To showcase some of the interesting talks we are in for at this years Annual Scientific meeting, we have invited some of the speakers to be guest-guest bloggers in our 2 min Guest blog segment, starting down south with Professor Wayne Gillett.

Professor Gillett will be speaking on Saturday morning on a Mechanism Based Approach to Gynecological Pain.

1. What is your current role/job/position? 

I recently came across this pearler in a blog post by a colleague on ultrasound:

“Lying is bad, but easing suffering is good – every school kid knows that.  But what if the lie eases someone’s pain, then it’d be good, no? But what if someone’s making lots of money out of it, that’d be profiteering wouldn’t it and that’s bad. Surely making money out of lying to people can’t be good?  But what if the act of handing over money helped convince someone the lie was true, which eased their pain, then it’d be okay, wouldn’t it?

Louise Parker

And it got me thinking…well would it?

Since then I’ve been reading a lot about the weird-and-wonderful world of placebos and I must admit, I’m hooked…

A placebo (by its technical definition) is a treatment with no known therapeutic value. When we think about placebo we typically think of the inactive substance given to participants in the control arm of a clinical trial.  But the placebo story is far more interesting than just little sugar pills divvied up during RCTs.

Things get really interesting when you start looking into the effects that those pills (or any other type of ‘inactive’ treatment for that matter) can have….now you have entered the realm of the ‘Placebo Effect’ and things are about to get groovy…

The ‘placebo effect’ is what makes round pills more effective than square ones of the same dose,  expensive medicines work better than cheaper versions with exactly the same ingredients and means that even placebos being addictive. This 3 minute video explains the effect brilliantly.

And, you don’t even need to actually recieve a placebo to get a placebo effect.  Also called the ‘meaning  response’  the effect is driven by the cultural meaning we attach to a treatment, along with our beliefs and expectations.

If you believe or expect a treatment to make you feel better it probably will.  If you have a nice, caring clinician, who you like and trust, you will probably do better than if you don’t.  These ‘non-specific’ effects work alongside the specific effects of the treatment you are receiving and have the ability to augment or undermine even an established treatment.

To borrow some words from Dr Ben Goldacre it is “not so much about the medicine, but the beliefs that we load onto it”.

This video by Derren Brown is an entertaining look at just what the placebo effect might be capable of.  What Derren gets up to in this experiment tests not only the limits of the placebo effect, but also stretches the ethical boundaries surrounding them.

Ben Goldacre, the author behind Bad Science agrees that the placebo effect creates an “interesting ethical hole”.

To give a placebo, by definition requires that you lie to patients.  In practicality deception on some level is kind of mandatory as to not undo the therapeutic effect through disclosure.  But if the evidence is pretty strong that lying to your patient can make them better, does that justify the lying? It’s a good question….

The use of placebo pills is generally accepted to be unethical.  While it is probably not okay to prescribe someone a sugar pill, and tell them it is an active medicine, for those of use working in Allied Health the water seems infinitely muddier. We are not in the business of prescribing medication anyway, so we aren’t likely to try and sneak a sugar pill past someone without their knowledge.  But a lot of the treatments we do use, look like they might work primarily via the placebo effect.

So my question to you: Is it okay to be delivering a treatment, that balance of the evidence indicates works only as well as a placebo and therefore is likely to be working via the meaning response/placebo effect? Is this the same, or different to prescribing someone a sugar pill and telling them its medicine?

For me, its an ethically uncomfortable question and I experience this discomfort regularly when the topic of acupuncture comes up.  Neill O’Connor addresses the same question of the ethics of “magic kisses” in physiotherapy here.

While there is still a deal of debate, when you look at the best quality evidence available there is a suggestion that acupuncture works only about as well as sham acupuncture using a telescopic needle that doesn’t pierce the skin.  If acupuncture does work only as well as a placebo, then one can conclude that the benefit of this treatment is substantially (or even wholly) down to the meaning response, rather than the specific effect of the needles.  In this way, it is technically a “placebo”.

