Joint Pain: Scams, Lies, and Exaggerations, Part 2

As an orthopedic nurse practitioner I see a constant stream of joint pain complaints. They stem from a variety of sources: injury, age-related changes, lifestyle issues, and autoimmune disorders. Patients will often Google their problems and/or their symptoms, and like most medical issues you can find truth on the Internet, but it is never easy or quick. A lot of what I do with patients is teaching, with a good deal of that time spent addressing long-standing myths or marketing scams. This post is part of an ongoing series about orthopedic problems, scams, and myths. Part 1 focused on the myths and quackery surrounding pain in weight-bearing joints. This post will focus on one of the most pervasive types of joint pain: back and neck pain.

Back pain is the second most common symptom-related reason for clinician visits in the United States. (Skin disorders are #1.) According to one study, up to 84 percent of adults have low back pain at some time in their lives. The spectrum of illness and morbidity associated with lower-back pain is broad. For many individuals, episodes of back pain are self-limited and resolve without specific therapy. For others, however, back pain is recurrent or chronic, causing significant pain that interferes with employment and quality of life. Rarely, acute back pain is a harbinger of serious medical illness, including infection, malignancy, or other systemic disease. Like all difficult-to-treat pain-related complaints, searching for cures on the Internet produces a lot of unproven and untested treatments, often based on guesses and poor assumptions. Sometimes there are outright scams. Let’s take a look at what pops up most frequently in the office.

Curing Back and Neck Pain with Bedding
This is by far the most widely accepted pseudoscience surrounding back and neck pain. Mattress and pillow manufacturers often like to promote the untested or hypothetical benefits of their particular brand, promising people less pain, better sleep, and miraculous improvements by their special foam-and-fabric design. The claims border on out-and-out false advertising. Since bedding is not a medical treatment they can pretty much say whatever they want. That doesn’t mean there is any truth to any of their statements. In 2014, the Canadian Agency for Drugs and Technology in Health did a systematic review of the research on mattresses and their effects on back and neck pain. Their findings were predictable and consistent with prior reviews, writing:

Limited conclusive evidence was identified regarding the efficacy of specific mattress types for treatment of back and neck pain. One trial was identified presenting evidence that firm mattresses may be the least effective treatment for lower back pain. Four guidelines were identified that found a lack of evidence to form a basis for mattress recommendations for the treatment of chronic back and neck pain of musculoskeletal origin.

Overall there is no evidence anywhere that any specific mode of sleeping is beneficial, including: special pillows, certain positions, levels of firmness, temperature, or customized bedding.

A USDA circular promoting home production of cotton mattresses. Via Wikimedia.

A USDA circular promoting home production of cotton mattresses. Via Wikimedia.

Bedding that is worn out and uncomfortable will impair your sleep and that will have a negative impact. And there is evidence that poor sleeping, medicated sleeping, or interrupted sleep complicates back and neck problems. Otherwise save your money. There is absolutly no evidence that a expensive mattresses or pillows are any better for back or neck problems than more affordable models.

As a interesting aside: the lowest incidence of back pain is found in developing countries, while wealthy, highly industrialized countries have the greatest incidences of back and neck pain. The minimal bedding typically found in poorer countries may indicate that bedding may be totally inconsequential. But this generalization has major flaws: it assumes that bedding is the main factor in neck and back pain. I believe that access to health care and relative seriousness of the problem makes it an ignored issued. Meaning, if you are starving or suffering with deadly disease, back pain is low on the scale of complaints when you finally get to see a doctor. Additionally in the west you see a distinct spike in pain complaints in countries that have the greatest social support for lower-back-pain sufferers, such as UK, Sweden, and United States. There is no secondary benefit in the third world, and this focusing on reporting and treatment may skew the argument.

Trancutaneous Electrical Nerve Stimulation (TENS) Devices
Heavily marketed TENS units use small battery-operated devices to provide continuous electrical impulses to the skin via surface electrodes, with the goal of providing symptomatic relief by modifying pain perception. They are sometimes used by physical therapists. Manufacturers of the devices have recently made a big push to market it as an over-the counter treatment, famously including ex-professional basketball player Shaquille O’Neal for a celebrity endorsement. Like many marginal treatments used in pain management, it lacks strong or supporting evidence. A systematic review included one small (n = 30) trial that found TENS superior to placebo. But a larger (n = 145), well-blinded trial found no differences between TENS and sham treatment on any measured outcome, suggesting that the small trial may have been too small to account for statistical noise.

TENS units usually have a prescribed treatment regimen of 20-60 minutes of stimulation. Patients at home often do not use them as a they are prescribed. Commonly they use them like a heating pad and/or ice pack for long periods of time. There is no evidence that long-term use of these devices is dangerous; still, it may produce problems with prolonged application. Although I will occasionally prescribe electrical stimulation as part of a physical therapy plan, I would not recommend it as a home treatment. Overall the current evidence indicates that electrical stim is probably at best a mild pain-relieving treatment, no better than massage or icing. The units are relatively expensive at $30 – 40 each.

