doctor/pharmacist to be sure, but in general terms, this is about as safe as most vegan whole foods; it just happens to also be something of a superfood, which puts it into the “nutraceutical” category. See also:
Review of the Safety and Efficacy of Moringa oleifera
Want to try some?
We don’t sell it, but here for your convenience is an example product on Amazon 😎
Enjoy!
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It’s OK That You’re Not OK – by Megan Devine
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Firstly, be aware: this is not a cheerful book. If you’re looking for something to life your mood after a loss, it will not be this.
What, then, will you find? A reminder that grief is also the final translation of love, and not necessarily something to be put aside as quickly as possible—or even ever, if we don’t want to.
Too often, society (and even therapists) will correctly note that no two instances of grief are the same (after all, no two people are, so definitely no two relationships are, so how could two instances of grief be?), but will still expect that if most people can move on quickly from most losses, that you should too, and that if you don’t then there is something pathological at hand that needs fixing.
Part one of the book covers this (and more) in a lot of detail; critics have called it a diatribe against the current status quo in the field of grief.
Part two of the book is about “what to do with your grief”, and addresses the reality of grief, how (and why) to stay alive when not doing so feels like a compelling option, dealing with grief’s physical side effects, and calming your mind in ways that actually work (without trying to sweep your grief under a rug).
Parts three and four are more about community—how to navigate the likely unhelpful efforts a lot of people may make in the early days, and when it comes to those people who can and will actually be a support, how to help them to help you.
In the category of criticism, she also plugs her own (paid, subscription-based) online community, which feels a little mercenary, especially as while community definitely can indeed help, the prospect of being promptly exiled from it if you stop paying, doesn’t.
Bottom line: if you have experienced grief and felt like moving on was the right thing to do, then this book isn’t the one for you. If, on the other hand, your grief feels more like something you will carry just as you carry the love you feel for them, then you’ll find a lot about that here.
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How To Out-Cheat “Cheat Days”
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Out-Cheating “Cheat Days” (Or Even Just “Cheat Meals”)
If you are in the habit of eating healthily, the idea of a “cheat day” probably isn’t appealing—because you simply don’t crave junk food; it’s not what your gut is used to.
Nevertheless, sometimes cheat days, or at least cheat meals, choose us rather than the other way around. If your social group is having a pizza night or meeting up at the burger bar, probably you’re going to be having a meal that’s not ideal.
So, what to do about it?
Well, first of all, relax. If it really is an exception and not a regular occurrence, it’s not going to have a big health impact. Assuming that your basic dietary requirements are taken care of (e.g. free from allergens as necessary, vegan/vegetarian if that’s appropriate for you, adhering to any religious restrictions that are important to you, etc), then you’re going to have a good time, which is what scientists call a “pro-social activity” and is not a terrible thing.
See also: Is Fast Food Really All That Bad? ← answer: yes it is, but the harm is cumulative and won’t all happen the instant you take a bite of a chicken nugget
Think positive
No, not in the “think positive thoughts” sense (though feel free, if that’s your thing), but rather: focus on adding things rather than subtracting things.
It’s said:
❝It’s not the calories in your food that make the biggest impact on your health; it’s the food in your calories❞e
…and that’s generally true. The same goes for “bad things” in the food, e.g. added sugar, salt, seed oils, etc. They really are bad! But, in this case you’re going to be eating them and they’re going to be nearly impossible to avoid in the social scenarios we described. So, forget that sunk treasure, and instead, add nutrients.
10almonds tip: added nutrients remain added nutrients, even if the sources were not glowing with health-appeal and/or you ate them alongside something unhealthy:
- Those breaded garlic mushrooms are still full of magnesium and fiber and ergothioneine.
- The chili-and-mint peas that came as an overpriced optional side-dish with your burger are still full of protein, fiber, and a stack of polyphenols.
…and so on. And, the more time you spend eating those things, the less time you spend eating the real empty-calorie foods.
Fix the flaw
We set out to offer this guide without arguing for abstemiousness or making healthy substitutions, because we assume you knew already that you can not eat things, and as for substitutions, often they are not practical, especially if dining out or ordering in.
Also, sometimes even when home-cooking something unhealthy, taking the bad ingredient out takes some of the joy out with it.
Writers example: I once incorrectly tried to solve the fat conundrum of my favorite shchi (recipe here) by trying purely steaming the vegetables instead of my usual frying/sautéing them, and let’s just say, that errant-and-swiftly-abandoned version got recorded in my nutrition-tracker app as “sad shchi”.
So instead, fix the flaw by countering it if possible:
- The meal is devoid of fiber? Preload with some dried figs (you can never have too many dried figs in your pantry)
- The meal is high in saturated fat? Enjoy fiber before/during/after, per what’s convenient for you. Fiber helps clear out excess cholesterol, which is usually the main issue with saturated fat.