(For the sake of this blog, let us just agree just for the moment that this indeed true and acupuncture is just a super dooper placebo – I’m trying to illustrate an ethical point here, not debate the efficacy of the treatment itself…if you are interested though you can find both sides of the acupuncture debate here, and here, and a summary here and decide for yourself)

So…

Is it still okay to use it? Should I be offering it to my patients? Or at least giving it to them if they ask for it?

And if a patient asks for an explanation of how the treatment works, should I tell them a lie to ease their pain? Or tell them the truth, thereby likely negating the mechanism by which it might help them?

Or do I keep my fingers crossed and just hope they don’t ask?

Looking for a new challenge in 2014?

Expressions of interest are currently being sought from people with an interest in joining the Ngau Mamae editing team. All positions will be for a fixed term and no previous publishing experience is required.

For more information please email Gwyn at gwyn.lewis@aut.ac.nz

Dr John Alchin, the previous hand behind the editors pen of Ngau Mamae is the next of our guest bloggers…

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1. What is your current role/job/position?  

I am a consultant at the Pain Management Centre, Burwood Hospital, Christchurch.  This entails:

• Seeing patients referred to us, both as new patients (as part of a Comprehensive Pain Assessment), and follow-ups. 
• I also take several sessions on our CHOICES program.  CHOICES is a 3 week full-time (9am – 4 pm, Monday – Friday), interdisciplinary group (5-8 pain patients in each group) cognitive-behavioural Pain Management Program.
• Other tasks include triaging patients referred to us; taking phone calls from other doctors (GPs, other hospital doctors) about their pain patients. 

2. How did you get into working in Pain Management?  

I got fascinated by pain through my primary specialty of Occupational Medicine, in which I trained in the last half of the 1980s.  I became increasingly interested in chronic pain as a problem in it’s own right, from the late 19809s on.  In the 1990s, working in this field, it became clear that the many patients I saw with chronic musculoskeletal pain (primarily low back, upper limb & neck) were presenting a complex problem, not a simple one, for which there was no quick and easy mechanical fix.  Then in 1997 I was asked if I wanted to take a position at the Burwood Pain Management Centre.  As that coincided with my being made redundant from Air NZ in mid 1997, in one of their periodic “Re-Organisations” (all the occupational medical units were closed, but were later reinstated), I took up the offer.   

But in fact pain fits in with my life-long interests in biological medicine – after school I went into medical school, not so much for the clinical work, but for the training in human biology, which is what particularly interested me: at high school my favourite branches of biology were genetics, cell structure and function, evolution, and human behaviour/psychology.  And now, in pain, I have come full circle back to these underlying interests.  Because to (try to!) understand the phenomenon of pain requires a familiarity with a broad range of biological subjects – it ranges from the genetics of pain and molecular processes in cells including neurons, through to larger structures, including the structure and function of the nervous system & brain; to human behaviour, psychology and psychiatry; and to social factors – the epidemiology, including role of social class, deprivation, the social welfare & medicolegal systems, and the news media in the clinical presentation of patients we see with pain.

3. If you weren’t working in Pain Management what would you be doing? 

My other favourite fields of medicine now are neurology, general internal medicine, psychiatry, epidemiology.  If I had my time over, these are also fields I could have gone into, in terms of my interests.

4. If you could invite any 3 people to have dinner, who would you choose and why? 

Hard question!  Who to choose?

From the medical/pain world, for their huge knowledge & wisdom about pain, and their nice personalities (but leaving out my NZ colleagues in chronic pain, as there are too many to list): Montreal’s Serge Marchand, Australians Michael Nicholas and Lorimer Moseley, Americans Norton Hadler & John Loeser.  And especially the British psychiatrist Professor Sir Simon Wessely, a wonderful researcher and writer.  