Acupuncture and dry-needling have both been studied in lower-back pain, although predominantly for chronic symptoms. The techniques differ in that acupuncture targets are typically determined by a traditional Chinese map linking specified points and lines (called “meridians”) to mystical physiologic variables and the flow of energy in the body. There are several schools and techniques and practitioners often invoke the fallacious appeal to ancient wisdom. Dry-needling involves the use of needles (frequently acupuncture needles) inserted directly at points of myofascial pain to try to relieve pain and tension at those points. This proposed underlying mechanism is an implausible pre-scientific idea that is invalidated by our current knowledge of physiology.

Acupuncture chart from the Ming Dynasty, called "The Pericardium Meridian of Hand-Jueyin." Via Wikimedia.

Acupuncture chart from the Ming Dynasty, called “The Pericardium Meridian of Hand-Jueyin.” Via Wikimedia.

Randomized trials of acupuncture and dry-needling tend to be small and heterogeneous in methodology, and blinding is difficult. The consensus of research appears to find it is no better than sham treatment and at best equivalent to manipulation and massage. Three acupuncture trials for acute lower-back pain were identified in a recent review; these studies found positive results, but the quality of the trials was too poor to draw definitive conclusions. Recent experiments have attempted to improve the blinded control of such trials by using acupuncture needles that are contained in an opaque sheath. In those experiments, the acupuncturist depresses a plunger. The needle remains unseen and the plunger (when there is no needle) conceals any sensation of the needle being inserted. Neither the practitioner nor the patient knows if the needle is actually inserted. These well-controlled studies show no difference between those who received needle insertion and those who did not—supporting the conclusion that acupuncture has no detectable specific health effect.

Ergonomics in the home or workplace

Ergonomic seat in Lam Tim Station, Hong Kong, China. Via Wikimedia.

Ergonomic design of strenuous job tasks in the workplace is an intuitively attractive preventive measure. An entire industry has been built around this premise, despite the paucity of supporting evidence. Rigorous evaluations of such interventions are difficult, because of heterogeneity in job tasks, restrictions imposed by labor and management, regulatory requirements, the difficulty of blinding, and many other factors. However, there is at least modest evidence from a clinical trial in which entire companies were randomly allocated to intervention or control conditions, suggesting that ergonomic design of job tasks may facilitate return to work and reduce the chronic nature of pain.

Although ergonomics is probably not harmful in any way, it has the same level of evidence as taking any host of implausible substances or treatments. I cannot recommend it. Spending a lot of money having someone changing your work or home space to be better for your back is probably not worth the money.

Corsets, Braces and Traction
Although there is some benefit to traction in radiculitis (pain radiating into the arms or lower extremities from a spinal issue), most of these treatment modes have little or no benefit. Exercise therapy seem to make people worse in the initial stages. High-quality evidence shows no benefit to exercise therapy in the initial two to three weeks, and no benefit to corsets, braces, or traction therapy. People often feel more secure in braces and they will anecdotally say they are helpful. Good research says bracing just doesn’t work, which is logical since it’s impossible to immobilize the neck or lower back with removable braces, and it does nothing to alleviate the weight upon the spinal column. In my opinion, for uncomplicated axial lower back pain skip the back braces. Exercise is helpful, especially for chronic lower back pain, though it’s not helpful for acute events.

Clicking and Popping of the Spine
Nothing gives people more concern than popping noises in the spine. It is a universal body issue. Young healthy spines pop due to dissolved gases in the spinal structures. Liquids within the soft tissues have gas dissolved in them. When you move or stretch the spine structures in the right way you reduce pressure in the fluid. Like a bottle of soda when you open the cap, bubbles appear in the fluid. A similar thing happens to fluids in your spine interspaces. Bubbles will appear, then collapse when the structure resumes its normal pressure, with the gas quickly redissolving. That quick appearance and dissolve results in an audible “pop” or snapping sensation. It is not pathology and does not cause damage. Older spines that pop and click are usually a little different. As we all age the structures in our back lose resiliency and bony structures that shouldn’t touch, do. With motion, that bone-on-bone contact can generate snapping and popping. It is a sign of pathology. It is a sign of age-related change to the spine. It is a symptom of what causes the pain, the spinal degeneration is the cause, the sensation is not dangerous or abnormal. Everyone does this to some degree and it is not indicative of a bigger problem.

Joint pain, backaches, headaches—we all get them. If anyone is offering simple solutions to complex problems you have good reason to be skeptical. Talk to your doctor; if he/she thinks you need to see a specialist then do so. Please don’t just Google it and self treat. You’re wasting your time, money, and maybe doing something dangerous.

