One of my favourite stories along these lines (this is from Ben Goldacre's great book Bad Science, and may be slightly misremembered in parts) is about Archie Cochrane, who gave his name to the Cochrane Collaboration, an organisation who rigorously analyse the evidence for medical treatments, even "obvious" ones. He set it up after being a Japanese prisoner of war, where he had to make decisions about medical treatment in the face of extremely callous treatment by the Japanese officers. They were often decisions you only hear about in philosophical games - e.g. do you save one person's life or the sight of ten people - and he realised that much of his medical training was not based on proper evidence.
In the UK in the 1970s, hospitals started equipping expensive cardiac units, specifically designed for the treatment of heart attacks, full of expensive medical equipment (and if HN doesn't mind a good-natured tease, cardiac surgeons don't exactly shun the heroic mode of medicine). Part-way through a Cochrane study of their effectiveness, the data was pointing to survival rates being slightly higher when people were treated at home rather than in the cardiac units, but the results were not statistically significant. He decided to play a trick and annouced at an interim meeting that the data were pointing the opposite way - that treatment in cardiac units showed slightly higher survival rates, but were still not statistically significant. The doctors in the meeting were extremely angry that he insisted that the study should go on because the results were not statistically significant and therefore no conclusions could be drawn from the data. It wasn't until later in the meeting that he came clean, and told them that the data were pointing in the other direction. Funnily enough, none of the doctors still called for the study to be halted early in the face of identical evidence, just pointing to a different conclusion.
This kind of thinking is so common I often wonder how the hell we manage to progress as a species. People seem to only ever look at the evidence that supports positions they originally adopted for bad reasons. I can't remember the last time I talked to anyone who could recall to me a single time they changed their mind based on seriously weighing evidence for & against their positions. People Google to find out why they're right and that's the end of it.
The Cochrane Collaboration is a noble effort but its impact is limited in practice. There is a huge incentive to produce papers in the modern medical system, and I'm in a good place to know that you can make the data say whatever you want with techniques such as meta analysis, which incidentally is a big part of Cochrane studies. Meta analysis as a field has grown trendemously because who doesn't want to publish high impact papers without having to gather any new data, right? Publication of end-to-end single-command build reproducible research should be the only one allowed at this point, with everything accessible to the reader, including data. I've been doing shit medical science for ten years already because of hierarchical pressure, and I'd love a change of course.
Nitpick: Cochrane was British then did not fight against the Japanese, and he was prisoner of war in a German camp.
Here is his story about the prisoners' camp[1] and there is no mention of blinding people, “just” German soldiers shooting or throwing grenades at random on prisoners.
I don't follow your anecdote. Why would the surgeons want a non-significant study to stop when they were coming out on top, and want it to continue when they were coming out on the bottom?
In either case it's non-significant, so continuing it will likely
1) continue to be negative, or
2) develop large enough n that the trend becomes signifant.
If it's 2, then the incentives are exactly the opposite of what you outlined, if I'm understanding what you wrote.
I mean Ben Goldacre's book itself is a pretty good example of people being irrational. He's mostly just covering the same ground as Marcia Angell's earlier book The Truth About Drug Companies, which "skeptics" hated. But when Goldacre published his book the same folks decided they loved it, presumably because it was written by a man.
I mean don't get me wrong, there's enough difference between them that it's absolutely worth reading both of them, but the difference in reception between them was shocking.
Does anyone have any examples of surgeries that are done today in modern medicine that are basically placebo? I'm surprised the article didn't give a single example.
"Does anyone have any examples of surgeries that are done today in modern medicine that are basically placebo?"
Spinal fusions for injuries not sustained in car accidents or horse throws or ... other literally back-breaking trauma.
People with plain old uninteresting everyone-gets-it back pain get spinal fusions - a major, invasive surgery. There is a complicated nexus of obesity, refusal to do PT exercises, and huge economic incentives for surgeons that lead to these procedures.
This critical review even mentions a Cochrane review[1]:
"... and often does not even result in the spine being fused. That last one is not a big deal, because the results of the surgery are not well correlated with whether or not the spine fuses."[2]
I've had 5 orthopedic surgeries and they were transformative -- and this article is written by an orthopedist!
There's some data [1] against these operations:
- Arthoscopic knee surgery
- Subacromial shoulder decompression
- Acromioplasty for rotator cuffs
- Vertebroplasty for the spine
That's 4 techniques out of...how many exactly?
It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. I don't want to get into the gory details but I feel incredibly grateful to have had such talented surgeons.
You can argue placebo but my years of ineffective physical therapy suggest otherwise.
