I was just on Radio 4’s PM program talking about the acupuncture study that’s in the news today, you can listen to it here (37 minutes in to the programme):

www.bbc.co.uk/radio4/news/pm/

Here are some references and background bits and bobs.

The paper itself was very interesting. It took 1200 people, with an average of 8 years back pain each: we can assume not been helped by biomedical treatments. They were split into three groups: one group had medical treatment; one group had proper, real, bells and whistles, needles in the “meridiens” acupuncture; and one group were treated with pretend acupuncture.

The results were fascinating: they set a threshold for “improved” (which was either a 33% improvement in 3 aspects of one score, or 12% improvement on another measuring scale). They found that people having acupuncture were almost twice as likely to reach this level of improvement in back pain as people on medical treatment (which had already let them down for 8 years of course). But even more interestingly, the pretend acupuncture group, where they just bunged needles in any old place with a bit of ceremony, did just as well as the people having proper, posh, theatrical, genuine acupuncture.

The press release is here, and the full academic paper is here:

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

I’ll try tomorrow to encourage them to make it free as always.

[edit 26/9/07: the American Medical Association have basically said no I think.]

I’ve written about the placebo before, how it about much more than a pill, but is about the cultural meaning of a treatment, our expectations, and more. It’s worth seeing these fascinating acupuncture results in that context:

www.badscience.net/?cat=41

Here’s what I wrote just last week on the subject:

There’s nothing inherently wrong with the idea of giving out sugar pills. The placebo effect can be very powerful, because it’s not just about the pill, it’s about the cultural meaning of the treatment: so we know from research that four placebo sugar pills a day are more effective than two for eradicating gastric ulcers (and that’s not subjective, you measure ulcers by putting a camera into your stomach); we know that salt water injections are a more effective treatment for pain than sugar pills, not because salt water injections are medically active, but because injections are a more dramatic intervention; we know that green sugar pills are a more effective anxiety treatment than red ones, not because of any biomechanical effect of the dyes, but because of the cultural meanings of the colours green and red. We even know that packaging can be beneficial.

It’s also really worth checking out this fascinating paper, comparing two different placeboes: a placebo pill, up against an elaborate placebo ritual involving a medical device (it was modelled on acupuncture). They found that the more elaborate placebo ritual was more effective than the tablet.

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

More even than that, I think back pain is incredibly interesting: in 90% no cause is found, and we know that things like psychosocial stressors, work problems, bed rest and depressive symptoms are significant risk factors for moving from a twinge to chronic enduring pain. There is no doubt that eg brief educational interventions (don’t avoid exercise, do avoid rest, do avoid specific exercises) are helpful.

Back pain is clearly a problem which requires more than simply pharmaceutical pills. The question is whether an elaborate, expensive, gimmicky and theatrical placebo ritual is an effective use of money, or whether other, cheaper, more pragmatic, honest psychosocial interventions might be more appropriate and cost effective.

Here is an excellent review of causes and treatments for back pain, setting out the clear evidence for keeping active, avoiding rest, and the role of psychosocial factors in the move from acute to chronic. I’ve pulled out some key quotes for people with lazy clicking fingers.

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



What are the most important prognostic indicators for chronicity? Early identification of patients with low back pain at risk for long term disability and sick leave is theoretically and practically important because early and specific interventions may be developed and used in this subgroup of patients. This is of special importance because recovery for people who develop chronic low back pain and disability is increasingly less likely the longer the problems persist. The transition from acute to chronic low back pain seems complicated, and many individual, psychosocial, and workplace associated factors may play a part. In this respect, increasing evidence indicates the importance of psychosocial factors.w7 A recently published systematic review of prospective cohort studies found that distress, depressive mood, and somatisation are associated with an increased risk of chronic low back pain.13 Table 1 shows a list of individual, psychosocial, and occupational factors, which have been identified as risk factors either for the occurrence of low back pain or for the development of chronicity. “Yellow flags” have been developed for the identification of patients at risk of chronic pain and disability. A screening instrument based on these yellow flags has been validated for use in clinical practice.14 The predictive value of the yellow flags and the screening instrument need to be further evaluated in clinical practice and research.

How effective are treatments in acute low back pain? The evidence that non-steroidal anti-inflammatory drugs relieve pain better than placebo is strong. Advice to stay active speeds up recovery and reduces chronic disability. Muscle relaxants relieve pain more than placebo, strong evidence also shows, but side effects such as drowsiness may occur. Conversely, strong evidence shows that bed rest and specific back exercises (strengthening, flexibility, stretching, flexion, and extension exercises) are not effective. These interventions mentioned were equally as effective as a variety of placebo, sham, or as no treatment at all. Moderate evidence shows that spinal manipulation, behavioural treatment, and multidisciplinary treatment (for subacute low back pain) are effective for pain relief. Finally, no evidence shows that other interventions (for example, lumbar supports, traction, massage, or acupuncture) are effective for acute low back pain.3

Box 3: Recommendations in the European clinical guidelines for diagnosis and treatment of chronic low back pain22 Diagnosis Diagnostic triage to exclude specific pathology and nerve root pain

triage to exclude specific pathology and nerve root pain Assessment of prognostic factors (yellow flags) such as work related factors, psychosocial distress, depressive mood, severity of pain and functional impact, prior episodes of low back pain, extreme symptom reporting, and patient’s expectations

of prognostic factors (yellow flags) such as work related factors, psychosocial distress, depressive mood, severity of pain and functional impact, prior episodes of low back pain, extreme symptom reporting, and patient’s expectations Imaging is not recommended unless a specific cause is strongly suspected

recommended unless a specific cause is strongly suspected Magnetic resonance imaging is best option for radicular symptoms, discitis, or neoplasm

resonance imaging is best option for radicular symptoms, discitis, or neoplasm Plain radiography is best option for structural deformities



