Medicalisation – don’t take it lying down.

September 29th, 2007 by Ben Goldacre in acupuncture, bad science, medicalisation, placebo | 69 Comments »

Ben Goldacre
The Guardian
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.

References:

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:

www.bmj.com/cgi/content/full/332/7538/391

You can read more about the placebo effect here:

www.badscience.net/?cat=41

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:

archinte.ama-assn.org/cgi/content/full/167/17/1892

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:

www.bmj.com/cgi/content/full/332/7555/1430

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

Treatment

  • Reassure patients (favourable prognosis)
  • Advise patients to stay active
  • Prescribe medication if necessary (preferably at fixed time intervals):
  • Paracetamol
  • 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:

www.mja.com.au/public/issues/175_09_051101/buchbinder/buchbinder.html

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.


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69 Responses



  1. Robert Carnegie said,

    October 6, 2007 at 12:18 am

    The Internet tells me it’s not unknown to have only one kidney for reasons besides exchanging one with a loved one. Effects include a greater risk of high blood pressure and reduced glomerular filtration rate. Obviously. But someone with only one kidney is still fit enough to punch you in the mouth.

  2. doris said,

    October 6, 2007 at 6:52 am

    Has any research group caried out brain imaging on subjects undergoing acupuncture?
    PET or fMRI?
    This sprang to mind because I recall that similar studies have been done on subjects who are adept in meditation.
    Incidentally,there is a large TCM Practice here in Bath:very costly,all practitioners are Chinese;however,I don’t know what relationship,if any, they have with local GPs.
    On emotional health;there must be many cultural factors at play,within different societies with differing customs and beliefs.

  3. jodyaberdein said,

    October 6, 2007 at 7:28 am

    Regarding having a kidney removed: Actually you will find that living related kidney donors have a higher than population average life expectancy, largely because we screen them for any serious problems and these tend to get sorted out whether or not you are fit enough to donate the kidney. There is a slightly increased risk of developing hypertension in later life it is thought.

  4. ips said,

    October 6, 2007 at 9:28 am

    Doris …..

    www.ftcm.org.uk/neuroimaging.htm

    FMRi and acupuncture

    noi.strategyonline.com/documents/noi-explain-pain-evidence.pdf

    explaining to people why they have persisting pain may also have lasting ‘central effects’ and also improve function .

    www.paulekman.com/

    Paul Ekman has done more studies on emotion than most –his papers are available to download.

  5. happeh said,

    October 6, 2007 at 6:17 pm

    pv – “What the aaa is so special about Chinese Medicine!”

    I cannot believe I am conversing with someone who thinks that is the proper way to have a scientific discussion. Your emotional statements do nothing but make everyone uncomfortable. You could easily say “Why is Chinese Medicine special”, and we would all understand you.

    The answer to your question pv, is that Chinese Medicine is based on a deeper knowledge of the human body than Western medicine has, or admits too. In all my exposure to Western Medicine, nothing I have seen makes me feel that Western Medicine knows how the human body works at a very deep level.

    Because they don’t know how the human body works at a deep level, their entire medicine is suspect. They have failed to take into account phenomenon that have a direct bearing on the majority of human illnesses.

    I think the fact that the Chinese developed this deep level knowledge of the body 1000’s of years ago, and modern technological medicine doesn’t know anything about it, makes Chinese Medicine pretty darn special.
    ——————-

    JodyaBerdein – I believe you probably mean well with your statements on kidney donation. I do not doubt the things you say might be true.

    I also do not believe that you have enough understanding of the human body to say what you are saying. What you are doing is quoting what other people say. To me, that means you have no personal knowledge of your own with which to answer questions. Any question I have for you, you must tell me to wait while you go find the answers from the people who know.

    I could explain exactly why kidney donation is bad. It is simple. Except for one thing. It will make no sense to you, because you never heard anything like it before. Your fellows will jeer and ridicule, and you will go with them, because what I say does not fit in with what other people say.

    Even though it is strange, it is reality. And for anyone with the patience, perseverance and mental focus necessary for scientific investigation, I could show them many different pieces of corroborative evidence for what I would say.