Instead of saying "Surgery, the Ultimate Placebo" this article should say "A handful of specific surgeries shown to be no better than a placebo" -- generically describing all surgeries as a placebo is clickbait, in my non-medical-professional opinion.
> It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. [...] You can argue placebo but my years of ineffective physical therapy suggest otherwise.
They don't though, do they. You can't disprove placebo with N=1.
If the placebo is the act of surgery then anything not surgery not working doesn't mean that the surgery worked by not placebo means.
Orthopedic surgery is, IMHO, one the most "controversial" medical fields. Ask an orthopedic surgeon, and the answer will be in most cases surgery. Ask a non-surgeon orthopedic, and the answer will be therapy. Source: Having gone through some consultations, and having family that spent their professional career in orthopedic rehab.
Thing is, for every case one of the above might wrong there are two cases they might be right. Sometimes both are right.
Personally, I choose to forgo surgery. I have no intention to become a professional athlete or compete again, so I stick with my original parts, so to say. I did stop snowboarding and kickboxing, so. My knees really don't like these sports anymore. And I don't like them enough to go through surgery. I switched to boxing and skiing. I am rather sure that I would chosen surgery like 10 years or so ago.
If a surgery’s effectiveness has not been evaluated vs a placebo, you cannot assume it to be effective based on anecdotes. Obviously there are many surgeries that are effective (repeating broken limbs, emergency surgeries, etc). Those surgeries having to do with pain relief are more nebulous.
My partner is a physical therapist, and in cases where it’s ineffective, it’s often because the patient is noncompliant or is doing it just to check off that “attempt” prior to surgery. A relative, as an example, goes to PT for all sorts of issues, but her real problems are psychological/neurological (due to brain damage); no amount of PT will ever heal her mind or change her excessive perception of pain.
It's really interesting how people with theoretical knowledge of what the placebo effect is can still refuse to believe in it in practice. From my experience, I think a lot of doctors don't really believe in these effects.
> Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears?
> Findings: In this noninferiority randomized clinical trial that included 321 patients, knee function that was measured by a self-administered questionnaire improved by 20.4 points in the physical therapy group vs 26.2 points in the early surgery group over a follow-up period of 24 months. The difference between the 2 treatment groups did not exceed the noninferiority margin of 8 points.
> Meaning: These results demonstrate noninferiority of physical therapy compared with early surgery with arthroscopic partial meniscectomy for improving self-reported knee function in patients with nonobstructive meniscal tears.
"Question: Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears?"
Vertical (deep, interior) meniscal tears can actually heal, since they have a blood supply, and the surgery for them is basically a coin flip - the results of which you only learn after a nine month recovery period.
You should absolutely be pursuing a rigorous course of PT to heal such a vertical meniscal tear. You should specifically look into whether your adductors (inner leg) are weaker than, and being overpowered by, your abductors (outer leg) resulting in knee valgus.
I had a meniscectomy a couple of years ago. When I looked at the monitor during the procedure, my meniscus was looking as if someone just threw an egg in boiling water, spread all around in thin strands.
Kind of hard to say you'll just do PT when a night of dancing leads to locking the knee at certain points.
At the way it was looking on the display, there is no way I did not have mechanical issues because of it.
Anecdotal evidence, but I tore my meniscus playing football when I was 14. I thought I would have to have surgery but the doctor just told me to use crutches and a knee brace for a while.
It healed up really well, didn't have any issues afterwards.
I had undiagnosed Familial Mediterranean Fever for years in my early 20s. Terrible, sickening abdominal inflammation attacks every few weeks.
After about 5 years I was desperate and one doctor said my gallbladder did show signs of low functioning, and recommended taking it out.
I did go into “remission” for about 8 months after. It eventually came back, but then faded soon after. It wasn’t until a few years later with a DNA test that I found the cause.
But I did always wonder if the surgery, along with my desperate hope to be better / not be wrong, had such a strong placebo effect that it actually did help me out.
> Familial Mediterranean fever (FMF) is a hereditary inflammatory disorder... an autoinflammatory disease caused by mutations in Mediterranean fever gene, which encodes a 781–amino acid protein called pyrin.
I'm halfway through the talk right now (shoutout to Youtube 2x speed). This is fascinating and brilliant, but so frustrating, because there is no way for us to ethically use placebos for human benefit. I would love if every doctor I ever saw first treated me with placebo, and only tried something else once placebo treatment was ineffective, but can that ethically be done without me knowing? And if I know, the placebo won't work.