From the non-medical world, for their knowledge, wisdom & (in some cases) their personalities: Radio NZ’s Kim Hill.  NZ poet Sam Hunt.  Clive James.  Political Philosopher Michael Sandel.  Scottish ethicist Alastair McIntyre.  Wonderful British novelist (& chronic pain sufferer) Hilary Mantel.  Leonard Cohen.  Bob Dylan (in theory – as I gather he may not be particularly genial).   Woody Allan.  Kate Blanchet.  A lot of old white men (except for Kim, Hilary & Kate) 

5. What is the most important advance you hope will be made in Pain in the next ten years?

Now an easy question!  Development and clinical availability of some more effective, more targeted analgesics for chronic non-malignant pain.  That would make my patients lives, and mine, a lot more pleasant.  It is very difficult, day after day, to tell patients that we cannot abolish their awful pain, and that there is a good chance that we won’t even be able to reduce it by a significant amount. 

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A few months back, I had a call from my parents-in-law.  Over breakfast that morning they had read an article in our local newspaper, The Press, about how antibiotics might be the cure for low back pain, and they wondered if I had seen it.

At that stage I hadn’t but since then I’ve been watching the story with interest – and as it turns out there has been a bit of a hoo-ha over it¹…

The Good

In April this year, a group of researchers from Denmark published the results of a rather interesting study in the European Spine Journal ². Here’s the essentials of the research:

• Double blinded RCT
• 162 subjects with Chronic Low Back Pain and “Type1 Modic changes” on MRI
• Treated with either 100 days of antibiotics (amoxicillin clavulanate) or 100 days of placebo.

(If you are interested in the nuts and bolts of the study – you can get that here)

The results were, well… pretty impressive.

The antibiotic group improved on all of the outcome measures used, and enjoyed a statistically and clinically significant reduction in both pain and disability compared with the placebo group.   Some of the lucky souls who got the antibiotics were still improving at one-year follow up.  As I said, pretty impressive stuff.

The treatment – Modic Antibiotic Spinal Therapy ( MAST) –  is based on the observation  that Type 1 Modic changes show up on MRI in about 6% of the general population but in 35-40% of people with chronic low back pain.  The theoretic basis behind the antibiotic treatment is that modic changes  are result of inflammation caused by low virulence anaerobic organisms infecting the discs. Treat the infection – and viola! See ya later chronic low back pain…

Now, the trial itself seems to have been relatively well conducted.  As with any trial, a few criticisms of the methodology have been raised, but overall the research results seem pretty robust.

What has created the hoo-ha is the way those results have been reported.

The Bad

At the time the study was published – well… nothing much happened.

Fearing that their results might go unnoticed and eager to avoid a repeat of the Helicobacter Pylori / Stomach Ulcer story, the researchers organised a press conference in May to try to create some media interest in their results.

Well – the ploy worked.  The media got interested and the story was picked up by mainstream media, across the globe.

The quality of the reporting varied from down and out sensationalism to more balanced, responsible journalism.  Sadly though, the vast majority seemed to subscribe to the  “why ruin a good story with the details” school of reporting- calling for Nobel prizes and promising  a cure for ½ million kiwis with back pain.

The problem is, that while the results of the trial were promising, they weren’t that good.

• Patients with Type 1 Modic Changes is likely to represent only a small, subgroup of the chronic low back pain population
• The improvement in pain among the Antibiotic group was significant, but it was only in the magnitude of 3 points on a Visual Analogue Scale (from 6.7/10 to 3.7/10) – while this might be “significant” it hardly represents a “cure”

Balancing these points with the downsides that widespread long term, antibiotic prescription might pose, there’s not quite as much to get excited about as the newspaper would have you believe. While antibiotics might work for a very specific type of patient in very specific circumstances, it’s really still too early to tell and the results should be taken with a grain of salt until the study can be replicated.

The authors themselves close their report by saying “we rely on our fellow colleagues to use clear evidence-based criteria and to avoid excessive antibiotic use” and “more confirmatory work in other populations and studies on improved protocols as well as the background science should be encouraged”.

