Sham surgery refers to faked invasive surgical procedures. While indisputably ethically a bit iffy, it’s really the only way to blind the patients and empirically determine if the intervention is effective. Several reviews of sham orthopaedic surgeries have demonstrated similar results to real surgery! This trend was identified when comparing shoulder labral repair surgery to sham, not just with perceived pain and patient satisfaction, but also with objective measures of function like joint stability. Similar results were found comparing sham vs actual surgery for arthritic knees, osteoporotic vertebral fractures and lateral epicondylitis (tennis elbow). There simply was not an impressive enough between group difference in either function or pain at a 2 year follow up to justify the risk of such an invasive intervention.
These studies have a relative small sample size and care must be taken before generalising the conclusions, however this surely challenges the long standing idea that we must correct altered anatomy or biomechanics to restore function and alleviate pain. These studies identify the body’s incredible capacity to modulate pain and function through beliefs, and this placebo effect must be further investigated.
It would be prudent for health care professionals to consider this before perpetuating the old school notion that your biology needs pills and procedures, rather than recognising that 100% of the time your pain is bio-psycho-social, and therefore requires a more holistic approach.
I’m sure all pain scientists can agree that biomechanics DO matter. Those who argue against this idea are misrepresenting the science. It is high time however that this idea of structuralism be de-emphasised and de-catastrophized as a growing body of evidence shows mechanisms of pain that have little or nothing to do with posture, alignment, and structure.
The medical community was (is!) trained to believe that things like pelvic tilt, core weakness, short muscles and structural findings on X-Rays (eg arthritic changes, disc bulges etc) cause significant nociception that creates pain. While in some cases this may be true, overwhelming research has shown a very poor correlation between many of these findings and how we experience pain. To be a little bit wonky, asymmetrical or imperfect is to be human. Let’s retire the Bogeyman and move on from terms like “Degenerative Disc Disease”, “Wear and Tear” and “Bone on Bone”. If practitioners can drop this outdated language that fosters fear and dependance on medical intervention, perhaps patients will have a better chance at managing their own well-being.
Pain is your body’s protective response when it believes you to be in danger. Pain is irrefutably contextual to your environment and when it persists you need a holistic approach in a collaborative team.
**DISCLAIMER: This post is not to discourage you from surgical intervention, rather as food for thought when deciding the best management for your symptoms.
References
Ciccozzi, M., Menga, R., Ricci, G., Vitali, M.A., Angeletti, S., Sirignano, A. and Tambone, V. (2016). Critical review of sham surgery clinical trials: Confounding factors analysis. Annals of Medicine and Surgery, [online] 12, pp.21–26. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109256/.
Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., Kalske, J. and Järvinen, T.L.N. (2013). Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. New England Journal of Medicine, [online] 369(26), pp.2515–2524. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1305189 [Accessed 27 Oct. 2019].
Schrøder, C.P., Skare, Ø., Reikerås, O., Mowinckel, P. and Brox, J.I. (2017). Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. British Journal of Sports Medicine, 51(24), pp.1759–1766.
Welliver, C., Kottwitz, M., Feustel, P. and McVary, K. (2015). Clinically and Statistically Significant Changes Seen in Sham Surgery Arms of Randomized, Controlled Benign Prostatic Hyperplasia Surgery Trials. The Journal of Urology, [online] 194(6), pp.1682–1687. Available at: https://pubmed.ncbi.nlm.nih.gov/26143113/ [Accessed 21 Sep. 2021].