I believe the placebo effect can also work just by telling someone about it (and then giving them the sugar pill or whatever). However, the whole placebo effect may just be (poor understanding of) statistics, namely regression to the mean. Here's an article [0] (found via Wikipedia on placebo [1])
A lot of placebo effects still show up when the patient knows they're getting placebos. It probably has some ritualistic advantage in helping them mentally.
I have direct experience in the "doctor's know that under their care it works".
In an earlier startup we developed a particular dissolving mesh that could be placed in situ in a surgical site to prevent adhesions. E.g. if you tear your rotator cuff, the healing of sewn up region will adhere not only to the cuff but other parts of your shoulder, preventing it from moving. The only fix is to (painfully) move the shoulder as it heals to tear those adhesions and form some scar tissue.
Experiments in animals showed that they would recover full motion in their joints with no apparent discomfort.
But when we interviewed doctors we discovered that they knew this was a terrible problem but blamed it on the techniques of other doctors. "When it's my turn on call I get these calls from patients, some in terrible pain. I am very careful and my patients never have this problem. This sounds like a great idea though I'd never use it myself." Of course we sometimes talked to multiple doctors in the same physician's group and they would say this about each other.
We ended up using the technology in a different (medical) application.
my brother had never water sky(ed) before, so after a month of vacation doing it, he felt his knees. he talk about it with two doctors and they both wanted to perform surgery on his knees. he went and got a third evaluation and the third doctor told him the truth: that he didn't needed surgery and the doctors were after his money. the doctor proceeded by putting my brother in physical therapy, which healed both of his knees.
this is a real history. but there are plenty of other medical shows about the same subject - surgeons trying to force surgery on people that don't actually need it.
This is dangerous thinking. For example when it comes to chronic pain, there is that belief being pushed that opioids are actually a placebo and they don't help. Then people are being sentenced to a talking therapies instead. These therapies try to implant the thought that all the pain people experience is in their heads and it is not real. If only they could just stop thinking about pain, then they wouldn't need to take any pills. This is one of the reasons why people turn to dealers, if doctors start to believe this and are made afraid of prescribing anything. Also organisations who get involved in such "therapies" promote them, because that is, let's be honest, rather easy money from the public health organisations. It fits the western perception of suffering, that it is noble and virtuous. I wish this topic was explored more by investigative journalists.
This is a baffling mischaracterisation of the arguments.
People don't say that opioids are a placebo. They say that people taking opioids develop tolerance for them and the meds lose effectiveness over time. This means that people are still in pain, but are now also taking dangerous and debilitating amounts of opioid meds. Their function is worse because of the opioids.
Providing talking therapy to these people isn't saying that the pain is not real. You saying this causes harm and you need to stop saying it, because you clearly do not understand what's happening.
When people have long term pain they lose function. They stop doing activities they used to enjoy. Their quality of life plummets. This makes their pain worse. (We know this, there's plenty of research.) Talking therapy aims to get people their life back by helping them regain function. They start to learn to live with pain. They get back to doing activities they enjoy. This doesn't eliminate pain, but it does lessen the pain and it improves quality of life.
You seem to think that "pain free but on opioids" is possible. For most[1] people in long term pain that's not possible, because opioids don't work like that.
I dealt with a case of chronic patellar tendonitis for years between ages 23 and 26. Debilitating to the point where I could not go anywhere that would require me to stand in line. The book Healing Back Pain by John Sarno, which is basically the talking therapy you mentioned, was hugely transformative for me. I was able to stop fixating on the pain and focus on strength training knowing that flare up were no big deal. I'm recovered now and regularly skateboarding and standing in line again.
Edit: I should mention I spent upwards of an hour each day for those years doing physical therapy rehab. I turned down recommendations of surgery during that time as well.
I think there is evidence that people's attitudes toward pain can affect both the amount of pain that they feel and how much they suffer from it, and more generally that there are mental skills related to pain management and experience that are genuinely useful. (Also, there are cases where classic psychotherapy or psychoanalysis methods led to an alleviation or complete disappearance of somatic pain symptoms, even without focusing at all on the symptoms or pain themselves... although it doesn't seem ethically appropriate to somehow assume that that would be the best treatment for everyone.)
I agree with the concern that this should not be seen as a substitute for helping reduce people's suffering with pain medication. But I think we also still have lots to learn about the mental component of pain and potentially identifying psychological interventions that make a difference in this area.
I also agree that the "all the pain people experience is in their heads" angle isn't a constructive one, both because of its proximity to accusing people of lying or malingering, and because it doesn't seem like a helpful summary of any apparently-beneficial psychological techniques.
I don't think there are any doctors, except perhaps a handful of cranks, who believe that opioids are "a placebo". Perhaps you mean something else? There are definitely doctors who underprescribe pain medications to certain groups of people - as I understand it, women are notably underprescribed pain medications for example - but that doesn't mean that those people think opioids are a "placebo".
