Saturday September 29 2007
One thing that always fascinates me, as I tug on my pipe in this armchair, is how reductionist, how mechanical, how sciencey and medical we like our stories about the body to be. This week a major new study was published on acupuncture. Many newspapers said it showed acupuncture performing better than medical treatment: in fact it was 8 million times more interesting than that.
They took 1162 patients who had suffered with back pain for an average of 8 years (so these were patients who had failed with medical treatment anyway) and divided them into 3 groups. The first group simply had some more medical treatment; the second group had full on acupuncture with all the trimmings, the needles all put carefully into the correct “meridiens” in accordance with ancient Chinese stuff, and so on; while the third group just had some bloke pretending to be an acupuncturist, sticking needles in their skin at random. The study set a threshold for “response to treatment”, which was an improvement of 33% on 3 items out of a bigger scale, or 12% on one symptom scale. So this was not “getting better”, or a “cure”.
I’m not carping, I’m just telling you what they measured. And what were the results? Firstly, 27% of the medical treatment group improved: this is an impressive testament to the well known healing power of simply “being in a trial”, since medical treatment hadn’t helped these patients for the preceding 8 years. Meanwhile 47% of the acupuncture group improved, but the sting is this: 44% of the fake acupuncture group improved too. There was no statistically signficant difference between proper, genuine ancient wisdom acupuncture, and fake, “bung a needle in, anywhere you fancy, with a bit of theatrical ceremony” acupuncture.
There are three possible explanations for this finding. One is that sticking needles in your body anywhere at random helps back pain due to some physiological mechanism. The second is that theatrical ceremony, reassurance, the thought of someone doing something useful, and a chat with someone nice helps back pain. (The third option is “a bit of both”).
Now as I have said so many times before, the placebo effect is not about a sugar pill, it’s about the cultural meaning of a treatment, and our expectations: we know from research that two sugar pills are more effective than one, that a salt water injection is better for pain than a sugar pill, that colour and packaging have a beneficial effect, and so on. Interestingly, there has even been a trial on patients with arm pain specifically comparing a placebo pill against a placebo ritual involving a sham medical device, modelled on acupuncture, which found that the elaborate ritual was more effective than the simple sugar pill. “Placebo” is not a unitary phenomenon, there is not “one type of placebo”.
But the most important background information missing from the news reports wasn’t about the details of the study: it was about back pain. Because back pain isnt like epilepsy or tuberculosis. Most of the big risk factors for a niggle turning into chronic longstanding back pain are personal, psychological, and social: things like depression, job dissatisfaction, unavailability of light duty on return to work, and so on.
And the evidence on treatments tells an even more interesting psychosocial story: sure, anti-inflammatory drugs are better than placebo. But more than that, bed rest is actively harmful, specific exercises can be too, and proper trial data shows that simply giving advice to “stay active” speeds recovery, reduces chronic disability, and reduces time off work.
We don’t like stories and solutions like that for our health problems. There are huge industries telling you that your tiredness is due to some “chromium deficiency” (buy the pill); your cloudy headed foggy feeling can be fixed with vitamin pills, pills, and more pills. It is a brave doctor who dares to bring up psychosocial issues for any complaint when a patient has been consistently told it is biomedical by every newspaper, every magazine, and every quack in town.
But in conditions like back pain or fatigue, information alone can make a difference to the suffering of millions. In Australia, a simple public information campaign (“Back Pain: don’t take it lying down”, arf) was shown to reduce back pain significantly in the whole population. Meanwhile journalists, patients, quacks, politicians and editors would all rather talk about magical, technical pills and rituals.
Here is the paper which compares two different placeboes, a placebo pill in one arm, against an elaborate placebo ritual involving a sham medical device modelled on acupuncture:
You can read more about the placebo effect here:
The full academic paper for the acupuncture study can be found in Archives of Internal Medicine Vol. 167 No. 17, September 24, 2007. I asked the American Medical Association to make it freely available, since it has been so heavily promoted and discussed, and is the focus of lots of public interest, and was funded by the public medical insurers in Germany. They refused, and for some slightly odd reasons in my opinion, but that is a story I will write on another day. If you have an academic login you can read the paper here, if you are denied access to this information then I agree, that is wrong:
Here is the real action, an excellent and current review of the literature on back pain from the British Medical Journal, and it’s free to access:
Since back pain is a problem with a lifetime incidence of 50-70%, you might as well read the paper, since you will need to know about it, I’ve extracted a couple of tables below.
The main challenge is the early identification (for example, based on psychosocial risk factors) of patients at risk for chronicity and subsequently preventing the chronicity from occurring.
Table 1 Risk factors for occurrence and chronicity of low back painw10
Risk factors Occurrence Chronicity Individual Age; physical fitness; weakness of back and abdominal muscles; smoking Obesity; low educational level; high levels of pain and disability Psychosocial Stress; anxiety; negative mood or emotions; poor cognitive functioning; pain behaviour Distress; depressive mood; somatisation Occupational Manual material handling; bending and twisting; whole body vibration; job dissatisfaction; monotonous tasks; poor work relationships and social support Job dissatisfaction; unavailability of light duty on return to work; job requirement of lifting for three quarters of the day
- Reassure patients (favourable prognosis)
- Advise patients to stay active
- Prescribe medication if necessary (preferably at fixed time intervals):
- Non-steroidal anti-inflammatory drugs
- Consider muscle relaxants or opioids
- Discourage bed rest
- Consider spinal manipulation for pain relief
- Do not advise back-specific exercises
And here is the paper showing that a simple public health campaign, encouraging people to get back to action as soon as possible, reduced the prevalence of back pain in a population:
The Victorian WorkCover Authority’s statewide media campaign “Back pain — don’t take it lying down”, which commenced in 1997 (Box 1), aimed to provide a new approach through prime-time television advertisements featuring health professionals, and sports and local television celebrities. The messages, all endorsed by the relevant professional healthcare organisations, were simple:
- back pain is not a serious medical problem;
- disability can be reduced and even prevented by positive attitudes; and
- treatment should consist of continuing to perform usual activities, not resting for prolonged periods, exercising and remaining at work.
The campaign counselled individuals with low back pain, their doctors and employers to avoid excessive medicalisation of the problem, and unnecessary diagnostic testing and treatment.
A three-part evaluation of this campaign (evaluating general population attitudes, general practitioners, and the WorkCover Authority claims database) suggests that there has been widespread adoption of these messages (Box 2).13,14 The campaign successfully managed to:
- “de-medicalise” a public health problem;
- ease the burden on general practitioners and specialists;
- empower workers to solve their own health challenges; and
- save workers’ compensation payments.
The success of the campaign has been attributed to many factors, including the simple, direct language used to convey the messages, and the evidence-based content, both pioneered by the authors of The back book.12 In addition, virtually every professional body with a stake in back pain in Australia supported the campaign.
And Benny’s Final Thought:
There is a fascinating irony here. While the flaky humanities graduate commentators in the media bang on about “scientism” and accuse doctors and scientists of being “reductionist”, while CAM therapists bang on about doctors being in the pocket of big pharma, and praise themselves for being “holistic” and “lifestyle oriented”… doctors seem to be the ones actually dishing out basic, sensible, evidence based non-technical lifestyle advice, and people are strangely resistant to hearing it.
Plus ca change, kids.