The Ugly

As a result of the way the story was run by the media, the authors of the paper have received a fair amount of flak from the scientific community, including scrutiny about a possible conflict of interest.  It looks like they must have spent the last few months answering hate mail if this months ESJ contents page is anything to go by.

At the end of the day I for one feel a bit sorry for them.  To borrow a quote from Harriet Hall “This was a well-designed study, carefully carried out, with a credible rationale, impressive results, and a cautious interpretation. This is how science should be done”

It’s the media who should be in the naughty corner.

The Question

Reports of patients asking about MAST as a result of the media coverage are starting to be reported in the blogging world. I’m interested if this has reached our part of the woods yet?

Let us know:

• Did you see the story published in mainstream media, and if so, where?
• Has anyone seen a patient asking for MAST as a result of reading the media coverage of the study?
• Are there other examples from the past, of media reports of a scientific study changing patient behaviour?

¹ hoo-ha or hoo-hah  n. Slang  1. A fuss; a disturbance: “the subject of this last hoo-hah” (William Safire).  2. A chortle or laugh: got a good hoo-ha out of that story

² Albert HB, Sorensen JS, Christensen BS, Manniche C. Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy. European Spine Journal. 22(4):697-707

Ross is next on our ‘mini-blog’ line up – and here’s another dinner party I would love to be a fly on the wall at! 

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1. What is your current role/job/position?   Paediatric Palliative Care and Pain Medicine Specialist at Starship Children’s Hospital, Auckland. I am also the Clinical Lead of the Paediatric Palliative Care National Clinical Network which is in its second year of formation.

I also participate on a number of other groups:        

• Immediate Past-President of the NZ Pain Society
• Chair of the Ministry of Health Palliative Care Advisory Group
• Board Trustee of International Children’s Palliative Care Network – Asia-Pacific representative

2. How did you get into working in Pain Management?  My route to working in Pain Management was circuitous with my interest developing during my Paediatric Palliative Care fellowship.

I had identified Pain Management as an important part of my learning and in the first year of fellowship I spent 6-months with the Paediatric Pain Service at Starship and The Auckland Regional Pain Service at Auckland City Hospital working in acute and chronic pain management.

In my second fellowship year I had a 5-month secondment with the Symptom Control Team at Great Ormond Street Hospital in London with Ann Goldman, PPC Consultant, which included participation in the chronic pain clinic.

My final fellowship year was spent with the Pain and Palliative Care Service at the Children’s Hospital at Westmead in Sydney where part of my fellowship was devoted to the psychological management of chronic pain in children with the Consult Liaison Psychiatry Service. These experiences only heightened my interest and ensured my clinical work with children in chronic pain.

3. If you weren’t working in Pain Management what would you be doing?  This question is relatively easy to answer as I am a Paediatrician first and foremost and specialist trained in Paediatric Palliative Care.

However, if I never went to medical school, which was almost the case, then I would most likely be undertaking some scientific endeavour. My initial degree was a Bachelor of Science in Physiology. Who knows maybe the enquiry would have been in some aspect of the neuroscience of pain.

4. If you could invite any 3 people to have dinner, who would you choose and why?  Well good food and wine needs the accompaniment of good conversation and I can think of no one better than having Billy Connelly at the table with boundless travel anecdotes and ribald humour.

The other two guests seated at the table would be Martha Stewart and Elle Macpherson. Martha as she has become a cooking hero of mine. I am a very recent and occasional viewer of the cooking channel and I have been taken by the calm ease with which she explains cooking and making it look achievable to an inept cook like me. It would also be a good opportunity to get a few tips and, after a few wines, hear about her incarceration for tax evasion. I could say Elle would provide insights into the fashion industry, life of a supermodel and running a successful business which are all true and very valid but more simply, Elle was my teenage poster girl.