- The meal is salty? Double down on your hydration before, during, and after. If that sounds like a chore, then remember, it’s more fun than getting bloated (which results, counterintuitively, from dehydration—because your body detects the salt, and panics and tries to retain as much water as possible to restore homeostasis, resulting in bloating) and hypertensive (which results from the combination of the blood having too much salt and too little water, and cells retaining too much water and pressing inwards because it is the cells themselves that are bloated). So, tending to your hydration can help mitigate all of the above.
- The meal is full of high-GI carbs? Preload with fiber, enjoy the carbs together with fats, and have something acidic (e.g. some kind of vinegar, or citrus fruit) with it if that’s a reasonable option. Yes, this does mean that a Whiskey Sour is better for your blood sugars than an Old Fashioned, by the way, and/but no, it doesn’t make either of them healthy.
- The meal is inflammatory? Doing all of the above things will help, as will eating it slowly/mindfully, which latter makes it less of a shock to your system.
See also: How To Get More Nutrition From The Same Food
Enjoy!
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What you need to know about endometriosis
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Endometriosis affects one in 10 people with a uterus who are of reproductive age. This condition occurs when tissue similar to the endometrium—the inner lining of the uterus—grows on organs outside of the uterus, causing severe pain that impacts patients’ quality of life.
Read on to learn more about endometriosis: What it is, how it’s diagnosed and treated, where patients can find support, and more.
What is endometriosis, and what areas of the body can it affect?
The endometrium is the tissue that lines the inside of the uterus and sheds during each menstrual cycle. Endometriosis occurs when endometrial-like tissue grows outside of the uterus.
This tissue can typically grow in the pelvic region and may affect the outside of the uterus, fallopian tubes, ovaries, vagina, bladder, intestines, and rectum. It has also been observed outside of the pelvis on the lungs, spleen, liver, and brain.
What are the symptoms?
Symptoms may include pelvic pain and cramping before or during menstrual periods, heavy menstrual bleeding, bleeding or spotting between periods, pain with bowel movements or urination, pain during or after sex or orgasm, fatigue, nausea, bloating, and infertility.
The pain associated with this condition has been linked to depression, anxiety, and eating disorders. A meta-analysis published in 2019 found that more than two-thirds of patients with endometriosis report psychological stress due to their symptoms.
Who is at risk?
Endometriosis most commonly occurs in people with a uterus between the ages of 25 and 40, but it can also affect pre-pubescent and post-menopausal people. In rare cases, it has been documented in cisgender men.
Scientists still don’t know what causes the endometrial-like tissue to grow, but research shows that people with a family history of endometriosis are at a higher risk of developing the condition. Other risk factors include early menstruation, short menstrual cycles, high estrogen, low body mass, and starting menopause at an older age.
There is no known way to prevent endometriosis.
How does endometriosis affect fertility?
Up to 50 percent of people with endometriosis may struggle to get pregnant. Adhesions and scarring on the fallopian tubes and ovaries as well as changes in hormones and egg quality can contribute to infertility.
Additionally, when patients with this condition are able to conceive, they may face an increased risk of pregnancy complications and adverse pregnancy outcomes.
Treating endometriosis, taking fertility medications, and using assistive reproductive technology like in vitro fertilization can improve fertility outcomes.
How is endometriosis diagnosed, and what challenges do patients face when seeking a diagnosis?
A doctor may perform a pelvic exam and request an ultrasound or MRI. These exams and tests help identify cysts or other unusual tissue that may indicate endometriosis.
Endometriosis can only be confirmed through a surgical laparoscopy (although less-invasive diagnostic tests are currently in development). During the procedure, a surgeon makes a small cut in the patient’s abdomen and inserts a thin scope to check for endometrial-like tissue outside of the uterus. The surgeon may take a biopsy, or a small sample, and send it to a lab.
It takes an average of 10 years for patients to be properly diagnosed with endometriosis. A 2023 U.K. study found that stigma around menstrual health, the normalization of menstrual pain, and a lack of medical training about the condition contribute to delayed diagnoses. Patients also report that health care providers dismiss their pain and attribute their symptoms to psychological factors.
Additionally, endometriosis has typically been studied among white, cisgender populations. Data on the prevalence of endometriosis among people of color and transgender people is limited, so patients in those communities face additional barriers to care.
What treatment options are available?
Treatment for endometriosis depends on its severity. Management options include:
- Over-the-counter pain medication to alleviate pelvic pain
- Hormonal birth control to facilitate lighter, less painful periods
- Hormonal medications such as gonadotropin-releasing hormone (GnRH) or danazol, which stop the production of hormones that cause menstruation
- Progestin therapy, which may stop the growth of endometriosis tissue
- Aromatase inhibitors, which reduce estrogen
In some cases, a doctor may perform a laparoscopic surgery to remove endometrial-like tissue.