    I think a person who can discuss an issue from their own knowledge, instead of having to go to someone else as you have to, is a person who has more authority on a subject.

    I could be wrong though. Maybe you should go ask someone?

  6. pv said,

    October 6, 2007 at 7:59 pm

    happeh said,

    October 6, 2007 at 6:17 pm

    “I cannot believe I am conversing with someone who thinks that is the proper way to have a scientific discussion…”

    aaaaa

  7. Ben Goldacre said,

    October 6, 2007 at 9:07 pm

    chaps please, swearing is unimaginative and stops people being able to read the page at work.

    happeh, while your excellently incoherent theories about masturbation causing all kinds of medical problems are genuinely fascinating to me (and can i particularly recommend happeh.com but also www.angrypenis.org for the videos) i’m not sure that people will be able to indulge you here. good luck elsewhere though.

  8. pv said,

    October 6, 2007 at 10:42 pm

    OK! Sorry Ben. If deletions are in order…

  9. jodyaberdein said,

    October 6, 2007 at 10:50 pm

    Funny that I don’t understand enough about the human body to know why kidney donation is bad for you.

    I just spent last week looking after two donors and today tending to five recipients. Perhaps someone should tell them?

    Dr Jody Aberdein BA MBBS DTMH MRCP

  10. jodyaberdein said,

    October 6, 2007 at 10:57 pm

    Now that I’ve got that off my chest I would like to pose two questions to Happeh.

    The first is how his personal experience can reliable detect an effect that occurs in a small proportion of people, e.g. 1 in 3000, and secondly how it can detect an effect which my occur 30 years hence.

    Furthermore perhaps he would like to pass comment on the data presented in this freely available editorial in Nephrology, Dialysis and Transplantation:

    ndt.oxfordjournals.org/cgi/content/full/18/5/871

  11. Robert Carnegie said,

    October 7, 2007 at 11:45 pm

    Come to think, isn’t it repeatedly reported that -actual- Chinese medical practitioners do a brisk business even taking organs such as kidneys out of people who wanted to keep them? Of course we should remember it’s very easy to make such allegations about people you don’t like.

  12. jodyaberdein said,

    October 8, 2007 at 6:50 am

    How fortuitously we seem to have come back on thread. For a moment I was thinking of apologizing for steering us off topic.

    www.guardian.co.uk/china/story/0,,1664750,00.html#article_continue

  13. happeh said,

    October 9, 2007 at 6:49 am

    Mr Goldacre. I am saddened that you find my theories on masturbation incoherent. Could you be more helpful perhaps? “Incoherent” gives me nothing to work with. I need to know what you are capable of understanding, then I can work from there. As it is now, I have no idea what you are capable of understanding, and what flies over your head.

    I am guessing you are looking for a linear progression type of website? That is not me. I work by immersing people in ideas, then helping them to make connections between all the various ideas. What I do is confusing to people who can only think in a linear way.
    ———–

    You say you are fascinated by what you read on the website? You want to be famous? I mean going down in history famous, not having your own website famous?

    Figure out what I am saying. If you, or any other scientist for that matter, can figure out what I am saying, then convince the rest of the scientific community, we will change western medical history.

    I am not like scientists. I am flexible. I can work with you or any other person that has difficulty understanding what I say. I won’t force you to do it my way. I will help you understand in a way that works for you.

    I have absolute confidence that if I can find one of you scientists or doctors with patience and native intellect, that we can work out a way to translate what I have to say into the kind of language that scientists will accept.

    If you are really a scientist, then you know this will not happen in 3 of my posts in your blog. Nor will it happen in days or weeks. It will probably take some time for complete understanding, just like taking 2 years of maths or science to ensure you get everything you are supposed to have.

    You say you are a scientist dedicated to correcting bad science. Let’s both of us correct this bad science that is called “western medicine”. The amount of foolishness they push is truly mind boggling.

    Or, if you are above it, send me one of your scientist buddies that does not have your good fortune to have a large website of their own. That friend of yours and I will go ahead and become world history famous, while you sit safely on the sidelines with your reputation intact.