5. What is the most important advance you hope will be made in Pain in the next ten years?  The most important advance I hope to be made in pain in the next ten years aside of the obvious finding a “panacea” is the more fundamental desire to see pain recognized in New Zealand as a serious health issue with appropriate resourcing of Pain Services. Extending this aspect, and very close to my heart, is that this recognition be extended to children and the needs of children in pain with a fair level of funding for this vulnerable group. The current resources for children are as close to non existent as they can be and are nothing short of appalling.

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It’s hard to remember a time ‘BI’ – that is: “before internet”.  Even though it really wasn’t all that long ago.  Things in the digital world change so quickly. In my first year at university (1998) I didn’t have an email address – now I have four or five (see, so many I’ve lost count). I think that is pretty significant change in a reasonably short period of time.  However, my Dad often trumps this story with one of his own – when he was at university the university only had one computer – and it took up the whole top floor of the Hocken Building (Otago University Alumni reading this will know the building I’m talking about). Today, in our household of two people, we have three computers, an ipad and two  smart phones. Safe to say, the internet has changed the way we live.

The opportunities for the use of social media in healthcare are huge.  It is estimated that 80% of internet users “google” for health information and the number of “e-patients” – engaged, educated and equipped healthcare consumers – is growing. Health Professionals without an online presence are not only missing out being involved in the ‘participatory medicine’ movement, but are also leaving the online space open for unscrupulous people to pedal, at best unproven, but potentially dangerous remedies to their patients.

However, setting sail in uncharted waters can be daunting.  There are stories out there about it all going wrong for health professionals who don’t get it quite right – like the NHS doctors posted on facebook “lying down” on the job who found themselves in hot water. According to a study recently published in JAMA violations of online professionalism are prevalent among physicians.  

So how does the savvy Health Professional endeavour to engage but still remain safe in the modern online world?  Here’s our top 5 quick tips:

1. Be aware of the potential pitfalls of using social media: learn from others mistakes.

2. Don’t “friend” your patients – considering creating both a professional and a personal presence.

3. Check your privacy settings: lock ‘em down!

4. Google yourself – do you like what you see? Does it represent you well? If no, set about changing it.

5. Adopt a ‘social media policy’: Personally, I like the Mayo Clinic’s approach to social media policy – summarisable in just 12 words.  I like simple.

Don’t Lie, Don’t Pry, Don’t Cheat, Can’t Delete, Don’t Steal, Don’t Reveal

Pretty good rules for life, as well as tweeting.

Or check if your employer, institution or professional association has a ‘Social Media Policy’.  The NZ and Australian Medical Associations have recently released a fantastic document “Social Media and the Medical Profession: A guide to online professionalism for medical practitioners and medical students”. It’s worth a read.

If in doubt, the ultimate litmus test is to ask yourself: “would I mind if 1 million people saw this right now?”.  If the answer is no, then you are probably good to go.  While social media does pose some unique, and potentially as-yet undiscovered threats as Farris Timimi, medical director for the Mayo Clinic Center for Social Media puts it:

“The biggest risk in health care social media is not participating in the conversation in the first place”

In the first of our new blog segments, spend a few minutes getting to know our President Elect – Brigitte Gertoberens.   I put 5 quick fire questions to Brigitte to find out a bit more about what she does, and who she thinks would make interesting dinner guests….

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1. What is your current role/job/position?  I am a full time consultant with The Auckland Regional Pain Service

2. How did you get into working in Pain Management?  My first boss when I started as an anesthetic registrar was into it!

3. If you weren’t working in Pain Management what would you be doing?  Travelling

4. If you could invite any 3 people to have dinner, who would you choose and why?  I would like to have diner with Odysseus as he could tell you a lot about sailing adventures in the Mediterranean, then Oriana Fallaci -I think she was a very brave, excellent journalist, and last not least Dynamo, the magician, as I would like to find out more about his self hypnosis skills-he can make his hands burn! Some of the people are not alive any more, but Dynamo might be able to take us on a time travel and we could have some  paleo food for dinner, which would add to the experience.