This really isn't true. (Source: I'm a psychiatrist who treats some forms of chronic pain, while also treating people with opioid use disorder who started with prescription pills).
Good psychotherapy for chronic pain explicitly acknowledges that pain is real and not just in the patient's head. Chronic pain is thought (at a grossly oversimplified level) to be due to nerve sensitization rather than acute trauma, but experience, co-morbid health problems, and life stressors all interact to influence this.
Psychotherapy for chronic pain helps people identify maladaptive behaviors that could be worsening chronic pain, and then help to set goals and learn skills to improve their overall function. On average, it's only modestly effective, but it's better than many alternatives.
Some people might say that opioids are a placebo. A more nuanced statement would be that most trials can't distinguish between opioids and placebo for chronic pain. That doesn't necessarily mean they don't work for an individual, it just means that it's an intervention based upon low-quality evidence. On the other hand, opioids come with significant (and occasionally catastrophic) risks, and so the decision to pursue a high-risk/low-benefit treatment is discouraged. There are always exceptions, but I've been really pleased with the results I've seen as we've moved further away from opioids for chronic non-cancer pain.
What does it mean for pain to be "real" vs experienced in one's head? I don't think this is an easy question, which is why our medical system struggles to deal with chronic pain.
This doesn't contain the details that would interest me.
My understanding is modern surgery routinely involves significant antibiotics to prevent serious infection during the operation. If that's followed with both "sham" surgeries and real surgeries, then it points to the possibility that the strong antibiotics are more important in some cases than the procedure.
There may be other medically significant details of sham surgeries that we overlook as not therapeutic. Many diagnostic exams involve not eating for x hours beforehand. Surgeries also can involve restrictions on diet during recovery or exposure to drugs like anesthesia that are given without intent to be therapeutic per se.
You can't really rule out the possibility that those types of things are therapeutically significant but overlooked because they are done to be curative.
Yeah it's always seemed bizarre to me that surgical procedures aren't held to the same standard of evidence as drugs and surgeons are allowed to pretty much make things up and do whatever they want as long as they don't engage in clear malpractice.
There is an absolutely fantastic quote relevant to this in An Astronaut's Guide to Life by Chris Hadfield (a fantastic book). Unfortunately, I don't have the book handy and cannot do it proper justice, but the part I refer to involves dozens of years after a childhood appendectomy when Hadfield was beginning his "real" astronaut career.
After experiencing severe abdominal pain at the surgical site, he was sent to a panel of surgeons for guidance. Going into surgery at this time would've been catastrophic to his career, as after a surgery one cannot fly into space for some extended period of time. At this point in his career Hadfield was relatively green, and there was a plethora of new astronauts as talented as he was just waiting to take his spot. Going into surgery at this point would have relegated him to a successful career at mission control, but not in space.
To the best of my recollection, his physician's opinion was he didn't need a full surgery to investigate this abdominal pain. However, the panel of surgeons universally, unequivocally recommended the gastrointestinal surgery. He states infinitely more eloquently than I can how applicable "uf you only have a hammer, everything looks like a nail" in regards to the surgical panel.
I recall he decided against the recommendations of the surgeon panel, and decided his abdominals wouldn't suddenly tear apart with potentially fatal results while orbiting earth in the ISS. It turns out he guessed right, and had one of the most prolific careers of any astronaut of the last few decades.
While this anecdote may make it seem like I am some anti-surgeon, anti-surgery person, let me state that I have had one surgery (besides wisdom teeth, which "doesn't count" as it's so common). It was an orthopedic reconstructive ulnar collateral (thumb) surgery, and my repaired thumb is honestly almost indistinguishable from my left thumb. And in this case it was clear surgery was needed, but after reading Hadfield's book and the parent article here it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery. I think just like overprescription of antibiotics, we as a society should look at the overprescription of surgeries for medical issues which can be treated without surgical intervention.
The column is fudging the facts to justify its bombast title.
Example:
> A systematic review found that placebo was just as effective as surgery in over half of the cases studied, and all of the recent trials comparing surgery to placebo have found that surgery was no better than placebo.
We note that that the text doesn't tell us...:
1. which kind of operation is supposedly not very helpful.
2. which kind of medical condition(s) were studied.
3. whether the relevant medical condition is transitory/accute or chronic;
4. whether the condition is known to be amenable to non-surgical treatment;
5. what review this was, exactly, and where one can read the details.
6. what, exactly, the review reviewed.
7. what happened in the less-than-half the cases.