    I know there must be scientists out there hungry for fame. Talk to me. I will give you your fame. Money usually goes with fame, so if you want money, you will probably get that too.

  14. happeh said,

    October 10, 2007 at 4:36 pm

    DrJodyaBerdein – I feel guilty because it looks like I avoided your posts. I honestly did not really see them. I saw Goldacre’s post, and wanted to deal with it.

    Dr Berdein. You may be a professional and at the top of your area in what western medicine teaches you. I believe that western medicine does not understand what kidney transplant does to people at a deep level, so they cannot instruct you on what happens in those situations. I don’t want to denigrate you at a personal level. I want to say that the western medical profession, and it’s practitioners, of which you are one, do not understand the human body at a deep level. So you cannot know how the things you do, such as kidney transplant, change the body at a deep level.

    I would hope you would not take personal or professional offence, and that maybe an informative kind of discussion could take place between us. I could say what I believe, and you could pick it apart as an intellectual discussion, and not as payback on someone who has impugned your professional reputation.
    ——————–

    Hey Goldacre! You still there! 😉 I got you. Yes I do. I have you. 😉 Please read the article at this link.

    tinyurl.com/38mha5

    That article discusses Symmetry of the Human Body. That is what I talk about. I am of a mind that these men were influenced by me. I have spent the last 1 1/2 years at the Guardian trying to get some doctor or scientist to listen to me about Asymmetry of the Human Body and it’s effects on the health of the Human Body. My website has more than a few articles on Symmetry of the Human Body.

    Last month an article on Symmetry of the Human Body was released. This month, here is another story on Symmetry of the Human Body.

    I think I got through to those scientists and doctors. I think they read a comment of mine and were stimulated to investigate. If they didn’t investigate because they were stimulated by a post of mine, it does not matter. Their work is the beginnings of the evidence that will eventually prove that what I say is correct.

    Get in on the ground floor, or wait until we are all famous and rich, and have it all figured out and written down in a simple linear way for you. The time period when you learn about Symmetry of the Human Body and it’s effects on the health of a human being is up to you.

  15. Robert Carnegie said,

    October 11, 2007 at 12:25 am

    If people don’t figure out what you’re saying, maybe it’s because you aren’t saying it. Communication is a one-way street, you know.

  16. jodyaberdein said,

    October 11, 2007 at 12:56 am

    Happeh,

    I fear we may be rapidly losing audience share here.

    By no means have you managed to offend me. In fact the very concept of offence gives me quite a lot of trouble, let alone when one is supposed to be discusssing science.

    I merely wanted to illustrate that if you go around stating things about people you don’t know then you are likely from time to time to be quite wrong.

    With regard to informative kinds of discussion I’m not sure I have much to add as you haven’t even attempted to respond to the specific points I made previously.

  17. suzy-w said,

    November 6, 2009 at 5:05 pm

    Hi Ben

    I have found this really late! I’m afraid the party’s already over, but I kind of agreed with what one of the respondents said that you seem a little prejudiced and I was wondering if you have tried “genuine ancient wisdom acupuncture”?

    Just out of interest, because it seems a lot of debates on the net are between people who do not have first-hand experience and I think that is a pretty basic requirement for an informed discussion.

    It’s a shame that no one seems to be able to discuss these subjects like adults. The first five or so comments usually seem to have at least a thin veneer of objectivity, but the best ones are at the end where everyone is name-calling and throwing hissy fits 🙂

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  19. JustMe said,

    July 1, 2010 at 8:10 am

    You are repeating what you have already said. As a matter of making a point, I should remind you that “good” critical appraisal should remove any pre-existing prejudice or bias from the writings. You fail to do this. You should be holding up your hands and saying that actually, needling anywhere may actually be causing a physiological response that this study has no way of showing. You do acknowledge that point in this blog but you also belittle the likelihood of it in the preceeding chapters and clearly demonstrate a pre-existing bias. There are many people on this website that follow you blindly, you have a responsibility to ensure that your own appraisal is fair- something that you claim to be promoting. Just because we do not understand mechanisms by which certain interventions work, does not mean we should dismiss them