5. What is the most important advance you hope will be made in Pain in the next ten years? The most important advance would be to find a really effective drug to treat allodynia

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There’s no denying the size and power of social media – Facebook has over 1 billion uses.  Each day 2 million blog posts are written. There are approximately 750 tweets per second. It would take you 500 years to watch all the videos on You Tube (source).

With so much content, it’s hard to know where to start.  Does one tweet, post, like, subscribe, update, check-in or pin? 

We want to create a library of the best social media resources out there in the area of pain and pain management.

Below is a list of Bronnie and my favourites, so far. The list is by no means complete – we need you to add yours. Jump over to our facebook page or our facebook members group, or comment below and add to the library.

Websites:

Pain Health: developed by the Western Australia Department of Health in collaboration with Curtin University, University of Western Australia and the Musculoskeletal Health Network –  reliable, practical and usable evidence-informed information and skills for people with pain

Webicina: curate medical social media resources for both health professionals and ‘e-patients’, across 80 medical topics, and in 17 languages. Chose the social media platform you are interested in, plug in your area of interest (from Anaesthesiology to Urology) and chose from the list of resources. Webicina also offer a free 16-part Social MEDia Course on social media in medicine – worth a look

Blogs:

Body in Mind: headed by Lorimer Moseley this regular blog guest stars posts from the research team  at Neuroscience Research Australia (NeuRA) and University of South Australia (UniSA) as well as collaborators in research experiments and clinical trials, and other bloggers who always have something interesting to say. The BIM team are also on Twitter @bodyinmind

Forward Thinking PT: written by US Physical Therapist Joseph Brence, a blog with the goal of assisting “in the delivery of quality, evidence-based reviews to help the average clinician improve their practice” – Joe is also on twitter @joebrence9

NOIJAM: a reasonably new blog from NOI Group based in South Australia, encouraging an open liberal discussion focusing on “bringing researchable ideas from the clinic to the fore @noigroup are also on Twitter

Facebook:

Neuroscience and Pain Science for Manual Physical Therapists: edited by Diane Jacobs, a Canadian Physiotherapist who seems to have an extraordinary ability to seek, find and post heaps of interesting neurosciences titbits.  Diane is busy – she also writes a great blog and is also on Twitter @dfjpt

Chronic Pain Australia: the facebook presence of our Australian cousin, Chronic Pain Australia.

Twitter: 

Twitter is possibly the least understood of the social media platforms.  It is possible to use Twitter as a “news headline” source – many of the tweeters below locate fascinating articles and posts from around the world, and some also add their own commentary. Twitter can also be used for discussions with international colleagues (using hashtags #), and when attending conferences, when hashtags are also used to give a brief snippets live from within an audience.

@RonanTKavanagh: a Rheumatologist with an interest health technology and Musicians Health

@iwhresearch: The Institute for Work & Health is a not-for-profit research organization that explores occupational health and safety and return-to-work issues

@Dr_Derek_Jones: working at Northumbria University; teaching occupational therapy; researching chronic pain; with a sociological bias.

@Neurophilosophy: A neuroscience blog about molecules, mind and everything in between,

@JRBtrip: Find evidence fast. Trip is a great, independent search engine helping users access high quality clinical evidence.

@painfultweets: sassy, snarky and sensible pain & injury science tweets from science writer Paul Ingraham 

@EdzardErnst: Emeritus professor,  alternative medicine  researcher, co-author of ‘Trick or Treatment’ (the guy that called Prince Charles a “snake-oil salesman”)

@somatosphere: collaborative website covering the intersections of medical anthropology, science & technology, cultural psychiatry, psychology and bioethics.

@somasimple: a place for Skeptical Manual and Physical Therapists

@cochranecollab: The Cochrane Collaboration needs no introduction – working together to provide the best evidence for health care

@wrtrohio: Barrett Dorko: Physical Therapist, Writer, Teacher. In private practice 28 years, manual care for painful problems.

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Infographic Source: www.go-globe.com/blog/social-media-facts