8. what chances of success the surgery purports to have. i.e. it might be a surgery which proponents suggest solves the problem in 45% of cases and has little effect (but no significant negative effect) in 55% percent of cases - in which case you "get what it says on the label".
Also, I would assume are almost no, or no trials comparing surgery to placebo where surgery is known, or reasonably assumed, to be efficacious. So those "recent trials" probably considered surgical procedures which are apriori under suspicion of not being efficacious. etc.
I've been told by more than one doctor (for chronic pain I had been having) to avoid seeing a surgeon unless absolutely necessary because they were worried the surgeon would recommend surgery even if it wasn't needed. I found it interesting. Seemed like they didn't trust their colleagues (or even they didn't trust me to make my own decision if I got the recommendation to undergo surgery).
Different, but a related topic that I've come to be fascinated by are athletic tools and techniques that are held as canon that turn out to have no scientific support.
The author talks about reactions of physicians dismissing convincing data — the befuddlement and dismissals — and it's the same reaction athletes and coaches give when they're part of some of a controlled trial.
This topic reminds me of a subthread of the last time we discussed Alzheimer's research. And more specifically about the great public tragedy caused by overconfidence on the part of medical researchers. The details are different, but the fundamental pattern is the same.
Sometimes animals are in abdominal pain, supplementary exams leave us clueless and we resort to surgery to see whats happening, nothing looks wrong inside, we stitch them back and the patient gets better nonetheless.
Had scoliosis-kyphosis fusion surgery when I was 14 and it was rapidly-progressing. All it did was cosmetic and bought me time until Functional Patterns was invented. Today I am 70% cured. It's basically strength training according to the body's myofascial slings (gait). Flat feet, knee valgus, scoliosis, jaw growth, forward head – it's all connected.
Still, no surgeon in the world would undo (as in chip away the bone grafts limiting my spinal mobility) my fusion.
Sloan-Kettering publishes a set of online predictive tools [1] patients can use to make statistical estimates of the outcomes of surgery and other treatments. They're based on data from thousands of patients.
Microdiscectomy for treatment of sciatica, numbness and foot drop from a herniated disc is highly effective (most people see a 90-100% reduction in symptoms) and minimally invasive. However, the longer term outcomes are mixed because many patients dont stick to the required long term PT (maintaining excellent core strength and avoiding risky activities like lifting heavy objects) and end up reinjuring themselves. Many people dont need the procedure and can releive symptoms through conservative therapy, but some cannot and will benefit from surgery, especially if the condition is causing extreme pain, weakness or loss of function that make physical therapy almost impossible. Its misleading for him to say that surgery “doesn’t work” when there are so many complicating factors impacting the population-wide, long term efficacy of a treatment. Surgery is just one step of many that you would take in order to recover and stay better. Talk to multiple surgeons as well as other patients to understand if surgery is the best option for your particular situation.
[+] [-] frereubu|5 years ago|reply
In the UK in the 1970s, hospitals started equipping expensive cardiac units, specifically designed for the treatment of heart attacks, full of expensive medical equipment (and if HN doesn't mind a good-natured tease, cardiac surgeons don't exactly shun the heroic mode of medicine). Part-way through a Cochrane study of their effectiveness, the data was pointing to survival rates being slightly higher when people were treated at home rather than in the cardiac units, but the results were not statistically significant. He decided to play a trick and annouced at an interim meeting that the data were pointing the opposite way - that treatment in cardiac units showed slightly higher survival rates, but were still not statistically significant. The doctors in the meeting were extremely angry that he insisted that the study should go on because the results were not statistically significant and therefore no conclusions could be drawn from the data. It wasn't until later in the meeting that he came clean, and told them that the data were pointing in the other direction. Funnily enough, none of the doctors still called for the study to be halted early in the face of identical evidence, just pointing to a different conclusion.
[+] [-] saas_sam|5 years ago|reply
[+] [-] rscho|5 years ago|reply
[+] [-] littlestymaar|5 years ago|reply
Here is his story about the prisoners' camp[1] and there is no mention of blinding people, “just” German soldiers shooting or throwing grenades at random on prisoners.
[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1444794/?page=1
[+] [-] appleflaxen|5 years ago|reply
In either case it's non-significant, so continuing it will likely
1) continue to be negative, or
2) develop large enough n that the trend becomes signifant.
If it's 2, then the incentives are exactly the opposite of what you outlined, if I'm understanding what you wrote.
[+] [-] Alex3917|5 years ago|reply
I mean don't get me wrong, there's enough difference between them that it's absolutely worth reading both of them, but the difference in reception between them was shocking.