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Disclaimer: This post is my personal opinion, it is not a substitute for medical care. It is for informational purposes only. The information on Skeptoid blog is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. This post does not reflect the opinion of my partners, professional affiliates, or academic affiliations. I have no financial conflicts of interest to disclose.

About Stephen Propatier

Stephen Propatier is a board certified acute care nurse practitioner specializing in spine and sports medicine. He is a member of the Society for Science Based Medicine.
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8 Responses to Joint Pain: Scams, Lies, and Exaggerations, Part 2

  1. Walter Clark says:

    Excellent report Stephen. I’m looking forward to more from you.

  2. Lazer says:

    I agree… very informative and enjoyable to read.

  3. Jon says:

    Hey, great article, really nicely explained. Just checking that it’s the right link for acupuncture (2005)? More recent reviews seem to be in support of acupuncture (dry needling) having an analgesic effect. Love to hear your comments.

  4. Thanks for bringing this up. I didn’t include the most recent studies that are best structured since they are pay only. This is probably the best one that demonstrated no effect.

    In respect to this review having a newer publishing date doesn’t mean it has newer information. This meta has been done so many times. It is so broad across with so many different modaltities and included “grey literature,” such as dissertations and conference reports. Search terms used were (systematic review OR meta-analysis) AND (acupuncture OR acupuncture therapy OR acupuncture points OR needle OR electro-acupuncture OR auricular-acupuncture OR warm-acupuncture OR dry needling OR trigger-point therapy OR moxibustion) AND (low back pain OR back pain OR backache OR lumbago OR sciatica OR dorsalgia). Then the researchers sorted them to the next step.
    If you look at the selected research tables you will see that the authors selected from all over the map including translated studies and dissertations. A good meta analysis isolates to one mode of treatment. Meaning acupuncture not- acupuncture, and electric stim acupuncture and dry needling and ear acupuncture. That inclusion is guaranteed a false positive since you are including far to many data points. Secondly good meta means you compare studies with similar controls. sham acupuncture is not just one type of control it has many meanings. everything from toothpics to fingers. Again a conflation of many different variables that will guarantee a positive finding.
    In my opinion, that is why it was published in the alt med journal rather than Spine or Anesthesia analgesia. They would never have accepted the methods of this meta-analysis.

    There are more methodological objections. Too many to put in a comment section. Bottom line if you use a shotgun your going to hit something, but I wouldn’t use a shotgun for surgery.

    If you take a good look at the discussion about the sham acupuncture discussion in their own paper they admit that no matter what type of sham or what location it is done on it “works.”
    That means it doesn’t work. It is the placebo effect with the ceremony to cement the effect. Consistent with the common special pleading surrounding acupuncture.
    If, indeed, sham acupuncture is no different from real acupuncture, the apparent improvement that may be seen after acupuncture is merely a placebo effect. Furthermore, it shows that the idea of meridians is purely imaginary. All that remains to be discussed is whether or not the placebo effect is big enough to be useful, and whether it is ethical to prescribe placebos.

  5. Stephen DeGiulio says:

    As for people in the wealthy, “developed” countries having a lot more lower back problems than those in poor countries (beginning of article)–I think there is another factor. In wealthy countries the average “chair time” that is, time sitting at desks, watching screens, in vehicles, at table, in theaters, etc. is much higher than in poor countries, where the poor often have to work constantly rather than sit down, since they have to do all their own domestic work, as well as any other work they can find to survive. Hence, they probably have stronger and more flexible backs as opposed to chronically shortened postural muscles as the wealthy tend to have. Wadayasay?

    • Well although that is good job of skeptical thinking. The incidence of back pain statistically goes up dramatically in line with physical jobs and also with declining incomes. So the population that has the lowest incident of back pain complaints statistically are the colloquially termed White Collar employees.

  6. Martin says:

    Very interesting article. I’ve had back pain and Piriformis Syndrome (similar to Sciatica) for a number of years. Due to my work, I’ve lived in a number of different states and, have had the benefit of different therapies, prescribed by different physicians…none of which worked. However, recently I had a Spinal Cord Stimulator implanted, and it has removed a great deal of my pain. For the first time in years I’ve reduced the opiod drugs by half, and will continue to reduce them further. I noticed that you failed to mention this treatment in your article. I had tried this therapy 15 years ago and it was termed a “failed surgery” because of some scar tissue that I had (from previous back surgeries). However, they have improved on the SCS in those 15 years and now the scar tissue is no problem. The next time you write such an article, please include this therapy, as it literally gave me my life back. Thanks.

    • Martin thanks for your thoughtful insight and anecdote. It is good point but spinal simulators for pain control have conflicting findings in research. Overall compared to index research they are disappointing. I am glad that it works for you but there overall efficacy is very low and you are a minority. Given the fact that they are fairly invasive I have reservations.

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