Depending on the severity of the patient’s symptoms and scar tissue, some doctors may also recommend a hysterectomy, or the removal of the uterus, to alleviate symptoms. Doctors may also recommend removing the patient’s ovaries, inducing early menopause to potentially improve pain.
Where can people living with endometriosis find support?
Given the documented mental health impacts of endometriosis, patients with this condition may benefit from therapy, as well as support from others living with the same symptoms. Some peer support organizations include:
- Endometriosis Coalition Patient Support Group (virtual)
- MyEndometriosisTeam (virtual)
- Endo Black, Inc. (Washington, D.C.)
- endoQueer (virtual)
For more information, talk to your health care provider.
This article first appeared on Public Good News and is republished here under a Creative Commons license.
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The Worry Trick – by Dr. David Carbonell
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Worry is a time-sink that rarely does us any good, and often does us harm. Many books have been written on how to fight anxiety… That’s not what this book’s about.
Dr. David Carbonell, in contrast, encourages the reader to stop trying to avoid/resist anxiety, and instead, lean into it in a way that detoothes it.
He offers various ways of doing this, from scheduling time to worry, to substituting “what if…” with “let’s pretend…”, and guides the reader through exercises to bring about a sort of worry-desensitization.
The style throughout is very much pop-psychology and is very readable.
If the book has a weak point, it’s that it tends to focus on worrying less about unlikely outcomes, rather than tackling worry that occurs relating to outcomes that are likely, or even known in advance. However, some of the techniques will work for such also! That’s when Dr. Carbonell draws from Acceptance and Commitment Therapy (ACT).
Bottom line: if you would like to lose less time and energy to worrying, then this is a fine book for you.
Click here to check out The Worry Trick, and repurpose your energy reserves!
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Holding Back The Clock on Aging
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Holding Back The Clock on Aging
This is Dr. Eric Verdin, President and CEO of the Buck Institute of Research on Aging. He’s also held faculty positions at the University of Brussels, the NIH, and the Picower Institute for Medical Research. Dr. Verdin is also a professor of medicine at University of California, San Francisco.
Dr. Verdin’s laboratory focuses on the role of epigenetic regulators (especially the behaviors of certain enzymes) in the aging process. He studies how metabolism, diet, and chemical factors regulate the aging process and its associated diseases, including Alzheimer’s.
He has published more than 210 scientific papers and holds more than 15 patents. He is a highly cited scientist and has been recognized for his research with a Glenn Award for Research in Biological Mechanisms of Aging.
And that’s just what we could fit here! Basically, he knows his stuff.
What we can do
Dr. Verdin’s position is bold, but rooted in evidence:
❝Lifestyle is responsible for about 93% of our longevity—only about 7% is genetics. Based on the data, if implementing health lifestyle choices, most people could live to 95 in good health. So there’s 15 to 17 extra years of healthy life that is up for grabs❞
~ Dr. Eric Verdin
See for example:
- From discoveries in aging research to therapeutics for healthy aging
- Optimism, lifestyle, and longevity in a racially diverse cohort of women
- Well-being, food habits, and lifestyle for longevity—evidence from supercentenarians
How we can do it
Well, we all know “the big five”:
- Good diet (Mediterranean Diet as usual is recommended)
- Good exercise (more on this in a moment)
- Good sleep (more on this in a moment)
- Avoid alcohol (not controversial)
- Don’t smoke (need we say more)
When it comes to exercise, generally recognized as good is at least 150 minutes per week of moderate intensity exercise (for example, a brisk walk, or doing the gardening), and at least three small sessions a week of high intensity exercise, unless contraindicated by some medical condition.
As for Dr. Verdin’s take on this…
What Dr. Verdin recommends is:
- make it personalized
- make it pre-emptive
- make it better
The perfect exercise plan is only perfect if you actually do it. And if you actually can do it, for that matter.
Prevention is so much better (and easier) than cure for a whole array of maladies. So while there may be merit in thinking “what needs fixing”, Dr. Verdin encourages us to take extra care to not neglect factors of our health that seem “good enough”. Because, give them time and neglect, and they won’t be!
Wherever we’re at in life and health, there’s always at least some little way we could make it a bit better. Dr. Verdin advises us to seek out those little improvements, even if it’s just a nudge better here, a nudge better there, all those nudges add up!
About sleep…
It’s perhaps the easiest one to neglect (writer’s note: as a writer, I certainly feel that way!), but his biggest take-away tip for this is:
Worry less about what time you set an alarm for in the morning. Instead, set an alarm for the evening—to remind you when to go to bed.
Want to hear directly from the man himself?
Here he is speaking on progress we can expect for the next decade in the field of aging research, as part of the 100 Minutes of Longevity session at The Longevity Forum, a few months ago:
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