[+] [-] owenversteeg|5 years ago|reply
[+] [-] rsync|5 years ago|reply
Spinal fusions for injuries not sustained in car accidents or horse throws or ... other literally back-breaking trauma.
People with plain old uninteresting everyone-gets-it back pain get spinal fusions - a major, invasive surgery. There is a complicated nexus of obesity, refusal to do PT exercises, and huge economic incentives for surgeons that lead to these procedures.
This critical review even mentions a Cochrane review[1]:
"... and often does not even result in the spine being fused. That last one is not a big deal, because the results of the surgery are not well correlated with whether or not the spine fuses."[2]
[1] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD...
[1] http://doctorskeptic.blogspot.com/2012/08/is-lumbar-spine-fu...
[+] [-] ordinaryperson|5 years ago|reply
I've had 5 orthopedic surgeries and they were transformative -- and this article is written by an orthopedist!
There's some data [1] against these operations:
- Arthoscopic knee surgery
- Subacromial shoulder decompression
- Acromioplasty for rotator cuffs
- Vertebroplasty for the spine
That's 4 techniques out of...how many exactly?
It's just an n=1 anecdote but my surgeries absolutely changed my life for the better. I don't want to get into the gory details but I feel incredibly grateful to have had such talented surgeons.
You can argue placebo but my years of ineffective physical therapy suggest otherwise.
Instead of saying "Surgery, the Ultimate Placebo" this article should say "A handful of specific surgeries shown to be no better than a placebo" -- generically describing all surgeries as a placebo is clickbait, in my non-medical-professional opinion.
[1] https://www.realclearscience.com/blog/2020/11/07/some_surger...
[+] [-] OJFord|5 years ago|reply
They don't though, do they. You can't disprove placebo with N=1.
If the placebo is the act of surgery then anything not surgery not working doesn't mean that the surgery worked by not placebo means.
But who cares how, it worked!
[+] [-] hef19898|5 years ago|reply
Thing is, for every case one of the above might wrong there are two cases they might be right. Sometimes both are right.
Personally, I choose to forgo surgery. I have no intention to become a professional athlete or compete again, so I stick with my original parts, so to say. I did stop snowboarding and kickboxing, so. My knees really don't like these sports anymore. And I don't like them enough to go through surgery. I switched to boxing and skiing. I am rather sure that I would chosen surgery like 10 years or so ago.
[+] [-] grumple|5 years ago|reply
My partner is a physical therapist, and in cases where it’s ineffective, it’s often because the patient is noncompliant or is doing it just to check off that “attempt” prior to surgery. A relative, as an example, goes to PT for all sorts of issues, but her real problems are psychological/neurological (due to brain damage); no amount of PT will ever heal her mind or change her excessive perception of pain.
[+] [-] rozab|5 years ago|reply
[+] [-] appleflaxen|5 years ago|reply
[+] [-] voxl|5 years ago|reply
[+] [-] chillwaves|5 years ago|reply
> Findings: In this noninferiority randomized clinical trial that included 321 patients, knee function that was measured by a self-administered questionnaire improved by 20.4 points in the physical therapy group vs 26.2 points in the early surgery group over a follow-up period of 24 months. The difference between the 2 treatment groups did not exceed the noninferiority margin of 8 points.
> Meaning: These results demonstrate noninferiority of physical therapy compared with early surgery with arthroscopic partial meniscectomy for improving self-reported knee function in patients with nonobstructive meniscal tears.
https://jamanetwork.com/journals/jama/fullarticle/2705186
[+] [-] rsync|5 years ago|reply
Vertical (deep, interior) meniscal tears can actually heal, since they have a blood supply, and the surgery for them is basically a coin flip - the results of which you only learn after a nine month recovery period.
You should absolutely be pursuing a rigorous course of PT to heal such a vertical meniscal tear. You should specifically look into whether your adductors (inner leg) are weaker than, and being overpowered by, your abductors (outer leg) resulting in knee valgus.
[+] [-] TylerE|5 years ago|reply
Reading further in their additional conclusions, the surgery group also did better in both pain and general health.
[+] [-] RealityVoid|5 years ago|reply
Kind of hard to say you'll just do PT when a night of dancing leads to locking the knee at certain points.
At the way it was looking on the display, there is no way I did not have mechanical issues because of it.
[+] [-] react_burger38|5 years ago|reply
It healed up really well, didn't have any issues afterwards.
[+] [-] nwienert|5 years ago|reply
I had undiagnosed Familial Mediterranean Fever for years in my early 20s. Terrible, sickening abdominal inflammation attacks every few weeks.
After about 5 years I was desperate and one doctor said my gallbladder did show signs of low functioning, and recommended taking it out.
I did go into “remission” for about 8 months after. It eventually came back, but then faded soon after. It wasn’t until a few years later with a DNA test that I found the cause.
But I did always wonder if the surgery, along with my desperate hope to be better / not be wrong, had such a strong placebo effect that it actually did help me out.
[+] [-] fernly|5 years ago|reply
https://en.wikipedia.org/wiki/Familial_Mediterranean_fever
[+] [-] ngngngng|5 years ago|reply
[+] [-] chias|5 years ago|reply
This is not a given:
https://www.health.harvard.edu/blog/placebo-can-work-even-kn...
https://www.npr.org/sections/health-shots/2016/10/27/4994752...
[+] [-] podiki|5 years ago|reply
[0] https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2796....
[1] https://en.wikipedia.org/wiki/Placebo#Confounding_factors
[+] [-] andai|5 years ago|reply
[+] [-] ummonk|5 years ago|reply
[+] [-] epmaybe|5 years ago|reply
[+] [-] gumby|5 years ago|reply
In an earlier startup we developed a particular dissolving mesh that could be placed in situ in a surgical site to prevent adhesions. E.g. if you tear your rotator cuff, the healing of sewn up region will adhere not only to the cuff but other parts of your shoulder, preventing it from moving. The only fix is to (painfully) move the shoulder as it heals to tear those adhesions and form some scar tissue.
Experiments in animals showed that they would recover full motion in their joints with no apparent discomfort.
But when we interviewed doctors we discovered that they knew this was a terrible problem but blamed it on the techniques of other doctors. "When it's my turn on call I get these calls from patients, some in terrible pain. I am very careful and my patients never have this problem. This sounds like a great idea though I'd never use it myself." Of course we sometimes talked to multiple doctors in the same physician's group and they would say this about each other.
We ended up using the technology in a different (medical) application.
[+] [-] atum47|5 years ago|reply
this is a real history. but there are plenty of other medical shows about the same subject - surgeons trying to force surgery on people that don't actually need it.
[+] [-] varispeed|5 years ago|reply
[+] [-] DanBC|5 years ago|reply
People don't say that opioids are a placebo. They say that people taking opioids develop tolerance for them and the meds lose effectiveness over time. This means that people are still in pain, but are now also taking dangerous and debilitating amounts of opioid meds. Their function is worse because of the opioids.
Providing talking therapy to these people isn't saying that the pain is not real. You saying this causes harm and you need to stop saying it, because you clearly do not understand what's happening.
When people have long term pain they lose function. They stop doing activities they used to enjoy. Their quality of life plummets. This makes their pain worse. (We know this, there's plenty of research.) Talking therapy aims to get people their life back by helping them regain function. They start to learn to live with pain. They get back to doing activities they enjoy. This doesn't eliminate pain, but it does lessen the pain and it improves quality of life.
You seem to think that "pain free but on opioids" is possible. For most[1] people in long term pain that's not possible, because opioids don't work like that.
[1] most, not all.
[+] [-] jakehilborn|5 years ago|reply
Edit: I should mention I spent upwards of an hour each day for those years doing physical therapy rehab. I turned down recommendations of surgery during that time as well.
[+] [-] schoen|5 years ago|reply
I agree with the concern that this should not be seen as a substitute for helping reduce people's suffering with pain medication. But I think we also still have lots to learn about the mental component of pain and potentially identifying psychological interventions that make a difference in this area.
I also agree that the "all the pain people experience is in their heads" angle isn't a constructive one, both because of its proximity to accusing people of lying or malingering, and because it doesn't seem like a helpful summary of any apparently-beneficial psychological techniques.
[+] [-] frereubu|5 years ago|reply
[+] [-] euthymiclabs|5 years ago|reply
Good psychotherapy for chronic pain explicitly acknowledges that pain is real and not just in the patient's head. Chronic pain is thought (at a grossly oversimplified level) to be due to nerve sensitization rather than acute trauma, but experience, co-morbid health problems, and life stressors all interact to influence this.
Psychotherapy for chronic pain helps people identify maladaptive behaviors that could be worsening chronic pain, and then help to set goals and learn skills to improve their overall function. On average, it's only modestly effective, but it's better than many alternatives.
Some people might say that opioids are a placebo. A more nuanced statement would be that most trials can't distinguish between opioids and placebo for chronic pain. That doesn't necessarily mean they don't work for an individual, it just means that it's an intervention based upon low-quality evidence. On the other hand, opioids come with significant (and occasionally catastrophic) risks, and so the decision to pursue a high-risk/low-benefit treatment is discouraged. There are always exceptions, but I've been really pleased with the results I've seen as we've moved further away from opioids for chronic non-cancer pain.
[+] [-] blix|5 years ago|reply
[+] [-] MichaelZuo|5 years ago|reply
From experience suffering, in any form, certainly enhances the idea of the golden rule, that is ‘Treat others as you would like others to treat you’.
[+] [-] tcoff91|5 years ago|reply
Also, all pain even acute is literally 'in your head'
[+] [-] DoreenMichele|5 years ago|reply
My understanding is modern surgery routinely involves significant antibiotics to prevent serious infection during the operation. If that's followed with both "sham" surgeries and real surgeries, then it points to the possibility that the strong antibiotics are more important in some cases than the procedure.
There may be other medically significant details of sham surgeries that we overlook as not therapeutic. Many diagnostic exams involve not eating for x hours beforehand. Surgeries also can involve restrictions on diet during recovery or exposure to drugs like anesthesia that are given without intent to be therapeutic per se.
You can't really rule out the possibility that those types of things are therapeutically significant but overlooked because they are done to be curative.
[+] [-] resoluteteeth|5 years ago|reply
[+] [-] oarabbus_|5 years ago|reply
After experiencing severe abdominal pain at the surgical site, he was sent to a panel of surgeons for guidance. Going into surgery at this time would've been catastrophic to his career, as after a surgery one cannot fly into space for some extended period of time. At this point in his career Hadfield was relatively green, and there was a plethora of new astronauts as talented as he was just waiting to take his spot. Going into surgery at this point would have relegated him to a successful career at mission control, but not in space.
To the best of my recollection, his physician's opinion was he didn't need a full surgery to investigate this abdominal pain. However, the panel of surgeons universally, unequivocally recommended the gastrointestinal surgery. He states infinitely more eloquently than I can how applicable "uf you only have a hammer, everything looks like a nail" in regards to the surgical panel.
I recall he decided against the recommendations of the surgeon panel, and decided his abdominals wouldn't suddenly tear apart with potentially fatal results while orbiting earth in the ISS. It turns out he guessed right, and had one of the most prolific careers of any astronaut of the last few decades.
While this anecdote may make it seem like I am some anti-surgeon, anti-surgery person, let me state that I have had one surgery (besides wisdom teeth, which "doesn't count" as it's so common). It was an orthopedic reconstructive ulnar collateral (thumb) surgery, and my repaired thumb is honestly almost indistinguishable from my left thumb. And in this case it was clear surgery was needed, but after reading Hadfield's book and the parent article here it was astounding how the surgeons were literally unable to see any mode of treatment which didn't involve surgery. I think just like overprescription of antibiotics, we as a society should look at the overprescription of surgeries for medical issues which can be treated without surgical intervention.
[+] [-] einpoklum|5 years ago|reply
Example:
> A systematic review found that placebo was just as effective as surgery in over half of the cases studied, and all of the recent trials comparing surgery to placebo have found that surgery was no better than placebo.
We note that that the text doesn't tell us...:
1. which kind of operation is supposedly not very helpful.
2. which kind of medical condition(s) were studied.
3. whether the relevant medical condition is transitory/accute or chronic;
4. whether the condition is known to be amenable to non-surgical treatment;
5. what review this was, exactly, and where one can read the details.
6. what, exactly, the review reviewed.
7. what happened in the less-than-half the cases.
8. what chances of success the surgery purports to have. i.e. it might be a surgery which proponents suggest solves the problem in 45% of cases and has little effect (but no significant negative effect) in 55% percent of cases - in which case you "get what it says on the label".
Also, I would assume are almost no, or no trials comparing surgery to placebo where surgery is known, or reasonably assumed, to be efficacious. So those "recent trials" probably considered surgical procedures which are apriori under suspicion of not being efficacious. etc.
[+] [-] Ozzie_osman|5 years ago|reply
[+] [-] teorema|5 years ago|reply
The author talks about reactions of physicians dismissing convincing data — the befuddlement and dismissals — and it's the same reaction athletes and coaches give when they're part of some of a controlled trial.
[+] [-] btilly|5 years ago|reply
https://news.ycombinator.com/item?id=24906758 was the discussion, and https://news.ycombinator.com/item?id=24910211 has the at times heated discussion that I am referring to.
[+] [-] hycaria|5 years ago|reply
[+] [-] theriddlr|5 years ago|reply
Still, no surgeon in the world would undo (as in chip away the bone grafts limiting my spinal mobility) my fusion.
[+] [-] hughw|5 years ago|reply
[1] https://www.mskcc.org/nomograms
[+] [-] ishtanbul|5 years ago|reply